Regional lymph node recurrence without intragastric lesions after curative endoscopic resection of early gastric cancer meeting the absolute indications of endoscopic resection A case report

Rationale: With the increase of gastric cancer surveillance and endoscopic resection techniques, the number of endoscopic resections being performed for the treatment of early gastric cancer in East Asian countries has been increasing. Previously, endoscopic resection has been limited to only differentiated type intramucosal cancers which had a diameter <= 2.0 cm, provided there was no evidence of ulceration and lymphovascular invasion, known as absolute indications. And recently, indications for endoscopic resection have been expanded to include even more cases. Patient concerns: A 57-year-old female, who had undergone curative endoscopic submucosal dissection for early gastric cancer under the absolute indications for endoscopic resection 5 years prior, was referred to the department of general surgery with metastatic perigastric lymph nodes without intragastric lesions. Diagnosis: Computed tomography scan revealed the presence of a few enlarged lymph nodes at the distal part of the lesser curvature of the stomach. And positron emission tomography scan further revealed the presence of two hypermetabolic lymph nodes near the common hepatic artery, suggestive of metastatic lymph nodes. Interventions: Laparoscopic distal gastrectomy and Roux-en-Y gastrojejunostomy with D2 lymph node dissection were performed. Outcomes: Final pathology report revealed the absence of any residual carcinoma in the stomach. However lymphovascular invasion of omental fat, and 3 out of 29 perigastric lymph nodes harvested had metastatic adenocarcinoma. Lessons: The case demonstrates that regional lymph node recurrence without intragastric lesions after curative resection of early gastric cancer meeting the absolute indications for endoscopic resection is possible even 5 years after resection of the primary lesion.