Digestive and Liver Disease 45 (2013) 651–656 Contents lists available at SciVerse ScienceDirect Digestive and Liver Disease j ourna l ho mepage: www.elsevier.com/lo cate/dld Digestive Endoscopy Long-term outcome of early gastric cancer after endoscopic submucosal dissection: Expanded indication is comparable to absolute indication Chan Hyuk Park, Suji Shin, Jun Chul Park, Sung Kwan Shin, Sang Kil Lee, Yong Chan Lee, Hyuk Lee ∗ Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea a r t i c l e i n f o Article history: Received 17 October 2012 Accepted 20 January 2013 Available online 17 February 2013 Keywords: Endoscopic submucosal dissection Indication Survival Recurrence a b s t r a c t Background: Endoscopic submucosal dissection has become widely used for early gastric cancer with an expanded indication, although there is no strong consensus. We aimed to compare the clinical and long-term oncological outcome after endoscopic submucosal dissection according to indication. Methods: Retrospective review of 1152 patients with 1175 lesions who had undergone endoscopic sub- mucosal dissection for early gastric cancer at tertiary educational hospital in Korea, between March 2005 and November 2011. Of these, 366 and 565 lesions were included in the absolute and expanded indication groups, respectively. Results: En bloc resection rates were not significantly different between the absolute and expanded indication groups. The complete resection rate was higher in the absolute indication group versus the expanded indication group (94.8% vs. 89.9%, respectively; P = 0.008). In the expanded indication group, complete resection rate was higher in the differentiated versus undifferentiated tumour subgroups (92.9% vs. 78.4%, respectively; P < 0.001). Recurrence rates were 7.7% in the absolute indication group vs. 9.3% in the expanded indication group (P = 0.524). Disease-free survival was not significantly different between the two indication groups (P = 0.634). Conclusions: Endoscopic submucosal dissection for early gastric cancer with expanded indication is a feasible approach to disease management. Periodic endoscopic follow-up is necessary to detect cancer recurrence. © 2013 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved. 1. Introduction Since the introduction of endoscopic mucosal resection (EMR) in the early 1990s, endoscopic resection has been a preferential treatment instead of gastrectomy for early gastric cancer (EGC) confined to the mucosa without lymph node metastasis because of minimal invasiveness [1–6]. However, EMR, the first developed method of endoscopic resection, is limited in that it is inadequate for en bloc resection of gastric lesions larger than 2 cm in diameter [7]. Endoscopic submucosal dissection (ESD) was developed for the purpose of en bloc resection, regardless of tumour size and location [8]. According to current guidelines, the absolute indication (AI) for endoscopic resection is a differentiated-type adenocarcinoma without ulcerative findings that is 2 cm or less in diameter, with tumour invasion confined to the mucosa [9]. These criteria, how- ever, are so strict that unnecessary surgeries are likely performed ∗ Corresponding author at: Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, 250 Seongsanno, Seodaemun-gu, Seoul, Postal code 120-752, Republic of Korea. Tel.: +82 2 2228 1978; fax: +82 2 393 6884. E-mail address: leehyuk@yuhs.ac (H. Lee). [10]. A study by Gotoda et al. on 5265 patients who had under- gone gastrectomy with lymph node dissection for EGC proposed criteria suggesting a low risk of lymph node metastasis [11]. Based on these observations, expanded indication (EI) for ESD was sug- gested [9]. Although ESD has become widely used according to EI [12–18], there is no strong consensus regarding EI due to concerns of increasing risk of lymph node metastasis [19–22]. To evaluate the practicality of ESD following the expanded criteria, we ana- lyzed the clinical and long-term oncological outcome after ESD for EGC, comparing AI versus EI. 2. Patients and methods 2.1. Patients Consecutive clinical data of 1152 patients with 1175 lesions who had undergone ESD for EGC between March 2005 and November 2011 were prospectively collected at our tertiary educational hos- pital in Seoul, Korea. ESD for EGC was performed based on EI. Although all lesions were considered to meet the expanded indica- tion through endoscopy and biopsy before ESD, 241 were revealed to be outside of EI after histopathological examination. These 241 lesions that did not satisfy AI or EI were excluded from the study. 1590-8658/$36.00 © 2013 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.dld.2013.01.014