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Is Additional Surgery Always Sufficient for Preventing Recurrence After Endoscopic Submucosal Dissection with Curability C-2 for Early Gastric Cancer?

Waku Hatta MD, PhD, Takuji Gotoda MD, PhD, FASGE, FACG, FRCP, Tsuneo Oyama MD, PhD, Noboru Kawata MD, Akiko Takahashi MD, Shiro Oka MD, PhD, Shu Hoteya MD, PhD, Masahiro Nakagawa MD, PhD, Masaaki Hirano MD, PhD, Mitsuru Esaki MD, Mitsuru Matsuda MD, PhD, Ken Ohnita MD, PhD, Ryo Shimoda MD, PhD, Motoyuki Yoshida MD, Osamu Dohi MD, PhD, Jun Takada MD, PhD, Keiko Tanaka MD, Shinya Yamada MD, PhD, Tsu
Gastrointestinal Oncology
Volume 26, Issue 11 / October , 2019



When a lesion does not meet the curative criteria of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC), referred to as non-curative resection or curability C-2 in the guidelines, an additional surgery is the standard therapy because of the risk of lymph node metastasis (LNM).


This study aimed to identify high-risk patients for recurrence after additional surgery for curability C-2 ESD of EGC.


This multicenter retrospective cohort study enrolled 1064 patients who underwent additional surgery after curability C-2 ESD for EGC. We evaluated the recurrence rate and the risk factors for recurrence after additional surgery in these patients.


The 5-year recurrence rate after additional surgery was 1.3%. Multivariate Cox analysis revealed that the independent risk factors for recurrence after additional surgery were LNM (hazard ratio [HR] 32.47; p < 0.001) and vascular invasion (HR 4.75; p = 0.014). Moreover, patients with both LNM and vascular invasion had a high rate of recurrence after additional surgery (24.6% in 5 years), with a high HR (119.32) compared with those with neither LNM nor vascular invasion. Among patients with no vascular invasion, a high rate of recurrence was observed in those with N2/N3 disease according to the American Joint Committee on Cancer TNM staging system (27.3% in 5 years), in contrast with no recurrence in those with N1 disease.


Patients with both LNM (N1–N3) and vascular invasion, as well as those with N2/N3 disease but no vascular invasion, would be candidates for adjuvant chemotherapy after additional surgery for curability C-2 ESD of EGC.

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