Introduction
In recent years remarkable progress has been made in the treatment of malignant tumors, including minimally invasive surgery1), the development of chemotherapy including immune checkpoint inhibitors2), drugs to prevent chemotherapy induced side effects3). As a result, the prognosis was improved, the number of patients with multiple primary malignant tumors increased. However, there is currently no evidence to support a specific treatment for multiple primary malignant tumors. Therefore, patient consent must be obtained, and options should be selected according to institution policies.
Aims & Methods
Aims: This study aimed to investigate the clinical outcomes and prognosis of patients who underwent endoscopic submucosal dissection (ESD) for early-stage gastric cancer (EGC) complicated with advanced primary malignant tumors of other organs, with 5-year absolute survival rate of less than 50 %.
Methods: This study enrolled 26 patients with advanced malignant tumors of other organs, with 5-year absolute survival rates of less than 50 %, who were selected from 3,703 patients with gastric cancer who underwent ESD at our hospital. Clinicopathological characteristics and outcomes of ESD were evaluated.
Results
Patient median age was 75.0 (50-90) years. The median tumor diameter was 20.0 (5-110) mm. Advanced malignant tumors of other organs included 5 patients with hepatocellular carcinoma, 5 with prostate cancer, 4 with esophageal cancer, 4 with colorectal cancer, 3 with lung cancer, 1 with renal cell carcinoma, 1 with breast cancer, 1 with gingival cancer, 1 with multiple myeloma, and 1 with malignant lymphoma. The clinical stages were cStage II in 6 patients, cStage III in 2, and cStage IV in 18, all evaluated under treatment or before treatment. In terms of EGC locations, there were 6 (23 %) U region patients, 6 (23 %) M region, and 14 (54 %) L region. Macroscopic types were 0-I 2 (7 %), 0-IIa 9 (35 %), 0-IIa+I 1 (4 %), 0-IIc 13 (50 %), and 0-IIc+IIa 1 (4 %). The main histological types included 23 (88%) with differentiated type, 3 (12%) with undifferentiated type, 18 (69 %) with pT1a, 3 (12 %) with pT1b1, and 5 (19 %) with pT1b2. Rates of en bloc resection were 100 %, curative resection was 62 %, noncurative resection was 38 % (including 5 patients with pT1b2, 1 patient with UL positive, 3 patients with undifferentiated and lesion size bigger than 20 mm, and 1 patient was positive for vertical margin). Adverse events included delayed bleeding in 1 (4%) patient, delayed perforation in 1 (4%), and postoperative pneumonitis in 1 (4%), all of which resulted in DIC and death within 30 days after ESD. The prognosis was death from advanced malignant tumors of other organs in 11 patients, death from other causes in 3 patients, and survival in 9 patients that did not suffer death due to EGC.
Conclusion
Although ESD was useful for local resection of EGC complicated with advanced malignant tumors, DIC triggered by an adverse event should be noted.
References
1) Uyama I, Suda K, Nakauchi M, et al. Clinical advantages of robotic gastrectomy for clinical stage I/II gastric cancer: a multi-institutional prospective single-arm study. Gastric Cancer 2019; 22(2): 377-385.
2) Brahmer J, Reckamp KL, Baas P, Crinò L, Eberhardt WEE, Poddubskaya E, et al. Nivolumab versus Docetaxel in Advanced Squamous-Cell Non-Small-Cell Lung Cancer. N Engl J Med. 2015; 373: 123-135.
3) Mellar Davis, David Hui, Andrew Davies, et al. MASCC antiemetics in advanced cancer updated guideline. Supportive Care in Cancer 2021; 29: 8097–8107.