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CC BY 4.0 · Endosc Int Open 2025; 13: a27494324
DOI: 10.1055/a-2749-4324
Original article

Lymph node metastases in early gastric cancer: Japanese Gastric Cancer Treatment Guidelines can be used for endoscopic resection in the West

Authors

  • Edward Young

    1   School of Medicine, Faculty of Health and Medical Sciences, University of Adelaide Press, Adelaide, Australia (Ringgold ID: RIN1066)
    2   Department of Gastroenterology, Lyell McEwin Hospital, Elizabeth Vale, Australia (Ringgold ID: RIN3187)

  • Louisa Edwards

    3   Department of Gastroenterology, Royal Adelaide Hospital, Adelaide, Australia (Ringgold ID: RIN1062)
    1   School of Medicine, Faculty of Health and Medical Sciences, University of Adelaide Press, Adelaide, Australia (Ringgold ID: RIN1066)

  • Aashish Maurya

    2   Department of Gastroenterology, Lyell McEwin Hospital, Elizabeth Vale, Australia (Ringgold ID: RIN3187)
    1   School of Medicine, Faculty of Health and Medical Sciences, University of Adelaide Press, Adelaide, Australia (Ringgold ID: RIN1066)

  • Andrew Ruszkiewicz

    4   Tissue Pathology, Lyell McEwin Hospital, Elizabeth Vale, Australia (Ringgold ID: RIN3187)

  • Hamish Philpott

    2   Department of Gastroenterology, Lyell McEwin Hospital, Elizabeth Vale, Australia (Ringgold ID: RIN3187)
    1   School of Medicine, Faculty of Health and Medical Sciences, University of Adelaide Press, Adelaide, Australia (Ringgold ID: RIN1066)

  • Rajvinder Singh

    5   Gastroenterology and Hepatology, Lyell McEwin Hospital, Elizabeth Vale, Australia (Ringgold ID: RIN3187)
    1   School of Medicine, Faculty of Health and Medical Sciences, University of Adelaide Press, Adelaide, Australia (Ringgold ID: RIN1066)
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Abstract

Background and study aims

The eCura system has been shown to accurately delineate early gastric cancers with negligible risk of lymph node metastases, which, therefore, would be considered endoscopically cured. However, this classification was based predominantly on data from high-incidence Eastern countries. We sought to assess whether these criteria can be safely applied in a Western population.

Patients and methods

Data were retrospectively recorded for patients who underwent gastrectomy in four Australian tertiary centee over two decades. Demographic data, lesion characteristics (size, differentiation, invasion depth, lymphovascular invasion, and ulceration) as well as number of lymph node metastases was recorded. Patients given neoadjuvant chemotherapy were excluded.

Results

A total of 1,465 gastrectomy specimens were reviewed, including in 558 patients who underwent resection of gastric adenocarcinoma without neoadjuvant chemotherapy (mean age 67.9, 64.2% male). Of these, 101 (18.1%, confidence interval [CI] 15.4%-21.9%) had T1 disease (T1a = 30, T1b = 71). Of the lesions, 11.5% (n = 64, CI 9.1%-14.4%) met the 2021 Japanese "absolute criteria" for endoscopic resection, with 7.8% of these (n = 5, CI 3.4%-17%) having positive lymph nodes at gastrectomy. Of them, 9.9% (n = 55, CI 7.6%-12.6%) would have been considered eCura A or B, with none of these having positive lymph nodes at gastrectomy.

Conclusions

The eCura system for defining endoscopic curability could have been safely applied in this Western population. Even in Western countries, patients with early gastric cancer that meets Japanese guidelines for endoscopic resection should, where possible, undergo en bloc endoscopic submucosal dissection. Lesions classified histologically as eCuraA or B should be considered endoscopically cured.

Keywords

Endoscopy Upper GI Tract - Precancerous conditions & cancerous lesions (displasia and cancer) stomach - Endoscopic resection (ESD, EMRc, ...) - GI Pathology


Publication History

Received: 29 June 2025

Accepted after revision: 14 November 2025

Accepted Manuscript online:
17 November 2025

Article published online:
04 December 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).

Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

Bibliographical Record
Edward Young, Louisa Edwards, Aashish Maurya, Andrew Ruszkiewicz, Hamish Philpott, Rajvinder Singh. Lymph node metastases in early gastric cancer: Japanese Gastric Cancer Treatment Guidelines can be used for endoscopic resection in the West. Endosc Int Open 2025; 13: a27494324.
DOI: 10.1055/a-2749-4324
 

  • References

  • 1 Thrift AP, Wenker TN, El-Serag HB. Global burden of gastric cancer: epidemiological trends, risk factors, screening and prevention. Nat Rev Clin Oncol 2023; 20: 338-349
    Search in Google Scholar
  • 2 Zhang X, Li M, Chen S. et al. Endoscopic screening in Asian countries is associated with reduced gastric cancer mortality: A meta-analysis and systematic review. Gastroenterology 2018; 155: 347-354.e349
    Search in Google Scholar
  • 3 Japanese Gastric Cancer Association. Japanese Gastric Cancer Treatment Guidelines 2021 (6th edition). Gastric Cancer 2023; 26: 1-25
    Search in Google Scholar
  • 4 Wang J, Wang L, Li S. et al. Risk factors of lymph node metastasis and its prognostic significance in early gastric cancer: A multicenter study. Front Oncol 2021; 11: 649035
    Search in Google Scholar
  • 5 Yanzhang W, Guanghua L, Zhihao Z. et al. The risk of lymph node metastasis in gastric cancer conforming to indications of endoscopic resection and pylorus-preserving gastrectomy: a single-center retrospective study. BMC Cancer 2021; 21: 1280
    Search in Google Scholar
  • 6 Hatta W, Gotoda T, Oyama T. et al. A scoring system to stratify curability after endoscopic submucosal dissection for early gastric Cancer: "eCura system". Am J Gastroenterol 2017; 112: 874-881
    Search in Google Scholar
  • 7 Gotoda T, Yanagisawa A, Sasako M. 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: 219-225
    Search in Google Scholar
  • 8 Bickenbach K, Strong VE. Comparisons of gastric cancer treatments: East vs. West. J Gastric Cancer 2012; 12: 55-62
    Search in Google Scholar
  • 9 Matsuda T, Saika K. The 5-year relative survival rate of stomach cancer in the USA, Europe and Japan. Jpn J Clin Oncol 2013; 43: 1157-1158
    Search in Google Scholar
  • 10 Rawla P, Barsouk A. Epidemiology of gastric cancer: global trends, risk factors and prevention. Prz Gastroenterol 2019; 14: 26-38
    Search in Google Scholar
  • 11 Park SH, Kang MJ, Yun EH. et al. Epidemiology of gastric cancer in Korea: Trends in incidence and survival based on Korea Central Cancer Registry Data (1999–2019). J Gastric Cancer 2022; 22: 160-168
    Search in Google Scholar
  • 12 Tate DJ, Klein A, Sidhu M. et al. Endoscopic submucosal dissection for suspected early gastric cancer: absolute versus expanded criteria in a large Western cohort (with video). Gastrointest Endosc 2019; 90: 467-479.e464
    Search in Google Scholar
  • 13 Probst A, Schneider A, Schaller T. et al. Endoscopic submucosal dissection for early gastric cancer: are expanded resection criteria safe for Western patients?. Endoscopy 2017; 49: 855-865
    Search in Google Scholar
  • 14 Hanada Y, Choi AY, Hwang JH. et al. Low frequency of lymph node metastases in patients in the United States with early-stage gastric cancers that fulfill Japanese endoscopic resection criteria. Clin Gastroenterol Hepatol 2019; 17: 1763-1769
    Search in Google Scholar
  • 15 Milhomem LM, Milhomem-Cardoso DM, da Mota OM. et al. Risk of lymph node metastasis in early gastric cancer and indications for endoscopic resection: is it worth applying the East rules to the West?. Surg Endosc 2021; 35: 4380-4388
    Search in Google Scholar
  • 16 Morais R, Libanio D, Dinis Ribeiro M. et al. Predicting residual neoplasia after a non-curative gastric ESD: validation and modification of the eCura system in the Western setting: the W-eCura score. Gut 2023; 73: 105-117
    Search in Google Scholar
  • 17 Young E, Wan N, Philpott H. et al. The West catching up with the East: High-magnification NBI is accurate for the diagnosis of gastric neoplasia in a Western population. J Gastroenterol Hepatol 2025; 40: 1128-1134
    Search in Google Scholar
  • 18 Papenfuss WA, Kukar M, Oxenberg J. et al. Morbidity and mortality associated with gastrectomy for gastric cancer. Ann Surg Oncol 2014; 21: 3008-3014
    Search in Google Scholar
  • 19 Dikken JL, van Sandick JW, Allum WH. et al. Differences in outcomes of oesophageal and gastric cancer surgery across Europe. Br J Surg 2013; 100: 83-94
    Search in Google Scholar
  • 20 Davis SS, Noll D, Patel P. et al. Gastrectomy mortality in Australia. ANZ J Surg 2022; 92: 2109-2114
    Search in Google Scholar
  • 21 Karanicolas PJ, Graham D, Gönen M. et al. Quality of life after gastrectomy for adenocarcinoma: a prospective cohort study. Ann Surg 2013; 257: 1039-1046
    Search in Google Scholar
  • 22 Theuer CP, Kurosaki T, Ziogas A. et al. Asian patients with gastric carcinoma in the United States exhibit unique clinical features and superior overall and cancer specific survival rates. Cancer 2000; 89: 1883-1892
    Search in Google Scholar
  • 23 Strong VE, Song KY, Park CH. et al. Comparison of gastric cancer survival following R0 resection in the United States and Korea using an internationally validated nomogram. Ann Surg 2010; 251: 640-646
    Search in Google Scholar
  • 24 Livingstone JI, Yasui W, Tahara E. et al. Are Japanese and European gastric cancer the same biological entity? An immunohistochemical study. Br J Cancer 1995; 72: 976-980
    Search in Google Scholar
  • 25 de Jong MHS, Gisbertz SS, van Berge Henegouwen MI. et al. Prevalence of nodal metastases in the individual lymph node stations for different T-stages in gastric cancer: a systematic review. Updates Surg 2023; 75: 281-290
    Search in Google Scholar
  • 26 Akiyama Y, Katai H, Kitabayashi R. et al. Frequency of lymph node metastasis according to tumor location in clinical T1 early gastric cancer: supplementary analysis of the Japan Clinical Oncology Group study (JCOG0912). J Gastroenterol 2023; 58: 519-526
    Search in Google Scholar
  • 27 Bao L, Gao H, Pu L. et al. Comparison of clinical outcomes and prognosis between surgery and endoscopic submucosal dissection in patients with synchronous multifocal early gastric cancer. BMC Surg 2023; 23: 292
    Search in Google Scholar
  • 28 Kim HM, Kim HK, Lee SK. et al. Multifocality in early gastric cancer does not increase the risk of lymph node metastasis in a single-center study. Ann Surg Oncol 2012; 19: 1251-1256
    Search in Google Scholar
  • 29 Kinami S, Yamada S, Takamura H. Confusion and prospects for carcinogenesis of gastric adenoma and dysplasia: What is the correct answer currently?. World J Gastroenterol 2022; 28: 6900-6908
    Search in Google Scholar
  • 30 Narii N, Sobue T, Zha L. et al. Effectiveness of endoscopic screening for gastric cancer: The Japan Public Health Center-based Prospective Study. Cancer Sci 2022; 113: 3922-3931
    Search in Google Scholar
  • 31 Hundahl SA, Stemmermann GN, Oishi A. Racial factors cannot explain superior Japanese outcomes in stomach cancer. Arch Surg 1996; 131: 170-175
    Search in Google Scholar