Ann Surg Treat Res.  2016 Sep;91(3):118-126. 10.4174/astr.2016.91.3.118.

Risk factors for lymph node metastasis in mucosal gastric cancer and re-evaluation of endoscopic submucosal dissection

Affiliations
  • 1Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea. hwangsh@pusan.ac.kr
  • 2Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea.
  • 3Department of Surgery, Pusan National University School of Medicine, Yangsan, Korea.
  • 4Department of Pathology, Pusan National University Yangsan Hospital, Yangsan, Korea.
  • 5Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.

Abstract

PURPOSE
The selection of the appropriate treatment strategy for patients with mucosal gastric cancer (MGC) remains controversial. In the present study, we aimed to determine the risk factors for lymph node (LN) metastasis in MGC and reassess the role of endoscopic submucosal dissection (ESD).
METHODS
We examined 1,191 MGC patients who underwent curative gastrectomy between January 2005 and December 2014. We determined the clinicopathologic risk factors for LN metastasis among the MGC patients.
RESULTS
Among 1,191 patients with MGC, 42 patients (3.5%) had LN metastasis. Univariate analysis indicated that age ≤ 50 years (P = 0.045), tumor invasion to the muscularis mucosa (P < 0.001), tumor size > 2 cm (P = 0.014), presence of ulceration (P = 0.01), diffuse type as per Lauren classification (P = 0.005), and undifferentiated-type histology (P = 0.001) were associated with LN metastasis. Moreover, multivariate analysis indicated that tumor invasion to the muscularis mucosa (P = 0.001; odds ratio [OR], 4.909), presence of ulceration (P = 0.036; OR, 1.982), and undifferentiated-type histology (P = 0.025; OR, 4.233) were independent risk factors for LN metastasis. In particular, LN metastasis was observed in some MGC cases with indications for ESD, including absolute indications (1 of 179, 0.6%) and expanded indications (9 of 493, 1.8%).
CONCLUSION
Although MGC patients can be treated via ESD, we recommend that they undergo a more aggressive treatment strategy if they have tumor invasion to the muscularis mucosa, ulceration, or undifferentiated-type histology in the final pathology report.

Keyword

Lymph nodes; Neoplasm metastasis; Stomach neoplasms; Risk factors

MeSH Terms

Classification
Gastrectomy
Humans
Lymph Nodes*
Mucous Membrane
Multivariate Analysis
Neoplasm Metastasis*
Odds Ratio
Pathology
Risk Factors*
Stomach Neoplasms*
Ulcer

Figure

  • Fig. 1 A 51-year-old woman with a preoperative clinical diagnosis of mucosal gastric cancer without lymph node (LN) metastasis, who was eventually pathologically confirmed as having LN metastasis after surgery. (A) Endoscopic image: early gastric cancer (EGC) gross type IIc with irregular margin at the lesser curvature of the lower body. (B) Endoscopic ultrasound image: a hypoechoic disruption of the superficial and deep mucosal layers is noted. The third (submucosal) layer is intact. (C) Abdominal computed tomography image: no evidence of focal wall thickening or a mass in the stomach is observed. (D) Final histological report.

  • Fig. 2 Mucosal gastric cancer within the lamina propria. (A-1) Well-differentiated adenocarcinoma only invading the lamina propria (H&E, ×40). (A-2) Cancer only invading the lamina propria (H&E, ×100) and mucosal gastric cancer with muscularis mucosa invasion. (B-1, -2). mucosal gastric cancer with muscularis mucosa invasion; (B-1) Well-differentiated adenocarcinoma invading the lamina propria and muscularis mucosa, in the background of ulcerative inflammation (H&E, ×40). (B-2). Tumor invading the muscularis mucosa, in the background of ulcerative inflammation (H&E, ×100) (arrow).

  • Fig. 3 (A) The frequency of lymph node metastasis according to differentiation, ulceration, and size, based on the indications of endoscopic submucosal dissection (ESD) in mucosal gastric cancer within lamina propria. (B) The frequency of lymph node metastasis according to differentiation, ulceration, and size, based on the indications of ESD in with muscularis mucosa invasion. *Absolute indications according to the new Japanese classification and treatment guidelines for gastric cancer. **Expanded indications according to the new Japanese classifications and treatment guidelines for gastric cancer.


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