Feasibility of endoscopic treatment and predictors of lymph node metastasis in early gastric cancer

Abstract

BACKGROUNDEndoscopic submucosal dissection (ESD) has been routinely performed in applicable early gastric cancer (EGC) patients as an alternative to conventional surgical operations that involve lymph node dissection. The indications for ESD have been recently expanded to include larger, ulcerated, and undifferentiated mucosal lesions, and differentiated lesions with slight submucosal invasion. The risk of lymph node metastasis (LNM) is the most important consideration when deciding on a treatment strategy for EGC. Despite the advantages over surgical procedures, lymph nodes cannot be removed by ESD. In addition, whether patients who meet the expanded indications for ESD can be managed safely remains controversial.AIMTo determine whether the ESD indications are applicable to Chinese patients and to investigate the predictors of LNM in EGC.METHODSWe retrospectively analyzed 12552 patients who underwent surgery for gastric cancer between June 2007 and December 2018 at the Affiliated Hospital of Qingdao University. A total of 1262 (10.1%) EGC patients were eligible for inclusion in this study. Data on the patients’ clinical, endoscopic, and histopathological characteristics were collected. The absolute and expanded indications for ESD were validated by regrouping the enrolled patients and determining the positive LNM results in each subgroup. Predictors of LNM in patients were evaluated by univariate and multivariate analyses.RESULTSLNM was observed in 182 (14.4%) patients. No LNM was detected in the patients who met the absolute indications (0/90). LNM occurred in 4/311 (1.3%) patients who met the expanded indications. According to univariate analysis, LNM was significantly associated with positive tumor marker status, medium (20-30 mm) and large (>30 mm) lesion sizes, excavated macroscopic-type tumors, ulcer presence, submucosal invasion (SM1 and SM2), poor differentiation, lymphovascular invasion (LVI), perineural invasion, and diffuse and mixed Lauren’s types. Multivariate analysis demonstrated SM1 invasion (odds ration [OR] = 2.285, P = 0.03), SM2 invasion (OR = 3.230, P < 0.001), LVI (OR = 15.702, P < 0.001), mucinous adenocarcinoma (OR = 2.823, P = 0.015), and large lesion size (OR = 1.900, P = 0.006) to be independent risk factors.CONCLUSIONThe absolute indications for ESD are reasonable, and the feasibility of expanding the indications for ESD requires further investigation. The predictors of LNM include invasion depth, LVI, mucinous adenocarcinoma, and lesion size.

Clinicopathological and prognostic features of early gastric cancer patients after surgery: a retrospective study

“…Similarly, Japanese Gastric Cancer Association (JGCA) points that nonulcerated, well-differentiated and lesions diameter less than 2 cm are the indications for EMR/EDS approach in EGC patients [24]. Additionally, our study also found that the invasive depth of EGC(T stage) and vascular invasion were also associated with lymph node metastasis, Chu YN et al also found that submucosal invasion depth and LVI were the predictive factors for lymph node metastasis [25], hence, it is truely for the application of ultrasound gastroscope to identify the invasive depths in EGC patients, which could not only measured the lesion size, but also measured the invasive depths of EGC tumors [26]. In collaboration with previous studies, our research indicated that tumor size ≤ 1.9 cm, ultrasound gastroscope presents the non-submucosa invasion and non-vascular invasion might be the indications for ESD/EMR in EGC patients.…”

Risk of Lymph Node Metastasis and Feasibility of Endoscopic Treatment in Ulcerative Early Gastric Cancer

“…16,17 Since the rate of LNM was approximately 14% in previous studies, radical surgery may be excessive in the large proportion of patients without LNM. [18][19][20] Gastrectomy often results in considerable postoperative complications, such as abdominal pain, nausea, vomiting, and dumping syndrome. 21 As endoscopic resection is considered a curative form of resection, it is recommended as an alternative to radical surgery under specific conditions.…”

“…In previous studies, depth of infiltration was also considered to be extremely relevant to LNM. 8,20,23,28,29 Some studies reported that, although the mucosa showed an enrichment of blood capillaries, lymphatic ducts were only abundant in the deeper lamina propria and submucosa. 30,31 This may explain the relationship between LNM and depth of invasion.…”

Early Gastric Cancer Lymph Node Metastasis Model and Prognostic Survival Prediction Model in Western Population

“…Lymph node metastasis is a major factor in the endoscopic treatment and prognosis of EGC patients [23,24]. In this study, we found that the lymph node metastasis rate of stage T1 gastric cancer after surgical resection was 14.5% (333/2294).…”