Lymph Node Metastasis, a Unique Independent Prognostic Factor in Early Gastric Cancer

Abstract

BackgroundLymph node metastasis (LNM) has been shown to be related to the prognosis of early gastric cancer (EGC). The choice of optimal treatment depends on an accurate pre-operative assessment of LNM status in EGC patients. However, in China, where EGC cases account for only a small part of gastric cancer (GC) cases, there are not enough data to make an accurate assessment. Therefore, this study, which involved a relatively large number of EGC patients, aimed to explore the relationship between clinicopathological characteristics and LNM in EGC.MethodsClinicopathological data from 205 EGC patients who underwent surgical resection at Sun Yat-Sen University Cancer Center from January 2000 to December 2011 were retrospectively analyzed. Clinicopathological characteristics were assessed to identify effective predictive factors for LNM and overall survival.ResultsLNM occurred in 52 (25.37%) EGC cases; of these cases, 18 occurred in intra-mucosal cancers (13 N1, 4 N2 and 1 N3), and 34 occurred in sub-mucosal cancers (22 N1, 7 N2 and 5 N3). Logistic regression analysis demonstrated that tumor differentiation (P=0.002), depth of tumor infiltration (P=0.004), vessel invasion (P=0.012), tumor size (P=0.020) and gender (P=0.022) were risk factors associated with LNM in EGC, listed in order of priority. The overall survival rate was 90.2%. Kaplan-Meier survival analysis showed that overall survival of EGC patients was significantly correlated with LNM (P=0.001), N staging (P<0.001) and invasion of lymphatic or blood vessels (P=0.010), but it was not correlated with tumor size, depth of tumor infiltration or tumor cell differentiation. Moreover, a multiple Cox regression analysis demonstrated that only N staging (P=0.001) could serve as an independent prognostic predictor in EGC patients.ConclusionsBecause LNM independently predicts the prognosis of EGC, endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) and laparoscopic partial gastrectomy should be cautiously used in high-risk EGC patients. A pre-operative assessment of LNM status based on clinicopathological factors may be useful for therapy planning.

Risk factors of lymph node metastasis in early gastric carcinomas diagnosed by WHO criteria in 379 Chinese patients

“…Unexpectedly, endoscopic ulcerated pattern was not identified as a risk factor for LNM in this cohort. According to Japanese investigators, ulcerated EGC are associated with an increased risk of LNM, which was not verified in our cohort and most other Chinese cohorts . We showed that ulcerated EGC tumors were primarily found in the DGC group with no increased LNM risk.…”

“…The standard criteria for endoscopic resection of EGC, according to the Japanese Gastric Cancer Association (JGCA) guidelines, include tumors with mucosal or submucosal invasion up to 500 µm (SM1), size up to 2 cm for EMR and 3 cm for ESD, having a non‐excavated gross pattern and a differentiated histological type (i.e., tubular and papillary adenocarcinomas of the Lauren classification). Although widely adopted, the application of the JGCA guidelines in the management of EGC in Chinese patients has been questioned by many Chinese studies that have identified different independent risk factors such as male sex, tumor size ≥2 cm and depth of tumor invasion. Several Chinese studies also reported the recurrence rates of up to 12.2% and LNM rates up to 25.4% .…”

“…Although widely adopted, the application of the JGCA guidelines in the management of EGC in Chinese patients has been questioned by many Chinese studies that have identified different independent risk factors such as male sex, tumor size ≥2 cm and depth of tumor invasion. Several Chinese studies also reported the recurrence rates of up to 12.2% and LNM rates up to 25.4% . In China EGC is defined based on the World Health Organization (WHO) criteria.…”

Risk factors of lymph node metastasis in 1620 early gastric carcinoma radical resections in Jiangsu Province in China: A multicenter clinicopathological study

“…Ulceration was again confirmed as a non‐risk factor of LNM in this large multicenter study. Overall, these results are parallel to those reported previously and add to the growing body of knowledge by providing more precise features of LNM in EGC of Chinese patients . The findings may help to improve the decision‐making process for managing Chinese patients with EGC.…”

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

“…While lymphovascular invasion has been confirmed worldwide as the most important risk factor for nodal metastasis in EGC [19,46,47], an extremely low frequency of nodal metastasis in EGC for intramucosal carcinoma, tumor size smaller than 2 cm, and superficial submucosal invasion without lymphovascular invasion, reported previously [43], has not been universally confirmed (Table 2). Several recent Chinese and Korean studies on nodal metastasis in EGC also demonstrate different risk factors such as female gender [18,19,48], intestinal type [47], and distal gastric location [18,49,50], but not ulceration [18,49,51]. A most recent systematic review of the world literature in 42 qualified studies shows low, but substantial, nodal metastasis rates of 6% for intramucosal carcinoma, 9% for EGC without lymphovascular invasion, 13% for the intestinal-type EGC, 13% for EGC with an elevated growth pattern, and 8% for EGC in the size smaller than 2 cm [47].…”