NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system 1 2 was adopted to define the strength of recommendations and the quality of evidence. Main recommendations
 1 ESGE recommends endoscopic en bloc resection for superficial esophageal squamous cell cancers (SCCs), excluding those with obvious submucosal involvement (strong recommendation, moderate quality evidence). Endoscopic mucosal resection (EMR) may be considered in such lesions when they are smaller than 10 mm if en bloc resection can be assured. However, ESGE recommends endoscopic submucosal dissection (ESD) as the first option, mainly to provide an en bloc resection with accurate pathology staging and to avoid missing important histological features (strong recommendation, moderate quality evidence). 2 ESGE recommends endoscopic resection with a curative intent for visible lesions in Barrett’s esophagus (strong recommendation, moderate quality evidence). ESD has not been shown to be superior to EMR for excision of mucosal cancer, and for that reason EMR should be preferred. ESD may be considered in selected cases, such as lesions larger than 15 mm, poorly lifting tumors, and lesions at risk for submucosal invasion (strong recommendation, moderate quality evidence). 3 ESGE recommends endoscopic resection for the treatment of gastric superficial neoplastic lesions that possess a very low risk of lymph node metastasis (strong recommendation, high quality evidence). EMR is an acceptable option for lesions smaller than 10 – 15 mm with a very low probability of advanced histology (Paris 0-IIa). However, ESGE recommends ESD as treatment of choice for most gastric superficial neoplastic lesions (strong recommendation, moderate quality evidence). 4 ESGE states that the majority of colonic and rectal superficial lesions can be effectively removed in a curative way by standard polypectomy and/or by EMR (strong recommendation, moderate quality evidence). ESD can be considered for removal of colonic and rectal lesions with high suspicion of limited submucosal invasion that is based on two main criteria of depressed morphology and irregular or nongranular surface pattern, particularly if the lesions are larger than 20 mm; or ESD can be considered for colorectal lesions that otherwise cannot be optimally and radically removed by snare-based techniques (strong recommendation, moderate quality evidence).

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Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.

In response to the rapid and wide acceptance and use of endoscopic treatments for early gastric cancer, the Japan Gastroenterological Endoscopy Society (JGES), in collaboration with the Japanese Gastric Cancer Association (JGCA), has produced 'Guidelines for ESD and EMR for Early Gastric Cancer', as a set of basic guidelines in accordance with the principles of evidence-based medicine. These Guidelines cover the present state of knowledge and are divided into the following seven categories: Indications, Preoperative diagnosis, Techniques, Evaluation of curability, Complications, Long-term postoperative surveillance, and Histology. Twenty-three statements were finally accepted as guidelines, and the majority of these were obtained from descriptive studies with lower evidence levels. A number of statements had to be created by consensus (the lowest evidence level), as evidence levels remain low for many specific areas in this field.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/den.12518

Guidelines for endoscopic submucosal dissection and endoscopic mucosal resection for early gastric cancer

Endoscopic submucosal dissection (ESD) allows en bloc resection of the entire lesion, permitting a higher curative resection rate and increased quality of life by minimizing the resection size compared with that of endoscopic mucosal resection (EMR). Although ESD has been implemented at most university hospitals in Korea, potential complications of ESD such as bleeding and perforation raise doubts in the therapeutic decision on use of the ESD procedure for early gastric cancer patients and in reimbursement decision making. This systematic review aimed to address both the effectiveness and safety outcomes of ESD versus EMR for early gastric cancer. MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and Koreamed were searched using the primary keywords “stomach neoplasm” AND “endoscopic submucosal dissection” AND “endoscopic mucosal resection.” To assess the quality of selected studies, the methodologic approach of the Scottish Intercollegiate Guidelines Network was used. Five effectiveness-relevant and three safety-relevant outcome measures were extracted. Bibliography management and metaanalysis for each outcome were conducted using Review Manager 5.0. Three nonconcurrent cohort studies and nine retrospective cohort studies were identified. Metaanalyses showed ESD to be significantly more effective than EMR for en bloc resection (odds ratio [OR], 8.43; 95% confidence interval [CI], 5.20–13.67), complete resection (OR, 14.11; 95% CI, 10.85–18.35), curative resection (OR, 3.28; 95% CI, 1.95–5.54), and local recurrence (risk ratio [RR], 0.13; 95% CI, 0.04–0.41). Whereas intraoperative bleeding (RR, 2.16; 95% CI, 1.14–4.09), perforation risk (RR, 3.58; 95% CI, 1.95–6.55), and operation time (standard mean difference [SMD], 1.55; 95% CI, 0.74–2.37) were significantly greater for ESD, overall bleeding risk (RR, 1.22; 95% CI, 0.76–1.98) and all-cause mortality (RR, 0.65; 95% CI, 0.08–5.38) did not differ significantly between ESD and EMR. Considering that bleeding risk did not differ significantly between ESD and EMR and that perforation risk usually does not lead to life-threatening disease, the effectiveness benefit of ESD can outweigh the overall harm compared with EMR on the condition that ESD is performed by experienced practitioners.

The effectiveness and safety of endoscopic submucosal dissection compared with endoscopic mucosal resection for early gastric cancer: a systematic review and metaanalysis

Authors M. Moehler, S.-E. Al-Batran, T. Andus, M. Anthuber, J. Arends, D. Arnold, D. Aust, P. Baier, G. Baretton, J. Bernhardt, H. Boeing, E. Böhle, C. Bokemeyer, J. Bornschein, W. Budach, E. Burmester, K. Caca, W. A. Diemer, C. F. Dietrich, M. Ebert, A. Eickhoff, C. Ell, J. Fahlke, H. Feußner, R. Fietkau, W. Fischbach, W. Fleig, M. Flentje, H. E. Gabbert, P. R. Galle, M. Geissler, I. Gockel, U. Graeven, L. Grenacher, S. Groß, J. T. Hartmann, M. Heike, V. Heinemann, B. Herbst, T. Herrmann, S. Höcht, R. D. Hofheinz, H. Höfler, T. Höhler, A. H. Hölscher, M. Horneber, J. Hübner, J. R. Izbicki, R. Jakobs, C. Jenssen, S. Kanzler , M. Keller, R. Kiesslich, G. Klautke, J. Körber, B. J. Krause, C. Kuhn, F. Kullmann, H. Lang, H. Link, F. Lordick, K. Ludwig, M. Lutz, R. Mahlberg, P. Malfertheiner, S. Merkel, H. Messmann, H.-J. Meyer, S. Mönig, P. Piso, S. Pistorius, R. Porschen, T. Rabenstein, P. Reichardt, K. Ridwelski, C. Röcken, I. Roetzer, P. Rohr, W. Schepp, P. M. Schlag, R. M. Schmid, H. Schmidberger, W.-H. Schmiegel, H.-J. Schmoll, G. Schuch, C. Schuhmacher, K. Schütte, W. Schwenk, M. Selgrad, A. Sendler, J. Seraphin, T. Seufferlein, M. Stahl, H. Stein, C. Stoll, M. Stuschke, A. Tannapfel, R. Tholen, P. Thuss-Patience, K. Treml, U. Vanhoefer, M. Vieth, H. Vogelsang, D. Wagner, U. Wedding, A. Weimann, H. Wilke, C. Wittekind und die Mitglieder der Autorengruppe

[German S3-Guideline "Diagnosis and Treatment of Esophagogastric Cancer"]

Therapeutic outcomes in 1000 cases of endoscopic submucosal dissection for early gastric neoplasms: Korean ESD Study Group multicenter study

Regulation of progeny sex by Anisopteromalus calandrae (Howard) in relation to host preference, host vulnerability and host size was studied with two host species, Sitophilus oryzae (L.) and Callosobruchus chinensis L. A. calandrae preferred S. oryzae to C. chinensis (preference index = 0.87). The progeny sex ratio (females/total) was significantly higher on C. chinensis, the less preferred host, than on S. oryzae regardless of the instar age of the two host species. A. calandrae could locate only a few young larvae of C. chinensis (≤third instar), which could be apparently due to the low vulnerability of the young larvae locating deeper in the adzuki bean kernels. The larval instar age of Sitophilus oryzae affect the progeny sex ratio of A. calandrae, but that of Callosobruchus chinensis did not except invulnerable ones. The progeny sex ratio of A. calandrae produced from C. chinensis, ranged from 0.66±0.05 to 0.82±0.02. The invulnerability of the young larval instar of C. chinensis and regulation of the progeny sex ratio by A. calandrae based on host size in a manner of absolute rule could explain the higher sex ratio on the young larval instar of C. chinensis, less preferred and less vulnerable host, than the old larval instar of S. oryzae, highly preferred host. The differences in host vulnerability could be another factor for A. calandrae assigning progeny sex ratio.

Won Young Cho

Papers

Therapeutic outcomes in 1000 cases of endoscopic submucosal dissection for early gastric neoplasms: Korean ESD Study Group multicenter study

Regulation of Progeny Sex by Anisopteromalus calandrae (Hymenoptera: Pteromalidae) in Relation to Host Preference, Host Vulnerability and Host Size