Local recurrence after non-curative gastric ESD with negative margins

Abstract

An 88-year-old man was referred to our hospital for treatment of gastric cancer. Endoscopy showed a flat elevation with central protrusion (lesion 1) and a shallow depression (lesion 2) in the antrum. Biopsy specimens revealed a moderately differentiated adenocarcinoma and a moderately to poorly differentiated adenocarcinoma, respectively. Although there was a slight possibility of SM invasion in lesion 1, endoscopic submucosal dissection (ESD) of both lesions was performed as a diagnostic procedure. En-bloc resections with negative margins were achieved, but pathological findings revealed the resections to be non-curative due to the following : well to moderately differentiated and papillary adenocarcinoma invaded SM2 layer with lymphovascular invasion (lesion 1) , and moderately to poorly differentiated adenocarcinoma limited to mucosa with lymphatic invasion (lesion 2) . However, additional gastrectomy was not performed at this time due to the patient’s older age. Endoscopy one year later showed local recurrence. After further evaluation of the patient, he was regarded as a suitable candidate for surgery and gastrectomy was performed. The resected specimen revealed mucinous and poorly to moderately differentiated adenocarcinoma with subserosal invasion and regional lymph node metastasis. After seven months, the patient was in good condition with no evidence of recurrence. Based on the outcome of this case, it is advisable to monitor for local recurrences after diagnosis of non-curative ESD with lymphovascular invasion even when en-bloc resections show negative margins.