Endoscopic Treatment for Early Gastric Cancer

  • Takuji Gotoda


In the history of gastric cancer treatment, many of the cases with gastric cancer discovered in the 1970s were in the advanced stage. As represented by the Appleby operation, extended radical surgery was globally accepted as a mainstream approach to gastric cancer, even in the early gastric cancer (EGC). With the widespread adoption of nationwide screening [1] in Japan and South Korea and the advancement of endoscope technology in the 1980s, the number of patients diagnosed with early gastric cancer has increased. Nowadays endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) offer less invasive options to patients. These options present important trade-offs such as less morbidity but also a higher risk of metachronous recurrence. Patients’ preferences and particularly fear of recurrence are important elements in choosing the optimal therapy.


Early gastric cancer Endoscopic mucosal resection Endoscopic submucosal dissection Lymph node metastasis 



confidence interval


early gastric cancer


endoscopic mucosal resection


EMR with cap-fitted panendoscope method


EMR using multiband ligation


endoscopic submucosal dissection

IT knife

insulated-tip diathermic knife


lymph node metastasis


quality of life


  1. 1.
    Gotoda T, Ishikawa H, Ohnishi H, et al. Randomized controlled trial comparing gastric cancer screening by gastrointestinal X-ray with serology for Helicobacter pylori and pepsinogens followed by gastrointestinal endoscopy. Gastric Cancer. 2015;18(3):605–11.CrossRefGoogle Scholar
  2. 2.
    Rembacken BJ, Gotoda T, Fujii T, et al. Endoscopic mucosal resection. Endoscopy. 2001;33:709–18.CrossRefGoogle Scholar
  3. 3.
    Soetikno R, Gotoda T, Nakanishi Y, et al. Endoscopic mucosal resection. Gastrointest Endosc. 2003;57:567–79.CrossRefGoogle Scholar
  4. 4.
    Gotoda T. Endoscopic resection of early gastric cancer. Gastric Cancer. 2007;10:1–11.CrossRefGoogle Scholar
  5. 5.
    Gotoda T, Yamamoto H, Soetikno R. Endoscopic Submucosal Dissection for early gastric cancer. J Gastroenterol. 2006;41:929–42.CrossRefGoogle Scholar
  6. 6.
    Jung HY. Endoscopic resection for early gastric cancer: current status in Korea. Dig Endosc. 2012;24:159–65.CrossRefGoogle Scholar
  7. 7.
    Hull M, Mino-Kenudson M, Nishioka NS, et al. Endoscopic mucosal resection: an improved diagnostic procedure for early gastroesophageal epithelial neoplasms. Am J Surg Pathol. 2006;30:114–8.CrossRefGoogle Scholar
  8. 8.
    Ludwig K, Klautke G, Bernhard J, et al. Minimally invasive and local treatment for mucosal early gastric cancer. Surg Endosc. 2005;19:1362–6.CrossRefGoogle Scholar
  9. 9.
    Ahmad NA, Kochman ML, Long WB, et al. Efficacy, safety, and clinical outcomes of endoscopic mucosal resection: a study of 101 cases. Gastrointest Endosc. 2002;55:390–6.CrossRefGoogle Scholar
  10. 10.
    Katsube T, Konno S, Hamaguchi K, et al. The efficacy of endoscopic mucosal resection in the diagnosis and treatment of group III gastric lesions. Anticancer Res. 2005;25:3513–6.PubMedGoogle Scholar
  11. 11.
    Deyhle P, Largiader F, Jenny P. A method for endoscopic electroresection of sessile colonic polyps. Endoscopy. 1973;5:38–40.CrossRefGoogle Scholar
  12. 12.
    Oguro Y. Endoscopic gastric polypectomy with high frequency currents. Stom Intest (in English abstract). 1974;9:309–16.Google Scholar
  13. 13.
    Tada M, Shimada M, Murakami F, et al. Development of strip-off biopsy. Gastroenterol Endosc (in English abstract). 1984;26:833–9.Google Scholar
  14. 14.
    Hirao M, Masuda K, Asanuma T, et al. Endoscopic resection of early gastric cancer and other tumors with local injection of hypertonic saline-epinephrine. Gastrointest Endosc. 1988;34:264–9.CrossRefGoogle Scholar
  15. 15.
    Inoue H, Endo M, Takeshita K, et al. A new simplified technique of endoscopic esophageal mucosal resection using a cap-fitted panendoscope (EMRC). Surg Endosc. 1992;6:264–5.CrossRefGoogle Scholar
  16. 16.
    Inoue H, Takeshita K, Hori H, et al. Endoscopic mucosal resection with a cap-fitted panendoscope for esophagus, stomach, and colon mucosal lesions. Gastrointest Endosc. 1993;39:58–62.CrossRefGoogle Scholar
  17. 17.
    Akiyama M, Ota M, Nakajima H, et al. Endoscopic mucosal resection of gastric neoplasms using a ligating device. Gastrointest Endosc. 1997;45:182–6.CrossRefGoogle Scholar
  18. 18.
    Soehendra N, Seewald S, Groth S, et al. Use of modified multiband ligator facilitates circumferential EMR in Barrett’s esophagus (with video). Gastrointest Endosc. 2006;63:847–52.CrossRefGoogle Scholar
  19. 19.
    Korenaga D, Haraguchi M, Tsujitani S, et al. Clinicopathological features of mucosal carcinoma of the stomach with lymph node metastasis in eleven patients. Br J Surg. 1986;73:431–3.CrossRefGoogle Scholar
  20. 20.
    Ell C, May A, Gossner L, et al. Endoscopic mucosectomy of early cancer and high-grade dysplasia in Barrett’s esophagus. Gastroenterology. 2000;118:670–7.CrossRefGoogle Scholar
  21. 21.
    Tanabe S, Koizumi W, Mitomi H, et al. Clinical outcome of endoscopic aspiration mucosectomy for early stage gastric cancer. Gastrointest Endosc. 2002;56:708–13.CrossRefGoogle Scholar
  22. 22.
    Kim JJ, Lee JH, Jung HY, et al. EMR for early gastric cancer in Korea: a multicenter retrospective study. Gastrointest Endosc. 2007;66:693–700.CrossRefGoogle Scholar
  23. 23.
    Ono H, Kondo H, Gotoda T, et al. Endoscopic mucosal resection for treatment of early gastric cancer. Gut. 2001;48:225–9.CrossRefGoogle Scholar
  24. 24.
    Hosokawa K, Yoshida S. Recent advances in endoscopic mucosal resection for early gastric cancer. Jpn J Cancer Chemother (in English abstract). 1998;25:483.Google Scholar
  25. 25.
    Gotoda T, Kondo H, Ono H, et al. A new endoscopic mucosal resection (EMR) procedure using an insulation-tipped diathermic (IT) knife for rectal flat lesions. Gastrointest Endosc. 1999;50:560–3.CrossRefGoogle Scholar
  26. 26.
    Yokoi C, Gotoda T, Oda I, et al. Endoscopic submucosal dissection (ESD) allows curative resection of local recurrent early gastric cancer after prior endoscopic mucosal resection. Gastrointest Endosc. 2006;64:212–8.CrossRefGoogle Scholar
  27. 27.
    Oyama T, Kikuchi Y. Aggressive endoscopic mucosal resection in the upper GI tract – hook knife EMR method. Min Invas Ther Allied Technol. 2002;11:291–5.CrossRefGoogle Scholar
  28. 28.
    Yahagi N, Fujishiro M, Kakushima N, et al. Endoscopic submucosal dissection for early gastric cancer using the tip of an electrosurgical snare (thin Type). Dig Endosc. 2004;16:34–8.CrossRefGoogle Scholar
  29. 29.
    Ono H, Hasuike N, Inui T, et al. Usefulness of a novel electrosurgical knife, the insulation-tipped diathermic knife-2, for endoscopic submucosal dissection of early gastric cancer. Gastric Cancer. 2008;11:47–52.CrossRefGoogle Scholar
  30. 30.
    Takeuchi Y, Uedo N, Ishihara R, et al. Efficacy of an endo-knife with a water jet function (Flushknife) for endoscopic submucosal dissection of superficial colorectal neoplasms. Am J Gastroenterol. 2010;105:314–22.CrossRefGoogle Scholar
  31. 31.
    Toyonaga T, Man-I M, Fujita T, et al. The performance of a novel ball-tipped Flush knife for endoscopic submucosal dissection: a case–control study. Aliment Pharmacol Ther. 2010;32:908–15.CrossRefGoogle Scholar
  32. 32.
    Suzuki S, Gotoda T, Kobayashi Y, et al. Usefulness of a traction method using dental floss and a hemoclip for gastric endoscopic submucosal dissection: a propensity score matching analysis (with videos). Gastrointest Endosc. 2016;83:337–46.CrossRefGoogle Scholar
  33. 33.
    Yoshida M, Takizawa K, Ono H, et al. Efficacy of endoscopic submucosal dissection with dental floss clip traction for gastric epithelial neoplasia: a pilot study (with video). Surg Endosc. 2016;30(7):3100–6.CrossRefGoogle Scholar
  34. 34.
    Japanese Gastric Cancer Association. Japanese classification of gastric carcinoma -3rd English edition. Gastric Cancer. 2011;14:101–12.CrossRefGoogle Scholar
  35. 35.
    Itoh H, Oohata Y, Nakamura K, et al. Complete ten-year postgastrectomy follow-up of early gastric cancer. Am J Surg. 1989;158:14–6.CrossRefGoogle Scholar
  36. 36.
    Ohta H, Noguchi Y, Takagi K, et al. Early gastric carcinoma with special reference to macroscopic classification. Cancer. 1987;60:1099–106.CrossRefGoogle Scholar
  37. 37.
    Sano T, Sasako M, Kinoshita T, et al. Recurrence of early gastric cancer – follow-up of 1475 patients and review of Japanese literature. Cancer. 1993;72:3174–8.CrossRefGoogle Scholar
  38. 38.
    Sasako M. Risk factors for surgical treatment in the Dutch gastric cancer trial. Br J Surg. 1997;84:1567–71.CrossRefGoogle Scholar
  39. 39.
    Sasako M, Kinoshita T, Maruyama K. Prognosis of early gastric cancer. Stom Intest (in English abstract). 1993;28:139–46.Google Scholar
  40. 40.
    Sano T, Kobori O, Muto T. Lymph node metastasis from early gastric cancer: endoscopic resection of tumour. Br J Surg. 1992;79:241–4.CrossRefGoogle Scholar
  41. 41.
    Tsujitani S, Oka S, Saito H, et al. Less invasive surgery for early gastric cancer based on the low probability of lymph node metastasis. Surgery. 1999;125:148–54.CrossRefGoogle Scholar
  42. 42.
    Yanai H, Matsubara Y, Okamoto T, et al. Clinical impact of strip biopsy for early gastric cancer. Gastrointest Endosc. 2004;60:771–7.CrossRefGoogle Scholar
  43. 43.
    Farrell JJ, Lauwers GY, Brugge WR. Endoscopic mucosal resection using a cap-fitted endoscope improves tissue resection and pathology interpretation: an animal study. Gastric Cancer. 2006;9:3–8.CrossRefGoogle Scholar
  44. 44.
    Gotoda T, Sasako M, Shimoda T, et al. An evaluation of the necessity of gastrectomy with lymph node dissection for patients with submucosal Invasive gastric cancer. Br J Surg. 2001;88:444–9.CrossRefGoogle Scholar
  45. 45.
    Etoh T, Katai H, Fukagawa T, et al. Treatment of early gastric cancer in the elderly patient: results of EMR and gastrectomy at a national referral center in Japan. Gastrointest Endosc. 2005;62:868–71.CrossRefGoogle Scholar
  46. 46.
    Yamao T, Shirao K, Ono H, et al. Risk factors for lymph node metastasis from intramucosal gastric carcinoma. Cancer. 1996;77:602–6.CrossRefGoogle Scholar
  47. 47.
    Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2010 (ver.3). Gastric Cancer. 2011;14:113–23.CrossRefGoogle Scholar
  48. 48.
    Gotoda T, Yanagisawa A, Sasako M, Ono H, Nakanishi Y, Shimoda T, et al. Incidence of lymph node metastasis from early gastric cancer: estimation with a large number of cases at two large centers. Gastric Cancer. 2000;3(4):219–25.CrossRefGoogle Scholar
  49. 49.
    Hirasawa T, Gotoda T, Miyata S, Kato Y, Shimoda T, Taniguchi H, et al. Incidence of lymph node metastasis and the feasibility of endoscopic resection for undifferentiated-type early gastric cancer. Gastric Cancer. 2009;12(3):148–52.CrossRefGoogle Scholar
  50. 50.
    Choi KK, Bae JM, Kim SM, Sohn TS, Noh JH, Lee JH, et al. The risk of lymph node metastases in 3,951 surgically resected mucosal gastric cancers: implications for endoscopic resection. Gastrointest Endosc. 2015;3. [Epub ahead of print].Google Scholar
  51. 51.
    The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointest Endosc. 2003;58(6 Suppl):S3–43.Google Scholar
  52. 52.
    Nagano H, Ohyama S, Fukunaga T, et al. Indications for gastrectomy after incomplete EMR for early gastric cancer. Gastric Cancer. 2005;8:149–54.CrossRefGoogle Scholar
  53. 53.
    Yano H, Kimura Y, Iwazawa T, et al. Laparoscopic management for local recurrence of early gastric cancer after endoscopic mucosal resection. Surg Endosc. 2005;19:981–5.CrossRefGoogle Scholar
  54. 54.
    Nakajima T, Oda I, Gotoda T, et al. Metachronous gastric cancers after endoscopic resection: how effective is annual endoscopic surveillance? Gastric Cancer. 2006;9:93–8.CrossRefGoogle Scholar
  55. 55.
    Nagano H, Fukunaga T, Hiki N, et al. Two rare cases of node-positive differentiated gastric cancer despite their infiltration to sm1, their small size, and lack of lymphatic invasion into the submucosal layer. Gastric Cancer. 2008;11:53–7.CrossRefGoogle Scholar
  56. 56.
    Oya H, Gotoda T, Kinjo T, et al. A case of lymph node metastasis following a curative endoscopic submucosal dissection of an early gastric cancer. Gastric Cancer. 2012;15:221–5.CrossRefGoogle Scholar
  57. 57.
    Chung JW, Jung HY, Choi KD, et al. Extended indication of endoscopic resection for mucosal early gastric cancer: analysis of a single center experience. J Gastroenterol Hepatol. 2011;26:884–7.CrossRefGoogle Scholar
  58. 58.
    Uedo N, Iishi H, Tatsuta M, Ishihara R, Higashino K, Takeuchi Y, et al. Longterm outcome after endoscopic mucosal resection for early gastric cancer. Gastric Cancer. 2006;9:88–92.CrossRefGoogle Scholar
  59. 59.
    Choi KS, Jung HY, Choi KD, et al. EMR versus gastrectomy for intramucosal gastric cancer: comparison of long-term outcomes. Gastrointest Endosc. 2011;73:942–8.CrossRefGoogle Scholar
  60. 60.
    Gotoda T, Iwasaki M, Kusano C, et al. Endoscopic resection of early gastric cancer treated by guideline and expanded National Cancer Centre criteria. Br J Surg. 2010;97:868–71.CrossRefGoogle Scholar
  61. 61.
    Chung IK, Lee JH, Lee SH, et al. Therapeutic outcomes in 1000 cases of endoscopic submucosal dissection for early gastric neoplasms: Korean ESD Study Group multicenter study. Gastrointest Endosc. 2009;69:1228–35.CrossRefGoogle Scholar
  62. 62.
    Lee H, Yun WK, Min BH, et al. A feasibility study on the expanded indication for endoscopic submucosal dissection of early gastric cancer. Surg Endosc. 2011;25:1985–93.CrossRefGoogle Scholar
  63. 63.
    Ahn JY, Jung HY, Choi KD, et al. Endoscopic and oncologic outcomes after endoscopic resection for early gastric cancer: 1370 cases of absolute and extended indications. Gastrointest Endosc. 2011;74:485–93.CrossRefGoogle Scholar
  64. 64.
    Kusano C, Iwasaki M, Kaltenbach T, et al. Should elderly patients undergo additional surgery after non-curative endoscopic resection for early gastric cancer? long-term comparative outcomes. Am J Gastroenterol. 2011;106:1064–9.CrossRefGoogle Scholar
  65. 65.
    Gotoda T, Yang HK. The desired balance between treatment and curability in treatment planning for early gastric cancer. Gastrointest Endosc. 2015;82(2):308–10.CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Takuji Gotoda
    • 1
  1. 1.Division of Gastroenterology and Hepatology, Department of MedicineNihon University School of MedicineTokyoJapan

Personalised recommendations