Annual follow up after ESD for early gastric cancer recommended

Almost all recurrent lesions in gastric epithelial cancer could be cured by endoscopic submucosal resection (ESD) with annual follow-up exams, say the authors of a Japanese study.

The research showed that with annual screening after the first year postsurgery, multiple cancers occurred at a constant rate, and almost all were successfully treated without the need for gastrectomy. However, the authors say more intensive screening may be needed during the first year to detect lesions missed at the time of surgery.

"Establishing an optimal surveillance strategy is important to reduce the gastric cancer death rate but also to detect multiple cancers during the early stage and avoid surgery for the secondary cancer," say Testuo Takehara (Osaka University, Japan) and colleagues.

The study included 1258 patients who had ESD performed for gastric epithelial neoplasm. They were followed up at least once a year for a mean time of 26.8 months, during which time multiple cancers were detected in 175 (13.9%) patients. Of these, 164 patients were treated by re-ESD, and did not require further treatment.

Overall, 110 (9%) patients had multiple cancers detected within a year of ESD, and 21 of these were classified as having been "missed" by presurgery endoscopy.

The authors noted that the missed cancers commonly occurred in the upper third of the stomach (33%) and in the lesser curvature of the posterior wall (81%), which are known blind spots for endoscopists. Furthermore, multivariate analysis showed that the odds of a miss were threefold higher among endoscopists who had performed under 500 procedures than those who had performed 500 or more (38 vs 11%).

For this reason, the authors recommend intensive follow up in the year following surgery, with screening intervals of a maximum of 6 months. They also suggest that presurgery endoscopy should only be performed by experienced endoscopists who have conducted the procedure at least 500 times.

After the first year following treatment, the multiple cancer incidence remained steady at an average of 3.5% per year, and massively invading cancer was detected in one patient more than 1 year after ESD (0.12%). Therefore, the authors recommend annual screening for at least 5 years following endoscopic resection.

Interestingly, they note that they did not find an association between successful treatment for Helicobacter pylori and the incidence of multiple cancers, which has previously been reported.

Writing in Gut, the authors say their findings reinforce the importance of preoperative evaluation and careful follow up but that prospective studies will be needed to confirm their recommendations.

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