Published online Oct 15, 2018. doi: 10.4251/wjgo.v10.i10.360
Peer-review started: July 3, 2018
First decision: July 11, 2018
Revised: August 24, 2018
Accepted: August 27, 2018
Article in press: August 28, 2018
Published online: October 15, 2018
For patients with poorly differentiated early gastric cancer (EGC), gastrectomy with lymphadenectomy is usually performed even though the gastric lesions can be completely removed with endoscopic submucosal dissection (ESD) due to the higher risk of lymph node metastasis (LNM). However, many surgical EGC cases actually do not have LNM, indicating that this surgery may not be necessary for many cases of EGC. To avoid this unnecessary surgery, the new technique combines ESD with laparoscopic lymph node dissection (LLND), which may lead to the elimination of unnecessary gastrectomy in poorly differentiated EGC patients having a potential risk of LNM.
We attempted to identify a subgroup of poorly differentiated EGC patients in whom the risk of LNM can be ruled out and treated them with ESD and LLND, which may serve as a breakthrough treatment for poorly differentiated EGC.
In this study, we intended to determine the risk factors that were predictive of LNM in poorly differentiated EGC patients and to provide some suggestions to guide the application of the combination of ESD and LLND for selected patients with poorly differentiated EGC.
We retrospectively analyzed 138 patients with poorly differentiated EGC who underwent gastrectomy with lymphadenectomy (between January 1990 and December 2015). We also retrospectively analyzed (by univariate and multivariate logistic regression analyses) the association between the clinicopathological factors and the presence of LNM. We further examined the relationship between the positive number of the significant predictive factors and the LNM rate.
Tumor size, depth of invasion and lymphatic vessel involvement were found to be independently risk clinicopathological factors for LNM in poorly differentiated EGC. Furthermore, we established a simple criterion to expand the possibility of using ESD and LLND for the treatment of poorly differentiated EGC.
ESD might be sufficient treatment for intramucosal poorly differentiated EGC if the tumor is less than or equal to 2 cm in size, and when lymphatic vessel involvement is absent upon postoperative histological examination. We found that the ESD with LLND may lead to the elimination of unnecessary gastrectomy in poorly differentiated EGC.
The minimization of therapeutic invasiveness in order to preserve quality of life is a major topic in the management of EGC. One of the critical factors in choosing minimally invasive surgery for EGC would be the precise prediction of whether the patient has LNM. Therefore, in the future, we will carry out this retrospective study to determine the clinicopathological factors that are predictive of LNM in EGC and to guide the individual application of minimally invasive surgery in a suitable subgroup of patients with EGC.