Risk of lymph node metastasis in early gastric cancer and indications for endoscopic resection: is it worth applying the
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Risk of lymph node metastasis in early gastric cancer and indications for endoscopic resection: is it worth applying the east rules to the west? Leonardo Medeiros Milhomem1 · Daniela Medeiros Milhomem‑Cardoso2 · Orlando Milhomem da Mota1 · Eliane Duarte Mota3 · Alan Kagan3 · Jales Benevides Santana Filho3 Received: 22 May 2020 / Accepted: 25 August 2020 © Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Background Early gastric cancers are associated with lymph node metastasis (LNM) in 15% of cases. Risk factors for LNM are well established in Eastern countries. Less invasive treatments, such as endoscopic or surgical laparoscopic resection, are well accepted in Eastern countries and a matter of intense debate in the West, were indications for such treatments are still contested The objective of the study is to determine risk factors related to LNM and to validate endoscopic resection indications. Methods The study was a retrospective cohort of 178 patients with early gastric cancer who underwent gastrectomy. Clinical and pathological factors were analyzed. The new rules of ER from JGCA were applied to the studied cohort. Results LNM was present in 13.48% of the cases, 3.96% (3/76) in T1a tumors and 20.58% (21/102) in T1b tumors. In univariate analysis ulceration (p = 0.04), differentiation grade (p = 0.04), submucosal invasion (p = 0.001), lymphatic invasion (p 3 cm 20% (2/10)
> 2 cm 0% (0/4) > 2 cm 10% (1/10)
Bold—absolute criteria, italic—expanded criteria, bold italic—relative criteria
respectively. Such data are comparable to other Western and also Eastern series published in the last 20 years (Table 6). Several dedicated studies have demonstrated some variables that are independently associated with LNM in EGC, including tumor size [23–27], presence of ulceration [28, 29], diffuse type of Laurén [30, 31], differentiation grade [28, 30], depth of the tumor [4, 25, 26, 30], and lymphatic and vascular invasion [4, 8, 26, 29–31]. Submucosal invasion and tumor differentiation were associated with increased risk of LNM in our study. This finding does not differ from published large oriental series. A linear increase in LNM rate is seen with a deeper tumor infiltration throughout the layers [25, 26, 30]. Surprisingly, there were no LNM in undifferentiated mucosal lesions regardless of the size. For such undifferentiated lesions, the presence of ulcerations seems to have a relevant role. This finding could be explained due to the limited number of undifferentiated cases (37 lesions) and should be a matter of future analysis as the expansion of ER indications for undifferentiated lesions is a matter of intense debate. In the present study, LNM risk started with M3 ulcerated lesions (5.5%) and increased dramatically when the
lesions reached SM layer. SM1, SM2, and SM3 lesions had 11.6%, 31.5%, and 27.2% of LNM, respectively. The paradox observed for SM2 and SM3 LNM rates is a fact probably related to the limited number of patients in our analy
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