Abstract
BackgroundEndoscopic resection (ER) has come to be recognized as a standard treatment for early gastric cancer (EGC). While its adoption is expanding, ER remains restricted to cases of EGC without lymph node metastasis for the treatment of local resection. On the other hand, histopathological analyses of surgically resected specimens of EGC have revealed the presence of lymph node (LN) metastasis in some cases of mucosal gastric cancer (MGC) and undifferentiated MGC (UD-MGC) is considered to have higher risk of nodal metastases than differentiated MGC (D-MGC). To evaluate the risk factors for LN metastasis in MGC, we investigated the characteristics of UD-MGC associated with LN metastasis.MethodsAmong all UD-MGC patients who underwent surgery as initial treatment, between January 2000 and March 2016, we reviewed the clinicopathological data, including the preoperative endoscopic findings and histopathological findings in the resected specimens, of the 11 UD-MGC patients who were identified as having lymph node metastasis. Furthermore, in comparison with cases without lymph node metastasis, we examined the possibility of expansion of the indication for local treatment.ResultsIn most of the cases of UD-MGC with LN metastasis, the lesions were relatively large (> 20 mm in diameter) and of the clearly depressed type with faded color and apparent border, and histopathology revealed a high percentage of cases with lymphatic invasion and a predominance of signet ring cell carcinomas. No cases with LN metastasis without depressed macroscopic type nor signet ring cell carcinoma component existed. A degree of invasion of lamina propria (LP) or muscularis mucosae (MM) had same relation to the risk of LN metastasis.ConclusionsIn this study, none of the cases of undifferentiated-type mucosal cancer (UD-MGC) with LN metastasis satisfied the current adoption criteria for ER. We suggested significant risk factors for LN metastasis in UD-MGC cases as depressed tumor type, presence of a signet ring cell carcinoma component, presence of lymphatic tumor invasion, and a large tumor size. More detailed analyses of the endoscopic and histopathological findings may allow further risk classification for LN metastasis in cases of UD-MGC.
Highlights
Endoscopic resection (ER) has come to be recognized as a standard treatment for early gastric cancer (EGC)
We analyzed the endoscopic and clinicopathological characteristics of these cases of UD-mucosal gastric cancer (MGC) with LN metastasis, and in comparison with cases without lymph node metastasis, we examined the possibility of expansion of the indication for local treatment
In addition to the above variables, we reviewed the endoscopic findings, histopathological pattern, number of metastatic LNs, and depth of tumor invasion (classified as lamina propria (LP) or muscularis mucosae (MM)) in the undifferentiated MGC (UD-MGC) patients identified as having LN metastasis, and the cases were limited to with lymph node metastasis, whose histopathological appearance was strictly examined to estimate factors of lymph node metastasis
Summary
Endoscopic resection (ER) has come to be recognized as a standard treatment for early gastric cancer (EGC). While its adoption is expanding, ER remains restricted to cases of EGC without lymph node metastasis for the treatment of local resection. Histopathological analyses of surgically resected specimens of EGC have revealed the presence of lymph node (LN) metastasis in some cases of mucosal gastric cancer (MGC) and undifferentiated MGC (UD-MGC) is considered to have higher risk of nodal metastases than differentiated MGC (D-MGC). Endoscopic resection (ER) has come to be adopted as a standard treatment method for cases of early gastric cancer (EGC) without lymph node (LN) metastasis, in place of conventional radical gastrectomy with LN dissection. Mucosal gastric cancer (MGC) is known to be associated with a small risk of LN metastasis, depending on the histopathological pattern, presence/absence of lymphatic/vascular invasion, size, and presence/absence of ulceration. Current criteria for adoption of ER, including the expanded criteria, are based on the analysis of the groups of patients to have an absent or lower risk of LN metastasis rather than on the risk of mortality from surgery [6], though indications for ESD in undifferentiated adenocarcinoma are still controversial regarding to the oncologic features of undifferentiated EGC
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