The Chinese Society of Clinical Oncology (CSCO): Clinical guidelines for the diagnosis and treatment of gastric cancer, 2021

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. 2021 Jul 1;41(8):747–795. doi: 10.1002/cac2.12193

Stage	Stratification	Grade I recommendations	Grade II recommendations
cT1aN0M0, Stage I	Patients suitable for EMR/ESD^a	EMR/ESD (Evidence 1B) Patients who had non‐radical resection with EMR/ESD must be re‐operated (Evidence 1A)^b	Patients with non‐radical resection must receive additional ESD, electrotomy, or close follow‐up upon providing informed consent (Evidence 2A)

Stage

Stratification

Grade I recommendations

Grade II recommendations

cT1aN0M0, Stage I

Patients suitable for EMR/ESD^a

EMR/ESD

(Evidence 1B)

Patients who had non‐radical resection with EMR/ESD must be re‐operated

(Evidence 1A)^b

Patients with non‐radical resection must receive additional ESD, electrotomy, or close follow‐up upon providing informed consent (Evidence 2A)

Abbreviations: EMR, endoscopic mucosal resection; ESD, endoscopic sub‐mucosal dissection;

Notes

^aPrinciples of EMR/ESD for early gastric cancer

Endoscopic resection of early gastric cancer mainly includes EMR and ESD. In principle, endoscopic therapy is suitable for tumors with the least risk of lymph node metastasis [32]. The initial absolute indications for endoscopic resection were previously identified as well‐differentiated tumors limited to mucosa invasion (T1a) with a diameter <2 cm and without ulceration. Following the publication of the results of a Japanese multicenter prospective single‐arm study (JCOG0607) [33], the 5th edition of the Japanese Gastric Cancer Guidelines [34] expanded the indications for EMR and ESD to differentiated cancers invading the mucosal layer with diameter <2 cm (cT1a) and without ulcerations; and expanded indications for ESD to differentiated cancers of diameter >2 cm without ulceration invading the intramucosal layer (cT1a), and differentiated cancers of diameter <3 cm with ulceration and invading the intramucosal layer (cT1a). The expanded indications for ESD include undifferentiated non‐ulcerated intramucosal carcinoma (cT1a) with diameter <2 cm. For the Chinese gastric cancer population, the clinical implications of the expanded indications are still being investigated in many centers across China.

^bEvaluation and curative strategies for endoscopic radical resection

The radicality of endoscopic resection is based on the extent of local resection and possibility of lymph node metastasis. Results of large‐scale case studies and systematic analyses showed that for cases with absolute indications and negative margins, the rate of lymph node metastasis was <1% and had a long‐term prognosis similar to surgical resection. For cases satisfying the expanded criteria, the rate of lymph node metastasis was <3%, but long‐term follow‐up data are awaited [33, 35, 36].

The radicality of endoscopic resection should be confirmed using the resected specimen on the postoperative pathological report, based on which the necessity of further treatment and follow‐up are to be determined.