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Evaluating Lymph Node Metastasis Risk in Mucosal Gastric Cancer Diagnosed with WHO Classification: Implications for Updated Endoscopic Submucosal Dissection Criteria

Authors
Jane Chungyoon Kim MD1, Yo-Seok Cho MD1, Kyoyoung Park MD1, Yoonjin Kwak, MD, PhD3,4, Seong-Ho Kong, MD, PhD1,5, Do Joong Park, MD, PhD1,2,5, Hyuk-Joon Lee, MD, PhD1,2,5, Hye Seung Lee, MD, PhD3,4,5, Han-Kwang Yang, MD, PhD1,2,5

Affiliations

  1. Department of Surgery, Seoul National University Hospital, Seoul, South Korea.
  2. Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea.
  3. Department of Pathology, Seoul National University Hospital, Seoul, South Korea.
  4. Department of Pathology, Seoul National University College of Medicine, Seoul, Republic of Korea.
  5. Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea.

Background
While endoscopic submucosal dissection (ESD) has gained popularity as a minimally invasive treatment for early gastric cancer (EGC), concerns persist regarding the risk of lymph node metastasis (LNM) within the expanded ESD criteria. This study aims to LNM risk in mucosal gastric cancer patients within updated ESD criteria and provide guidance for personalized treatment.

Methods
We conducted a retrospective cohort study of 2,232 mucosal gastric cancer patients who underwent curative gastrectomy at Seoul National University Hospital. We assessed clinicopathological factors, including age, gender, tumor size, tumor location, ulcer presence, histological type, lymphovascular invasion (LVI), and the number of metastatic lymph nodes.

Results
LNM occurred in 3.35% of patients. Undifferentiated-type (UD-type) tumors within updated ESD criteria (size ≤2cm, without ulceration) had a 2.1% LNM rate, while Differentiated-type (D-type) tumors (no ulcers with size>2cm or presence of ulcer with size≤3cm) showed 3.3% and 1.4% LNM rates, respectively. D1+ LN dissection sufficed for mucosal gastric cancers. Multivariate analysis identified large tumor size, ulceration, UD-type, and lymphovascular invasion (LVI) as significant LNM risk factors, with UD-type tumors consistently having higher LNM rates than D-type tumors across size categories.

Conclusion
This study underscores substantial LNM risk in mucosal gastric cancer under updated ESD criteria. Individualized treatment and counseling, especially for young patients with good performance status, are vital. These findings advocate for a cautious approach to managing mucosal gastric cancer, aligning treatment with patient characteristics and risks.