Outcomes and precautions of endoscopic submucosal dissection for undifferentiated-type early gastric cancer

Since the development of techniques for endoscopic submucosal dissection (ESD), the indication range of endoscopic resection (ER) has been extended in early gastric cancer (EGC) treatment. For undifferentiated-type EGC, tumors with an intramucosal depth of invasion, no ulceration and a diameter of 20 mm or less were included in the expanded indications for ER in the Japanese Gastric Cancer Treatment Guidelines 2010. Nonetheless, because of difficulty in detecting lesions that meet the criteria for ER, the number of endoscopically resected cases of undifferentiated-type EGC is less than that of differentiated-type EGC.

We retrospectively investigated the outcomes of ESD in 38 patients with 40 lesions of EGC in which the dominant pathological type was confirmed to be undifferentiated (signet ring cell carcinoma, poorly differentiated adenocarcinoma, mucinous adenocarcinoma) on histological examination of resected specimens.

Margin involvement and submucosal infiltration were common noncurative factors. Precise evaluation of the area and depth of lesions is a problem to be solved. Among a total of five patients with involved or uncertain horizontal margins, one of two patients who underwent additional surgery had residual cancer, and one of three patients who were observed had recurrence.

Undifferentiated-type EGC with a positive horizontal margin may relapse after ESD. It is therefore essential to precisely evaluate the area of the lesion and to perform resection with an adequate safety margin to decrease the risk of recurrence.