examine each lymph node would be expected to detect some micrometastases which would be overlooked by routine techniques. However, this cannot be the only explanation for their unusually high incidence of nodal metastases, as other similar studies have found that additional sectioning results in only a minimal increase in the number of positive nodes detected'.
We have reported that nodal involvement is closely associated with certain characteristics of the primary gastric lesion, such as large tumour size and the presence of intratumoural ulceration' '.
Unfortunately, Hayes et al. have not included details of the primary tumours. In a small series such as this the inclusion of a large number of such high-risk cancers could result in a high incidence of nodal metastases. It is also possible that tumour depth may have been underestimated in large, ulcerated lesions.
Another important issue is their conclusion that the conservative treatment which we have advocated is 'not appropriate'. We have very carefully established criteria for endoscopic treatment or local excision of early gastric cancer. Even in Japan where gastric cancers as small as 5 mm in diameter are often found, only 20 per cent of early gastric cancers satisfy these criteria (all of the following: mucosal tumour, less than 2 cm in diameter, histologically differentiated, raised or depressed type without histological ulceration or scar). We would like t o know how many of the 28 patients with cancers reported by Hayes et a / . satisfy our criteria and whether they had nodal metastasis.
We believe that extended lymphadenectomy is an appropriate treatment for gastric cancer. However, some patients with early disease can benefit from stomach conservation without having an increased risk of cancer recurrence. Endoscopic treatment has already become an important treatment option in Japan. British patients with similar tumours should also benefit, particularly in a situation where the average operative mortality rate exceeds 10 per cent after extended surgery'.