Abstract
BackgroundWhen the risk of lymph node metastasis (LNM) is considered minimal in patients with early gastric cancer (EGC), endoscopic submucosal dissection (ESD) is an effective alternative to radical resection. This study aims to estimate the feasibility of ESD for EGC with ulceration.Patients and MethodsWe retrospectively reviewed data from 691 patients who underwent gastrectomy for EGC with ulceration. Subsequently, a stratification system for lesions was created based on the expanded ESD criteria, and the associations between the subgroups and the rate of LNM were analyzed.ResultsLNM was confirmed in 16.5% (114/691) of patients. Univariate analysis demonstrated that age, sex, tumor size, macroscopic features, depth of invasion, tumor differentiation, Lauren type, lymphovascular invasion (LVI), and perineural invasion were associated with LNM. Multivariate analysis showed that LVI [odds ratio (OR) = 16.761, P < 0.001], SM1 invasion (OR = 2.159, P = 0.028), and SM2 invasion (OR = 3.230, P < 0.001) were independent risk factors for LNM. LNM occurred in undifferentiated mucosal tumors, with ulceration being 1.7% (2/116) when the lesion was smaller than 20 mm. Further stratification revealed that among lesions < 30 mm in size, undifferentiated tumors with SM1 invasion had a higher rate of LNM and a lower disease-free survival rate than differentiated tumors with SM1 invasion and tumors limited to the mucosal layer.ConclusionsDepth of invasion and LVI were strongly associated with LNM in ulcerative EGC. Endoscopic resection may be applicable for undifferentiated mucosal ulcerative EGC < 30 mm in size, and additional investigation is needed to evaluate its safety.
Highlights
RESULTSThird, and 18 (2.6%) were in the upper third. In total, 405 (58.6%) lesions were small, while 174 (25.2%) lesions were medium-sized, and 112 (16.2%) lesions were large
When the risk of lymph node metastasis (LNM) is considered minimal in patients with early gastric cancer (EGC), endoscopic submucosal dissection (ESD) is an effective alternative to radical resection
LNM Lymph node metastasis, OR odds ratio, CI confidence interval, BMI body mass index, H. pylori Helicobacter pylori, CEA carcinoembryonic antigen, M tumor confined within the mucosal layer, SM1 tumor invading the superficial (\ 0.5 mm in depth) submucosa, SM2 tumor invading the deep ([ 0.5 mm in depth) submucosa, LVI lymphovascular invasion
Summary
Third, and 18 (2.6%) were in the upper third. In total, 405 (58.6%) lesions were small, while 174 (25.2%) lesions were medium-sized, and 112 (16.2%) lesions were large. LNM was associated with age, sex, tumor size, macroscopic features, depth of invasion, tumor differentiation, Lauren type, presence of LVI, and presence of perineural invasion on univariate analysis. As presented, differentiated mucosal cancers with ulceration and size B 30 mm, which were included in the expanded ESD criteria, had a relatively low rate of LNM. Age (years) B 60 [ 60 Sex Male Female BMI (kg/m2) B 28 [ 28 Smoking Absence Presence Drinking Absence Presence Hypertension Absence Presence H. pylori infection Negative Positive CEA Negative Positive Location Upper Middle Lower Lesion size Small (B 20 mm) Medium-sized (20–30 mm) Large ([ 30 mm) Macroscopic type 0–IIc (depressed) 0–III (excavated) Number of tumors Single Multitude Invasion depth M SM1 SM2 Differentiation Differentiated Undifferentiated LVI Absence. M tumor confined within the mucosal layer, SM1 tumor invading the superficial (\ 0.5 mm in depth) submucosa, D differentiated type, UD undifferentiated type
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