Clinical characteristics and therapeutic strategies of atypical meningioma

Background  Atypical meningioma accounts for about 4.7% to 7.2% of all kinds of meningiomas, which is invasive with a relatively high recurrence and mortality. The objective of this study was to investigate the clinical manifestations and therapeutic strategies of atypical meningioma.

Methods  A total of 74 patients who underwent surgical treatment and pathologically confirmed for atypical meningioma in Neurosurgery Department of Beijing Tiantan Hospital from January 2003 to December 2008 were enrolled in this study. The characteristics of the tumors as well as therapeutic regimens and follow-up data were reviewed. After surgery, 56 patients underwent radiotherapy. Patients were followed up for about 3.5 years (range, 0.5–6.0 years), and 58 patients completed follow-up.

Results  Of the 58 patients who completed follow-up, good recovery was found in 30, neurological dysfunction in 15, and death in 13. Of the 58 patients, 21 had recurrent meningioma and 18 underwent a second surgery.

Conclusions  Atypical meningioma is difficult to manage, with a high recurrence rate and poor survival. The extent of tumor resection and histological grade are the key determinants of outcome. Radiation therapy can be used as an adjunctive treatment after total or partial resection.

     

New prognostic parameters for very-low-risk gastrointestinal stromal tumors

Background  According to the National Institutes of Health consensus criteria, gastrointestinal stromal tumors (GISTs) smaller than 2 cm in diameter with less than 5 mitotic figures per 50 high-power fields are considered very-low-risk GISTs, but these two indices alone cannot reliably predict a benign outcome during long-term follow-ups. Therefore, identification of additional parameters for predicting the clinical behavior of GISTs is necessary.

Methods  Eighty-eight patients with tumors that meet the very-low-risk GIST criteria were retrospectively investigated and morphological parameters of tumors associated with the biological behavior of very-low-risk GISTs were evaluated in the present study. The Kaplan-Meier method was used to calculate disease-free survival rates.

Results  Eighty-one patients were followed up for one to 16.3 years. Five cases of relapses were identified in the patients. Distinctive infiltrative growth patterns such as muscularis propria, muscularis mucosa, or nerve infiltration were identified by microscopy in 4 patients with the relapse, including three patients who experienced multiple recurrences. The infiltrative growth features became more obvious in multiple recurrent tumors compared to the single recurrent tumor, while only one developed relapse in 76 patients without infiltration (P <0.0001).

Conclusion  Microscopic infiltrative growth patterns of the tumor may have clinical significance in predicting the prognosis of very-low-risk GISTs.

     

Does urothelial cancer of bladder behave differently in young patients?

Background  Bladder urothelial cancer has been diagnosed at an increasing rate among young adults in China while the clinical outcomes remain highly controversial. To optimize the management of young patients with bladder cancer, we examined whether bladder urothelial cancer in young patients behaved differently from that in the elder patients.

Methods  From 1994 to 2008, a database of bladder urothelial cancer patients at a major tertiary medical center was retrospectively reviewed. The clinical and pathological parameters of patients who were less than 40 years of age and a series of patients older than 40 years of age as the control group during the same period were compared. A survival analysis was performed using the Kaplan–Meier method and log-rank test, and Cox regression was performed to identify clinical parameters that affected the clinic outcomes.

Results  Young bladder cancer patients had a lower male-to-female ratio and were less likely to have advanced stages and high-grade cancers at the initial diagnosis. Tumors in young bladder cancer patients tended to be less multifocal at diagnosis. In addition, young patients had a lower recurrence rate and longer recurrence interval than older patients. The Kaplan-Meier curve and Log-rank test showed that young patients had significantly better cancer specific survival than old patients. The univariate and multivariate Cox regression analysis revealed that tumor grade is the sole predictor for tumor recurrence in young patients.

Conclusions  Young patients with bladder cancer have favorable pathological features and clinical outcomes than older patients. These findings argue for more conservative management approaches for young patients with bladder cancer.

     

Arsenic trioxide: an ancient drug revived

Objective  To summarize the clinical applications of arsenic trioxide (ATO) in the treatment of acute promyelocytic leukemia (APL), as well as non-APL malignancies and to discuss the mechanisms and adverse effects involved in ATO administration.

Data sources  The data in this article were collected from PubMed and CHKD database with relevant English and Chinese articles published from 1957 to 2011, with key words including acute promyelocytic leukemia, arsenic trioxide, treatment, and mechanism.

Study selection  Articles including any information about ATO in the treatment of APL were selected.

Results  APL is a rare subtype of acute myeloid leukemia, with dismal prognosis under treatment with traditional chemotherapy. ATO impressively increases the complete remission rate and prolongs survival of patients with APL, with only mild and transient adverse effects. The advances in the understanding of multiple mechanisms involved in ATO treatment will benefit more cancers in future.

Conclusion  Deeper understanding of mechanisms involved in ATO treatment may provide rationales for future clinical applications in a number of human malignancies.

     

Evaluation of whether serum tumor markers in patients with epithelial ovarian carcinoma change following chemotherapy

Background  Phenotypic and genotypic heterogeneity is a known feature of many cancers. Whether serum tumor marker kinds vary and change following chemotherapy is still unclear. The aim of this study was to investigate whether there is a change in the expression of serum tumor markers following chemotherapy, and the potential clinical significance in patients with epithelial ovarian carcinoma (EOC) or primary serous peritoneal carcinoma (PSPC).

Methods  Samples were collected before surgery, during chemotherapy and during follow-up for enzyme-linked immunosorbent assay (ELISA)-based evaluation of serum CA-125, CA19-9 and CP2 levels in patients with EOC or PSPC who had received primary debulking surgery followed by adjuvant chemotherapy. In total, 72 patients were examined, including 37 patients with recurrent lesions and 35 patients receiving first-line chemotherapy.

Results  In 35 de novo patients, 20% (7/35) demonstrated a significant changed serum tumor marker kinds among whom the patients with mucinous carcinoma (57.1%, 4/7) showed resistance to chemotherapy. In the 37 recurrent patients, 51.4% (19/37) had changed serum tumor markers, of whom 57.9% (11/19) presented with serous carcinoma. There was no significant difference in median progression-free survival or overall survival in patients with drug-sensitive or drug-resistant recurrence in patients with changed tumor marker kinds relative to those with unchanged markers. However, for patients with changed serum tumor markers there was a trend towards prolonged survival compared with the unchanged serum tumor marker group. In the 17 patients with secondary recurrence, 37.5% (6/17) had changed tumor marker levels. The ratios of CA-125/CP2 and CA-125/CA19-9 were significantly different after either chemotherapy or recurrence.

Conclusions  Serum tumor marker expression in patients with EOC or PSPC may change after chemotherapy or recurrence, indicating that in addition to the markers that are abnormal before surgery, those markers that are normal should also be monitored during chemotherapy and follow-up.

     

Prognostic value of clinical characteristics and immunophenotypic biomarkers in 115 patients with primary central nervous system lymphoma

Background  Clinical outcome in patients with primary central nervous lymphoma (PCNSL) is variable and poorly predictable. This study investigated the association of clinical features and immune markers with prognosis of patients with PCNSL.

Methods  One hundred and fifteen newly diagnosed PCNSL patients at the study institution were considered eligible for this study. Clinical characteristics and biochemical assay data were collected. Immunohistochemical staining of Cyclin D3, Cyclin E, Foxp1, and LMO2 were performed. All cases were followed-up regularly.

Results  The common sites of involvement were frontal lobe (54.8%) and thalamus (16.5%). Diffuse large B-cell lymphoma composed of 96.5% of the cases. The median overall survival was 22 (4–41) months, and the 5-year survival rate was 22.8%. Age >65 years, serum globulin >40 g/L, large size of tumor, lymphocyte count ³1´10⁹/L, and expression of Cyclin D3 and Cyclin E were associated with poor prognosis of PCNSL. Expressions of Foxp1, LMO2, and CD44 were not related to the survival. Expression of Cyclin E, large tumor size, and high serum globulin were independent prognostic factors for PCNSL.

Conclusions  PCNSL prognosis is relatively poor. Age, high tumor burden, higher lymphocyte count, expression of Cyclin D3, and Cyclin E are inferior prognostic factors for PCNSL.

     

An Asian population-based survival analysis of patients with distal esophageal and gastric cardia adenocarcinomas

Background  Gastroesophageal junction adenocarcinomas include adenocarcinomas of the distal esophagus (DE) and gastric cardia (GC). It is controversial whether these tumors are the same entity and whether they have the same survival rates. Patients with DE and GC adenocarcinomas have a similar survival rate in the US; however, data are lacking in Asian countries. Therefore, we conducted a retrospective study to understand the implications of the tumor location in the survival of Asian patients.

Methods  A total of 209 patients with pathologically confirmed DE and GC adenocarcinomas, from 2005 to 2007, were included in the study. We identified patients with adenocarcinomas of the DE (DE group, n=91) and GC (GC group) (n=118). We performed an unadjusted survival analysis using the Kaplan-Meier method, and used a Cox proportional hazards regression model to adjust for potential confounding covariates.

Results  We found no significant difference between the overall survival of the DE and GC groups. The 3-year survival rates were 44.8% and 53.0%, respectively, and the 5-year survival rates were 27.9% and 30.2%, respectively (P=0.162). We found no significant difference in early staging, advanced staging, different T staging, and different N staging, between the groups. Both advanced post-operative N staging and advanced AJCC staging had a significant adverse effect on survival.

Conclusions  Patients with DE and GC adenocarcinomas have similar survival rates in the Asian population. Both post-operative N staging and AJCC staging are prognostic factors.

     

Pancreatic and peri-pancreatic lesions mimic pancreatic islet

Objective  This pictorial review aimed to summarize the most possible differential diagnosis of pancreatic islet cell tumor (PICT).

Data sources  Data used in this review were mainly from Medline and Pubmed in English. And all clinical images in this review were from Department of Radiology, Peking Union Medical College Hospital, Beijing, China.

Study selection  Cases of pancreatic cystadenoma, solid pseudo-papillary tumor of the pancreas, pancreatic metastasis, pancreatic adenocarcinoma, para-pancreatic neuroendocrine tumors, Castleman disease, gastrointestinal stromal tumor, splenic artery aneurysm and accessory spleen were selected in this pictorial review for differential diagnosis of PICT.

Results  Careful analysis of imaging features and correlation with the clinical manifestations may allow a more specific diagnosis. It is also important that the radiologist is familiar with the anatomic variants and disease entities which mimic pancreatic islet cell tumor in order to avoid an improper treatment protocol.

Conclusions  Many congenital anatomic variants or other pancreatic and peri-pancreatic diseases may mimic MDCT appearance of pancreatic islet cell tumor. Radiological, clinical and pathological characteristics should be considered for the final diagnosis.

     

Clinical and histopathologic features of biofilm-associated chronic rhinosinusitis with nasal polyps in Chinese patients

Background  Biofilms have given new insights to the understanding of pathogenesis of chronic rhinosinusitis (CRS). However, the link between biofilms formation and local inflammatory response remains poorly defined in CRS with nasal polys. The aim of this study was to determine the potential association of the presence of biofilms in the nasal mucosal tissues with clinical features in Chinese patients, which had CRS with nasal polyps (CRSwNP).

Methods  A total of 19 patients with CRSwNP and 12 patients with non-CRS were subjected to endoscopic surgery and their nasal mucosal tissue specimens were examined histologically and by scanning electron microscopy (SEM). Their demographic and clinical features were recorded.

Results  Thirteen (68.4%) out of the 19 specimens from patients with CRSwNP, but none from control patients, were positive for biofilms that displayed typical characteristics of bacterial and fugal structures. The presence of biofilms in the nasal mucosal tissues was associated with significantly greater values of purulent nasal discharge and preoperative Lund-Kennedy scores, higher levels of serum total IgE and percentages of subjects with endoscopic surgery (ESS) history in patients with CRSwNP, and more severe inflammation in the nasal mucosal tissues of patients with CRSwNP.

Conclusion  Our study demonstrated the presence of biofilms in the nasal mucosal tissues of many patients, contributing to the understanding of the pathogenic process of CRSwNP in Chinese patients.

     

Bleb-associated endophthalmitis treated by sclera patch graft, vitrectomy and endoscopic cyclophotocoagulation

Background  Bleb-associated endophthalmitis (BAE) is a rare but severe complication of trabeculectomy with poor outcome. Various surgical methods were explored to treat such patients. However, there is no defined protocol. The aim of this study was to describe a new combined operation, and to demonstrate the outcome of the treatment.

Methods  Nine patients with BAE were enrolled in our study. The combined operation including pars plana vitrectomy (PPV), sclera patch graft (SPG) and endoscopic cyclophotocoagulation (ECP) was used to treat these patients.

Results  In the follow-up of 18–24 months, all patients with the endophthalmitis were cured, the useful visual acuity was preserved in 7 patients, and the intraocular pressure (IOP) of 8 patients was controlled just after first operation, only one needed another trans-scleral cyclophotocoagulation.

Conclusion  This combined operation is a useful method for treating the patients with BAE, with SPG and vitrectomy to control the endophthalmitis and ECP to balance the postoperative IOP.

     

早期胃癌淋巴结转移预测因素

目的 分析早期胃癌淋巴结转移预测因素.方法 回顾性分析我院1996年-2010年手术治疗的719例早期胃癌中与淋巴结转移相关的临床病理资料.结果 早期胃癌淋巴结转移率为14.9％.单因素分析表明影响早期胃癌淋巴结转移的因素主要有肿瘤部位、肿瘤大小、组织学类型、浸润深度和脉管侵润.多因素分析显示肿瘤浸润深度、组织学类型和脉管侵润与早期胃癌淋巴结转移显著相关.结论 早期胃癌淋巴结转移与肿瘤浸润深度、组织学类型和脉管侵润因素相关;缩小手术在早期胃癌治疗中是合适的.     

Extended indication criteria for endoscopic mucosal resection of early gastric cancer with special reference to lymph node metastasis--examination by multivariate analysis

The purpose of this study was to clarify extended indication criteria of endoscopic mucosal resection (EMR) for early gastric cancer (EGC) by analyzing the independent risk factors involved in lymph node metastasis (LNM). Subjects were 422 patients who underwent gastrectomy with lymph node dissection for EGC at the Kurume University Hospital from 1994 to 2001. The EGCs were mucosal cancers (M) in 252 cases and submucosal cancers (SM) in 170 cases. Twelve clinico-pathological factors were assessed for their possible association with LNM. On univariate analysis, EGC with LNM showed the following characteristics: size; 3.1 cm or more, ulceration; present, heterogeneity; present, differentiation; poor, lymphatic vascular invasion; present, and invasion depth; SM2 (cancer penetration of submucosal layer, 0.5 mm or more from the muscularis mucosa). On multivariate analysis, the following four factors were identified as independent risk factors; invasion depth: Odds Ratio (OR) 10.9, lymphatic vascular invasion: OR 10.6, size: OR 3.2, and ulceration: OR 3.2. The incidence of LNM was 0% (0/141) (95% confidence interval, 0-2.6%) when these risk factors met the following four conditions: invasion depth; M or SM1 (cancer penetration of submucosal layer, less than 0.5 mm), lymphatic vascular invasion; absent, size; 3.0 cm or less, and ulceration; absent. It is concluded that EMR is a suitable radical treatment for EGC, and that the indication criteria for EMR can be extended depending on the results of the histological evaluation of the en bloc/total resected specimen concerning the above four factors for LNM.     

中老年早期胃癌浸润深度相关因素分析及其与淋巴结转移的关系

目的 研究中老年早期胃癌浸润深度与临床病理特征的相关性,探讨早期胃癌浸润深度的相关危险因素及其与淋巴结转移的关系.方法 回顾分析2013年1月-2019年12月,六安市人民医院普通外科收治的110例中老年早期胃癌患者的临床及病理资料,分析早期胃癌浸润深度和淋巴结转移与各临床病理特征的关系,采用logistic回归模型分...     

Preoperative Neutrophil Lymphocyte Ratio and Platelet Lymphocyte Ratio Cannot Predict Lymph Node Metastasis and Prognosis in Patients with Early Gastric Cancer: a Single Institution Investigation in China

In the present study, we aimed at exploring the applied value of preoperative neutrophil lymphocyte ratio (NLR) and platelet lymphocyte ratio (PLR) in the prediction of lymph node metastasis (LNM) and prognosis in patients with early gastric cancer (EGC). We retrospectively analyzed a total of248 consecutive patients who underwent curative gastrectomy to be identified T1 stage gastric adenocarcinoma between January 1, 2010 and May 1, 2016 in a single institution. According to median preoperative NLR and PLR value, we divided the patients into four groups: high NLR >1.73 and low NLR <1.73, high PLR >117.78 and low PLR <117.78. Furthermore, to evaluate the relationship between preoperative NLR and PLR values, we categorized patients according to cutoff preoperative NLR-PLR score of 2 [high NLR (>1.73) and high PLR (>117.78)], 1 [either high NLR or high PLR], and 0 [neither high NLR nor high PLR], Statistical analyses were conducted using SPSS 20.0 software. The results showed that the preoperative NLR or PLR values, lower or higher, could not predict the LNM in patients with EGC (both P=0.544>0.05). The invasive depth of tumor was significantly correlated with LNM of EGC (P0.001). Kaplan-Meier plots illustrated that preoperative NLR and PLR values were not associated with overall survival (OS) in patients with EGC. It was concluded that the preoperative NLR and PLR may be the predictors for LNM and prognosis in patients with advanced gastric cancer; nevertheless, they cannot predict LNM and prognosis in patients with EGC.     

71例老年早期胃癌的临床分析

目的：研究老年早期胃癌患者的临床病理特征、手术治疗方式及预后因素。方法：回顾性分析我院1996年1月～2005年12月干部病房收治的71例老年早期胃癌的临床病理资料。结果 ：本组病例占同时期收治胃癌患者的33.8%,57.7%的患者无症状;本组手术切除率为100.0%,手术死亡率为1.4%;术后5年生存率为94.1%,10年生存率为91.5%。单因素分析表明肿瘤浸润深度、淋巴结转移、淋巴管癌栓显著影响老年早期胃癌患者的预后（P〈0.05）。结论：规律胃镜检查能有效提高早期胃癌发现率;年龄不是老年早期胃癌患者根治切除的禁忌证;浸润深度、淋巴结转移、淋巴管癌栓是影响老年早期胃癌预后的重要因素。     

混合型早期胃癌淋巴结转移情况及对预后的影响

  目的  探讨混合型早期胃癌淋巴结转移的规律以及淋巴结转移对远期预后的影响。  方法  选取2014年1月到2016年1月上海交通大学医学院附属苏州九龙医院收治的87例混合型早期胃癌患者作为研究对象，均接受手术治疗。对患者进行随访，观察总生存时间（OS），分析混合型早期胃癌淋巴结转移的规律以及淋巴结转移对OS影响。  结果  87例混合型早期胃癌患者中，20例淋巴结转移，67例未转移，淋巴结转移率为22.99%。淋巴结转移患者肿瘤直径、淋巴管受累率、黏膜下层比例、溃疡型比例高于非淋巴结转移患者，差异有统计学意义（P < 0.05）。Logistic分析结果显示，浸润深度、淋巴管受累、肿瘤大小是混合型组淋巴结转移的影响因素（P < 0.05）。随访时间48～72个月，平均随访时间（62.8±4.8）个月，失访6例，患者3 a生存率为90.1%，5 a生存率为86.4%。Kaplan-Meier法并Log-rank检验显示，混合型组淋巴结转移患者OS短于非淋巴结转移患者（P < 0.05）。Cox分析结果显示，淋巴管受累、淋巴结转移、血管受累、浸润深度是混合型早期胃癌患者生存的独立影响因素（P < 0.05）。  结论  混合型早期胃癌淋巴结转移率高，肿瘤直径大、浸润黏膜下层、淋巴管受累患者淋巴结转移风险增高，且淋巴结转移患者预后差，死亡率高。     

Prognostic significance of metastatic lymph nodes ratio in patients with gastric adenocarcinoma after curative gastrectomy

Background We evaluated the impact of the number of metastatic lymph nodes and the metastatic lymph nodes ratio （the ratio between metastatic lymph nodes and total dissected lymph nodes,MLNR） in patients with gastric adenocaminoma following curative gastrectomy and also analyzed the relationship between the number of removed lymph nodes and prognosis in node-negative gastric cancer.Methods From January 2005 to December 2010,1 390 patients who were diagnosed with gastric adenocarcinoma and underwent curative gastrectomy were included.In particular,lymph node metastasis was not present in 515 patients.The number of metastatic lymph nodes and the metastatic lymph nodes ratio were selected for univariate and multivariate analyses to evaluate their influences on the disease outcome.The survival curve was presented according to the number of removed lymph nodes in node-negative gastric cancer using Kaplan-Meier plots.Results The overall 5-year survival rate was 54％ in this group.Univariate analysis revealed that age category,macroscopic appearance,histological grade,tumor size,depth of primary tumor invasion,number of metastatic lymph nodes,metastatic lymph nodes ratio,tumor,nodes,metastasis-classification （TNM） stage and status of lymphovascular,and vessel invasion have significant impact on survival.The number of metastatic lymph nodes and the metastatic lymph nodes ratio both have significant impact on survival （P ＜0.001）.However,in multivariate analyses,only the metastatic lymph nodes ratio was identified to be an independent prognostic factor （P ＜0.001）.The number of removed lymph nodes in node-negative was a strong prognostic factor of survival,the more lymph nodes dissected,the better the survival.Conclusions The metastatic lymph nodes ratio has more significant prognostic value for survival in patients with gastric cancer following curative gastrectomy than the number of metastatic lymph nodes.The number of removed lymph nodes miaht be an important proanostic factor for gastric cancer without lymph node metastasis.     

腹腔镜与开腹手术在早期胃癌根治术的对比研究

目的探讨腹腔镜早期胃癌根治术的疗效和应用价值。方法进行腹腔镜与开腹术早期胃癌根治术的35例和42例患者,分别作为LAP组OPEN组。结果两组患者在手术时间、术中出血量、术后恢复肛门排气时间、术后进食半流食时间、术后住院时间、手术费用等方面有显著差异（P〈0．05）,两组患者在总住院费用、清扫淋巴结数量、肿瘤切缘以及肿瘤部位、手术切除方式、淋巴结清扫范围、并发症、浸润深度、淋巴结转移、复发率等方面无统计学意义（P〉0．05）。结论腹腔镜胃癌根治术在临床治疗上具有诸多优势,且具有较高的手术安全性和较好的治疗效果。     

胃癌神经侵犯与预后的相关性分析

目的探讨胃癌神经侵犯(Perineural invasion PNI)与胃癌预后的相关性。方法回顾性分析328例胃癌根治术后患者的临床病理资料(根据2002年日本肿瘤协会公布的JGC-TNM分期标准),研究神经侵犯与胃癌临床病理参数的关系及其对胃癌预后的意义。结果χ2检验结果显示:胃癌神经侵犯与浸润深度、TNM分期及淋巴结转移均显著相关(P<0.05)。单因素分析显示:PNI(+)组患者的中位生存时间及5年生存率明显低于PNI(-)组患者(P=0.018),与胃癌患者预后密切相关。多因素COX回归分析显示神经侵犯不是影响胃癌术后患者生存的独立预后因素(P=0.238)。结论胃癌神经侵犯与胃癌患者预后有关,并提示预后不良,但不能作为判断胃癌患者预后的独立指标。     

Proximal gastric cancer: lymph node metastatic patterns according to different T stages dictate surgical approach

Background As a common form of gastric cancer migration,lymph node metastasis largely affects the surgical treatment and prognosis of gastric cancer.Surgery is the fundamental curative option for gastric cancer that varies depending on different stages.The study aimed to compare the clinicopathological characteristics and lymph node metastatic patterns in patients of proximal gastric cancer with different T stages and investigate a reasonable radical gastrectomy approach in terms of the range of lymphadenectomy for proximal gastric cancer.Methods In our retrospective study,the data of 328 patients of proximal gastric cancer with different T stages were analyzed.By comparing the differences of lymph node metastatic rate and ratio,we investigated the clinicopathological characteristics and metastatic patterns of lymph nodes.Also,we were especially interested in the differences in survival rates between patients with and without No.5 and 6 group metastasis with the same TNM stage.Results The overall lymph node metastatic rate and ratio of advanced proximal gastric cancer were 73.4％ and 23.3％,respectively.The tumors of different T stages were statistically significant in size and differentiation degree （P ＜0.05）,multivariate analysis showed that the depth of tumor invasion was an independent risk factor for lymph node metastasis in proximal gastric cancer （RR,12.025; 95％ CI,2.326 to 62.157; P=0.003）.The overall survival rate of patients with No.5,6 group lymph node metastasis and those without was significantly different,but the differences in survival rates between patients with and without No.5 and 6 group metastasis with the same TNM stage were not statistically significant.Conclusions Different T stages in proximal gastric cancer showed different patterns and characteristics of lymph node metastasis.D2 lymphadenectomy in patients with early gastric cancer had little survival benefit because metastasis to level 2 nodes was rare.Therefore the range of the lymph node dissection in radical gastrectomy