• dysplasia
• early gastric cancer
• endoscopic submucosal dissection
• lymph node metastasis
• treatment outcome

• K08 DK125876 NIDDK NIH HHS
• P30 CA008748 NCI NIH HHS
• U01 CA265729 NCI NIH HHS
• National Cancer Institute

• 81860433 zhen zong

The use of endoscopic submucosal dissection (ESD) for treating early signet ring cell carcinoma (SRC) is controversial due to the risk of lymph node metastasis.

To carry out a meta-analysis to evaluate ESD for therapeutic efficacy and safety in early signet ring cell gastric cancer.

The PubMed, Web of Science, Cochrane Library, and EMBASE databases were used to search for relevant studies evaluating the therapeutic efficacy and safety of ESD in SRC. The rates of recurrence, complete resection, incomplete resection, curative resection, en bloc resection, and adverse events were extracted and analyzed. The methodological quality of the enrolled studies was assessed using the Newcastle-Ottawa Scale. Publication bias was evaluated by the Egger’s test. Institutional review board approval and written consent were not needed for this report.

This meta-analysis enrolled seven studies with 653 participants undergoing ESD treatment for early SRC. The overall recurrence rate was 0.010 [95% confidence interval (CI): 0.000-0.040, Z = 1.422, P = 0.155]. The total lymphovascular invasion rate was 0.038 (95%CI: 0.007-0.088, Z = 3.026, P = 0.002). The total en bloc resection rate was estimated at 0.984 (95%CI: 0.925-1.000, Z = 19.463, P = 0.000). The total complete and incomplete resection rates were estimated at 0.785 (95%CI: 0.596-0.928, Z = 9.789, P = 0.000) and 0.188 (95%CI: 0.016-0.468, Z = 2.531, P = 0.011), respectively. The total procedure-associated gastric hemorrhage and perforation rates were estimated at 0.026 (95%CI: 0.005-0.061, Z = 3.006 P = 0.003) and 0.004 (95%CI: 0.000-0.028, Z = 0.938, P = 0.348), respectively. The curative resection, vertical margin invasion, and lateral margin invasion rates were 72.1% (145/341), 2.3% (8/348), and 34.45% (41/119), respectively.

ESD constitutes a promising therapeutic approach for early undifferentiated SRC gastric cancer. However, further improvements are required for increasing its treatment efficacy and reducing adverse outcomes.

• Endoscopic submucosal dissection
• Endoscopy
• Early gastric cancer
• Signet ring cell
• Meta-analysis

• Endoscopic resection
• Gastric adenocarcinoma
• Lymph node metastasis

• Adenocarcinoma/surgery
• Humans
• Lymph Nodes/pathology
• Lymphatic Metastasis/pathology
• Neoplasm Invasiveness/pathology
• Neoplasm Staging
• Retrospective Studies
• Stomach Neoplasms/surgery

• Cancer
• Curative Resection
• Dysplasia
• ESD
• Surveillance

• Colectomy
• Colonoscopy
• Polyps

Gastric cancer accounts for a significant proportion of worldwide cancer-related morbidity and mortality. The well documented precancerous cascade provides an opportunity for clinicians to detect and treat gastric cancers at an endoscopically curable stage. In high prevalence regions such as Japan and Korea, this has led to the implementation of population screening programs. However, guidelines remain ambiguous in lower prevalence regions. In recent years, there have been many advances in the endoscopic diagnosis and treatment of early gastric cancer and precancerous lesions. More advanced endoscopic imaging has led to improved detection and characterization of gastric lesions as well as superior accuracy for delineation of margins prior to resection. In addition, promising early data on artificial intelligence in gastroscopy suggests a future role for this technology in maximizing the yield of advanced endoscopic imaging. Data on endoscopic resection (ER) are particularly robust in Japan and Korea, with high rates of curative ER and markedly reduced procedural morbidity. However, there is a shortage of data in other regions to support the applicability of protocols from these high prevalence countries. Future advances in endoscopic therapeutics will likely lead to further expansion of the current indications for ER, as both technology and proceduralist expertise continue to grow.

• Gastric cancer
• Endoscopy
• Endoscopic imaging
• Endoscopic mucosal resection
• Endoscopic submucosal dissection

• Artificial Intelligence
• Dissection
• Gastroscopy
• Humans
• Republic of Korea/epidemiology
• Stomach Neoplasms/diagnostic imaging
• Stomach Neoplasms/epidemiology

Certain gastric cancers exhibit some primitive phenotypes, which may indicate a high malignancy. In histologically differentiated early gastric cancer (EGC), the presence and the clinicopathological significance of the primitive phenotype remain unclear.

Using immunohistochemical staining we detected the expression of three primitive phenotypic markers SALL4, Glypican-3(GPC3), and AFP in whole tissue sections of differentiated EGC (gastrectomy specimens, n = 302). For those cases with primitive phenotypes, we analyzed their clinicopathological features and evaluated whether the criteria for endoscopic resection were met.

We found that 9.3% (28/302) of all differentiated EGC cases have primitive phenotypes, and most of these cases (25/28) exhibit a histomorphology similar to conventional differentiated EGC. Patients with primitive phenotypes had a deeper invasion, a higher rate of ulcer and lymphatic invasion than cases without primitive phenotype. Moreover, patients with primitive phenotypes displayed a significantly higher frequency of LNM than those without (57.1% vs 8.8%, P < 0.001). Multivariate analysis revealed that presence of primitive phenotypes was an independent risk factor for LNM (P = 0.001, HR 6.977, 95% CI: 2.199–22.138). Interestingly, we found 2 cases with primitive phenotypes developed LNM, and they both met the expanded indications of endoscopic resection for differentiated EGC.

A small number of differentiated EGC have primitive phenotypes, which were closely related to LNM and were an independent risk factor for LNM. Given its highly aggressive behavior, differentiated EGC with primitive phenotypes should be evaluated with stricter criteria before endoscopic resection, or considered to give an additional surgical operation after endoscopic resection.

• Early gastric cancer
• Endoscopic resection
• GPC3
• Primitive phenotype
• SALL4

• Anatomy
• Grossing
• Margins
• Staging
• Tissue sections

Traditional laparoscopic No.12a lymph node dissection in radical gastrectomy for gastric cancer may damage the peripheral blood vessels, and is not conducive to the full exposure of the portal vein and the root ligation of the left gastric vein. We recommend a new surgical procedure, the portal vein approach, to avoid these problems.

25 patients with advanced gastric cancer underwent radical laparoscopic gastrectomy and No.12a lymph node were dissected by portal vein approach, including 7 cases with total gastrectomy, 18 cases with distal gastric resection, 14 males and 11 females. Operative time, intraoperative blood loss, time to first flatus, postoperative hospital stay, number of total lymph node dissection and No.12a lymph node dissection, No.12a lymph node metastasis rate and postoperative complications were statistically observed.

All the patients were operated successfully and No.12a lymph node were cleaned by portal vein approach. A total of 683 lymph nodes were dissected, with the average number of lymph nodes dissection and positive lymph nodes were (27.3 ± 12.7) and (3.8 ± 5.6) respectively. The average number of No.12a lymph node dissection was (2.4 ± 1.95) and the metastasis rate of No.12a lymph node was 16% (4/25). The average operation time of radical laparoscopic distal and total gastrectomy were (239.2 ± 51.4) min and (295.1 ± 27.7) min respectively. The mean intraoperative blood loss was (134.0 ± 65.7) ml, and postoperative first anal exhaust time was (2.24 ± 0.86) d. The mean time to fluid intake was (4.2 ± 1.7) d, and postoperative hospitalization time was (9.6 ± 5.0) d. Without portal vein injure, anastomotic leakage, gastrointestinal bleeding, intestinal obstruction and other complications were observed in all patient.

Our results show that the laparoscopic No.12a lymph node dissection by portal vein approach for gastric cancer is safe, feasible and has certain clinical application value.

• No.12a lymph node
• gastric cancer
• laparoscopic surgery
• lymphadenectomy
• portal vein approach

• Comparison
• Epidemiology
• Risk of Death
• SEER (Surveillance
• Tumor
• and End Results Program)

• early gastric cancer
• endoscopic resection
• gastrectomy
• histological type
• prognosis

• Endoscopic submucosal dissection
• Endoscopy
• Lymph nodes
• Neoplasms
• Stomach

• Adult
• Aged
• Asia
• Endoscopic Mucosal Resection
• Gastric Mucosa
• Humans
• Japan
• Middle Aged
• Neoplasm Recurrence, Local
• Retrospective Studies
• Stomach Neoplasms
• Treatment Outcome

• Early gastric cancer
• and End Result database
• cancer-specific survival
• epidemiology
• lymph node metastasis
• overall survival
• surveillance

• endoscopic resection
• endoscopic submucosal dissection
• gastric cancer

• T32 DK007740 NIDDK NIH HHS

• Endoscopic submucosal dissection
• Lymphovascular invasion
• Stomach neoplasm
• Submucosal invasion

• National Cancer Center

• curability
• early gastric cancer
• endoscopic resection
• guidelines
• indication

Endoscopic resection (ER) has been increasingly performed in the treatment of early gastric cancer (GC). However, lymph node metastasis (LNM) can cause treatment failure with ER, especially in T1b patients. Here, we attempted to develop a miRNA‐based classifier to detect LNM in T1b patients. Based on high‐throughput data from The Cancer Genome Atlas, we identified 20 miRNAs whose expression significantly changed in T1‐2 GC with LNM vs T1‐2 GC without LNM. We then developed a miRNA signature to predict LNM of T1b GC using the LASSO model and backward step wise elimination approach in a training cohort. Furthermore, the predictive accuracy of this classifier was validated in both an internal testing group of 63 patients and an external independent group of 114 patients. This systematic and comprehensive in silico study identified a 7‐miRNA signature with an area under the receiver operating characteristic curve (AUROC) value of 0.843 in T1‐2 GC and 0.911 in T1 EGC. The backward elimination was further used to develop a 4‐miRNA (miR‐153‐3p, miR‐708, miR‐940 and miR‐375) risk‐stratification model in the training cohort with an AUROC value of 0.898 in cohort 2. When pathologic results were used as a reference, the risk model yielded AUROC values of 0.829 and 0.792 in two cohorts of endoscopic biopsy specimens. This novel miRNA‐LNM classifier works better than the currently used pathologic criteria of ER in T1b EGC. This classifier could individualize the management of T1b patients and facilitate treatment decisions.

• gastric cancer
• lymph node metastasis
• miRNA
• risk-stratification