Is endoscopic submucosal dissection safe for papillary adenocarcinoma of the stomach?

Table 1 Clinicopathological characteristics of patients who underwent surgical operation for papillary adenocarcinoma-type early gastric cancers n (%)

Characteristic
No. of patients	49
Median age, yr (range)	66 (48-80)
Gender
Male	35 (71)
Female	14 (29)
Location
Upper third	5 (10)
Middle third	2 (4)
Lower third	42 (86)
Macroscopic shape
Elevated	36 (73)
Flat	0 (0)
Depressed	13 (27)
Ulceration	12 (24)
Histologic type
PP type	28 (57)
MP with diff.	14 (29)
MP with undiff.	7 (14)
Median size, mm (range)	30 (9-105)
≤ 30	24 (49)
> 30	25 (51)
Depth of invasion
Mucosa (m1:m2:m3)	14 (0:0:14) (29)
Submucosa (sm1:sm2)	35 (8:27) (71)
Lymphovascular invasion	15 (31)
Lymph node metastasis	9 (18)

PP type: Pure papillary type; MP with diff.: Mixed papillary type with differentiated component; MP with undiff.: Mixed papillary type with undifferentiated component.

Table 2 Clinicopathological characteristics of patients with lymph node metastasis

Patient No.	Gender/age	Tumor location	Macroscopic type	Ulceration	Histologic type	Tumor size (mm)	Depth of invasion	Lymphovascular invasion	Pre-treatment ESD indication	Primary treatment
1	F/63	Lower third	IIa	-	PP	35	sm2	+	Out	Op
2	M/58	Lower third	IIa	-	MP + diff.	48	m3	-	In (expanded)	Op
3	F/75	Lower third	I + IIa	-	MP + undiff.	105	sm2	+	Out	Op
4	F/71	Lower third	IIc	+	PP	25	sm2	-	Out	Op
5	M/67	Lower third	I	-	MP + undiff.	23	sm2	-	Out	Op
6	M/64	Lower third	IIc	+	PP	35	sm2	+	Out	Op
7	M/58	Lower third	IIc + III	+	MP + undiff.	55	sm2	+	Out	Op
8	M/68	Lower third	IIa + IIb	-	PP	27	sm2	+	Out	Op
9	F/63	Lower third	IIa	-	MP + diff.	30	sm1	+	In (expanded)	ESD

PP type: Pure papillary type; MP + diff.: Mixed papillary type with differentiated component; MP + undiff.: Mixed papillary type with undifferentiated component; ESD: Endoscopic submucosal dissection; Out: Out-of-ESD indication; In: In ESD indication; Op: Operation.

Table 3 Predictive factors of lymph node metastasis in papillary adenocarcinoma-type early gastric cancers n (%)

Factors	Lymph node metastasis		P value
	Present(n = 9)	Absent(n = 40)
Location			0.712
Upper third	0 (0)	5 (100)
Middle third	0 (0)	2 (100)
Lower third	9 (21.4)	33 (78.6)
Macroscopic type			0.683
Elevated	6 (16.7)	30 (83.3)
Depressed	3 (23.1)	10 (76.9)
Ulceration			0.498
Absent	6 (16.2)	31 (83.8)
Present	3 (25.0)	9 (75.0)
Histologic type			0.470
PP type	4 (14.3)	24 (85.7)
MP with diff.	2 (16.7)	10 (83.3)
MP with undiff.	3 (33.3)	6 (66.7)
Tumor size			0.253
≤ 30 mm	3 (12.5)	21 (87.5)
> 30 mm	6 (24.0)	19 (76.0)
Depth of invasion			0.195
Mucosa	1 (7.1)	13 (92.9)
Submucosa	8 (22.9)	27 (77.1)
Lymphovascular invasion			0.016
Absent	3 (8.6)	32 (91.4)
Present	6 (42.9)	8 (57.1)

PP type: Pure papillary type; MP + diff.: Mixed papillary type with differentiated component; MP + undiff.: Mixed papillary type with undifferentiated component.

Table 4 Lymph node metastasis in papillary adenocarcinoma-type early gastric cancers according to the current endoscopic submucosal dissection indication criteria n (%)

	Mucosal cancer (n = 14)				Submucosal cancer (n = 35)
	Ulcer (-) (n = 10)		Ulcer (+) (n = 4)		sm1 (n = 8)		sm2 (n = 27)
	≤20 mm	> 20 mm	≤30 mm	> 30 mm	≤30 mm	> 30 mm	Any size
	(n = 6)	(n = 4)	(n = 2)	(n = 2)	(n = 5)	(n = 3)	(n = 27)
Lymph node metastasis	0 (0)	1 (25)	0 (0)	0 (0)	1 (20)	0 (0)	7 (26)

Table 5 Clinicopathological characteristics of patients who underwent endoscopic submucosal dissection for papillary adenocarcinoma-type early gastric cancer n (%)

Characteristic
No. of patients	24
Median age, yr (range)	68 (56-80)
Gender
Male	19 (79)
Female	5 (21)
Location
Upper third	4 (17)
Middle third	0 (0)
Lower third	20 (83)
Macroscopic shape
Elevated	23 (96)
Flat	1 (4)
Depressed	0 (0)
Ulceration	5 (21)
Histologic type
PP type	13 (54)
MP with diff.	9 (38)
MP with undiff.	2 (8)
Median size, mm (range)	22 (6-59)
≤ 30	18 (75)
> 30	6 (25)
Depth of invasion
Mucosa (m1:m2:m3)	14 (0:4:10) (58)
Submucosa (sm1:sm2)	10 (4:6) (42)
Lymphovascular invasion	5 (21)
Lymph node metastasis	1 (4)

PP type: Pure papillary type; MP with diff.: Mixed papillary type with differentiated component; MP with undiff.: Mixed papillary type with undifferentiated component.

Table 6 Clinicopathologic characteristics of patients in out-of-endoscopic submucosal dissection indication

Patient No.	Gender/age	Ulceration	Histologic type	Tumor size (mm)	Pre-treatment ESD indication	Depth of invasion	LVI	Additional surgery	Follow-up period (mo)	Recurrence
1	M/74	-	PP	18	Absolute	m3	+	Yes	3	No
2	M/80	-	MP + undiff.	18	Absolute	sm2	+	Yes	7	No
3	M/68	-	PP	18	Absolute	sm2	-	Yes	18	No
4	M/66	-	PP	13	Absolute	sm2	-	Yes	20	No
5	M/56	+	PP	32	Expanded	m2	-	No	34	No
6	M/78	+	MP + diff.	34	Expanded	m3	-	No	3	No
7	M/74	+	PP	59	Expanded	m3	-	No	26	No
8	M/56	-	PP	24	Expanded	sm1	+	Yes	3	No
9	F/63	-	MP + diff.	30	Expanded	sm1	+	Yes	51	No
10	F/71	+	MP + diff.	32	Expanded	sm1	-	No	41	No
11	M/65	-	PP	22	Expanded	sm2	-	Yes	8	No
12	M/66	-	MP + diff.	24	Expanded	sm2	+	Yes	26	No
13	F/73	-	MP + undiff.	31	Expanded	sm2	-	Yes	24	No

ESD: Endoscopic submucosal dissection; LVI: Lymphovascular invasion; PP type: Pure papillary type; MP + diff.: Mixed papillary type with differentiated component; MP + undiff.: Mixed papillary type with undifferentiated component.