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Lymph Node Metastasis in Mucosal Gastric Cancer

Reappraisal of Expanded Indication of Endoscopic Submucosal Dissection

Oh, Seung-Young MD, MS; Lee, Kyung-Goo MD, MS; Suh, Yun-Suhk MD, MS; Kim, Min A. MD, PhD; Kong, Seong-Ho MD, PhD; Lee, Hyuk-Joon MD, PhD; Kim, Woo Ho MD, PhD; Yang, Han-Kwang MD, PhD

doi: 10.1097/SLA.0000000000001649

Objective: To evaluate risk factors for lymph node (LN) metastasis in mucosal gastric cancer, particularly the effect of cellular differentiation, and implications for the indication of endoscopic submucosal dissection (ESD).

Summary Background Data: The indication of ESD has been expanded to undifferentiated-type (UD-type) gastric cancer despite risk of LN metastasis.

Methods: Patients who underwent radical gastrectomy for pT1a stage primary gastric adenocarcinoma between 2008 and 2012 were retrospectively analyzed. We evaluated risk factors of LN metastasis using univariate and multivariate analyses. Pathologic slides of primary tumor and metastatic LNs from LN positive patients were reviewed.

Results: A total of 1003 mucosal gastric cancer patients were enrolled, and mean number of retrieved LNs was 35.5. Eighteen (1.8%) among them had LN metastasis: 2 of the 502 differentiated-type (D-type) patients and 16 of the 501 UD-type patients (0.4% vs 3.2%, P < 0.001). Type of cellular differentiation was a significant risk factor for LN metastasis in univariate and multivariate analyses. Of 216 UD-type patients satisfying the expanded indication of ESD, 5 patients (2.3%) showed LN metastasis. Despite more aggressive clinical features such as larger size of tumor and more LN metastasis, the UD-type cancer showed a less invasion into the muscularis mucosae layer than the D-type cancer.

Conclusions: Because UD-type cancer is a risk factor for LN metastasis in mucosal gastric cancer, ESD cannot be concluded to be a better option than surgery in all UD-type cancer patients. Redefinition of the expanded indication of ESD is required.

*Department of Surgery, Seoul National University College of Medicine, Seoul, Korea

Department of Pathology, Seoul National University College of Medicine, Seoul, Korea

Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea.

Reprints: Han-Kwang Yang, MD, PhD, Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 110-744, Seoul, Korea. E-mail:

Disclosure: This study was supported by a research grant from the Seoul National University Hospital Research Fund (No. 0420143040).

The authors report no conflicts of interest.

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