Predictive factors for lymph node metastasis in early gastric cancer with submucosal invasion: analysis of a single institutional experience

OBJECTIVE: An accurate assessment of a potential lymph node metastasis is an important issue for the appropriate treatment of early gastric cancer. Minimizing the amount of invasive procedures used in cancer treatment is critical for improving the patient's quality of life. Therefore, this study analyzed the predictive risk factors for a lymph node metastasis in early gastric cancer with a submucosal invasion. METHODS: The data from 1043 patients surgically treated for early gastric cancer with submucosal invasion between 2002 and 2005 were reviewed retrospectively. The patients were divided into 3 layers according to their depth: SM1, SM2, and SM3. The clinicopathological variables predicting a lymph node metastasis were evaluated. RESULTS: A lymph node metastasis was observed in 19.4% of patients. The tumor size, histologic type, Lauren classification, tumor depth, and perineural invasion showed a positive correlation with the rate of lymph node metastasis and N category by univariate analysis. Multivariate analyses revealed the tumor size (>or=2 cm) and lymphatic involvement to be significantly and independently related to lymph node metastasis. The presence of lymphatic involvement was the strongest predictive factor for a lymph node metastasis, being observed in 43.8% of cases in which a lymph node metastasis had been revealed. No lymph node metastasis was observed in the 12 cases with no lymphatic involvement, SM1 invasion, and tumor size <1 cm. CONCLUSIONS: Lymphatic involvement and tumor size are independent risk factors for a lymph node metastasis in early gastric cancer with submucosal invasion. Minimal invasive treatment, such as endoscopic mucosal resection, may be possible in highly selective submucosal cancers with no lymphatic involvement, SM1 invasion, and tumor size <1 cm.     

Angiogenesis as an unfavorable factor related to lymph node metastasis in early gastric cancer

Background: Recent studies suggest that angiogenesis enhances tumor growth and metastasis. Lymph node metastasis influences the prognosis and selection of treatment modalities in cancers. In this study, the authors investigated the correlation between angiogenesis and clinicopathologic features to determine whether angiogenesis correlated with lymph node metastasis in early-stage gastric cancer. Methods: A total of 97 specimens from patients with early gastric cancer were studied by immunohistochemical methods using anti-Factor VIII-related antigen antibody. Results: Tumor size was significantly correlated with microvessel count, which increased as tumor size increased. Microvessel counts from tumors with lymphatic vessel invasion, lymph node metastasis, and submucosal invasion were significantly higher than those without. Furthermore, microvessel count was an independent factor that influenced lymph node metastasis (P=.0016) by multivariate logistic regression analysis. Conclusion: In the early stage of gastric carcinoma, angiogenesis is an independent factor that impacts on lymph node metastasis.     

Appropriate lymph node dissection for early gastric cancer based on lymph node metastases

BACKGROUND: Lymph node dissection in patients with early gastric cancer is controversial because lymph node metastases are much less common than in advanced cancer. Therefore, routine extensive lymph node dissection with wide resection of the stomach may be excessive, and an appropriate lymph node dissection procedure in patients with early gastric cancer should be established. METHODS: Retrospectively, 588 consecutive patients with early gastric cancer were analyzed by univariate and multivariate analysis to predict lymph node metastases with clinicopathologic variables. The sites and rates of lymph node metastases for each tumor location were mapped. RESULTS: In early gastric cancer, depth of invasion was an independent predictive factor of lymph node metastases. In cancer confined to the mucosa, however, tumor diameter was the only predictive factor. In contrast, tumor diameter, macroscopic appearance, and histologic type were not predictive factors in early gastric cancers invading the submucosa. In mucosal cancer, metastasis to lymph nodes was confined to the paragastric lymph nodes on the same side of the stomach as the tumor. In submucosal cancer, the incidence of lymph node metastasis was 2% to 17% in group 1 and 1% to 3% in group 2 lymph nodes. CONCLUSIONS: In mucosal cancer, lymph node dissection is unnecessary for tumors measuring less than 30 mm, and limited lymph node dissection with local gastrectomy is appropriate when tumor diameters are 30 mm or greater. In submucosal cancer, gastrectomy with dissection of group 1 and some group 2 lymph nodes should be sufficient to remove all nodal metastases.     

Lymph node metastasis as a significant prognostic factor in early gastric cancer: Analysis of 1,136 early gastric cancers

Background: Gastric cancer is the most frquent cancer and the leading cause of death from cancer in Korea. Early gastric cancer has been defined as a gastric carcinoma confined to mucosa or submucosa, regardless of lymph node status, and has an excellent prognosis with a >90% 5-year survival rate. From 1974 to 1992, we encountered 7,606 cases of gastric cancer and performed 6,928 gastric resections. Among them, 1,136 cases were early gastric cancer (14.9% of all gastric cancer cases and 16.4% of resected gastric cancer cases). Methods: A retrospective analysis of 1,136 cases of early gastric cancer was performed to evaluate the prognostic significance of clinicopathologic features (sex, age, tumor location, gross type, histologic type, depth of invasion, status of lymph node metastasis, resection type). Lymph node metastasis was classified into three groups: N(n=0) for no lymph node metastasis; N(n=1–3) for one to three lymph node metastases; and N(n>3) for more than three lymph node metastases. All patients received radical total or subtotal gastrectomy with lymph node dissection. Results: In univariate and multivariate analysis of these nine factors, the only statistically significant prognostic factor was regional lymph node metastasis (p<0.001). The others had no statistically significant association with prognosis. Lymph node metastasis was present in 178 cases (15.7%). The factors associated with the lymph node metastasis were depth of invasion and gross type [protruding type (e.g., types I, IIa)]. One hundred twenty-five of these patients had one to three lymph node metastases, and 53 cases had more than three lymph node metastases. The difference in 5-year survival rates among these groups was statistically significant: 94.5% for N(n=0), 88.3% for N(n=1–3), and 77.3% for N(n>3). Conclusion: We propose that for early gastric cancer, lymph node dissection is necessary in addition to gastric resection, at least in patients with a high risk of lymph node metastasis.     

Is lymphadenectomy needed for all submucosal gastric cancers?

OBJECTIVE: To find out if it is feasible to extend the indication for local resection of submucosal gastric cancer without increasing the risk of lymph node metastases. DESIGN: Retrospective study. SETTING: University hospital, Japan. SUBJECTS: 104 patients with gastric cancer confined to the submucosal layer who underwent conventional gastrectomy with lymphadenectomy. INTERVENTIONS: The risk of nodal metastases was analysed retrospectively depending on the depth of submucosal invasion, size of the tumour, and other clinicopathological findings. MAIN OUTCOME MEASURES: The degree of submucosal invasion, size of the tumour, and incidence of lymph node metastasis. RESULTS: 15/104 patients (14%) had lymph node metastases. No patient in whom submucosal invasion was less than 500 microm or tumour was less than 15 mm in diameter developed lymph node metastases. Fewer patients had lymphatic permeation (37/89) and venous involvement (21/89) in the group without lymph node metastases. CONCLUSION: These data seem to support the hypothesis that early, minimally invasive, gastric cancer measuring < 15 mm in diameter could be treated by endoscopic mucosal or local resection, and gastrectomy with lymphadenectomy might be unnecessary.     

Evaluation of the necessity for gastrectomy with lymph node dissection for patients with submucosal invasive gastric cancer

BACKGROUND: When cancer cells are found in the submucosal layer of an endoscopically resected specimen, patients are recommended to undergo gastrectomy with lymph node dissection. If it were possible to identify those patients in whom the risk of lymph node metastasis was negligible, it might be possible to avoid surgery. METHODS: Among those who underwent gastrectomy for gastric cancer from 1980 to 1999, 1091 patients with a cancer invading the submucosa were studied. Clinicopathological factors (sex, age, tumour location, macroscopic type, size, ulceration, histological type, lymphatic-vascular involvement and degree of submucosal penetration) were investigated for their possible association with lymph node metastasis. RESULTS: Lymph node metastases were found in 222 patients (20.3 per cent). Univariate analysis showed that larger tumour size (more than 30 mm), undifferentiated histological type, lymphatic-vascular involvement and massive submucosal penetration had a significant association with lymph node metastasis. Tumour size, histological type and lymphatic-vascular involvement were independent risk factors for lymph node metastasis. By combining these three factors with submucosal penetration of less than 500 microm, 117 patients could be selected as having a minimal risk of lymph node metastasis (95 per cent confidence interval 0-3.1 per cent). CONCLUSION: Lymphadenectomy may not be necessary for patients with gastric cancer invading the submucosa who fulfil the above conditions     

Strategy for lymphadenectomy of gastric cancer

To determine the extent of lymphadenectomy necessary to cure early gastric cancer, the relationship between the frequency of nodal involvements and the extent of the primary invasion was examined in 274 patients with primary cancer of the stomach. We also evaluated the relationship between the number of metastatic lymph nodes, the pattern of metastases to the nodes, and the histologic type of the primary tumor. In early gastric cancer, lymph node metastasis was more frequent in protruded-type cancer with invasion into the submucosa more than 3 cm in diameter and located in the lower third of the stomach, but was limited to the group 1 lymph nodes, which were defined as being anatomically located nearest to the cancer. In cancer invading into the muscularis propria, metastasis to the group 2 or 3 lymph nodes, which were defined as being anatomically located farther from the cancer than group 1, was found. The number of lymph nodes involved and extent of cancer metastasis in these lymph nodes metastasis, differentiated early gastric cancer had more lymph node involvement and wider extent of metastases than undifferentiated cancers. The cancer cells sometimes replaced most of the node and invaded the perinodal fatty tissue, even in early gastric cancer. In addition, it is occasionally difficult to distinguish macroscopically early gastric cancer with submucosal invasion from cancer invaded into the muscle layer. In conclusion, group 1 and 2 lymph nodes, including perinodal fatty tissue, should be removed completely, even in early gastric cancer, except for carcinoma in situ, particularly when the cancer is of the differentiated type.     

Superficially spreading cancer of the stomach

Background Superficially spreading cancer (SSC) of the stomach is rare and extends widely along the mucosa or submucosa of the stomach. This study was conducted to clarify the clinicopathologic characteristics and prognosis of patients with SSC. Methods SSC was defined as a tumor invading the mucosa or submucosa and measuring ≥5 cm in size. The clinicopathologic findings and outcomes of 36 patients with SSC were compared with those of 300 patients with early gastric cancer (EGC) measuring ≤5 cm and 271 with advanced gastric cancer measuring ≥5 cm. Results SSC was significantly different from ordinary EGC in tumor size, frequency of lymph node metastasis, lymphatic invasion, venous invasion, and stage II, III and IV disease. The frequency of serosal invasion, lymph node metastasis, and lymphatic and venous invasions in cases of SSC was significantly lower than with advanced gastric cancer. Although tumor size of SSC evaluated before operation was smaller than that on the resected specimen, the 10-year survival rate was not different between SSC and ordinary EGC. Conclusions SSC was characterized by high frequency of lymph node metastasis and preoperative underestimation of tumor size. SSC should be treated by a gastrectomy and lymphadenectomy with sufficient resection margin.     

Les cancers superficiels de l'estomac: expérience chirurgicale et étude des facteurs de pronostic chez 102 patients

Study aimThe aim of this retrospective study was to analyze the characteristics, treatment and prognosis of early gastric carcinoma in a series of 102 patients.MethodsBetween 1973 and 1994, 102 patients (68 males, 34 females) with a mean age of 65 years, were operated on for an early gastric carcinoma. Mean follow-up was 7 years. Survival was calculated using the Kaplan-Meier method. Prognosis was determined with univariate and multivariate analysis according to Cox model.ResultsThe carcinoma was limited to the mucosa in 57 patients (56%) and extended to the submucosa in 45 (44%). There was a lymph node invasion in 17 patients (16.5%). The postoperative mortality rate was 5.8% (n = 6). Secondary deaths occurred in relation with the gastric cancer in 10.4% (n = 10). The 5-and 10-year actuarial crude survival rates were 84% and 68.6%, respectively. Univariate analysis of prognosis factors showed a significant survival difference according to the age (P = 0.001), submucosal extension (P = 0.03), lymph node invasion (P = 0.0005) and type of gastric resection performed (P = 0.03). With multivariate analysis of prognostic factors, advanced patient age and lymph node metastases were the only statistically significant independent prognostic factors (P = 0.0002 and P= 0.002, respectively).ConclusionsPrognosis of early gastric cancer is usually excellent. Patients with high risk of recurrence may be identified in relation with prognostic factors and mainly with lymph node invasion.     

Predictors of lymph node metastasis in early gastric cancer.

Data were analysed on 396 patients with early gastric cancer who underwent resection in this department; special reference was made to lymph node metastasis. Metastases were present in the dissected lymph nodes of 47 patients (11.9 per cent). The survival rate for patients with metastasis to lymph nodes was lower than for those without such metastasis (P less than 0.05). Lymph node metastasis was associated with larger tumour, a higher incidence of submucosal invasion, a higher rate of lymphatic vessel involvement, an advanced stage of disease and a non-curative resection rate of 6.4 per cent. Multivariate analysis showed that the independent risk factors for lymph node metastasis in patients with early gastric cancer were large tumour size, lymphatic vessel involvement and invasion into the submucosal layer. In patients with these risk factors, lymph node dissection and postoperative adjuvant therapy should be performed in an attempt to prevent recurrence in the form of lymph node metastasis.     

常规苏木精-伊红染色诊断早期胃癌黏膜下淋巴管浸润状况的价值

目的评价常规苏木精-伊红染色诊断早期胃癌黏膜下淋巴管浸润状况的价值。方法4420例接受剖腹胃癌D2根治术的早期胃癌．常规方法行苏木精-伊红染色检测黏膜下淋巴管浸润状况，并与病理诊断淋巴结转移状况作比较。结果全组早期胃癌患者中，常规苏木精-伊红染色诊断黏膜下淋巴管浸润的灵敏度、特异度、准确度、阳性预测值和阴性预测值分别为54．5％、82．0％、78．9％、27．4％和93．5％；其中2426例局限于黏膜内者分别为14．5％、98．0％、95．8％、15．8％和97．8％；而1994例侵及黏膜下层者则分别为60．3％、57．8％、58．3％、28．1％和84．2％。黏膜下淋巴管浸润阳性率与淋巴结转移阳性率显著相关（P〈0.01）；但与早期胃癌的预后无关（P〉0.05）。黏膜下淋巴管浸润阳性组和阴性组术后5年生存率分别为84．4％和87．3％．中位生存期分别为6998d和7237d，平均生存期分别为6163．9d和6042．6d（P=0．2495）。结论常规苏木精-伊红染色准确度过低．不适合于诊断早期胃癌黏膜下淋巴管浸润状况。     

胃黏膜下层癌淋巴结转移临床病理因素分析

【摘要】 目的 研究胃黏膜下层癌淋巴结转移率及其影响因素。 方法 回顾性分析南京医科大学第一附属医院1998年1月至2007年12月手术证实的181例胃黏膜下层癌的临床病理资料,对病人年龄、性别、肿瘤组织学类型、形态学类型、大小、部位、浸润深度、脉管内癌栓等与淋巴结转移的关系进行单因素与多因素分析。 结果 胃黏膜下层癌淋巴结转移率为20.44%。影响胃黏膜下层癌淋巴结转移的因素主要有肿瘤组织学类型（分化型 vs 分化不良型,P =0.0352）、直径大小（＜2cm vs ≥2cm,P =0.0143）、部位（近端胃vs胃体vs远端胃,P =0.0254）及脉管内癌栓（无vs有,P =0.0323）。Logistic回归分析显示肿瘤组织学类型与大小为胃黏膜下层癌淋巴结转移的独立性危险因素。结论 胃黏膜下层癌淋巴结转移与肿瘤组织学类型、大小、部位及脉管内癌栓等因素有关。临床上应参考上述临床病理因素判断淋巴结转移风险,制定合适的治疗方案。     

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??Clinicopathological Characteristics Associated with Lymph Node Metastasis in Early Gastric Cancer with Submucosal Invasion SHEN Li-zong, HUANG Yi-ming, SUN Mao-cai, et al. Department of General Surgery, the First Affiliated Hospital, Nanjing Medical University, Nanjing 210029, China Corresponind author: SHEN Li-zong, E-mail: shenlz@163.com Abstract Objective To investigate the clinicopathological characteristics of early gastric cancer with submucoal invasion associated with lymph node metastasis. Methods The data from 181 patients surgically treated for early gastric cancer with submucosal invasion between 1998 and 2007 were reviewed retrospectively. The clinicopathological variables associated with lymph node metastasis were evaluated. Results Lymph node metastasis was observed in 20.44% of patients. The histological classification, tumor size, location in the stomach and presence of vascular or lymphatic invasion showed a positive correlation with the rate of lymph node metastasis by univariate analysis. Multivariate analyses revealed histological classification and tumor size to be significantly and independently related to lymph node metastasis. Conclusion Histological classification, tumor size, location in the stomach and presence of vascular or lymphatic invasion are risk factors for lymph node metastasis in early gastric cancer with submucoal invasion. Minimal invasive treatment, such as endoscopic submucosal dissection, may be possible in highly selective cancers.     

Distribution of Lymph Node Metastasis Including Micrometastasis in Gastric Cancer with Submucosal Invasion

Abstract The purpose of this retrospective study was to analyze the distribution of lymph node metastases, including micrometastases, according to the location of the gastric cancer with submucosal invasion. A total of 118 patients with submucosal gastric cancer were enrolled in this study. The distribution of lymph node metastases was examined according to tumor location. Immunohistochemical examination using anti-cytokeratin antibody was performed to examine nodal micrometastases in 118 patients. Lymph node metastasis was found in 19.5% (23/118) of the patients. Significant differences were found for tumor size and depth, lymphatic invasion, and venous invasion for patients with and without nodal metastasis. The distribution of lymph node metastasis for tumors at upper or middle portions of the stomach was mainly found along the left gastric artery. The distribution of lymph node metastasis for tumors in the lower and lesser curvature varied. Immunohistochemical analysis found that 15 of 23 patients with lymph node metastasis found by histologic examination had micrometastases. The presence of two or more lymph node micrometastases was found in these 15 patients, and they were distributed in another stations, including distant nodes. The incidence of micrometastasis was 24.2% (23/95) in pN0 patients. Lymph node micrometastases were confined to regional nodes near the primary tumor. When planning minimally invasive treatment for submucosal gastric cancer, it is important to understand the distribution of lymph node metastasis, including micrometastasis, according to tumor location.     

Significant prognostic factors in patients with early gastric cancer

BACKGROUND: Early gastric cancer is defined as a gastric carcinoma confined to the mucosa or submucosa regardless of lymph node status, and it has an excellent prognosis with a 5-year survival rate of more than 90%. From 1985 to 1995, we encountered 266 cases of early gastric cancer in our hospital. METHODS: A retrospective analysis of the 266 cases of early gastric cancer was performed to evaluate the prognostic significance of clinicopathological features (age, gender, tumor size, tumor location, depth of invasion, lymph node metastasis, histological type, lymphatic invasion, vascular invasion, histological growth pattern, cancer-stromal relationship and type of operation). RESULTS: The overall survival rate of all the patients with early gastric cancer was 95.7%. In univariate analysis, the statistical significant prognostic factors were regional lymph node metastasis (P = 0.0004), lymphatic invasion (P = 0.0053) and cancer-stromal relationship (P = 0.0016). Absence of lymph node metastasis and lymphatic invasion, and a medullary-type histopathology were associated with improved survival. In multivariate analysis, the statistically significant prognostic factors were lymph node metastasis and cancer-stromal relationship. CONCLUSIONS: Presence of lymph node involvement and a scirrhous type of gastric cancer are associated with poor prognosis. Lymph node dissection with gastric resection is necessary for patients with early gastric cancer who have a high risk of lymph node metastasis. Postoperative chemotherapy is recommended for a scirrhous type of early gastric cancer.     

早期胃癌淋巴结转移潜在危险因素分析

目的:探讨影响早期胃癌淋巴结转移的潜在危险因素,指导胃癌淋巴结清扫术(D1或D2)的合理应用。方法:回顾性分析1995年3月—2010年6月经手术治疗的336例早期胃癌患者的临床病理资料,对影响早期胃癌淋巴结转移的潜在危险因素进行单因素及多因素分析。结果:早期胃癌淋巴结转移与性别(P=0.010)、年龄(P=0.013)、肿瘤部位(P=0.042)、有无合并溃疡(P=0.001)、浸润深度(P<0.0001)、有无脉管癌栓(P<0.0001)有关,合并有溃疡(P=0.012)、浸润至黏膜下层(P=0.008)及有脉管癌栓(P=0.001)是淋巴结转移的独立性危险因素;黏膜内癌淋巴结转移与肿瘤部位(P=0.007)及大小(P=0.010)有关,肿瘤直径>20mm(P=0.041)是黏膜内癌淋巴结转移的独立性危险因素。结论:合并有溃疡、浸润至黏膜下层及有脉管癌栓的早期胃癌患者进行手术时,建议行淋巴结清扫(D2)术;肿瘤直径>20mm黏膜内癌也要考虑行淋巴结清扫(D2)术。     

早期胃癌血管内皮生长因子的表达及其与淋巴结转移的关系

目的检测血管内皮生长因子(VEGF)家族在早期胃癌中的表达及探讨其与早期胃癌血管增生及淋巴结转移的关系。方法用免疫组织化学方法检测97例早期胃癌VEGF家族的表达及肿瘤血管计数,并将其家族表达与肿瘤部位、组织学类型、组织浸润及淋巴结转移等进行相关分析。结果VEGF家族的表达与肿瘤部位及组织学类型无关(P>0.05)。VEGF-A和C的表达与胃壁静脉浸润、淋巴管浸润及淋巴结转移有关(P<0.05)。在浸润阳性或淋巴结转移阳性肿瘤中,VEGF-A和C表达阳性率较高(P<0.05)。VEGF-C表达阳性肿瘤多位于黏膜下(P<0.05)。VEGF-A、B、C与微血管计数有关,阳性表达肿瘤内血管计数明显增多(P<0.05)。多变量分析显示,VEGF-C表达是影响早期胃癌淋巴结转移的独立因素。结论术前对肿瘤组织进行VEGF-C的检测有助早期胃癌术式的选择及术后辅助治疗。     

Clinicopathologic Characteristics and Surgical Outcomes of Mucinous Gastric Carcinoma

Background The clinicopathologic characteristics of mucinous gastric carcinoma (MGC), an uncommon subtype of gastric carcinoma, were examined by comparing 45 MGC and 1255 non-MGC (NGC) cases. Methods Of 1300 gastric cancer patients, 1184 (early, n = 568; advanced, n = 616) underwent potentially curative or palliative resection. Age, sex, tumor location, tumor diameter, macroscopic appearance, depth of invasion, lymph node metastasis, lymphatic invasion, and venous invasion were monitored. Results In all registered patients, MGC patients’ characteristics were as follows: advanced-stage disease (P = .0293), macroscopically ill-defined tumors (P = .0051), deeper invasion (P = .0046), and more lymph node involvement (P = .0008). Although there were no significant differences between curatively resected MGC and NGC advanced-cancer patients, in curatively resected early-cancer patients, depth of invasion (P = .0060) and lymphatic invasion (P = .0374) were significantly different. Survival time in all registered patients was shorter for MGC patients (P = .0489). Survival of curatively resected advanced and early gastric cancer patients was not significantly different. Age, macroscopic appearance, tumor diameter, depth of invasion, lymph node metastasis, and curability, but not histological type, were independent prognostic factors in all registered patients. Histological type also did not influence prognosis after curative resection. MGC patients had significantly more metastatic lymph nodes and lymphatic and venous invasion. Survival was significantly different (P = .0450) between all patients with undifferentiated and differentiated MGC, but not in curatively resected patients. Conclusions MGC patients’ poor prognosis correlates with advanced disease at diagnosis. Therapeutic and follow-up plans after curative resected MGC and NGC should remain the same, possibly with alterations according to the former’s histological subtype.     

Risk factors predictive of lymph node metastasis in depressed early gastric cancer

BACKGROUND: This study was conducted to identify risk factors predictive of regional lymph node metastasis in depressed early gastric cancer and further to establish an objective criterion useful to indicate additional surgical treatment in cases in which submucosal tumor extension becomes evident by endoscopic mucosal resection (EMR). METHODS: Data from 276 patients surgically treated for depressed early gastric cancer were collected, and the relationship between the patient and tumor characteristics, and the lymph node metastasis was retrospectively evaluated by multivariate analysis. RESULTS: In the multivariate logistic regression model, female sex, a larger tumor size (20 mm or more), submucosal invasion, and presence of lymphatic vessel involvement were found to be independent risk factors for lymph node metastasis. Among 145 patients with submucosally invasive carcinoma, no lymph node metastasis was observed in patients who showed none of the other three risk factors, whereas 14.3% and 23.3% of patients with one and two of these factors had lymph node metastasis, respectively. The lymph node metastasis rate was calculated to be 86.7% in patients who had all three factors. CONCLUSIONS: Submucosal invasion, female sex, tumor size of 20 mm or more, and lymphatic vessel involvement were significantly and independently related to the presence of lymph node metastasis in depressed early gastric cancer. The positive number of the latter three risk factors is a simple criterion to indicate additional surgical treatment in cases with submucosal invasion revealed first by EMR.     

Most Important Lymph Node Information in Gastric Cancer: Multivariate Prognostic Study

Background: In gastric cancer, the level and number of lymph node metastases is useful for predicting survival, and there are several staging systems for lymph node metastasis. The aim of this study was to compare the several lymph node classifications and to clarify the most important lymph node information associated with prognosis using multivariate analysis.Methods: A total of 106 patients with histologically node-positive gastric cancer treated by radical gastrectomy and extended lymph node dissection (D2, D3) were studied. The level of lymph node metastasis was categorized simply as Level I nodes (perigastric, No.1–6), Level II nodes (intermediate, No.7–9), and Level III nodes (distant, No.10–16), irrespective of the tumor location. The Level II nodes included lymph nodes along the left gastric artery, common hepatic artery, and celiac trunk.Results: Overall 5-year survival rate was 51%. Univariate analysis showed that 5-year survival rate was significantly influenced by the level of positive nodes (P < .01), total number of positive nodes (P < .01), number of positive Level I nodes (P < .01), and number of positive Level II nodes (P < .01), in addition to the tumor location (P < .05), tumor size (P < .05), gross type (P < .01), and depth of wall invasion (P < .01). Of these, independent prognostic factors associated with 5-year survival rate were the number of positive Level II nodes (0–1 vs. 2) (62% vs. 19%, P < .01) and the depth of wall invasion (within vs. beyond muscularis) (79% vs. 43%, P < .01).Conclusions: Among several staging systems for lymph node metastases, the number of positive Level II nodes provided the most powerful prognostic information in patients with node-positive gastric cancer. When there were two or more metastases in the Level II nodes, prognosis was poor even after D2 or D3 gastrectomy.