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Marcus Kodama Ramos2, Marina Pereira2, André R. Dias2, Osmar K. Yagi2, Sheila F. Faraj3, Adriana V. Safatle-Ribeiro2, Evandro S. Mello3, Fauze Maluf-Filho2, Bruno Zilberstein1, Ivan Cecconello1, Ulysses Ribeiro*1,2
1Gastroenterology, University of São Paulo, Sao Paulo, SP, Brazil; 2Gastroenterology, Sao Paulo Cancer Institute of Hospital das Clinicas, ICESP-HCFMUSP, Sao Paulo, SP, Brazil; 3Pathology, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil

Background: The presence of lymph node metastasis (LNM) is the most important prognostic factor for patients with early gastric cancer (EGC). Although the D2 gastrectomy has been the gold standard treatment, patients with no risk of LNM can be treated safely by minimally invasive treatments and more limited lymphadenectomy. Thus, it is imperative to identify the main risk factors for LNM. However, there are only few studies available examining the factors associated with LNM in western populations, and the adequacy of the endoscopic resection (ER) criteria in Western EGC remains undefined.

Objective: to determine the risk factors for LNM in EGC and verify the effectiveness of the endoscopic treatment according to the traditional and expanded criteria in a western population

Methodology: Baseline and outcome data from gastric cancer patients who underwent gastrectomy with D2 lymphadenectomy between 2009 and 2015 were collected from electronic medical database records. The clinicopathological characteristics were assessed to determine which factors are related to LNM. The traditional and expanded criteria for ER were applied to determine whose patients would have been possible candidates for endoscopic treatment.

Results: Among 474 enrolled patients, 105 presented EGC (22.1%). Mean number of LN retrieved was 35.6% and LNM occurred in 13.3% of all EGC (10% T1a and 15.4% T1b). In multivariable analysis, tumor size, venous, lymphatic and perineural invasions were independent predictors of LNM. The recurrence rate was higher in EGC patients with metastases (pN+) compared to those without metastasis (pN0) (7.1% vs. 2.2%, p=0.28). A significantly greater proportion of patients without LNM were alive at follow-up compared with patients who have LNM (91.2% vs. 71.4%, p=0.032). The recurrence-free survival rate of patients with LNM was 92.9%, whereas in pN0 patients was 97.8% (p=0.254). Based on guidelines for curative ER, no LNM were found in tumors that fulfil the traditional criteria and 13.6% of patients who matched the expanded criteria had LNM. In particular, no LNM was found in differentiated mucosal tumors ≤30mm; and submucosal tumor ≤20mm, regardless of other characteristics.

Conclusion: Tumor size, venous, lymphatic and perineural invasion were factors associated to LNM and should be considered as indicators for surgical treatment of EGC. Expanded criteria for ER can be safely adopted only in selected cases.

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