Retrospective Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Aug 26, 2020; 8(16): 3474-3482
Published online Aug 26, 2020. doi: 10.12998/wjcc.v8.i16.3474
Combination of endoscopic submucosal dissection and laparoscopic sentinel lymph node dissection in early mucinous gastric cancer: Role of lymph node metastasis
Hua Li, Li-Li Zhao, Xiao-Chong Zhang, Deng-Xiang Liu, Gui-Ying Wang, Zhi-Bin Huo, Shu-Bo Chen
Hua Li, Li-Li Zhao, Xiao-Chong Zhang, Deng-Xiang Liu, Zhi-Bin Huo, Shu-Bo Chen, Institute of Cancer Control, Xingtai People’s Hospital, Xingtai 054001, Hebei Province, China
Gui-Ying Wang, Department of General Surgery, Fourth Affiliated Hospital of Hebei Medial University, Shijiazhuang 050000, Hebei Province, China
Author contributions: Li H, Zhao LL, Zhang XC, and Liu DX contributed equally to this work; Huo ZB, Chen SB, and Wang GY should be regarded as co-corresponding authors of this article; Huo ZB, Chen SB, and Wang GY designed the research; Li H analyzed the data and drafted the manuscript; Zhao LL and Zhang XC revised the manuscript critically for important intellectual content and contributed to the data analysis; Liu DX helped draft the manuscript; all authors read and approved the final manuscript.
Institutional review board statement: This study is a retrospective study for the data of patients collected from the Department of Surgical Oncology, Xing Tai People’s Hospital during 1988-2016. No human body was involved in this study. According to our hospital’s policy, this study does not require an approval by the hospital institutional review board.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: No conflict of interest is declared by the authors.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Zhi-Bin Huo, PhD, Professor, Institute of Cancer Control, Xingtai People’s Hospital, No. 16 Hongxing Street, Xingtai 054001, Hebei Province, China. zhibinhwcwk@126.com
Received: March 20, 2020
Peer-review started: March 20, 2020
First decision: April 29, 2020
Revised: July 5, 2020
Accepted: July 16, 2020
Article in press: July 16, 2020
Published online: August 26, 2020
Processing time: 158 Days and 0.5 Hours
ARTICLE HIGHLIGHTS
Research background

Endoscopic submucosal dissection (ESD) has become a standard treatment for tumors meeting the specific criteria characteristic of very low lymph node metastasis (LNM) risk: Intramucosal differentiated adenocarcinoma and ≤ 2 cm in size with no ulcers. Meanwhile, in undifferentiated early gastric cancer with a high risk of LNM, gastrectomy with lymph node dissection is usually performed as the standard surgical procedure. For undifferentiated gastric cancer, it consists of mucinous adenocarcinoma, poorly differentiated adenocarcinoma, and primary signet ring cell carcinoma. However, for approximately 96% of surgical patients with early mucinous gastric cancer (EMGC) confined to the mucosa, no LNM was observed, suggesting that it might be over-treated for these cases. Therefore, we have proposed new methods to minimize gastric resection for EMGC. The new technique allows minimally invasive resection of gastric lesions through ESD and laparoscopic sentinel lymph node dissection (SLND).

Research motivation

We attempted to identify a subgroup of EMGC patients in whom the risk of LNM can be ruled out and treated them by ESD and SLND, which may serve as a breakthrough treatment for EMGC.

Research objectives

We carried out this retrospective study to determine the clinicopathological factors that are predictive of LNM in EMGC. Furthermore, we established a simple criterion to expand the possibility of using ESD and SLND for the treatment of EMGC.

Research methods

The association between the clinicopathological factors and the presence of LNM was retrospectively analyzed by univariate and multivariate logistic regression analyses. Odds ratios (OR) with 95% confidence intervals (CIs) were calculated. We further examined the relationship between the positive number of the three significant predictive factors and the LNM rate.

Research results

Depth of invasion (OR = 7.342, 95%CI: 1.127-33.256, P = 0.039), the tumor diameter (OR = 9.158, 95%CI: 1.348-29.133, P = 0.044), and lymphatic vessel involvement (OR = 27.749, 95%CI: 1.821-33.143, P = 0.019) were found to be significant and independent risk factors for LNM by multivariate analysis. For patients with one, two, and three of the risk factors, the LNM rates were 9.1%, 33.3%, and 75.0% respectively. LNM were not found in seven patients without one or more of the three risk factors.

Research conclusions

ESD might be a sufficient treatment for intramucosal EMGC if tumor size ≤ 2 cm, and when LVI is absent upon postoperative histological examination. The combination of ESD and SLND could be recommended as an effective, minimally invasive treatment for EMGC patients having a potential risk of LNM.

Research perspectives

The minimalization of therapeutic invasiveness in order to preserve quality of life is a major topic in the management of early gastric cancer. One of the critical factors in choosing minimally invasive surgery for EMGC would be the precise prediction of whether the patient has LNM or not. Therefore, in the future, the combination of ESD and SLND could be recommended as an effective, minimally invasive treatment for EMGC patients having a potential risk of LNM.