1. Indications for gastrectomy after incomplete EMR for early gastric cancer Hideki Nagano1,4, Shigekazu Ohyama1, Tetsu Fukunaga1, Yasuyuki Seto1, Junko Fujisaki2, Toshiharu Yamaguchi1, Noriko Yamamoto3, Yo Kato3, and Akio Yamaguchi4 1 Department of Surgery, Cancer Institute Hospital, 3-10-6 Ariake, Koto-ku, Tokyo 135-8550, Japan 2 Department of Internal Medicine, Cancer Institute Hospital, Tokyo, Japan 3 Department of Pathology, Cancer Institute Hospital, Tokyo, Japan 4 First Department of Surgery, Faculty of Medicine, University of Fukui, Fukui, Japan Gastric Cancer Vol 8, Aug. 2005

2. Background EGC (early gastric cancer) –EMR (endoscopic mucosal resection) ↑ by improvement diagnostic device and EMR technique –Laparotomy ↓ and quality of life (QOL) ↑ –incomplete resection  no defined strategy AIM –clarify the incidence of en-bloc and complete resections –evaluate the adequacy of our therapeutic strategy by determining the risk of residual cancer or lymph node metastasis

3. Patients and methods January 1991 and December 2000 726 pts. who underwent EMR for primary gastric cancer Indications of EMR for gastric cancer –Histologically differentiated-type carcinoma (pap, tub1, tub2) mucosal layer, without ulceration or ulcer scars, <30mm –Undifferentiated-type carcinoma remaining in the intramucosal layer without ulceration or ulcer scars, <5 mm in size, regardless of the lesion’s gross appearance Methodology of EMR –strip biopsy method, HSE solution, cap-fitted aspiration mucosal resection, multi-fragment resection –extended immediately, fixed with pins, reconstruct criteria of complete resection –no cancer exposure to any cut end and the line between normal tissue and the portion denatured

4. Table 1. Classification of patients with incomplete resection Therapeutic strategy –Intramucosal ca. with lateral residue  F/U, additional endoscopic treatment, surgical resection with LN dissection –Invade the surface of the submucosal layer  choose between close F/U or surgery – massive infiltration of the tumor to submucosal layer  strongly recommend surgical resection with level 2 LN dissection

5. Results

6. Table 2. incidence of complete and incomplete resection En-bloc resection 529 pts.(72.9%) 303: f/u, 45: op.

7. Evaluation of patients with additional surgery 45 (12.9%) of 348 patients, 6.2% of all patients –2 pts.(0.6%) : submucosal ca. –17(81.0%) : en-bloc resection  16 : residual ca. 4(19.0%) : multi-fragmented resection  2 : residual ca.

8. –Residual ca: 1-mucosal layer 1-sumucosal layer

9. –Residual ca.: 1-mucosal layer 3-submucosal layer –More macroscopically-depressed type lesions compared to group C –Higher incidence of residual cancer and LN metastasis in group B, C, and D

10. Details of node-positive patients –1.1% of incomplete EMR, 8.9% of those with additional surgery

11. Conclusion Group A ; treat using endoscopy  modified gastrectomy >conventional gastrectomy Group B ; additional surgery  further examination Group C & D : absolute indication for surgery Guarantee of strategy for incomplete EMR  improve QOL of EGC patients