Title: Risk of Lymph Node Metastasis and Feasibility of Endoscopic Submucosal Dissection
in Undifferentiated-type Early Gastric Cancer
Version: 1 Date: 07 Jan 2023
Reviewer:  Takeshi Kubota
Reviewer's report:
The authors assessed the feasibility of endoscopic submucosal dissection (ESD) for
undifferentiated-type early gastric cancer (UEGC) by analyzing the risk factors for lymph
node metastasis (LNM) after curative gastrectomy. The results are convincing and valuable
for clinical practice. However, the similar larger scale analysis has been performed (1), which
has already been indicated in Japanese guidelines and cited worldwide. In addition, some
confirmatory trials have already been done and published (2,3). Furthermore, it did not notice
a big difference in the results. The authors described in the ‘Background’ that ESD for UEGC
is still not widespread in China because of the lack of confidence in curative resection by both
endoscopists and patients, but, basiclally, the subject is the same Asian population as the above
cited references.
(1) Hirasawa T, Gotoda T, Miyata S, et al. Incidence of lymph node metastasis and the
feasibility of endoscopic resection for undifferentiated-type early gastric cancer. Gastric Cancer.
2009;12(3):148-52.
(2) Hasuike N, Ono H, Boku N, et al. Gastrointestinal Endoscopy Group of Japan Clinical
Oncology Group (JCOG-GIESG). A non-randomized confirmatory trial of an expanded
indication for endoscopic submucosal dissection for intestinal-type gastric cancer (cT1a): the
Japan Clinical Oncology Group study (JCOG0607). Gastric Cancer. 2018 Jan;21(1):114-123.
(3) Takizawa K, Ono H, Hasuike N, et al. Gastrointestinal Endoscopy Group (GIESG) and the
Stomach Cancer Study Group (SCSG) of Japan Clinical Oncology Group. A nonrandomized,
single-arm confirmatory trial of expanded endoscopic submucosal dissection indication for
undifferentiated early gastric cancer: Japan Clinical Oncology Group study (JCOG1009/1010).
Gastric Cancer. 2021 Mar;24(2):479-491.
Other major comments
1. In preoperative endoscopic diagnosis, which decides the indication of ESD, it must be said
that it is fatal not to perform EUS.
2. Multivariate analysis with factors of 8-9 for 69 events (LNM) is unreasonable.
3. The description regarding risk factors for LNM in UEGC in the ‘Result’ section that their size
was larger, and the proportions of ulceration, SM infiltration, and LVI were also significantly
higher (P<0.05) is understandable. However, although the authors touch the result that there is
a difference in the presence or absence of LNM due to differences in BMI, Hb, and PLR in
the 3rd paragraph of the ‘Discussion’ section, the content is unclear. Are NLR, PLR, and MLR
necessary for this analysis?
Minor comments
1. The number of female patients in the text of results is different from the number in Table1.
2. The border of tumor size is <2cm in the text of ‘Result’, whereas it is #2cm in Table 1.
3. In Table 1and 4: ‘Fmale’, ‘fmale’ # ‘Female’, ‘female’.
4. In Table 3, please clarify which includes just 2cm.
Title: Risk of Lymph Node Metastasis and Feasibility of Endoscopic Submucosal Dissection
in Undifferentiated-type Early Gastric Cancer
Version: 1 Date: 07 Jan 2023
Reviewer:  Takeshi Kubota
Reviewer's report:
The authors assessed the feasibility of endoscopic submucosal dissection (ESD) for
undifferentiated-type early gastric cancer (UEGC) by analyzing the risk factors for lymph
node metastasis (LNM) after curative gastrectomy. The results are convincing and valuable
for clinical practice. However, the similar larger scale analysis has been performed (1), which
has already been indicated in Japanese guidelines and cited worldwide. In addition, some
confirmatory trials have already been done and published (2,3). Furthermore, it did not notice
a big difference in the results. The authors described in the ‘Background’ that ESD for UEGC
is still not widespread in China because of the lack of confidence in curative resection by both
endoscopists and patients, but, basiclally, the subject is the same Asian population as the above
cited references.
(1) Hirasawa T, Gotoda T, Miyata S, et al. Incidence of lymph node metastasis and the
feasibility of endoscopic resection for undifferentiated-type early gastric cancer. Gastric Cancer.
2009;12(3):148-52.
(2) Hasuike N, Ono H, Boku N, et al. Gastrointestinal Endoscopy Group of Japan Clinical
Oncology Group (JCOG-GIESG). A non-randomized confirmatory trial of an expanded
indication for endoscopic submucosal dissection for intestinal-type gastric cancer (cT1a): the
Japan Clinical Oncology Group study (JCOG0607). Gastric Cancer. 2018 Jan;21(1):114-123.
(3) Takizawa K, Ono H, Hasuike N, et al. Gastrointestinal Endoscopy Group (GIESG) and the
Stomach Cancer Study Group (SCSG) of Japan Clinical Oncology Group. A nonrandomized,
single-arm confirmatory trial of expanded endoscopic submucosal dissection indication for
undifferentiated early gastric cancer: Japan Clinical Oncology Group study (JCOG1009/1010).
Gastric Cancer. 2021 Mar;24(2):479-491.
Other major comments
1. In preoperative endoscopic diagnosis, which decides the indication of ESD, it must be said
that it is fatal not to perform EUS.
2. Multivariate analysis with factors of 8-9 for 69 events (LNM) is unreasonable.
3. The description regarding risk factors for LNM in UEGC in the ‘Result’ section that their size
was larger, and the proportions of ulceration, SM infiltration, and LVI were also significantly
higher (P<0.05) is understandable. However, although the authors touch the result that there is
a difference in the presence or absence of LNM due to differences in BMI, Hb, and PLR in
the 3rd paragraph of the ‘Discussion’ section, the content is unclear. Are NLR, PLR, and MLR
necessary for this analysis?
Minor comments
1. The number of female patients in the text of results is different from the number in Table1.
2. The border of tumor size is <2cm in the text of ‘Result’, whereas it is #2cm in Table 1.
3. In Table 1and 4: ‘Fmale’, ‘fmale’ # ‘Female’, ‘female’.
4. In Table 3, please clarify which includes just 2cm.
Please review this paper.
user
Title: Risk of Lymph Node Metastasis and Feasibility of Endoscopic Submucosal Dissection
in Undifferentiated-type Early Gastric Cancer
Version: 1 Date: 07 Jan 2023
Reviewer:  Takeshi Kubota
Reviewer's report:
The authors assessed the feasibility of endoscopic submucosal dissection (ESD) for
undifferentiated-type early gastric cancer (UEGC) by analyzing the risk factors for lymph
node metastasis (LNM) after curative gastrectomy. The results are convincing and valuable
for clinical practice. However, the similar larger scale analysis has been performed (1), which
has already been indicated in Japanese guidelines and cited worldwide. In addition, some
confirmatory trials have already been done and published (2,3). Furthermore, it did not notice
a big difference in the results. The authors described in the ‘Background’ that ESD for UEGC
is still not widespread in China because of the lack of confidence in curative resection by both
endoscopists and patients, but, basiclally, the subject is the same Asian population as the above
cited references.
(1) Hirasawa T, Gotoda T, Miyata S, et al. Incidence of lymph node metastasis and the
feasibility of endoscopic resection for undifferentiated-type early gastric cancer. Gastric Cancer.
2009;12(3):148-52.
(2) Hasuike N, Ono H, Boku N, et al. Gastrointestinal Endoscopy Group of Japan Clinical
Oncology Group (JCOG-GIESG). A non-randomized confirmatory trial of an expanded
indication for endoscopic submucosal dissection for intestinal-type gastric cancer (cT1a): the
Japan Clinical Oncology Group study (JCOG0607). Gastric Cancer. 2018 Jan;21(1):114-123.
(3) Takizawa K, Ono H, Hasuike N, et al. Gastrointestinal Endoscopy Group (GIESG) and the
Stomach Cancer Study Group (SCSG) of Japan Clinical Oncology Group. A nonrandomized,
single-arm confirmatory trial of expanded endoscopic submucosal dissection indication for
undifferentiated early gastric cancer: Japan Clinical Oncology Group study (JCOG1009/1010).
Gastric Cancer. 2021 Mar;24(2):479-491.
Other major comments
1. In preoperative endoscopic diagnosis, which decides the indication of ESD, it must be said
that it is fatal not to perform EUS.
2. Multivariate analysis with factors of 8-9 for 69 events (LNM) is unreasonable.
3. The description regarding risk factors for LNM in UEGC in the ‘Result’ section that their size
was larger, and the proportions of ulceration, SM infiltration, and LVI were also significantly
higher (P<0.05) is understandable. However, although the authors touch the result that there is
a difference in the presence or absence of LNM due to differences in BMI, Hb, and PLR in
the 3rd paragraph of the ‘Discussion’ section, the content is unclear. Are NLR, PLR, and MLR
necessary for this analysis?
Minor comments
1. The number of female patients in the text of results is different from the number in Table1.
2. The border of tumor size is <2cm in the text of ‘Result’, whereas it is #2cm in Table 1.
3. In Table 1and 4: ‘Fmale’, ‘fmale’ # ‘Female’, ‘female’.
4. In Table 3, please clarify which includes just 2cm.
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