Published online Jan 14, 2015. doi: 10.3748/wjg.v21.i2.667
Peer-review started: June 13, 2014
First decision: July 9, 2014
Revised: July 16, 2014
Accepted: July 24, 2014
Article in press: July 25, 2014
Published online: January 14, 2015
AIM: To evaluate the biopathologic features and clinical significance of nodal micrometastasis (MI) in early gastric cancer (EGC).
METHODS: Among 1022 EGC patients who underwent gastrectomy with lymphadenectomy of D1 + β or more from March 2001 to December 2005 at the Korean National Cancer Center, available nodal metastasis was found in 90 pT1N1 patients. Nodal metastasis was confirmed by immunohistochemistry (IHC) with cytokeratin and patients were classified into MI and macrometastasis (MA) groups based on the main tumor burden according to the 6th International Union Against Cancer/American Joint Committee on Cancer staging system; the main tumor burden with a diameter of greater than 0.2 mm but no greater than 2 mm as MI, and greater than 2 mm as MA of the representative metastatic node. Proliferative and apoptotic activities of the primary tumor and the nodal metastasis were measured by IHC with Ki-67 and terminal deoxynucleotidyl transferase dUTP nick end labeling, respectively. Biopathologic and clinical features of the patients were analyzed and compared between MI and MA groups. Patients with recurrence were compared with those without recurrence to identify risk factors for recurrence.
RESULTS: Thirty-seven patients showed MI and the other 53 patients revealed MA in the lymph node; the incidence of patients with MI and MA was 41.1% and 58.9%. The main tumor burden was 0.9 and 4.6 mm in the representative metastatic node, respectively. Japanese N2 stations were more frequently involved in MA group (20.9%) than in MI group (10.3%) but the difference was not statistically different (P = 0.338). Proliferative and apoptotic activities of MI were decreased than those of MA (26.7% vs 40.5%, P = 0.004 and 1.0% vs 3.0%, P < 0.001, respectively). However, nodal MI in the current study showed a relatively high proliferative activity and an equivalent apoptotic activity compared to other cancers in the previously published studies. Recurrence was observed in 6 patients during the mean follow up period of 87.6 ± 26.2 mo. The recurrence was significantly associated with the presence of MA (P = 0.041) and lymphovascular invasion of the primary tumor (P = 0.032).
CONCLUSION: Lymphadenectomy of D1 + β or more might be necessary in patients with MI in sentinel node to prevent recurrence by clearing MI involving Japanese N2 station.
Core tip: Nodal micrometastasis in early gastric cancer (EGC) has a relatively high proliferative and an equivalent apoptotic activities compared to other cancers. The incidence of Japanese N2 station micrometastasis involvement is about 10%. Lymphadenectomy of D1+β or more might be necessary if micrometastasis is identified during sentinel node biopsy in EGC.