Risk factors for lymph node metastasis in histologically poorly differentiated type early gastric cancer

Background: We retrospectively evaluated the predictive factors for lymph node metastasis in poorly differentiated early gastric cancer (poorly differentiated tubular adenocarcinoma, signet-ring cell carcinoma, mucinous adenocarcinoma) in order to examine the possibility of endoscopic resection for poorly differentiated early gastric cancer.

Methods: A total of 573 patients with histologically poorly differentiated type early gastric cancer (269 mucosal and 304 submucosal), who had undergone curative gastrectomy, were enrolled in this study. Risk factors for lymph node metastasis were evaluated by univariate and logistic regression analysis.

Results: Lymph node metastasis was observed in 74 patients (12.9 %) (6 with mucosal cancer and 68 with submucosal cancer). By univariate analysis risk factors for lymph node metastasis were lymphovascular invasion (LVI) (presence), depth of invasion (submucosa), and tumor diameter (> 20 mm), ulcer or ulcer scar (presence), and histological type (mucinous adenocarcinoma). By multivariate analysis, risk factors for lymph node metastasis were LVI, depth of invasion, and tumor diameter. In mucosal cancers, the incidence of lymph node metastasis was 0 % irrespective of LVI in tumors smaller than 20 mm, and 1.7 % in tumors 20 mm or larger without LVI. In submucosal cancers, the incidence of lymph node metastasis was 2.4 % in tumors smaller than 20 mm without LVI.

Conclusions: A histologically poorly differentiated type mucosal gastric cancer measuring less than 20 mm and without LVI may be a candidate for endoscopic resection. This result should be confirmed in a larger study with many patients.

References

• 1 Kong S H, Park D J, Lee H J. et al . Clinicopathologic features of asymptomatic gastric adenocarcinoma patients in Korea.  Jpn J Clin Oncol. 2004;  34 1-7
• 2 Fukao A, Tsubono Y, Tsuji I. et al . The evaluation of screening for gastric cancer in Miyagi Prefecture, Japan: a population-based case-control study.  Int J Cancer. 1995;  60 45-48
• 3 Nakajima T. Gastric cancer treatment guidelines in Japan.  Gastric Cancer. 2002;  5 1-5
• 4 Gotoda T, Yamamoto H, Soetikno R M. Endoscopic submucosal dissection of early gastric cancer.  J Gastroenterol. 2006;  41 929-942
• 5 Ono H, Hasuike N, Inui T. et al . Usefulness of a novel electrosurgical knife, the insulation-tipped diathermic knife-2, for endoscopic submucosal dissection of early gastric cancer.  Gastric Cancer. 2008;  11 47-52
• 6 Ono H, Kondo H, Gotoda T. et al . Endoscopic mucosal resection for treatment of early gastric cancer.  Gut. 2001;  48 225-229
• 7 Sano T, Kobori O, Muto T. Lymph node metastasis from early gastric cancer: endoscopic resection of tumour.  Br J Surg. 1992;  79 241-244
• 8 Gotoda T, Yanagisawa A, Sasako M. et al . Incidence of lymph node metastasis from early gastric cancer: estimation with a large number of cases at two large centers.  Gastric Cancer. 2000;  3 219-225
• 9 Kunisaki C, Akiyama H, Nomura M. et al . Lymph node status in patients with submucosal gastric cancer.  Ann Surg Oncol. 2006;  13 1364-1371
• 10 Li C, Kim S, Lai J F. et al . Risk factors for lymph node metastasis in undifferentiated early gastric cancer.  Ann Surg Oncol. 2008;  15 764-769
• 11 Park Y D, Chung Y J, Chung H Y. et al . Factors related to lymph node metastasis and the feasibility of endoscopic mucosal resection for treating poorly differentiated adenocarcinoma of the stomach.  Endoscopy. 2008;  40 7-10
• 12 Ha T K, An J Y, Youn H K. et al . Indication for endoscopic mucosal resection in early signet ring cell gastric cancer.  Ann Surg Oncol. 2008;  15 508-513
• 13 Hamilton S R, Aaltonen L A, eds. Pathology and genetics of tumours of the digestive system. World Health Organization classification of tumours, vol 2. Lyon; IARC Press 2000: 37-52
• 14 Sobin L H, Wittekind C H, eds. TNM: classification of malignant tumours. 6th ed. New York; Wiley-Liss 2002
• 15 Japanese Gastric Cancer Association . Japanese Classification of Gastric Carcinoma, 2nd edn.  Gastric Cancer. 1998;  1 10-24
• 16 Kunisaki C, Shimada H, Nomura M, Akiyama H. Appropriate lymph node dissection for early gastric cancer based on lymph node metastases.  Surgery. 2001;  129 153-157
• 17 Hyung W J, Cheong J H, Kim J. et al . Application of minimally invasive treatment for early gastric cancer.  J Surg Oncol. 2004;  85 181-185
• 18 Abe N, Watanabe T, Sugiyama M. et al . Endoscopic treatment or surgery for undifferentiated early gastric cancer?.  Am J Surg. 2004;  188 181-184
• 19 Nasu J, Nishina T, Hirasaki S. et al . Predictive factors of lymph node metastasis in patients with undifferentiated early gastric cancers.  J Clin Gastroenterol. 2006;  40 412-415
• 20 Ye B D, Kim S G, Lee J Y. et al . Predictive factors for lymph node metastasis and endoscopic treatment strategies for undifferentiated early gastric cancer.  J Gastroenterol Hepatol. 2008;  23 46-50
• 21 Ryu K W, Choi I J, Doh Y W. et al . Surgical indication for non-curative endoscopic resection in early gastric cancer.  Ann Surg Oncol. 2007;  14 3428-3434
• 22 Yano H, Kimura Y, Iwazawa T, Monden T. Laparoscopic management for local recurrence of early gastric cancer after endoscopic mucosal resection.  Surg Endosc. 2005;  19 981-985