Version July 2025
INTRODUCTION —
Early gastric cancer (EGC) is a cancer that invades the mucosa or submucosa (T1), irrespective of lymph node metastasis. The significance of EGC extends beyond patient care in Eastern Asia, encompassing other fields and patient populations. EGC has driven the development of imaging technologies (ie, image enhanced endoscopy and magnification chromoendoscopy) in addition to endoscopic resection techniques (ie, endoscopic mucosal resection [EMR] and endoscopic submucosal dissection [ESD]). (See "Chromoendoscopy" and "Overview of endoscopic resection of gastrointestinal lesions".)
This topic will review management and prognosis of EGC. The clinical features, diagnosis, and staging of EGC are discussed separately. (See "Early gastric cancer: Clinical features, diagnosis, and staging".)
Other issues related to gastric cancer are also discussed separately:
●Epidemiology – (See "Epidemiology of gastric cancer".)
●Risk factors, including Heliobacter pylori infection – (See "Risk factors for gastric cancer" and "Helicobacter pylori: Epidemiology, pathophysiology, and overview of disease associations", section on 'Gastric malignancy'.)
●Pathology and molecular pathogenesis – (See "Gastric cancer: Pathology and molecular pathogenesis".)
●Clinical features and diagnosis of invasive gastric cancer – (See "Clinical presentation, diagnosis, and staging of gastric cancer".)
●Surgical therapy – (See "Surgical management of invasive gastric cancer".)
●Systemic therapy – (See "Initial systemic therapy for metastatic esophageal and gastric cancer" and "Second- and later-line systemic therapy for metastatic gastric and esophageal cancer".)
●Palliation of advanced gastric cancer – (See "Local palliation for advanced gastric cancer".)
INITIAL MANAGEMENT
General measures
Eradicate H. pylori infection — For patients with EGC and H. pylori infection, we initiate eradication therapy because H. pylori is a well-known risk factor for gastric cancer and is associated with increased risk for metachronous gastric cancers. (See "Gastric cancer: Pathology and molecular pathogenesis", section on 'Helicobacter pylori' and "Helicobacter pylori: Epidemiology, pathophysiology, and overview of disease associations", section on 'Gastric malignancy'.)
H. pylori organism burden may be lower in patients with precancerous tumors and early cancers, thereby reducing the yield of gastric biopsy. For patients with EGC and negative biopsies for H. pylori, we obtain H. Pylori serology. We use eradication therapy for patients with positive serology but no history of receiving therapy for H. pylori, even if gastric biopsies are negative. Diagnostic testing and treatment regimens for eradicating H. Pylori are discussed separately. (See "Indications and diagnostic tests for Helicobacter pylori infection in adults" and "Treatment of Helicobacter pylori infection in adults".)
Some studies, including two randomized trials, have suggested that eradicating H. pylori decreases the risk of developing metachronous dysplasia or cancer following treatment for EGC [1-5], but others have not [6,7].This issue was addressed in a systematic review and meta-analysis of two trials and eight cohort studies that included patients with EGC who were treated with endoscopic resection [8]. After adjusting for baseline gastric cancer incidence, patients who had endoscopic resection followed by H. Pylori eradication therapy had a lower incidence of metachronous gastric cancer compared with those who received no eradication therapy (incidence rate ratio [IRR] 0.46, 95% CI 0.35-0.60) [8]. This result compared favorably to the benefit of eradication in asymptomatic infected individuals without a prior history of EGC (IRR 0.62, 95% CI 0.49-0.79).
A similar magnitude of protective benefit was shown in a subsequent randomized trial of eradication therapy in 470 patients following endoscopic resection of EGC or high-grade adenoma (hazard ratio [HR] for metachronous cancer in the treatment group 0.50; 95% CI 0.26 to 0.94) [2].
In several regions with high incidence of gastric cancer, routine screening and eradication for H. pylori have been implemented, and these issues are discussed separately. (See "Gastric cancer screening", section on 'Helicobacter pylori eradication'.)
Specialty referral — Many patients with EGC are under the care of a gastroenterologist when the diagnosis is made, and we encourage referral to an oncologist for long-term management.
Selecting an intervention — Selecting a tumor resection method depends on the characteristics of the tumor (tumor size, morphology), available endoscopic expertise, and willingness of the patient to undergo long-term endoscopic surveillance following endoscopic resection. Guidelines from multiple professional societies have reviewed the role of endoscopic resection in treating EGC, and the following discussion is largely consistent with consensus recommendations [9-14].
We perform endoscopic resection in patients with early gastric cancer who have no clinical suspicion for lymph node metastases and all of the following tumor features (algorithm 1 and table 1) [9,15]:
●Histology: Differentiated
●Tumor size: ≤20 mm
●Morphology: No ulceration
●Tumor type: Intestinal
●No suspected lymphovascular invasion
These tumor characteristics are also referred to as absolute criteria for endoscopic resection because such tumors can be resected en bloc and have low risk for lymph node metastasis (<1 percent) [9,16].
Endoscopic submucosal dissection (ESD) has emerged as the preferred endoscopic technique when endoscopic expertise is available because ESD achieves higher curative, complete (R0), and en bloc resection rates than endoscopic mucosal resection (EMR) [17-19]. However, ESD is associated with longer procedure times and higher risk of perforation [17]. We may use EMR to remove selected tumors (ie, elevated, nonulcerated tumors with size ≤10 mm) [20]. (See 'Endoscopic resection' below.)
Larger tumors that meet the absolute criteria are at higher risk of requiring piecemeal resection during EMR, which is associated with higher recurrence rates [21-28]. ESD achieves en bloc resection of larger tumors and a deeper resection margin in patients with submucosal involvement who are candidates for endoscopic resection.
We typically refer patients with EGC and any of the following features for surgical management (ie, gastrectomy and resection of lymphatic nodes) (see "Surgical management of invasive gastric cancer" and "Partial gastrectomy and gastrointestinal reconstruction"):
●Histology: Poorly differentiated
●Tumor size: >20 mm in diameter
●Morphology: Ulcerated tumors
●Suspected lymphovascular invasion
●Tumor type: Diffuse
Patients with EGC and biopsy-proven or clinically suspicious nodal metastases (based on pretreatment staging evaluation) should also be evaluated for surgical management, as they may not be appropriate candidates for endoscopic resection.
Following gastrectomy, patients with stage II or higher tumors typically receive adjuvant therapy (table 2). (See "Surgical management of invasive gastric cancer", section on 'Adjuvant therapy'.)
Some centers perform endoscopic resection for tumors with higher risk features, but data demonstrating long-term efficacy after resecting such tumors are lacking. Thus, use of endoscopic resection for tumors meeting expanded criteria remains investigational, and this is consistent with guidelines from the Japanese Gastric Cancer Association. The expanded criteria include nonulcerated differentiated tumors of any size, ulcerated differentiated tumors <30 mm, or differentiated tumors <30 mm with superficial submucosal invasion (<500 micrometer below the muscularis mucosa) [9,29].
The expanded criteria were informed by a large case series of patients with early gastric cancer who underwent gastrectomy with lymph node dissection [29]. Subsequent data from a systematic review suggested that patients meeting expanded criteria were at an increased risk of lymph node metastases compared with those meeting absolute criteria, but overall rates were low (0.2 versus 0.7 percent) [30].
Patients with tumors that do not meet absolute criteria for endoscopic resection but who cannot undergo surgery because of comorbidities have relative indications for endoscopic resection [10].
In the absence of randomized trials comparing different treatment strategies, management of early gastric cancer is informed by observational studies, consensus recommendations, and clinical experience [13,31-33]. Studies have suggested that overall survival was similar for patients who underwent ESD or surgery; however, ESD was associated with less procedure-related morbidity. In a systematic review of 20 studies including over 6000 patients with EGC meeting the absolute criteria, there were no significant differences in 4- and 5- year overall and disease-free survival between patients who had ESD compared with surgery [13]. Patients treated with ESD had lower rates of peri-procedure infection (0.3 versus 7.7 percent; relative risk [RR] 0.12, 95% CI 0.02-0.71) and shorter procedure times (mean difference, 129.8 minutes less). In a prior meta-analysis of 13 studies comparing ESD with surgery in 6739 patients with EGC, there were no significant differences in overall survival or disease-free survival between ESD and surgery (96 percent in both groups; odds ratio [OR] 0.96, 95% CI 0.74-1.25 and 96 versus 99 percent; OR 1.86, 95% CI 0.57-6.0) [31].
Endoscopic resection
Treatment approach — For most patients with EGC who meet criteria for endoscopic resection, we perform ESD rather than EMR (table 1). ESD often achieves en bloc, complete (R0), and curative resection. Limitations of ESD include that it uses specialized equipment, is technically challenging, requires advanced endoscopic training, and may not be widely available.
For selected patients (ie, those with small [ie, ≤10 mm], elevated, and nonulcerated tumors), EMR is a reasonable alternative.
Endoscopic submucosal dissection — ESD (where available) is first line therapy for patients with early gastric cancers that are >10 mm and fulfill absolute criteria because ESD often achieves en bloc, complete removal of larger mucosal and submucosal tumors (table 1 and image 1):
●Technique – ESD is an advanced technique for endoscopic resection that uses a specialized electrosurgical knife to remove the tumor by circumferentially incising the surrounding mucosa and then removing the tumor by dissecting the submucosal layer away from the proper muscle layer [10]. (See "Overview of endoscopic resection of gastrointestinal lesions", section on 'Procedures'.)
●Efficacy and safety – Data from expert referral centers suggested that ESD was effective for complete removal of EGC and was associated with low risk of recurrence. In an observational study including 907 EGCs that met absolute criteria and were treated with ESD, the rate of complete resection (ie, en bloc resection with negative margins) was 96 percent [34]. In addition, overall survival and recurrence-free rates at five years were 94 and 100 percent, respectively.
For patients with EGC, ESD is more likely to achieve complete resection than EMR [17-19], although ESD requires a longer procedure time and specialized endoscopic skills. In a meta-analysis of 18 studies comparing ESD with EMR in 6723 patients with EGC, ESD was associated with higher likelihood of achieving en bloc resection (OR 9.0; 95% CI 6.66-12.17) and curative resection (OR 2.92; 95% CI 1.85-4.61) [17]. In addition, ESD was associated with lower risk of local recurrence (OR 0.18; 95% CI 0.09-0.34). However, the risk of perforation was higher with ESD (OR 2.55, 95% CI 1.48-4.39), while the risk of bleeding was not significantly different between the two groups.
ESD is generally a safe procedure, although data suggest that postprocedural bleeding rates range from 4 to 10 percent and perforation rates are <3 percent [13,19,35]. As an example, in a study from a center in Japan that included over 10,000 EGCs removed with ESD, postprocedural bleeding and perforation occurred in 4.4 and 2.3 percent of patients, respectively [19].
●Limitations – Limitations of ESD include that it uses specialized equipment, is technically challenging, requires advanced endoscopic training, and may not be widely available. ESD was initially developed in Japan, and endoscopic expertise and experience with ESD have been expanding into other geographic regions [36,37]. As an example, in a study including 139 patients with EGC who underwent ESD in North America, reported rates of en bloc resection and complete (R0) resection were 94 and 75 percent, respectively [38].
ESD typically takes longer to perform than EMR. In a meta-analysis of 13 studies comparing ESD with EMR in over 6000 patients with EGC, procedure time was longer with ESD (weighted mean difference, 49 minutes 95% CI 22-75) [13].
Endoscopic mucosal resection — For patients with EGCs that are elevated, small (ie, ≤10 mm) and nonulcerated, we perform EMR by lifting the tumor and the surrounding mucosa with a submucosal injection of normal saline solution and then removing the tumor with a polypectomy snare [10]. (See "Overview of endoscopic resection of gastrointestinal lesions", section on 'Endoscopic mucosal resection'.)
Observational data suggested that EMR is effective for treating selected patients with EGC. In a study of 131 patients who underwent EMR for small, differentiated, mucosal EGC, the 5- and 10-year overall survival rates were 84 and 64 percent, respectively [39]. The disease-specific survival rates at 5- and 10-years of follow-up were both 99 percent. In a subsequent series of 39 patients with EGC meeting the absolute criteria who underwent EMR in Europe, 38 patients (97 percent) achieved remission after endoscopic therapy [40]. However, recurrent or metachronous tumors developed in 11 patients (29 percent) during a mean follow up of 57 months, yet all were treated successfully with repeat endoscopic therapy.
EMR of gastric tumors is generally a safe procedure, although major adverse events include bleeding (approximately 5 percent) and perforation (less than 1 percent). (See "Overview of endoscopic resection of gastrointestinal lesions", section on 'Adverse events'.)
Surgical resection — We refer most patients with EGC for surgical resection as the primary intervention if the tumor does meet the absolute criteria (ie, mucosal tumor, size ≤20 mm, no ulceration, differentiated histology) (algorithm 1 and table 1). Complete surgical removal of a gastric cancer with resection of adjacent lymph nodes provides the best chance for long-term survival in such patients [41-43]. Surgical treatment for localized gastric cancer including lymph node dissection, is discussed in detail separately. (See "Surgical management of invasive gastric cancer".)
MANAGEMENT AFTER ENDOSCOPIC RESECTION
Postprocedure care — We administer a proton pump inhibitor (PPI) orally for 72 hours after gastric endoscopic mucosal resection (EMR) and for eight weeks after gastric endoscopic submucosal dissection (ESD) to lower the risk of postprocedural bleeding [44,45], although the optimal PPI dose and initial route of administration have not been well established [35,46-48].
Patients with curative endoscopic resection — A curative endoscopic resection is defined as en bloc, complete removal of an EGC that is differentiated, invades no more than the superficial submucosal (sm1), has negative margins, and has no lymphovascular invasion [12].
Surveillance strategies — There are no randomized trials to guide surveillance strategies following the treatment of EGC. We follow consensus-based guidelines from the National Comprehensive Cancer Network [49], which suggest risk-stratified post-treatment surveillance as follows:
For resected Tis disease treated by endoscopic resection:
●History and physical examination every 3 to 6 months for years 1 to 2, every 6 to 12 months for years 3 to 5, and then annually.
●Complete blood count and chemistry profile as indicated.
●Upper endoscopy every six months for one year, then annually for three years.
●Radiologic imaging as clinically indicated based on symptoms and concern for recurrence, such as weight loss or abdominal pain. (See "Clinical presentation, diagnosis, and staging of gastric cancer", section on 'Signs and symptoms'.)
For T1a disease treated by endoscopic resection:
●History and physical examination every 3 to 6 months for years 1 to 2, every 6 to 12 months for years 3 to 5, and then annually.
●Complete blood count and chemistry profile as indicated.
●Upper endoscopy every six months for one year, then annually for up to five years. After five years, upper endoscopy is performed as needed based on symptoms and/or radiographic findings.
●CT chest, abdomen, and pelvis with oral and intravenous contrast as clinically indicated.
For T1a/T1b disease or pathologic stage II disease treated with gastrectomy, postoperative surveillance is discussed separately. (See "Surgical management of invasive gastric cancer", section on 'Post-treatment surveillance'.)
Guidelines for post-treatment surveillance from European Society for Medical Oncology (ESMO) also advise tailoring the surveillance strategy to individual patients and the stage of the disease but provide no specific guidance for those with EGC [11].
For surveillance upper endoscopy, we typically visualize the gastric mucosa with high-definition white light and narrow band imaging (NBI). We systematically examine and photo-document each anatomic area of the stomach (antrum, pylorus, incisura, lesser curve, greater curve, fundus, and cardia) using an examination method similar to the diagnostic evaluation [50,51]. (See "Early gastric cancer: Clinical features, diagnosis, and staging", section on 'Diagnostic evaluation'.)
Surveillance is important because it detects cancers that may have been missed during the initial endoscopic evaluation or that developed subsequently. The use of surveillance upper endoscopy is supported by consensus guidelines and observational studies [49,52-54]. In a study including 1258 patients with EGC who underwent ESD followed by surveillance endoscopy every 6 to 12 months, synchronous (occurring within one year of ESD) or metachronous (after one year) cancers were detected in 175 patients (14 percent) during a median follow-up of 27 months [52]. Local recurrence was detected in five patients (0.4 percent). Most of the synchronous and metachronous cancers (94 percent) were successfully treated with repeat ESD.
Patients with noncurative endoscopic resection
Clinicopathologic features — Endoscopic resection of EGC is noncurative if any of the following are present:
●Positive horizontal or vertical margin (see 'Positive horizontal margins only' below)
●Deep submucosal invasion
●Lymphovascular invasion
●Undifferentiated histology
●Piecemeal resection
Management — We refer most patients who have EGC and noncurative endoscopic resection for surgery. (See 'Clinicopathologic features' above and "Surgical management of invasive gastric cancer".)
Observational studies have suggested that gastrectomy with lymph node dissection improved survival in patients with EGC and noncurative endoscopic resection [55,56]. In a systematic review of 21 studies including 4870 patients with EGC and noncurative resection, subsequent surgical resection was associated with lower risk of overall mortality and disease-related mortality compared with no gastrectomy (hazard ratio [HR] 0.34, 95% CI 0.27-0.44, and HR 0.50, 95% CI 0.35-0.73, respectively) [55].
The goal of surgery is to remove the residual tumor and suspicious lymph nodes. However, some patients with noncurative resection may be at high risk for surgery because of comorbidities or they may wish to avoid further invasive interventions. For such patients, assessing risk of lymph node metastasis may inform treatment decisions. In a systematic review of 21 studies including 4870 patients with noncurative resection, risk factors associated with lymph node metastasis included lymphatic invasion (odds ratio [OR] 4.65, 95% CI 2.9-26.8), deep submucosal invasion (OR 2.68, 95% CI 3.16-6.84), positive vertical margins (OR 2.30, 95% CI 1.70-3.11), and tumor size >3 cm (OR 1.73, 95% CI 1.30– 2.32) [55]. In addition, further intervention may provide limited benefit for patients who do not have a long life expectancy. In a study of 159 patients with noncurative endoscopic resection for EGC who had no additional treatment, overall three- and five-year survival rates were 83 and 77 percent, respectively [57]. Survival rates were 62 and 42 percent for patients with lymphovascular invasion.
Adjuvant chemotherapy is generally used for all patients with node-positive or T3N0 tumors (table 2) [10,11]. However, this recommendation has been challenged for patients with no more than one or two lymph node metastases (ie, T1N1 tumors) [58,59]. The benefit of adjuvant therapy for resected T2N0 gastric cancer is controversial. A general discussion of adjuvant therapy for resected gastric cancer is presented in detail elsewhere. (See "Adjuvant and neoadjuvant treatment of gastric cancer", section on 'Initial potentially curative resection'.).
Positive horizontal margins only — We typically refer patients who have positive horizontal margins following endoscopic resection of EGC for surgical resection, although optimal treatment for such patients has not been well defined. Some observational studies have reported that patients with positive horizontal margins (in the absence of positive vertical margins, submucosal invasion, and lymphovascular invasion) may be successfully treated with additional endoscopic therapy [60-64]. As an example, in a study including 99 patients with 101 post-ESD tumors with positive horizontal margins who were followed for a median of 59 months, subsequent therapy with ESD or argon plasma coagulation was associated with recurrent or residual tumors in 4 percent and 7 percent of patients, respectively [60]. In another series of 77 patients with positive horizontal margins following ESD, local recurrence occurred in 10 patients (13 percent) after a median follow-up of 60 months [61]. On multivariate analysis, a positive horizontal margin ≥6 mm was associated with an increased risk of recurrence (HR 21; 95% CI 5.2-83 percent). Eight patients underwent ESD, and two patients underwent gastrectomy. There were no deaths due to gastric cancer, and the overall five-year survival rate was 94 percent.
PROGNOSIS
Survival and disease recurrence — For patients who are treated for EGC, the rates of five-year survival are >90 percent overall, nearly 100 percent for mucosal tumors, and 80 to 90 percent for submucosal tumors [65]. Survival rates are similar for patients undergoing endoscopic and surgical resections [66-68]. (See 'Selecting an intervention' above.)
For patients who had endoscopic resection for EGC, the estimated rates of developing recurrence or metachronous tumors have ranged from 10 to 20 percent [52,68-70]. (See 'Patients with metachronous gastric cancer' below.)
Thus, patients who had curative endoscopic resection undergo endoscopic surveillance. (See 'Patients with curative endoscopic resection' above and 'Patients with local disease recurrence' below.)
The recurrence rate after surgery ranges from 1 to 5 percent in reports from Asia [66,71,72] and from 5 to 15 percent in studies from other geographic regions [73]. These variable recurrence rates partially reflect differences in the length of follow-up but may also be due to differences in the pathologic diagnosis [74].
Disease course without treatment — Limited data suggested that for patients with untreated EGC, disease progression occurs slowly. In an early report including 56 patients with EGC who did not receive therapy, 36 patients (64 percent) developed advanced disease within five years of follow up [75]. EGC may represent a meta-stable biologic state, with doubling times in several years, versus advanced cancer, with doubling times of less than a year. (See "Gastric cancer: Pathology and molecular pathogenesis".)
Patients with lymph node involvement — Studies have suggested that lymph node involvement occurs in up to 10 percent of mucosal EGC and 20 to 30 percent of submucosal EGC [44,76-79].
The prognostic importance of lymph node involvement in EGC has been illustrated in studies from patients who have undergone gastrectomy [80-82]. In a study including 652 patients with surgically resected EGC, overall survival at 10 years stratified according to lymph node involvement (ie, zero nodes; one to three nodes; four to six nodes; and >6 positive nodes) were 92, 82, 73, and 27 percent, respectively [81]. In an earlier study, rates of long-term survival were 95 percent in patients with no lymph node involvement, 88 percent in those with one to three nodes involved, and 77 percent in those with >3 nodes involved [80]
SPECIAL POPULATIONS
Patients with metachronous gastric cancer — Some patients with a history of EGC develop metachronous gastric cancer (ie, a second tumor diagnosed more than one year after the initial diagnosis). In a study including 1526 patients with EGC who underwent curative ESD, the cumulative incidence of metachronous EGC at 5, 7, and 10 years was 9.5, 13.1, and 22.7 percent, respectively [53]. Factors associated with metachronous gastric dysplasia and cancer following endoscopic submucosal dissection (ESD) have included failure to eradicate H. pylori and age ≥60 years [1,83].
As with the original tumor, metachronous EGC may be treated with endoscopic therapy or surgery, depending on the tumor characteristics and local expertise. History of partial gastrectomy is not an absolute contraindication to endoscopic therapy. (See 'Selecting an intervention' above.)
Differentiating a metachronous gastric cancer from disease recurrence may be difficult, but a different histologic type than the original tumor and non-anastomotic location favors metachronous cancer. (See 'Patients with local disease recurrence' below.)
Patients with local disease recurrence
Risk factors — Piecemeal resection of EGC is a risk factor for local disease recurrence. In study of 149 patients with EGC who underwent endoscopic mucosal resection (EMR) followed by endoscopic surveillance, piecemeal resection was associated with higher rates of disease recurrence compared with en bloc resection (28 versus 0 percent) [64]. Recurrent cancer was treated with surgery or additional endoscopic therapy, and there were no deaths from gastric cancer during 10-years of follow-up.
Data also suggested that risk of local recurrence was higher with EMR compared with ESD, and this is discussed above. (See 'Endoscopic resection' above.)
Treatment — Treatment options for patients who develop recurrent EGC include surgery and repeat endoscopic resection (typically ESD). However, criteria for endoscopic resection of recurrent tumor are uncertain. Thus, we perform endoscopic ultrasound to assess the depth of invasion and then repeat endoscopic therapy in patients who meet absolute criteria (table 1). We refer patients who do not meet absolute criteria for surgical resection.
Studies have suggested that endoscopic resection for recurrent disease was effective for patients who meet criteria for endoscopic therapy [84-86]. In a series of 95 patients with tumor recurrence following endoscopic resection (EMR in 75 cases, ESD in 20 cases), repeat endoscopic resection was curative in 77 patients (81 percent) [84]. None of those patients developed further tumor recurrence. Although the report did not indicate how patients were chosen for endoscopic resection, most had disease limited to the mucosa (96 percent) and had no evidence of lymphovascular invasion (99 percent).
Local treatment options for patients with recurrent gastric cancer invading beyond the submucosa include surgery or radiation therapy with or without adjuvant chemotherapy. (See "Local palliation for advanced gastric cancer", section on 'Radiation therapy' and "Surgical management of invasive gastric cancer", section on 'Treatment of recurrent disease'.)
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gastric cancer".)
INFORMATION FOR PATIENTS —
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Stomach cancer (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Definition – Early gastric cancer (EGC) is defined as adenocarcinoma that is confined to the mucosa or submucosa, with or without lymph node involvement (T1, any N) (table 2). EGC has a significantly better prognosis (approximately 90 percent five-year survival rate) than invasive gastric cancer.
●General measures – General measures for patients with EGC include (see 'General measures' above):
•Eradication therapy for patients with H. pylori infection. H. pylori is a well-known risk factor for gastric cancer, and therapeutic regimens are discussed separately. (See "Helicobacter pylori: Epidemiology, pathophysiology, and overview of disease associations", section on 'Gastric malignancy' and "Treatment of Helicobacter pylori infection in adults".)
•Oncology consultation for long-term management.
●Selecting an intervention for tumor resection – For patients with EGC that meets absolute criteria (table 1) and no clinical suspicion for lymph node metastases, we suggest endoscopic resection rather than gastrectomy (Grade 2C). Endoscopic resection is less invasive than surgery but has been associated with similar long-term outcomes. (See 'Selecting an intervention' above.)
We typically refer patients with tumors that do not meet absolute criteria for surgical management (ie, gastrectomy and resection of lymphatic nodes) (algorithm 1). Patients who do not meet criteria for endoscopic resection are at increased risk for lymph node metastases, which is associated with tumor recurrence. (See "Surgical management of invasive gastric cancer" and "Partial gastrectomy and gastrointestinal reconstruction".)
●Endoscopic resection – For most patients with EGC who meet criteria for endoscopic resection, we suggest endoscopic submucosal dissection (ESD) rather than endoscopic mucosal resection (EMR) (Grade 2C). ESD often achieves en bloc, complete (R0), and curative resection. Limitations of ESD include that it uses specialized equipment, is technically challenging, requires advanced endoscopic training, and may not be widely available. (See 'Endoscopic resection' above.)
For selected patients (ie, those with small [ie, ≤10 mm], elevated, and nonulcerated tumors), EMR is a reasonable alternative.
●Patients with curative endoscopic resection – A curative resection is characterized by en bloc, complete removal of an EGC that is differentiated, invades no more than the superficial submucosa (sm1), and has no lymphovascular invasion. (See 'Patients with curative endoscopic resection' above.)
Patients with EGC who have undergone curative endoscopic resection should undergo risk-stratified post-treatment surveillance, including periodic history and physical exam, laboratory testing and radiologic imaging as indicated, and endoscopic surveillance at the following intervals (see 'Surveillance strategies' above):
•Patients with Tis disease – Upper endoscopy every six months for one year, then annually for up to three years
•Patients with T1a disease – Upper endoscopy every six months for one year, then annually for up to five years, then as needed based on symptoms and/or radiographic findings.
●Patients with noncurative endoscopic resection – Endoscopic resection of EGC is noncurative if any of the following are present (see 'Patients with noncurative endoscopic resection' above):
•Positive horizontal or vertical margins (see 'Positive horizontal margins only' above)
•Deep submucosal invasion
•Lymphovascular invasion
•Undifferentiated histology
•Piecemeal resection
We refer most patients with EGC and noncurative endoscopic resection for surgical resection. (See 'Surgical resection' above and "Surgical management of invasive gastric cancer".)
●Screening – Screening methods for patients at risk for gastric cancer include endoscopy, radiology, and non-invasive testing (eg, H. pylori serology). Screening for gastric cancer is discussed in detail separately. (See "Gastric cancer screening".)
