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COMMENT

With improved diagnostic techniques, there has beenan increased recognition of both precancerous lesionsand truly early gastric cancer, particularly in Japan. Thelimited anatomic extent and excellent prognosis forsome of these small very early cancers makes conserva-

tive, minimally invasive treatment techniques, such asendoscopic mucosal resection or limited laparoscopic re-

DOI 10.1002/jso.20229

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Minimally Invasive Treatment for Gastric Cancer 193

� 2005 Wiley-Liss, Inc.

section, appealing treatment choices. The potential pro-blems that arise when considering these new therapeuticapproaches for these early neoplastic lesions includeboth the possibility of inadvertent spread of the cancerby the more limited intervention and the possibility ofproviding inadequate resection for a subgroup of thesepatients, particularly those with capability for lymphaticspread. Dr. Noh and his colleagues have described anumber of minimal approaches to early gastric cancerand have given us convincing retrospective data demon-strating that neither of these adverse possibilities is aproblem if patient selection for these procedures is reallyappropriate.

For the concern that all of us share regarding thepossibility of unrecognized lymphatic spread in patientsundergoing these procedures, these authors have takenadvantage of a large, well-studied, uniformly-treatedgroup of early gastric patients in their own institution tomore accurately determine who might be at risk forlymphatic spread. They then used this information todevelop clear-cut guidelines for the selection of patientsfor these minimal procedures. Experience has shown thusfar that the minimally invasive approach to these earlycancers, without extended lymph node dissection, can besafely accomplished if strict criteria are met. Theseinclude the size of the lesion, the limitation of the lesionto the mucosa, and the absence of undifferentiated

histology or vessel invasion on histologic study. Althoughthey have outlined a very reasonable approach for patientselection for these limited treatments, they urge thatthe final conclusion regarding the role of these pro-cedures await results from prospective randomized trials.Nevertheless, the results they describe with these variouslimited procedures in carefully selected patient popula-tions are impressive both from the quality of life stand-point and essentially equal treatment outcomes. The onlydisappointing feature of this presentation is that theproportion of gastric lesions in the Western world thatmeet their criteria for these procedures is very small.

With improved diagnostic techniques, there has beenan increased recognition of both precancerous lesionsand truly early gastric cancer, particularly in Japan. Thelimited anatomic extent and excellent prognosis for someof these small very early cancers makes conservative,minimally invasive treatment techniques, such as endo-scopic mucosal resection or limited resection, an impor-tant consideration.

If we can emulate the early diagnostic approachaccomplished in Japan, we may accomplish more wide-spread utilization of these treatment procedures describedby Noh and his colleagues.

Walter Lawrence, Jr., MD

Guest Editor

194 Noh et al.