## Lymph Node Metastasis in Gastric Cancer **Key Point:** Perigastric (N1) lymph nodes — located along the lesser and greater curvature of the stomach — are the **most common** site of lymph node metastasis in gastric cancer, as they are the first-echelon (tier-1) nodes directly adjacent to the gastric wall. ### Japanese Gastric Cancer Association (JGCA) Lymph Node Classification | Node Group | Location | Tier | Frequency of Metastasis | |------------|----------|------|-------------------------| | **N1 (Perigastric)** | Along lesser/greater curve, cardia, pylorus | 1st echelon | **Most common (first involved)** | | **N2 (Regional)** | Left gastric, celiac, splenic, hepatic, right gastric | 2nd echelon | Less common than N1 | | **N3 (Extended regional)** | Para-aortic, hepatoduodenal, superior mesenteric | 3rd echelon | Less common | | **M1 (Distant)** | Supraclavicular (Virchow's), pericardial, distant | Distant | Least common | **High-Yield:** Lymphatic spread in gastric cancer follows a stepwise pattern along the blood supply of the stomach. N1 perigastric nodes are the **first and most frequently involved** nodes because they lie immediately adjacent to the stomach wall and receive direct lymphatic drainage. This is consistent with the principle that regional (first-echelon) nodes are the most common site of metastasis in any solid organ malignancy. **Clinical Pearl:** Specific patterns of N1 involvement by tumor location: - **Proximal/cardia tumors** → lesser curve and paracardial nodes - **Distal/antral tumors** → right gastroepiploic and pyloric nodes - **Greater curve tumors** → left gastroepiploic and short gastric nodes **Warning:** Do not confuse "most common site of metastasis" with "most important nodes to dissect." D2 lymphadenectomy (removing N1 + N2 nodes) is the standard of care for curative-intent gastrectomy, but this does not mean D2 nodes are the most commonly involved — N1 perigastric nodes are involved earliest and most frequently, especially in early and locally advanced disease. **Reference:** Bailey & Love's Short Practice of Surgery (27th ed.); Japanese Gastric Cancer Association Treatment Guidelines; Harrison's Principles of Internal Medicine (21st ed.) — gastric cancer chapter confirms perigastric nodes as the primary (most common) site of nodal spread. **Mnemonic:** **P-FIRST** — **P**erigastric nodes are **F**irst, most **I**mmediate, most **R**egular, **S**ite of **T**umor spread in gastric cancer.
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