Is lymphadenectomy necessary for early gastric cancer?

Although early gastric cancer (T1, NX) in Japan has been reported to have an excellent prognosis, the experience with this cancer in the United States is limited. The treatment of these tumors in Japan is becoming less aggressive as "good prognostic factors" are increasingly recognized. Our objective was to identify predictors of nodal disease and survival in a large cohort of Western patients with T1 tumors.

A retrospective review of our prospective data base from July 1985 to March 1998 revealed 165 patients undergoing surgical resection for T1 gastric tumors. Clinicopathological factors analyzed and compared included presence of positive nodes, tumor size (> or =4.5 vs. <4.5 cm), depth (mucosal vs. submucosal), grade (poor vs. moderate and well), and tumor site (proximal vs. distal), presence of venous or perineural invasion, and Lauren's classification. Factors predicting lymph node involvement and disease-specific survival were evaluated by univariate and multivariate analysis.

Median follow-up time was 36 months. The actuarial 5-year survival was 88%. Thirteen patients (8%) died of disease. Lymph node involvement was present in 31 tumors (19%), with a 5-year survival of 91% with negative nodes vs. 78% with positive nodes. On univariate and multivariate analysis, the presence of tumor submucosal invasion (P<.05), venous invasion (P = .02), and size of 4.5 cm and larger (P = .02) was significantly associated with an increased risk for nodal positivity. On univariate analysis of survival, node-positive tumors (P = .02) and tumors 4.5 cm and larger (P = .008) were significantly associated with decreased survival. On multivariate analysis, only node-positive tumors were significantly (P = .01) associated with decreased survival. Those tumors that were limited to the mucosa and less than 4.5 cm in size (n = 47) had a 4% rate of positive nodes. In contrast, those tumors that were 4.5 cm and larger and had penetrated into the submucosa (n = 16) had a 56% chance of positive nodes.

Early gastric carcinoma in North America has an excellent prognosis, similar to that in Japan. Tumors that are limited to the mucosa and smaller than 4.5 cm could be considered for limited resection without lymphadenectomy.