Multiple synchronous early gastric cancers: high-risk group and proper management

Multiple early gastric cancers (MEGCs) may be easily missed on preoperative gastroscopy because the lesions are predominantly small and flat. This may increase the risks of gastric remnant lesions and recurrence. We aimed to define high-risk group of MEGC and suggest proper management of missed lesion after partial gastrectomy.

A total of 117 patients with MEGCs and 2182 with solitary EGC who underwent gastrectomy between 2008 and 2010 were retrospectively analyzed to determine their clinicopathologic characteristics. We also assessed their family history, the presence of Helicobacter pylori infection, and of precancerous lesions; and the results of microsatellite instability and immunohistochemical staining of the primary (largest) lesion for p53, human epidermal growth factor receptor [HER1], and HER2 were also reviewed.

MEGCs occurred more frequently in elderly males and in patients with adenoma, atrophic gastritis, or a family history of gastric cancer. These patients had more favorable pathologic findings, including less deep invasion, better differentiation, more intestinal type, and less frequent lymphovascular/perineural invasion than patients with solitary EGCs. The mean size of MEGCs was smaller (2.44 cm vs 3.36 cm) but there was no difference in the number of metastatic lymph nodes. Most accessory lesions were confined to the mucosal layer, with their average diameter was 1.82 cm.

A careful preoperative gastroscopy should be performed in patients at high risk of MEGCs and more cautious postoperative endoscopic surveillance of the remnant stomach is required. For missed foci on remnant stomach, endoscopic resection can be a good option if it meets the criteria.