Clinical Features and Risk Factors for Lymph Node Metastasis in Early Signet Ring Cell Gastric Cancer

Nomogram for pre-procedural prediction of lymph node metastasis in patients with submucosal early gastric cancer

BACKGROUND

The treatment of early gastric cancer (EGC) is contingent upon the status of lymph node metastasis (LNM). Accurate preoperative prediction of LNM is critical for reducing unnecessary surgeries. This study seeks to evaluate the risk factors for LNM in submucosal EGC and develop a predictive model to optimize therapeutic decision-making.

METHODS

A retrospective analysis was performed on clinical data from 389 patients with T1b-stage EGC who underwent radical gastrectomy. Univariate and multivariate analyses were conducted to identify independent risk factors, followed by the development of a nomogram to predict LNM. The model's efficacy was validated through receiver operating characteristic curves, calibration curves, and decision curve analysis.

RESULTS

Of the 389 patients, 77 had LNM. Logistic regression analysis identified gender, CA199 levels, tumor location, degree of differentiation, presence of ulcers, and lymph node enlargement on CT as independent risk factors for LNM. A nomogram was constructed to assess the risk of LNM, demonstrating strong predictive accuracy with an area under the curve of 0.82 in the training set and 0.74 in the validation set, along with good sensitivity and positive predictive value.

CONCLUSIONS

This study presents a reliable preoperative nomogram to estimate the likelihood of LNM in submucosal EGC, providing valuable guidance for determining the most effective treatment strategies for patients.

Endoscopic Submucosal Dissection Criteria for Differentiated-type Early Gastric Cancer Are Applicable to Mixed-type Differentiated Predominant

BACKGROUND

There is a lack of sufficient evidence on whether mixed-type differentiated predominant early gastric cancer (MD-EGC) can be treated endoscopically by referring to the criteria for differentiated-type early gastric cancer (EGC). This study aims to evaluate the efficacy of endoscopic submucosal dissection (ESD) in MD-EGC.

METHODS

Patients with differentiated-type EGC treated with ESD first from January 2015 to June 2021 were reviewed, including MD-EGC and pure differentiated-type EGC (PD-EGC). Clinical data, including the clinicopathological characteristics, resection outcomes of ESD, and recurrence and survival time, were collected, and the difference between MD-EGC and PD-EGC was tested.

RESULTS

A total of 48 patients (48 lesions) with MD-EGC and 850 patients (890 lesions) with PD-EGC were included. Compared with PD-EGC, MD-EGC had a higher submucosal invasion rate (37.5% vs. 13.7%, P <0.001) and lymphatic invasion rate (10.4% vs. 0.4%, P <0.001). The rates of complete resection (70.8% vs. 92.5%, P <0.001) and curative resection (54.2% vs. 87.4%, P <0.001) in MD-EGC were lower than those of PD-EGC. Multivariate analysis revealed that MD-EGC (OR 4.26, 95% CI, 2.22-8.17, P <0.001) was an independent risk factor for noncurative resection. However, when curative resection was achieved, there was no significant difference in the rates of recurrence ( P =0.424) between the 2 groups, whether local or metachronous recurrence. Similarly, the rates of survival( P =0.168) were no significant difference.

CONCLUSIONS

Despite the greater malignancy and lower endoscopic curative resection rate of MD-EGC, patients who met curative resection had a favorable long-term prognosis.

Latest guideline of endoscopic submucosal dissection of early gastric cancer may not be suitable for Chinese patients: retrospective study findings from two centers

BACKGROUND

To analyze the diagnostic efficiency of the four absolute endoscopic submucosal dissection (ESD) indications for lymph node metastasis (LNM) of Chinese patients with early gastric cancer (EGC).

METHODS

We retrospectively analyzed EGC patients who underwent radical D2 gastrectomy from January 2019 to December 2022. We evaluated the rate of LNM, false-negative rate, and negative predictive value of the four ESD indications.

RESULTS

Of enrolled 2722 EGC patients, 388 (14.3%) patients presented LNM. Tumor size > 2 cm, ulceration, submucosal invasion, undifferentiated type, and lymphovascular invasion were independent risk factors of LNM in patients with EGC. 1062 (39%) cases of EGC conformed to the four EDS indications; however, 4% of them had LNM. 451 cases were fully in accord with the fourth ESD indication (undifferentiated intramucosal carcinoma without ulceration and a maximum lesion diameter of ≤ 2 cm), and 35 of them had LNM, with a false-negative rate (FNR) of 9.02% and a negative predictive value (NPV) of 92.24%. There was significant difference among the four indications in terms of the rate of LNM (1.0% vs 1.5% vs 1.3% vs 7.8%, P < 0.001), FNR (1.03% vs 0.52% vs 0.26% vs 9.02%, P < 0.001), and NPV (98.99% vs 98.53% vs 98.75% vs 92.24%, P < 0.001).

CONCLUSION

Overall, the fourth ESD indication was associated with a high rate of LNM compared to the other three indications. Thus, it might not be safe to classify it as an absolute indication in Chinese patients with EGC.

Risk Factors of Lymph Node Metastasis and Prognosis in 891 Chinese Patients With Submucosal Early Gastric Carcinoma, Emphasizing Differences Between Gastric Cardiac and Noncardiac Origins

Differences in risk factors (RF) of lymph node metastasis (LNM) and prognosis between submucosal early gastric cardiac (SEGCC) and noncardiac (SEGNCC) carcinomas remain unclear. In this study, we investigated and compared RF of LNM and prognosis in 891 patients with radical gastrectomy for SEGCC (n=217) or SEGNCC (n=674). Compared with SEGNCC, SEGCC displayed significantly higher proportion of elderly patients (70 y or above), the elevated macroscopic type, well/moderately differentiated tubular and low-grade papillary adenocarcinomas, as well as low-grade tumor budding, but lower prevalence of the depressed macroscopic type, poorly differentiated tubular adenocarcinoma, mixed adenocarcinoma, poorly cohesive carcinoma, lymphovascular invasion (LVI), perineural invasion, and high-grade tumor budding. By univariate analysis, significant RF for LNM of the cohort included female sex, poor differentiation, SM2 invasion, LVI, intermediate-grade and high-grade tumor budding, whereas tumor size, histology type, and perineural invasion were the significant RF for LNM in SEGNCC. By multivariate analysis, significant independent RF for LNM included female sex and LVI in SEGCC but were female sex, mixed adenocarcinoma, LVI, and high-grade tumor budding in SEGNCC. The 5-year overall survival was significantly worse in SEGCC than in SEGNCC for patients with LNM, but not for those without. For overall survival, LNM was the only significant independent RF in SEGCC, whereas age 70 years or above and LNM were independent RF in SEGNCC. The results of our study provided the clinicopathologic evidence for individualized clinical management strategies for these 2 groups of patients and suggested different pathogenesis mechanisms between SEGCC and SEGNCC.

Clinical Features of Gastric Signet Ring Cell Cancer: Results from a Systematic Review and Meta-Analysis

BACKGROUND

Conflicting results about the prognostic relevance of signet ring cell histology in gastric cancer have been reported. We aimed to perform a meta-analysis focusing on the clinicopathological features and prognosis of this subgroup of cancer compared with other histologies.

METHODS

A systematic literature search in the PubMed database was conducted, including all publications up to 1 October 2021. A meta-analysis comparing the results of the studies was performed.

RESULTS

A total of 2062 studies referring to gastric cancer with signet ring cell histology were identified, of which 262 studies reported on its relationship with clinical information. Of these, 74 were suitable to be included in the meta-analysis. A slightly lower risk of developing nodal metastases in signet ring cell tumours compared to other histotypes was found (especially to undifferentiated/poorly differentiated/mucinous and mixed histotypes); the lower risk was more evident in early and slightly increased in advanced gastric cancer. Survival tended to be better in early stage signet ring cell cancer compared to other histotypes; no differences were shown in advanced stages, and survival was poorer in metastatic patients. In the subgroup analysis, survival in signet ring cell cancer was slightly worse compared to non-signet ring cell cancer and differentiated/well-to-moderately differentiated adenocarcinoma.

CONCLUSIONS

Most of the conflicting results in signet ring cell gastric cancer literature could be derived from the lack of standardisation in their classification and the comparison with the different subtypes of gastric cancer. There is a critical need to strive for a standardised classification system for gastric cancer, fostering clarity and coherence in the forthcoming research and clinical applications.

A nomogram for predicting lymph node metastasis in early gastric signet ring cell carcinoma

At present, the risk factors for lymph node metastasis in early gastric signet ring cell carcinoma (SRCC) remain unclear. However, it is worth noting that the LNM rate and prognosis of early gastric SRCC are superior to those of other undifferentiated cancers. With advancements in endoscopic technology, the 5-year survival rate following endoscopic treatment of early gastric cancer is comparable to traditional surgery while offering a better quality of life. The objective of this study was to develop a nomogram that can predict lymph node status in early gastric SRCC before surgery, aiding clinicians in selecting the optimal treatment strategy. A research cohort was established by retrospectively collecting data from 183 patients with early gastric SRCC who underwent radical gastrectomy with lymph node dissection at our hospital between January 2014 and June 2022. The predictors of early gastric signet ring cell carcinoma lymph node metastasis were identified in the study cohort using the least absolute selection and shrinkage operator (Lasso) and multivariate regression analysis, and a nomogram was developed. The discrimination, accuracy, and clinical practicability of the nomogram were assessed using receiver operating characteristic (ROC) curve analysis, calibration curve analysis, and decision curve analysis. The incidence of lymph node metastasis was 21.9% (40/183) overall. Multivariate logistic regression analysis revealed that tumor size and lymphovascular invasion (LVI) were independent risk factors for lymph node metastasis. Lasso regression analysis demonstrated that tumor size, invasion depth, LVI, E-cadherin expression, dMMR, CA242, NLR, and macroscopic type were associated with lymph node metastasis. The integrated discrimination improvement (IDI) (P = 0.034) and net reclassification index (NRI) (P = 0.023) were significantly improved when dMMR was added to model 1. In addition, the area under curve (AUC) (P = 0.010), IDI (P = 0.001) and NRI (P < 0.001) of the model were significantly improved when type_1 was included. Therefore, we finally included tumor size, invasion depth, dMMR, and macroscopic type to establish a nomogram, which had good discrimination (AUC = 0.757, 95% CI 0.687-0.828) and calibration. Decision curve analysis showed that the nomogram had good clinical performance. We have developed a risk prediction model for early gastric signet ring cell carcinoma that accurately predicts lymph node involvement, providing clinicians with a valuable tool to aid in patient counseling and treatment decision-making.

Prognostic Survival Significance of Signet Ring Cell (SRC) Gastric Cancer: Retrospective Analysis from a Single Western Center

INTRODUCTION

Signet ring cell carcinoma accounts for 35% to 45% of all gastric cancer. Despite the acknowledgment of its more aggressive pathological features, various controversies surrounding this topic still exist. Thus, we investigate the clinical pathological characteristics and survival prognostic significance of signet ring cell components in patients affected by gastric cancer.

METHODS

From January 2004 to December 2020, in a retrospective study, we enrolled 404 patients with gastric cancer who were curatively treated in our department. The male-to-female ratio was 249/142, and the median age was 75 (range 37-94). We dichotomized patients into two groups (75 patients vs. 316 patients) based on the signet ring cell presence; according to preoperative, operative, and postoperative characteristics, we performed a univariate and multivariate analysis for overall survival.

RESULTS

Signet ring cell carcinoma indicated an increasing incidence trend over the time analyzed. Overall median survival of signet ring cell and non-signet ring cell carcinoma were, respectively, 16 vs. 35 months, p < 0.05. In early gastric cancer, the prognosis of the signet ring cell is better than that of the non-signet ring cell, as opposed to advanced cancer. Among the entire population in the multivariate analysis, the only independent factors were preoperative serum albumin level, complete surgical resection, level of lymphadenectomy, and pathological stage. Recurrence occurred more frequently in patients affected by signet ring cell, but in our data, we could not identify a peculiar site of recurrence.

CONCLUSIONS

Signet ring cell carcinoma has a specific oncogenetic phenotype and treatment resistance heterogeneity; however, it is not always associated with poor prognosis. According to our results, a radical surgical procedure associated with an adequate lymphadenectomy should be advocated to improve patients survival. Gastric cancer patients with signet ring cell components should draw clinicians' attention.

The differences in biological behavior and gene expression characteristics between pure and mixed early gastric signet ring cell carcinomas

BACKGROUND

The biological behavior of signet ring cell carcinoma (SRCC) in early gastric cancer (EGC) is not well understood.

AIMS

We aimed to investigate the clinicopathologic and prognostic differences, and explore differences in the gene expression characteristics between pure early SRCC and mixed early SRCC.

METHODS

We retrospectively analyzed 1707 EGC patients. We also conducted a meta-analysis to compare biological behavior in pure SRCC and mixed SRCC. We explored gene expression levels of N6-methyadenosine (m6A) regulators in pure SRCC and mixed SRCC.

RESULTS

Compared with pure SRCC, mixed SRCC was associated with an increased risk of submucosal invasion, perineural invasion, LVI and LNM. LNM was more common in mixed SRCC than with pure SRCC who met the indications for endoscopic submucosal dissection (ESD) (16.67% vs 2.78%). There was no difference in the overall survival between pure SRCC and mixed SRCC in EGCs (P=0.10). Expression of m6A regulators WTAP, FTO and VIRMA was significantly higher in mixed SRCC than that in pure SRCC (P<0.05).

CONCLUSION

Mixed SRCC displayed more aggressive biological behavior than pure SRCC in EGC. WTAP, FTO and VIRMA were expressed at significantly different levels in the two types of EGC, and may have important roles in the observed differences in biological behavior.

Single-cell analysis of gastric signet ring cell carcinoma reveals cytological and immune microenvironment features

Gastric signet ring cell carcinoma (GSRC) is a special subtype of gastric cancer (GC) associated with poor prognosis, but an in-depth and systematic study of GSRC is lacking. Here, we perform single-cell RNA sequencing to assess GC samples. We identify signet ring cell carcinoma (SRCC) cells. Microseminoprotein-beta (MSMB) can be used as a marker gene to guide the identification of moderately/poorly differentiated adenocarcinoma and signet ring cell carcinoma (SRCC). The upregulated differentially expressed genes in SRCC cells are mainly enriched in abnormally activated cancer-related signalling pathways and immune response signalling pathways. SRCC cells are also significantly enriched in mitogen-activated protein kinase and oestrogen signalling pathways, which can interact and promote each other in a positive feedback loop. SRCC cells are shown to have lower cell adhesion and higher immune evasion capabilities as well as an immunosuppressive microenvironment, which may be closely associated with the relatively poor prognosis of GSRC. In summary, GSRC exhibits unique cytological characteristics and a unique immune microenvironment, which may be advantageous for accurate diagnosis and treatment.

Risk of lymph node metastasis and feasibility of endoscopic submucosal dissection in undifferentiated-type early gastric cancer

BACKGROUND

Whether endoscopic submucosal dissection (ESD) applies to undifferentiated-type early gastric cancer (UEGC) remains controversial. We aimed to analyze the risk factors for lymph node metastasis (LNM) in UEGC and evaluate the feasibility of ESD.

METHODS

This study included 346 patients with UEGC who underwent curative gastrectomy between January 2014 and December 2021. Univariate and multivariate analyses of the correlation between clinicopathological features and LNM were conducted, and the risk factors for exceeding the expanded ESD indications were evaluated.

RESULTS

The overall LNM rate in UEGC was 19.94%. Among the preoperatively assessable factors, submucosal invasion (odds ratio [OR] = 4.77, 95% confidence interval [CI]: 2.14-10.66) and > 2 cm(OR = 2.49, 95% CI: 1.20-5.15) were independent risk factors for LNM, while postoperative independent risk factors were > 2 cm (OR = 3.35, 95% CI: 1.02-5.40) and lymphovascular invasion(OR = 13.21, 95% CI: 5.18-33.70). Patients who met the expanded indications had a low LNM risk (4.1%). Additionally, tumors located in the cardia (P = 0.03), non-elevated type (P < 0.01) were independent risk factors for exceeding the expanded indications in UEGC.

CONCLUSIONS

ESD may be applicable for UEGC meeting the expanded indications, and preoperative evaluation should be cautious when the lesion is non-elevated type or located in the cardia.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (12/05/2022 ChiCTR2200059841 ).

Predictive factors of lymphatic metastasis and evaluation of the Japanese treatment guidelines for endoscopic resection of early gastric cancer in a high-volume center in Perú

Purpose

This study aimed to identify the predictive factors of lymph node metastasis (LNM) in patients with early gastric cancer (EGC) and to evaluate the applicability of the Japanese treatment guidelines for endoscopic resection in the western population.

Methods

Five hundred-one patients with pathological diagnoses of EGC were included. Univariate and multivariate analyses were conducted to identify the predictive factors of LNM. EGC patients were distributed according to the indications for endoscopic resection of the Eastern guidelines. The incidence of LNM was evaluated in each group.

Results

From 501 patients with EGC, 96 (19.2%) presented LNM. In 279 patients with tumors with submucosal infiltration (T1b), 83 (30%) patients had LNM. Among 219 patients who presented tumors > 3 cm, 63 (29%) patients had LNM. Thirty-one percent of patients with ulcerated tumors presented LMN (33 out of 105). In 76 patients and 24 patients with lymphovascular and perineural invasion, the percentage of LMN was 84% and 87%, respectively. In the multivariate analysis, a tumor diameter >3 cm, submucosal invasion, lymphovascular, and perineural invasion were independent predictors of LMN in EGC. No patient with differentiated, non-ulcerated mucosal tumors presented LNM regardless of tumor size. Three of 17 patients (18%) with differentiated, ulcerated mucosal tumors and ≤ 3 cm presented LNM. No LNM was evidenced in patients with undifferentiated mucosal tumors and ≤ 2 cm.

Conclusions

The presence of LNM in Western EGC patients was independently related to larger tumors (>3 cm), submucosal invasion, lymphovascular and perineural invasion. The Japanese absolute indications for EMR are safe in the Western population. Likewise, Western patients with differentiated, non-ulcerated mucosal tumors, and larger than 2 cm are susceptible to endoscopic resection. Patients with undifferentiated mucosal tumors smaller than 2 cm presented encouraging results and ESD could be recommended only for selected cases.

Update on diagnosis and treatment of early signet-ring cell gastric carcinoma: A literature review

Gastric signet-ring cell gastric carcinoma (GSRC) is an unfavorable subtype of gastric cancer (GC) that presents with greater invasiveness and poorer prognosis in advanced stage than other types of GC. However, GSRC in early stage is often considered an indicator of less lymph node metastasis and more satisfying clinical outcome compared to poorly differentiated GC. Therefore, the detection and diagnosis of GSRC at early stage undoubtedly play a crucial role in the management of GSRC patients. In recent years, technological advancement in endoscopy including narrow-band imaging and magnifying endoscopy has significantly improved the accuracy and sensitivity of the diagnosis under endoscopy for GSRC patients. Researches have confirmed that early stage GSRC that meets the expanded criteria of endoscopic resection showed comparable outcomes to surgery after receiving endoscopic submucosal dissection (ESD), indicating that ESD could be considered standard treatment for GSRC after thorough selection and evaluation. This article summarizes the current knowledge and updates pertaining to the endoscopic diagnosis and treatment of early stage signet-ring cell gastric carcinoma.

Risk factors for cervical lymph node metastasis of head and neck squamous cell carcinoma: A retrospective population-based study

INTRODUCTION

Head and neck squamous cell carcinoma (HNSCC) is characterized by high frequency of early cervical lymph node metastases (LNMs), resulting in poor survival of patients. However, cervical LNMs are difficult to detect, which makes the decision-making of which patients should undergo neck dissection surgery challenging for surgeons. This study aimed to analyze the clinicopathological risk factors associated with cervical LNM and determine the indications for neck dissection in HNSCC patients.

METHODS

The medical records of patients diagnosed with HNSCC who were treated at our hospital between January 2010 and June 2020 were retrospectively reviewed. A database of their clinicopathological data, including sex, age at diagnosis, primary tumor regions, tumor size, and grade, was constructed. The associations of these clinicopathological features with cervical LNM were analyzed using univariate and multivariate logistic regression analyses. The TCGA database were used to externally validate the risk factors.

RESULTS

Overall, 531 patients with HNSCC were included; 38.6% had confirmed pathological cervical LNM. Univariate and multivariate analyses identified that tumor size and grade were independent risk factors associated with LNM (odds ratio = 1.338, 95% CI: 1.015-1.767, p &lt; 0.05; odds ratio = 1.936, 95% CI: 1.46-2.587, p &lt; 0.0001, respectively). The significant positive associations of tumor size and grade with LNM were externally validated in the TCGA datasets.

CONCLUSIONS

HNSCC patients with large tumor size or poor tumor differentiation degree were at high risk of lymph node metastasis and were recommended to undergo neck dissection.

Undifferentiated-predominant mixed-type early gastric cancer is more aggressive than pure undifferentiated type: a systematic review and meta-analysis

BACKGROUND

Studies have shown that differentiated-predominant mixed-type early gastric cancer (EGC) is more aggressive than pure differentiated-type EGC. However, the biological behaviour of undifferentiated-predominant mixed-type (MU) EGC and pure undifferentiated-type (PU) EGC are controversial. This study was conducted to compare the biological behaviour of MU EGC and PU EGC.

METHODS

A systematic review and meta-analysis of observational studies was conducted using literature published through PubMed and Embase from inception to 9 November 2021. Inclusion criteria were: (1) a direct or indirect comparison of MU and PU; (2) patients with EGC; (3) a specified outcome of lymph node metastasis (LNM), lymphovascular invasion, submucosal invasion and/or ulcer findings; and (4) the primary lesion was obtained. The literature search, data extraction and quality assessment were performed by two independent reviewers. The meta-analysis was conducted with a random-effect model using the Mantel-Haenszel method.

RESULTS

Twelve publications with 5644 patients were included. Patients with MU EGC had significantly higher risk of LNM (OR 2.28; 95% CI 1.72 to 3.03) and submucosal invasion (OR 2.19; 95% CI 1.90 to 2.52) compared with patients with PU EGC. No difference was found between patients with MU and PU EGC with respect to lymphovascular invasion risk (OR 1.81; 95% CI 0.84 to 3.87). After stratifying the data according to depth of tumour invasion, a significantly higher risk for LNM was associated with intramucosal MU EGC (OR 2.56; 95% CI 1.66 to 3.95) and submucosal MU EGC (OR 2.63; 95% CI 2.06 to 3.06). Submucosal MU EGC also had a significantly higher risk of lymphovascular invasion (OR 2.40; 95% CI 1.79 to 3.21) compared with submucosal PU EGC.

DISCUSSION

Patients with MU EGC had an increased risk of submucosal invasion and LNM compared with patients with PU EGC . MU patients with submucosal EGC also had an increased lymphovascular invasion risk compared with PU patients. Therefore, attention should be focused on the clinical management of patients with MU EGC.