A Risk-prediction Model Based on Lymph-node Metastasis for Incorporation Into a Treatment Algorithm for Signet Ring Cell-type Intramucosal Gastric Cancer

Pyo, Jeung Hui; Shin, Cheol Min; Lee, Hyuk; Min, Byung‐Hoon; Lee, Jun; Kim, Su; Choi, Min Gew; Sohn, Tae Sung; Bae, Jae Moon; Kim, Kyung; Kim, Hye; Jung, Sin‐Ho; Kim, Jae; Kim, Sung Hoon

doi:10.1097/sla.0000000000001602

Cited by 37 publications

(34 citation statements)

References 27 publications

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“…The average frequency of nodal metastasis (based on the data listed in Table 1) is only 4.2% for intramucosal signet ring cell carcinoma, over 5-fold less for signet ring cell carcinoma with submucosal invasion (23%), which has been confirmed by logistic regression analysis of nodal metastasis frequency in early signet ring cell carcinoma between intramucosal and submucosal invasion [39,40]. The independent risk factors of nodal metastasis in 1,544 mucosa-confined signet ring cell carcinomas, reported by a Korean multicenter study, include tumor size >1.7 cm, elevated growth pattern, and lymphovascular invasion [41]. Kim et al [42] most recently discovered that none of 189 surgical resections of early signet ring cell carcinoma in the size smaller than 2 cm without ulceration demonstrated nodal metastasis, suggesting that endoscopic resection may be an effective and safe alternative to surgical gastrectomy for intramucosal signet ring cell carcinoma under certain circumstances.…”

Section: Low Risk Of Nodal Metastasis For Intramucosal Signet Ring Cementioning

confidence: 78%

Clinicopathology of Early Gastric Carcinoma: An Update for Pathologists and Gastroenterologists

Huang¹,

Zou

2016

Gastrointest Tumors

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Background: The WHO defines early gastric carcinoma (EGC) as invasive carcinoma up to the submucosal layer, regardless of nodal metastasis. The recent study results indicate that EGC varies in location, histology, nodal metastasis, and prognosis. Summary: The heterogeneity in EGC may be related to various types of epithelial stem cells. The most important stem cells include Lgr5⁺ cells at the base of a gastric unit in the antrum-pylorus-cardia, Mist1⁺ cells at the isthmus/Troy⁺ cells at the base in the corpus-fundus, and Sox2⁺ cells at the base in almost all regions. Dysregulation of these cells along with environmental factors transform stem cells in different regions into malignancy in genetically susceptible populations. Key Message: The 2 most vulnerable regions for EGC have been found along the lesser curvature: the cardia in elderly patients and antrum-angularis in mid-aged and elderly patients. Most hereditary early-onset gastric carcinomas are concentrated in the corpus-fundus of young women. By histology, the most common EGC type is tubular adenocarcinoma in many growth patterns, starting in the neck of a gastric unit. Worse prognosis has been found in early papillary, compared to tubular, adenocarcinoma, related to deeper penetration, more lymphovascular invasion, and more liver and nodal metastases. Contrary to the common belief, intramucosal signet ring cell carcinoma demonstrates low risk of nodal metastasis, comparable to early intestinal-type EGC. Practical Implications: The overall risk for nodal metastasis in EGC is low but significant. It is urgent to organize multicenter studies on risk of nodal metastasis in EGC in order to establish more reliable clinical practice guidelines to treat EGC patients.

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Section: Low Risk Of Nodal Metastasis For Intramucosal Signet Ring Cementioning

confidence: 78%

Clinicopathology of Early Gastric Carcinoma: An Update for Pathologists and Gastroenterologists

Huang¹,

Zou

2016

Gastrointest Tumors

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“…Several variables associated with LNM have been reported previously, including sex, [20] depth of invasion, [7] macroscopic type, [8] tumor size, [9] and LVI. [6] In both this cohort and Japanese series, SRC histology tends to spread more superficially instead of invading deeply.…”

Section: Discussionmentioning

confidence: 99%

“…Consequently, we proposed this treatment algorithm as ESD indication for patients with early gastric SRC. Different from previous studies, [6–8,10] the highlight of the treatment algorithm is to provide a quantified risk score for individual counseling before ESD. In clinical practice, surgeons were encouraged to discuss with patients to determine a satisfied risk threshold.…”

Section: Discussionmentioning

confidence: 99%

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A nomogram for predicting the likelihood of lymph node metastasis in early gastric signet ring cell carcinoma

et al. 2016

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Treatment algorithm has not been established for early gastric cancer with signet ring cell carcinoma (SRC), which has a reported low rate of lymph node metastasis (LNM) similar to differentiated cancer. A cohort of 256 patients with early gastric SRC at our center between January 2002 and December 2015 were retrospectively reviewed. Multivariate logistic regression analysis was used to determine the independent factors of LNM. A nomogram for predicting LNM was constructed and internally validated. Additional external validation was performed using the database from Cancer Institute Ariake Hospital in Tokyo (n = 1273). Clinical performance of the model was assessed by decision analysis of curve. The overall LNM incidence was 12.9% (33/256). The multivariate logistic model identified sex, tumor size, and LVI as covariates associated with LNM. Subsequently, a nomogram consisted of sex, tumor size, and depth of invasion was established. The model showed qualified discrimination ability both in internal validation (area under curve, 0.801; 95% confidence interval [CI], 0.729–0.873) and in external dataset (area under curve, 0.707; 95% CI, 0.657–0.758). Based on the nomogram, treatment algorithm for early gastric SRC was proposed to assist clinicians in making better decisions. We developed a nomogram predicting risk of LNM for early gastric SRC, which should be helpful for patient counseling and surgical decision-making.

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“…Hirasawa et al reported that tumor sizes greater than 21 mm, lymphatic-vascular capillary involvement, and submucosal penetration were considered as risk factors for lymph node metastasis in a series of 3843 cases diagnosed with undifferentiated-type early gastric cancer who underwent gastrectomy [9]. Recently, Pyo et al demonstrated tumor sizes larger than 17 mm, elevated tumor type, and lymphatic-vascular involvement to be significantly associated with lymph node metastasis [10]. The present case would be a candidate for curative resection with expanded criteria according to the Japanese guidelines because of the identification of an undifferentiated lesion with a diameter of 15 mm without ulceration.…”

Section: Case Presentationmentioning

confidence: 99%

A case of undifferentiated-type mucosal gastric cancer with multiple lymph node metastases fulfilling the curative criteria for endoscopic resection according to routine pathological analysis

et al. 2016

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BackgroundEndoscopic resection is accepted as the standard treatment for early mucosal gastric cancer, and its indications have recently been expanded while its long-term outcomes are still unclear. Herein, we present a didactic case of undifferentiated-type mucosal gastric cancer fulfilling the expanded indication and curative criteria for endoscopic submucosal dissection (ESD), having synchronous multiple lymph node metastases.Case presentationA 40-year-old woman was found to have a Helicobacter pylori infection at a standard health check with no abdominal symptoms. She received an upper gastrointestinal endoscopy and found to have an undifferentiated-type mucosal gastric cancer with the size of 15 mm in diameter without ulceration, which fulfilled the expanded indication for ESD. According to patient’s preference, we performed laparoscopy-assisted distal gastrectomy with D1+ lymph node dissection, and routine pathological analysis revealed a predominantly signet ring cell carcinoma limited to the mucosa without ulceration or any vessel involvement; on the other hand, 15 lymph node metastases were detected. Then, we added deep sectioning of the whole tumoral area at a thickness of 20 μm and immunohistochemical analyses. As the result, an isolated lymphatic capillary involvement of the extremely superficial submucosa was identified in a single histological section, and pathological diagnosis was corrected to ly1. She received postoperative adjuvant chemotherapy with an S-1 oral agent and had no recurrence under strict surveillance for 1 year postoperatively.ConclusionsWhen we perform ESD for undifferentiated-type gastric cancer, deep sectioning of the whole tumoral area into thin slices and immunohistochemical staining using D2-40 should be practically considered.

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A Risk-prediction Model Based on Lymph-node Metastasis for Incorporation Into a Treatment Algorithm for Signet Ring Cell-type Intramucosal Gastric Cancer

Abstract: A RSS may help to predict LNM and evaluate endoscopic submucosal dissection feasibility in patients with intramucosal SRC.

Cited by 37 publications

References 27 publications

Clinicopathology of Early Gastric Carcinoma: An Update for Pathologists and Gastroenterologists

Clinicopathology of Early Gastric Carcinoma: An Update for Pathologists and Gastroenterologists

A nomogram for predicting the likelihood of lymph node metastasis in early gastric signet ring cell carcinoma

A case of undifferentiated-type mucosal gastric cancer with multiple lymph node metastases fulfilling the curative criteria for endoscopic resection according to routine pathological analysis

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