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June 20, 2026Open Access

Endoscopic resection or radical gastrectomy? Risk factors for lymph node metastasis in early gastric cancer: a systematic review and meta-analysis

Key Points

This research aims to identify risk factors for lymph node metastasis in early gastric cancer to optimize treatment strategies.
Systematic review and meta-analysis conducted according to PRISMA guidelines.
Literature search carried out across multiple databases including PubMed and Scopus.
Study quality and bias assessed using ROBINS-I tool, with certainty evaluated using the GRADE framework.
Identified predictors of lymph node metastasis include lymphovascular invasion (OR = 9.04, 95% CI: 7.18-11.37) and tumor size ≤ 2 cm (OR = 0.39, 95% CI: 0.36-0.43).
Male patients had lower odds of lymph node metastasis (OR = 0.69, 95% CI: 0.65-0.72).
Elevated CA199 levels (> 37 U/mL) showed a strong association with lymph node metastasis (OR = 4.02, 95% CI: 1.46-11.11).

Abstract

BACKGROUND: The management of EGC hinges on accurate LNM risk assessment, guiding the critical choice between endoscopic resection (ER) and radical gastrectomy. This study provides a comprehensive evidence synthesis to optimize treatment selection. METHODS: This systematic review and meta-analysis (PROSPERO CRD420251152013) was conducted in accordance with PRISMA guidelines. A comprehensive literature search of PubMed, Web of Science, Scopus, and Embase was performed for studies published up to September 5, 2025. Study quality and risk of bias were assessed using the ROBINS-I tool, and the certainty of evidence for each association was evaluated with the GRADE framework. Statistical heterogeneity was investigated, and the sources were explored through meta-regression where appropriate. RESULTS: One hundred one studies were included. Meta-analysis identified predictors: LVI (OR = 9.04, with LVI negative as reference, 95% CI: 7.18-11.37), mucosal invasion (T1a) (OR = 0.20, with T1b as reference, 95% CI: 0.19-0.22), tumor size ≤ 2 cm (OR = 0.39, with > 2 cm as reference, 95% CI: 0.36-0.43), differentiated histology (OR = 0.45, with undifferentiated type as reference, 95% CI: 0.40-0.50), PNI (OR = 3.41, with PNI negative as reference, 95% CI: 2.46-4.71), ulceration (OR = 1.68, with ulceration negative as reference, 95% CI: 1.37-2.05), age ≤ 60 years (OR = 1.13, with > 60 years old as reference, 95% CI: 1.06-1.21), male (OR = 0.69, with females as reference, 95% CI: 0.65-0.72), middle location (OR = 0.96, with other parts as reference, 95% CI: 0.90-1.02), CEA > 0.5 ng/mL (OR = 1.35, with CEA ≤ 0.5ng/mL as reference, 95% CI: 1.04-1.75), CA199 > 37 U/mL (OR = 4.02, with CA199 ≤ 37 U/mL as reference, 95% CI: 1.46-11.11), CA125 (OR = 1.17, with CA125 ≤ 35 U/mL as reference, 95% CI: 0.48-2.81), CA724 (OR = 1.33, with CA724 ≤ 7 U/mL as reference, 95% CI: 0.84-2.11). All reported pooled ORs represent unadjusted estimates derived from univariate data. CONCLUSION: This meta-analysis provides a comprehensive evidence base for risk stratification in EGC. By distinguishing patients suitable for ER from those requiring radical operation, our findings serve as a critical guide for optimizing clinical practice and resolving the therapeutic dilemma between endoscopy and radical surgery.

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