Surgical Endoscopy

, Volume 33, Issue 1, pp 26–32 | Cite as

The incidence of lymph node metastasis in submucosal early gastric cancer according to the expanded criteria: a systematic review

  • Mohamed M. AbdelfatahEmail author
  • Mohamed Barakat
  • Mohamed O. Othman
  • Ian S. Grimm
  • Noriya Uedo
Review Article



For successful endoscopic treatment of early gastric cancer (EGC), absolute criteria for a curative en bloc resection were initially established to include predominantly differentiated mucosal lesions ≤ 2 cm in diameter without ulceration. These indications were subsequently expanded to include larger, ulcerated, and predominantly undifferentiated mucosal lesions. In addition, differentiated type adenocarcinomas ≤ 3 cm with slight submucosal invasion of < 500 µm (pT1b1) are regarded as “curative” under the expanded criteria. However, data derived from studies of surgical specimens in patients with pT1b1 EGC have yielded varying rates of lymph node metastasis (LNM).


A systemic review was conducted using the pooled analysis to calculate the incidence of LNM in pT1b1 EGC, and to investigate whether using a cut-off value of < 300 µm would decrease the risk of LNM in patients with submucosal EGC.


Nineteen articles were included. 1507 patients with pT1b1 EGC met the expanded indications. The incidence of LNM was 3% (45 out of 1507 patients). In a subgroup analysis of three studies, there was no significant difference in the LNM between pT1b EGC < 300 µm and < 500 µm [3/121(2.5%) vs. 5/180 (2.8%)] (OR 0.89, 95% CI 0.22–3.54).


Overall, expanding the indications for endoscopic resection of EGC to include lesions ≤ 3 cm T1b1 is associated with a potential risk of LNM of 3%. In countries outside of Japan, we found a slightly higher risk of LNM (4.0%). These estimates of LNM should be incorporated into decisions regarding further management of patients with EGC ≤ 3 cm who are found to have slight submucosal invasion (< 500 µm) in an ESD specimen. Standardization of specimen handling and histological evaluation is essential if the Japanese results of endoscopic treatment for EGC are to be successfully applied in other parts of the world.


Foregut Esophagus and stomach Surgery/interventions Malignant gastric diseases 


Compliance with ethical standards


Dr. Ian S. Grimm is a consultant at Boston Scientific. Mohamed M. Abdelfatah, Mohamed Barakat, Mohamed O. Othman, and Noriya Uedo declare that they have no conflict of interest or financial ties to disclose.


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Division of Gastroenterology and HepatologyEast Carolina UniversityGreenvilleUSA
  2. 2.Department of Internal MedicineNYC HealthNew YorkUSA
  3. 3.Gastroenterology and Hepatology SectionBaylor College of MedicineHoustonUSA
  4. 4.Division of Gastroenterology and HepatologyUniversity of North CarolinaChapel HillUSA
  5. 5.Department of Gastrointestinal OncologyOsaka International Cancer InstituteOsakaJapan

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