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Journal of Peking University (Health Sciences) ›› 2023, Vol. 55 ›› Issue (2): 299-307. doi: 10.19723/j.issn.1671-167X.2023.02.014

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Pathological evaluation of endoscopic submucosal dissection for early gastric cancer and precancerous lesion in 411 cases

Ju-mei LIU1,Li LIANG1,Ji-xin ZHANG1,Long RONG2,Zi-yi ZHANG1,You WU1,Xu-dong ZHAO2,Ting LI1,*()   

  1. 1. Department of Pathology, Peking University First Hospital, Beijing 100034, China
    2. Center of Endoscopy, Peking University First Hospital, Beijing 100034, China
  • Received:2022-11-22 Online:2023-04-18 Published:2023-04-12
  • Contact: Ting LI E-mail:lixiaoting12@hotmail.com

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Abstract:

Objective: To evaluate the pathological characteristics of endoscopic submucosal dissection (ESD) specimens for early gastric cancer and precancerous lesions, accumulating experience for clinical management and pathological analysis. Methods: A total of 411 cases of early gastric cancer or precancerous lesions underwent ESD. According to the Japanese guidelines for ESD treatment of early gastric cancer and classification of gastric carcinoma, the clinicopathological data, pathologic evaluation, concordance rate of pathological diagnosis between preoperative endoscopic forceps biopsies and their ESD specimens (in 400 cases), as well as the risk factors of non-curative resection of early gastric cancer, were analyzed retrospectively. Results: 23.4% (96/411) of the 411 cases were adenoma/low-grade dysplasia and 76.6% (315/411) were early gastric cancer. The latter included 28.0% (115/411) non-invasive carcinoma/high-grade dysplasia and 48.7% (200/411) invasive carcinoma. The concordance rate of pathological diagnosis between endoscopic forceps biopsies and ESD specimens was 66.0% (264/400), correlating with pathological diagnosis and lesion location (P < 0.01). The rate of upgraded diagnosis and downgraded diagnosis after ESD was 29.8% (119/400) and 4.2% (17/400), respectively. Among the 315 cases of early gastric cancer, there were 277 cases (87.9%) of differentiated type and 38 cases (12.1%) of undifferentiated type. In the study, 262 cases (83.2%) met with absolute indication, while 53 cases (16.8%) met relative indication. En bloc and curative resection rates were 98.1% and 82.9%, respectively. Risk factors for non-curative resection included a long diameter >20 mm (OR=3.631, 95%CI: 1.170-11.270, P=0.026), tumor infiltration into submucosa (OR=69.761, 95%CI: 21.033-231.376, P < 0.001)and undifferentiated tumor histology (OR=16.950, 95%CI: 4.585-62.664, P < 0.001). Conclusion: Several subjective and objective factors, such as the limitations of biopsy samples, the characteristics and distribution of the lesions, different pathological understanding, and the endoscopic sampling and observation, can lead to the differences between the preoperative and postoperative pathological diagnosis of ESD. In particular, the pathological upgrade of postoperative diagnosis was more significant and should receive more attention by endoscopists and pathologists. The curative resection rate of early gastric cancer in ESD was high. Non-curative resection was related to the long diameter, the depth of tumor invasion and histological classification. ESD can also be performed in undifferentiated early gastric cancer if meeting the indication criteria. The comprehensive and standardized pathological analysis of ESD specimens is clinically important to evaluate the curative effect of ESD operation and patient outcomes.

Key words: Early gastric cancer, Dysplasia, Endoscopic submucosal dissection, Pathological evaluation

CLC Number: 

  • R735.2

Table 1

Clinical and pathological characteristics of 411 patients"

  Clinical and pathological characteristics LGD
(n=96)		 NIC/HGD
(n=115)		 IC
(n=200)		 Total
(n=411)
Gender, male/female 50/46 76/39 157/43 283/128
Age/years, ${\bar x}$±s 63.27±11.21 65.10±9.82 64.45±9.59 64.36±10.05
Location, n
   Cardia fundus 20 23 63 106
   Gastric body 11 20 31 62
   Gastric corpus 17 20 30 67
   Antrum 47 50 73 170
   Multifocal lesion 1 2 3 6
Subclassification of type 0, n
   0-Ⅰ 1 0 9 10
   0-Ⅱa 49 53 68 170
   0-Ⅱb 39 33 68 140
   0-Ⅱc 7 29 43 79
   0-Ⅲ 0 0 12 12
Long diameter/mm, ${\bar x}$±s 14.75±15.81 16.70±13.11 16.05±12.54 15.93±13.51
Infiltration depth, n
   Intramucosal (pT1a) 96 115 151 362
   pT1b1 (SM1) - - 26 26
   pT1b2 (SM2) - - 23 23
Lymphatic or venous invasion, n 5 5
   VM positive 2 3 6 11
   HM positive 0 0 6 6

Figure 1

Comparison of pathological diagnosis between gastroscopic biopsy and ESD in 4 cases A, biopsy specimen showed LGD; B, ESD specimen showed intramucosal invasive cancer; C, biopsy specimen showed NIC/HGD; D, ESD specimen showed moderately differentiated adenocarcinoma; E, biopsy specimen showed NIC/HGD; F, ESD specimen showed "Crawling-type" adenocarcinoma; G, biopsy specimen showed chronic gastritis; H, ESD specimen showed adenocarcinoma of fundic-gland type, infiltration to submucosa (A to F, HE ×200; G and H, HE × 50)."

Table 2

Comparison of pathological diagnosis between gastroscopic biopsy and ESD specimens in 400 cases of gastric cancer and precancerous lesions"

Diagnosis of gastroscopic biopsy nDiagnosis of ESD
Nonneoplastic lesion LGD NIC/HGD IC
Nonneoplastic lesion 8 0 5 0 3
LGD 120 0 75 32 13
NIC/HGD 153 0 12 75 66
IC 119 0 1 4 114
Total 400 0 93 111 196

Table 3

Comparison of pathological diagnosis between gastroscopic biopsy and ESD specimens at different sites"

Location n
(N=400)		 Diagnosis of biopsyDiagnosis of ESDConcordance rate/%
Nonneoplastic lesion LGD NIC/HGD IC
Gastric fundus 102 Nonneoplastic lesion 0 1 0 3 55.9
LGD 0 16 4 5
NIC/HGD 0 3 15 27
IC 0 0 2 26
Gastric body 62 Nonneoplastic lesion 0 3 0 0 59.7
LGD 0 7 7 3
NIC/HGD 0 1 13 11
IC 0 0 0 17
Gastric corpus 65 Nonneoplastic lesion 0 0 0 0
LGD 0 15 6 2 70.8
NIC/HGD 0 2 13 9
IC 0 0 0 18
Gastric 165 Nonneoplastic lesion 0 1 0 0 72.1
LGD 0 36 14 3
NIC/HGD 0 6 33 19
IC 0 1 2 50
Multifocal lesion 6 Nonneoplastic lesion 0 0 0 0
LGD 0 1 1 0 83.3
NIC/HGD 0 0 1 0
IC 0 0 0 3

Table 4

Analysis for factors associated with upgraded pathology in ESD specimens"

Items Diagnostic consistency/downgrading (n=281) Diagnostic upgrade (n=119) Statistics P
Location, n (%) 11.885 0.017
   Fundus 62 (22.1) 40 (33.6)
   Body 38 (13.5) 24 (20.2)
   Corpus 48 (17.1) 17 (14.3)
   Fundus 128 (45.6) 37 (31.1)
   Multifocal lesion 5 (1.8) 1 (0.8)
Subclassification of type 0, n (%) 6.094 0.186
   0-Ⅰ 4 (1.4) 6 (5.0)
   0-Ⅱa 119 (42.3) 47 (39.5)
   0-Ⅱb 101 (35.9) 36 (30.3)
   0-Ⅱc 49 (17.1) 26 (21.8)
   0-Ⅲ 8 (2.8) 4 (3.4)
Long diameter/mm, ${\bar x}$±s 15.28±12.16 17.71±16.50 -1.631 0.104
Age/years, ${\bar x}$±s 64.18±10.37 64.24±9.33 -0.056 0.955
Diagnosis of ESD, n (%) 40.181 < 0.001
   LGD 88 (31.3) 5 (4.2)
   NIC/HGD 79 (28.1) 32 (26.9)
   IC 114 (40.6) 82 (68.9)

Table 5

Comparative analysis of factors associated with curative and non-curative resection of ESD"

ItemsCurabilityStatistics P
Curative (n=261) Non-curative (n=44)
Gender, n (%)
   Male 192 (73.6) 31 (70.5) 0.185 0.667
   Female 69 (26.4) 13 (29.5)
Location, n (%) 15.055 0.003
   Fundus 60 (23.0) 21 (47.7)
   Body 44 (16.9) 6 (13.6)
   Corpus 46 (17.6) 3 (6.8)
   Fundus 108 (41.4) 10 (27.3)
   Multifocal lesion 3 (1.1) 2 (4.5)
Subclassification of type 0, n (%) 7.682 0.082
   0-Ⅰ 6 (2.3) 3 (6.8)
   0-Ⅱa 103 (39.5) 13 (29.5)
   0-Ⅱb 86 (33.0) 12 (27.3)
   0-Ⅱc 58 (22.2) 12 (27.3)
   0-Ⅲ 8 (3.1) 4 (9.1)
Histological classification, n (%) 46.507 < 0.001
   Differentiated type 243 (93.1) 25 (56.8)
   Undifferentiated type 18 (6.9) 19 (43.2)
Submucosal infiltration, n (%) 146.819 < 0.001
   pT1a (M) 247 (94.6) 10 (22.7)
   pT1b (SM) 14 (5.4) 34 (77.3)
Long diameter/mm, n (%) 6.353 0.012
   ≤20 mm 201 (77.0) 26 (59.1)
   >20 mm 60 (23.0) 18 (40.9)

Table 6

Multivariate analysis of parameters affecting non-curative resection"

Items B OR (95%CI) P
Long diameter (>20 mm) 1.290 3.631 (1.170-11.270) 0.026
Submucosal infiltration 4.245 69.761 (21.033-231.376) < 0.001
Undifferentiated type histology 2.830 16.950 (4.585-62.664) < 0.001
Location
Fundus 0.748 2.114 (0.089-50.175) 0.643
Body 1.912 6.766 (0.244-187.853) 0.260
Corpus 2.352 10.502 (0.291-379.266) 0.199
Fundus 1.219 3.385 (0.132-86.479) 0.461
Multifocal lesion 1

Table 7

Comparison of clinical and pathological characteristics between differentiated type and undifferentiated type adenocarcinoma"

ItemsHistological classificationStatistics P
Differentiated type
(n=277)		 Undifferentiated type
(n=38)
Location, n (%) 5.763 0.189
   Fundus 81 (29.2) 5 (13.2)
   Body 44 (15.9) 7 (18.4)
   Corpus 44 (15.9) 6 (15.8)
   Fundus 104 (37.5) 19 (50.0)
   Multifocal lesion 4 (1.4) 1 (2.6)
Subclassification of type 0, n (%) 15.205 0.003
   0-Ⅰ 7 (2.5) 2 (5.3)
   0-Ⅱa 114 (41.2) 7 (18.4)
   0-Ⅱb 89 (32.1) 12 (31.6)
   0-Ⅱc 60 (21.7) 12 (31.6)
   0-Ⅲ 7 (2.5) 5 (13.2)
Submucosal infiltration, n (%) 18.820 < 0.001
   pT1a (M) 243 (87.7) 23 (60.5)
   pT1b (SM) 34 (12.3) 15 (39.5)
   Lymphatic (Ly) or venous (V) invasion, n (%) 16.076 0.001
   Ly0 and V0 276 (99.6) 34 (89.5)
   Ly1 or V1 1 (0.4) 4 (10.5)
Vertical margin (VM), n (%) 0.409 1.000
   VM0 262 (94.6) 37 (97.4)
   VM1 8 (2.9) 1(2.6)
   VMX 7 (2.5) 0 (0.0)
Horizontal margin (HM), n (%) 9.086 0.010
   HM0 270 (97.5) 33 (86.8)
   HM1 3 (1.1) 3 (7.9)
   HMX 4 (1.4) 2 (5.3)
Curability, n (%) 34.635 < 0.001
   Curative 243 (87.7) 18 (47.4)
   Non-curative 25 (9.0) 19 (50.0)
   Not evaluated 9 (3.2) 1 (2.6)
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