Characteristics of submucosal gastric carcinoma
with lymph node metastatic disease
H J Son, S Y Song,1 S Kim,3 J H Noh,2 T S Sohn,2 D S Kim1 & J C Rhee
Histopathology 2005, 46, 158–165.
Presented by intern 張家維
Introduction
2nd most common cause of cancer deaths
 East Asia and south America
 Korea and Japan  early detection
 Early Gastric Carcinoma
Mucosa or Submucosa
 5-year survival rate
 Lymph node metastasis
prognosis, submucosal invasion

Introduction
Depth of submucosal layer viaries
 The depth of submucosal gastric carcinoma
(SMGC)
 Lymph node metastasis
macroscopic appearance, location, size,
tumor area, differentiation, invasion depth,
submucosal vascularity, fibrosis near the
tumor area
 Age- and Sex- matched

Materials and methods
Sampling: 248 patients SMGC
 Surgical resection
 Samsung Medical Centre (Seoul, Korea)
 1995/Jan.~ 2002/Oct.
 Total 917 patients SMGC
124 LN metastasis (13.5%)
 Anticancer therapy X
 Evidence of metastatic disease X

Materials and methods
124 SMGC with LN metastasis
 124 SMGC without LN metastasis
 Age- and Sex- matched
 Specimens  routinely examined
 10% formalin
 Embedded in paraffin
 H & E stained

Materials and methods
Macroscopic:
Japanese Endoscopic Society Classification
Elevated, Depressed, Flat
 Microscopic:
Lauren classification

Materials and methods

Depth of submucosal invasion
1.Ocular lens scale, distance between the
lower edge of the muscularis mucosa and
the deepest invading front of the tumor
cells
2.sm3 method: sm1, sm2, sm3
3.sm2 method: smi , sme
Materials and methods
Tumor size
Longest dimension of the tumor area
 Tumor area
Longest dimension X its prependicular
counterpart
 Tumor vessels
vessels with a smooth muscle coat in the
submucosa

Materials and methods
Statistical analysis:
Log linear model, McNemar’s test, A paired
t-test, Wilcoxon’s signed rank test
 P-value < 0.05  statistically significant
 SAS, version 6.12

Results
Pathological parameters and lymphnode metastatic disease
124 SMGC with lymph node metastasis
69 males (55.6%), 55 females (44.4%)
31~83 y/o, the mean age 56.3 y/o
 The main locations of the tumors
60 lower, 61 middle, 3 upper 1/3
 Tumor size
5~125 mm, the mean = 45 mm
 Tumor area
0.8~105.0 cm2, the mean = 17.1 cm2

Results
Pathological parameters and lymphnode metastatic disease
The gross types of the tumors
35 elevated (28.2%), 85 depressed (68.5%),
4 flat (3.2%)
 The histological differentiations (Lauren’s)
53 intestinal (42.7%), 65 diffuse (52.8), 6
mixed (4.8%)
 111 N1 (89.5%), 13 N2 (10.5%)

Results
Pathological parameters and lymphnode metastatic disease
Significantly associated with node-positive SMGC
1. presence of lymphatic tumor emboli
2. a larger tumor area
3. a larger tumor size
4. a non-flat gross type
5. an increased vascularity
 No significant relationship
1. location
2. Lauren classification
3. tumor related fibrosis

Results
Depth-related parameters and lymph node metastatic disease
Ocular scale-measured depth
1. proved to have a significant correlation
with node-positive SMGC
2. superficial invasive, deeply invasive (2mm)
 The sm3 method
not well correlated
 The sm2 method
not well correlated

Results
Multivariate analyses for possible indicators of LN metastatic disease
Multivariate logistic regression analysis
location, gross type, Lauren’s classification,
lymphatic tumor emboli, increased
vascularity, tumor-related fibrosis, tumor
size, depth (sm2 method)
 The incidence of lymph node metastatic
disease increased in the presence of
lymphatic tumor emboli and in the tumors
that invaded more than half of the
submucosal layer

Discussion
EGC, the “early”
horrible disaster  curable disease
early diagnosis and treatment programs
 The term of EGC has 2 innate defect
1. lymph node metastatic diseases
2. discriminate submucosal tumor call invasion
 5-year survival rate
93~99% for node-negative EGC
73~90% for node-positive EGC
90~100% for intramucosal confinement
73~90% for submucosal invasion

Discussion
The treatment now for EGC
conducting minimally invasive surgical procedures 
endoscopic mucosal resection, laparoscopic partial
resection
need careful and intensively subclassification
 Remove all metastatic lymph nodes ?
chance of a cure↓
 Factors related to lymph node metastatic disease

Discussion
SMGC lymph node metastasis rate
10~25%
 917 SMGC in this tiral
13.5% LN metastasis
 The parameters related to LN metastasis
lymphatic tumor emboli (uni- or multi- variate
analysis)
depth-related (accurate invasion depth, sm2
method)

Discussion

The best way to represent a submucosal tumor invasion
Tsuchiya et al. = sm3
not appropriate for classifying tumor from
endoscopic biopsy specimen
Yasuda et al. = accurately the depth
submucosal tumor invasion of locally
resected tumor > 300μm  gastrectomy +
LN dissection
Japanese Classification of Gastric Cancer criteria (0.5mm)
depth of submucosal tumor invasion < 0.5mm  sm1
depth of submucosal tumor invasion > 0.5mm  sm2
Discussion
Univariate analysis
accurate depth of tumor invasion
 Multivariate analysis
relative depth of tumor invasion
 Both accurate depth and relative depth of tumor
invasion are important in predicting LN metastasis
of SMGC
 A small group of superficial submucosal tumor
invasions (even <1mm)
presented LN metasitasis

Discussion
In general, EGC with LN metastasis
large, depressed growth (or ulcer), poorly
differentiated adenocarcinoma associated with peptic
ulceration
 Tumor size
contact with submucosal lymphatics and venules
 Vascularity
higher incidence in node-positive SMGC
LN metastasis might be associated with tumor cells
coming into contact with submucosal lymphatic and
venules

Discussion
Lymphatic tumor invasion and deeper tumor invasion
into the submucosa
simple and easy parameters for predicting LN
metastasis from limited surgery specimens
 Small group of superficial involvement of submucosa
LN metastasis
 Carefully selected patients for minimalizing operation
 Pathologist should carefully investigate the lymphatic
invasion and the depth of tmor invasion

Characteristics of intramucosal gastric carcinoma
with lymph node metastatic disease
S Y Song, S Park,2 S Kim,3 H J Son1 & J C Rhee1
Presented by intern 張家維
Results

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




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macroscopic appearance
location
size
differentiation
presence of ulceration
vascularity
presence of gastritis cystica profunda-like
glandular proliferation
disruption of the muscularis mucosae and invasion
into the muscularis mucosae
Results

diffuse type histology (P < 0.001) and deep
invasion into the muscularis mucosae (P <
0.05) were indicators of node-positive
intramucosal EGCs
Conclusions
These histological indicators are easily
accessible and seem to predict lymph node
metastatic disease in limited surgical
specimens.
 Patients should be carefully selected despite
the recent trend toward less invasive resection
of EGCs, especially for those apparently
confined to the mucosa.

Thank you for your attention