Background Pathological T1 (pT1) gastric cancer showed excellent prognosis, however lymph node metastasis sometimes reflects patients with dismal prognosis. In this study, we investigated prognosis of pT1 gastric cancer with lymph node metastasis to identify prognostic factors. Patients and Methods Among 1,442 gastric cancer patients between 2002 and 2010, 73 (5%) of pT1 with lymph node metastasis were identified. Univariate prognostic factors were applied to multivariate Cox proportional hazards model. Results (1) Among the 1,442 patients, pT1 was composed of 333 patients with pT1a and 423 patients with pT1b, which included 9 (2.7%) and 64 cases (15.1%) with lymph node metastasis, respectively. (2) Ten (13.7%) patients of the 73 patients with lymph node metastasis showed tumor relapse. Univariate negative prognostic factors were tumor size (p=0.03), intraoperative bleeding (p=0.03), and perioperative transfusion (POT)(p=0.001), as well as 14th JGCA Stage (p<0.0001), and multivariate analysis identified 14th JGCA Stage (p=0.0004) and POT (p=0.03) as independent prognostic factors. (3) pT1 gastric cancer representing pN3 (Stage IIB) was rare (n=4) and unique entity from a prognostic point of view, exhibiting dismal prognosis (0% at 5 years). We thereafter identified 17 such cases from 5,204 gastric cancer including the earliest cases. Prognosis of such 17 patients was very unique, in that recurrences occurred even 5 years after curative operation, and the frequent recurrent sites were bone. Conclusion pT1 gastric cancer prognosis is robustly affected by pN3 and POT, and Stage IIB disease showed unique prognosis requiring special attention even after 5 years of operation.