Prognostic Implications of Tumor Differentiation in Clinical T1N0 Gastric Adenocarcinoma.

BACKGROUND Current guidelines recommend neoadjuvant chemotherapy in patients with locoregional gastric adenocarcinoma. Patients diagnosed with early stage gastric adenocarcinoma are usually managed with upfront surgical intervention. However, pathologic staging in a subset of these clinically staged patients identifies more advanced locoregional disease requiring adjuvant treatment. Therefore, identifying these patients prior to surgical intervention is critical to ensure employment of the appropriate treatment paradigm. The aim of the current study was to define patient characteristics associated with clinical understaging in early gastric cancer. METHODS Using the National Cancer Database (2004-2014) we identified 3892 individuals with clinical T1N0 gastric adenocarcinoma who underwent upfront definitive surgery, had negative surgical margins, and did not receive preoperative chemotherapy or radiotherapy. Patient characteristics were compared between those with pathologic stage T1N0 and those that were upstaged upon surgery. RESULTS Twenty-seven percent of clinical T1N0 gastric adenocarcinomas had a change in stage due to pathologically defined ≥T2 disease or positive lymph nodes. Individuals that were upstaged had a higher tumor grade compared with those with pathologic stage T1N0. Specifically, 41.9% (530/1264) of individuals with a poorly differentiated tumor were upstaged, compared with only 10.7% (70/656) with a well differentiated tumor. Around 75% of cases involved upstaging due to T misclassification. The highest percentage of upstaging was shown for tumors located at the fundus and body of the stomach. CONCLUSIONS Upstaging of clinical T1N0 gastric adenocarcinoma is characterized by higher tumor grade and is mostly a result of a change in T stage. These findings mandate thorough workup in order to identify clinically staged T1N0 patients requiring preoperative chemotherapy. IMPLICATIONS FOR PRACTICE Upstaging of clinical T1N0 gastric adenocarcinoma is characterized by higher tumor grade and is mostly a result of a change in T stage. These findings mandate thorough workup in order to identify clinically staged T1N0 patients requiring preoperative chemotherapy.