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Background/Aims@#It is uncertain whether additional endoscopic treatment may be chosen over surgery in patients with positive lateral margins (pLMs) as the only non-curative factor after endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). We aimed to compare the long-term outcomes of additional endoscopic treatments in such patients with those of surgery and elucidate the clinicopathological factors that could influence the treatment selection. @*Methods@#A total of 99 patients with 101 EGC lesions undergoing additional treatment after noncurative ESD with pLMs as the only non-curative factor were analyzed. Among them, 25 (27 lesions) underwent ESD, 29 (29 lesions) underwent argon plasma coagulation (APC), and 45 (45 lesions) underwent surgery. Clinicopathological characteristics and long-term outcomes were compared. @*Results@#Residual tumor was found in 73.6% of cases. The presence of multiple pLMs was associated with higher risk of residual tumor (p=0.046). During a median follow-up of 58.9 months, recurrent or residual lesions after additional ESD and APC were found in 4% (1/25) and 6.8% (2/29) of patients, respectively. However, all were completely cured with surgery or repeated ESD. There were no extragastric recurrences after additional endoscopic treatment. Lymph node metastasis was identified after additional surgery in one (2.2%) patient with an EGC showing histological heterogeneity. @*Conclusions@#Given the favorable long-term outcomes, additional ESD or APC may be an acceptable choice for patients with pLMs as the only non-curative factor after ESD for EGC. However, clincopathological characteristics such as multiple pLMs and histological heterogeneity should be considered in the treatment selection.
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Gastric papillary adenocarcinoma is one of the histological variants of gastric cancer that shows more aggressive clinicopathological behavior compared to tubular adenocarcinoma. Previous studies have reported higher lymphovascular and submucosal invasion rates for papillary adenocarcionoma than those of tubular adenocarcinoma. However, the current guidelines categorize papillary adenocarcinoma and tubular adenocarcinoma together as differentiated-type tumor and have recommended the same endoscopic submucosal dissection criteria. Thus, concerns have been raised regarding the appropriateness of the current policy. To validate the current guidelines, the lymph node metastasis rate from surgical specimen studies as well as the long-term outcomes of endoscopic submucosal dissection for papillary adenocarcinomas need to be taken into consideration. In this review, I aimed to review the current understanding of the clinical and pathological features of papillary adenocarcinoma. In addition, I aimed to generate an integrated view regarding the outcomes of endoscopic submucosal dissection and surgery for papillary adenocarcinoma in order to evaluate the appropriateness of the current guidelines.
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Gastric papillary adenocarcinoma is one of the histological variants of gastric cancer that shows more aggressive clinicopathological behavior compared to tubular adenocarcinoma. Previous studies have reported higher lymphovascular and submucosal invasion rates for papillary adenocarcionoma than those of tubular adenocarcinoma. However, the current guidelines categorize papillary adenocarcinoma and tubular adenocarcinoma together as differentiated-type tumor and have recommended the same endoscopic submucosal dissection criteria. Thus, concerns have been raised regarding the appropriateness of the current policy. To validate the current guidelines, the lymph node metastasis rate from surgical specimen studies as well as the long-term outcomes of endoscopic submucosal dissection for papillary adenocarcinomas need to be taken into consideration. In this review, I aimed to review the current understanding of the clinical and pathological features of papillary adenocarcinoma. In addition, I aimed to generate an integrated view regarding the outcomes of endoscopic submucosal dissection and surgery for papillary adenocarcinoma in order to evaluate the appropriateness of the current guidelines.
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Purpose@#When patients with early gastric cancer (EGC) undergo non-curative endoscopic submucosal dissection requiring gastrectomy (NC-ESD-RG), additional medical resources and expenses are required for surgery. To reduce this burden, predictive model for NC-ESDRG is required. @*Materials and Methods@#Data from 2,997 patients undergoing ESD for 3,127 forceps biopsyproven differentiated-type EGCs (2,345 and 782 in training and validation sets, respectively) were reviewed. Using the training set, the logistic stepwise regression analysis determined the independent predictors of NC-ESD-RG (NC-ESD other than cases with lateral resection margin involvement or piecemeal resection as the only non-curative factor). Using these predictors, a risk-scoring system for predicting NC-ESD-RG was developed. Performance of the predictive model was examined internally with the validation set. @*Results@#Rate of NC-ESD-RG was 17.3%. Independent pre-ESD predictors for NC-ESD-RG included moderately differentiated or papillary EGC, large tumor size, proximal tumor location, lesion at greater curvature, elevated or depressed morphology, and presence of ulcers. A risk-score was assigned to each predictor of NC-ESD-RG. The area under the receiver operating characteristic curve for predicting NC-ESD-RG was 0.672 in both training and validation sets. A risk-score of 5 points was the optimal cut-off value for predicting NCESD-RG, and the overall accuracy was 72.7%. As the total risk score increased, the predicted risk for NC-ESD-RG increased from 3.8% to 72.6%. @*Conclusions@#We developed and validated a risk-scoring system for predicting NC-ESD-RG based on pre-ESD variables. Our risk-scoring system can facilitate informed consent and decision-making for preoperative treatment selection between ESD and surgery in patients with EGC.
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Polyethylene glycol (PEG) is a major component of bowel preparation solution for colonoscopy. It has been recognized as a safe and effective osmotic laxative that is rarely immunogenic. We here report a case of anaphylaxis due to PEG. A 49-year-old female came to the outpatient clinic wanting to find the cause of skin rash, nausea and respiratory difficulty after ingesting bowel evacuant solution (Clicool). She had visited local Emergency Department at the time of event and was diagnosed with anaphylaxis. We performed skin tests with components of Clicool to identify the cause of anaphylactic reactions. The result showed a positive skin response only to PEG. In contrast, skin test done in the control showed no reactions to PEG. This is the first case that revealed PEG to be an exact cause of anaphylaxis after ingesting a bowel evacuant.