Sentinel Lymph Node Navigation Surgery for Early Gastric Cancer: Is It a Safe Procedure in Countries with Non-Endemic Gastric Cancer Levels? A Preliminary Experience

Burgeoning study of sentinel-node analysis on management of early gastric cancer after endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) represents an organ-preserving alternative to surgical resection of early gastric cancer. However, even with ESD yielding en-bloc resection specimens, there are concerns regarding tumor spread such as with larger lesions, ulcerated lesions, undifferentiated pathology and submucosal invasion. Sentinel node navigational surgery (SNNS) when combined with ESD offers a minimally invasive alternative to the traditional extended gastrectomy and lymphadenectomy if lack of lymph node spread can be confirmed. This would have a clear advantage in terms of potential complications and quality of life. However, SNNS, though useful in other malignancies such as breast cancer and melanoma, may not have a sufficient sensitivity for malignancy and negative predictive value in EGC to justify this as standard practice after ESD. The results of SNNS may improve with greater standardization and more involved dissection, technological innovations and more experience and validation such that the paradigm for post-ESD resection of EGC may change and include SNNS.

An aggressive early gastric cancer: Kodama's PenA type

BACKGROUND

To investigate the role of Kodama PenA subtype in influencing survival in patients with early gastric cancer (EGC).

METHODS

All patients surgically treated for EGC at 7 Italian centers (Forlì, Varese, Siena, Verona, Milan, Rome and Perugia) belonging to the Italian Research Group for Gastric Cancer (GIRCG) from January 1982 and December 2009 were included.

RESULTS

PenA patients were 230 (21.5%) while other types were 839 (78.5%). Nodal metastases were more common in PenA (30.7%) than non-PenA (10.4%) EGCs. Among preoperative variables, only age (OR 1.02; 95% CI 1.00-1.03, p = 0.009) and macrotype III (OR 1.95; 95% CI 1.39-2.75, p = 0.0001) were significantly associated with Pen A type. Survival analysis performed on N0 patients demonstrated that only size >2 cm (HR 1.85; 95% CI 1.12-3.05, p = 0.017) and age (HR 1.06; 95% CI 1.03-1.08, p < 0.0001) were independent poor prognostic factor. Among N+ patients age (HR 1.04; 95% CI 1.00-1.07, p = 0.048), number of positive lymph nodes (HR 1.13; 95% CI 1.05-1.20, p = 0.0002) and PenA (HR 4.23; 95% CI 1.70-10.55, p = 0.002) were significantly correlated with poor prognosis at multivariate analysis.

CONCLUSIONS

Kodama PenA subtype was the most powerful independent prognostic factor in patients with nodal metastases. Its status should always be investigated in EGCs patients.

N staging: the role of the pathologist

Gastric cancer is the second cause of cancer-related mortality worldwide. Metastases, including lymph nodes ones, heavily influence the prognosis of this disease. The pathological detection of positive lymph nodes is pivotal for an optimal prognostication and clinical management of affected individuals. Several factors influence the pathological investigation of surgical specimens, ultimately affecting the number of retrieved lymph nodes and, with it, the reliability of N staging. The pathologist plays a central role in optimizing this process. Factors influencing lymph node retrieval and analysis will be herein reviewed, together with the procedures adopted for an optimal pathological analysis of lymph nodes in gastric cancer.