Background and Aims
Japanese criteria for curative endoscopic resection of early gastric cancer initially
included nonulcerated, well-differentiated mucosal lesions ≤2 cm in diameter, known
as the absolute criteria. Subsequently, these indications were expanded to include
larger, ulcerated, and undifferentiated mucosal lesions as well as differentiated
lesions with slight submucosal invasion. Whether patients meeting the expanded criteria
can be managed safely without gastrectomy and lymph node dissection has been controversial.
The risk of lymph node metastasis (LNM) in patients who met the expanded criteria
is a critical factor in determining the best course of management for these patients.
Methods
We comprehensively searched main reference databases for studies that included patients
who underwent gastrectomy and lymph node dissection for early gastric cancer. A meta-analysis
was conducted by using the random effects model. Relative risk reduction was used
to compare the incidence of LNM in patients meeting the absolute criteria as compared
with those meeting the expanded criteria.
Results
Twelve studies met the inclusion criteria, providing a total of 9798 patients. The
incidence of LNM was 0.2% for patients who met the absolute criteria as compared with
0.7% for patients who met the expanded criteria. Analysis of the various components
of the expanded criteria was conducted, revealing that the incidence of LNM for differentiated
mucosal lesions ≤3 cm with ulceration and for differentiated mucosal lesions without
ulceration, irrespective of size, was 16 of 2814 (0.57%), reference range (RR) 3.01;
P = .02 and 8 of 3004 (0.27%), RR 1.69; P = .37, respectively, only marginally higher than the risk of LNM associated with
the absolute criteria. In contrast, undifferentiated mucosal lesions ≤2 cm and differentiated
lesions <3 cm with slight submucosal invasion had a significantly higher incidence
of LNM in comparison with the absolute criteria (25/972 [2.6%], RR 6.79; P = .0004 and 8/315 [2.5%], RR 6.30; P = .004, respectively).
Conclusion
Overall, expanding the indication for endoscopic resection to include mucosal nonulcerated
differentiated lesions irrespective of size and differentiated mucosal ulcerated lesions <3
cm is justified with minimal increased risk in comparison to the absolute criteria.
However, expanding the indication for undifferentiated lesions ≤2 cm and differentiated
lesions with slight submucosal invasion (T1b) should be balanced with the risks of
surgery, given the increased risk of LNM in these patients.
Abbreviations:
EGC (early gastric cancer), ESD (endoscopic submucosal dissection), LND (lymph node dissection), LNM (lymph node metastasis)To read this article in full you will need to make a payment
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Article info
Publication history
Published online: September 28, 2017
Accepted:
September 19,
2017
Received:
July 8,
2017
Footnotes
DISCLOSURE: M. Othman is a consultant for Olympus and Boston Scientific. All other authors disclosed no financial relationships relevant to this publication.
See CME section; p. 573.
If you would like to chat with an author of this article, you may contact Dr Othman at [email protected]
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