The impact of endoscopic submucosal dissection for gastric adenocarcinomas in the United States

Recent studies show promise for endoscopic submucosal dissection (ESD) in the United States, but do not identify the potential impact of ESD among newly diagnosed gastric cancers. We utilize the Veterans Health Administration to identify cancers suitable for ESD, to define the role of ESD in the United States. Retrospective cohort study using the Veterans Affairs Central Cancer Registry to identify patients with gastric cancer who underwent surgical resection from 1995 to 2018. TNM stage was used to categorize those who would meet absolute vs expanded indications for ESD. Primary outcome was lymph node status. Secondary analysis was performed with death as outcome. Of 12,584 primary gastric cancers, 4735 (37.6%) were nonmetastatic gastric adenocarcinomas. Median age at diagnosis was 70.3 years, 4676 (98.8%) male. Total 2306 (48.7%) underwent surgical resection, of which 636 (27.6%) were T1 lesions or cancer in situ. Of these, 44 (6.9%) met absolute indications for resection, 99 (15.6%) met established expanded criteria, and 98 (15.4%) may meet expanded criteria. Half of all tumors in each group were proximal in location. Rate of lymph node positivity was: 4.5%; 95% confidence interval [CI]: 0.5-15.5% in absolute group; 8.1%; 95% CI: 3.6-15.3% in expanded group; 13.3%; 95% CI: 7.3-21.6 in those potentially meeting expanded criteria. Lymph nodes positivity was associated with death (hazard ratio 1.49; 95% CI: 1.36-1.62, P < 0.001). Less than 10% of T1 or in situ cancers meet absolute criteria for ESD. Those that meet expanded criteria had higher risk for lymph node metastases, particularly proximal tumors. Future studies should evaluate the safety of ESD in proximal gastric tumors. (c) 2020 Elsevier Inc. All rights reserved.