Clinicopathological Analysis as Predictive Factors for Recurrence in Early Gastric Cancer

Discussion

Although the prognosis of EGC is excellent, a small but definite number of postoperative recurrences have been reported. The recurrence rate of EGC treated by gastrectomy has been reported to vary from 1.4% to 6.4%^[6,^7]. In our study, the recurrence rate for gastrectomy with lymphadenectomy was 7.6%.

The risk factors related to recurrence of EGC have been discussed in several articles^[8]. Ichiyoshi et al.^[9] reported that the elevated type, and positive lymph nodes were significantly associated with a high risk of recurrence. Shiozawa et al.^[6]considered some other factors, such as submucosal invasion, a gross appearance of IIa + IIc type and a tumor size > 40 mm. However, in our study, lymph node metastases were the only significant predictive factor for the recurrence of EGC using univariate analysis. Lymph node metastases have been repeatedly proposed as one of the most important predictive factors in many studies^[10,11], which are similar to our results. The postoperative recurrence rate with and without lymph node metastasis, was 18.9% and 5.7% respectively.

Excessive gastrectomy and lymphadenectomy may affect perioperative morbidity and mortality. We have to look to improving post-operative function and quality of life after gastric cancer surgery without adversely affecting long term outcome^[12]. Therefore, minimally invasive treatments such as EMR are considered to be appropriate options for EGC patients. However, current application of EMR is limited to indications^[13]. Thus, we sought to expand the use of EMR to EGC by retrospectively examining recurring EGC to determine predictive factors for recurrence.

In our study, univariate analysis demonstrated that the presence of lymph node metastasis was the only predictive factor for recurrence. Although lymph node metastases seem to identify a high-risk population that perhaps should not be offered EMR, this can be determined only after gastrectomy with lymphadenectomy. Thus, these pathological features are not useful in EMR. Based on our finding, there were no proper predictive factors to determine EGC cases with a high risk of recurrence or preoperatively determine which operation (gastrectomy with lymphadenectomy or EMR) should be performed.

The application of adjuvant chemotherapy for lymph node metastatic EGCs has been a controversial issue. Sano et al.^[14] recommended that adjuvant chemotherapy for EGC with lymph node metastasis is not recommended, because of its low incidence of recurrence, but Maehara et al.^[15] supported adjuvant chemotherapy because of the high susceptibility of cancer cells within lymph nodes to chemotherapeutic agents. In our study, the postoperative recurrence rate was 18.9% in patients with lymph node metastasis, and 5.7% in those without. This result suggests that EGC with lymph node metastasis could be considered in a high risk individual who is a good for candidate for adjuvant treatment such as chemotherapy.

In conclusion, lymph node metastases were the only predictive factor for recurrence. However, this cannot be confirmed before surgery or EMR. This pathologic factor was not useful to identify patients at high risk for recurrence who should be offered gastrectomy rather than EMR. Although after gastrectomy with lymphadenectomy for EGC, patients with lymph node metastasis should be considered as candidates for adjuvant treatment.