Precision Treatment of Early Gastric Cancer After Non-curative Endoscopic Submucosal Dissection

The treatment of early gastric cancer (EGC) following non-curative endoscopic submucosal dissection (ESD) requires a sophisticated and evidence-based approach. The results of the studies by Lee et al. [1] and Yang et al. [2] featured in this issue suggest the viability of a combined approach consisting of observation and surgery that is tailored to each patient's unique condition and risk profile after ESD. In cases with only lateral resection margin positivity (pLM), many studies have reported the efficacy of additional endoscopic resection or follow-up observation [3, 4]. The Korean Practice Guidelines for Gastric Cancer 2022 also present the possibility of follow-up observation in limited cases of pLM alone [5]. Lee et al. [1] also demonstrated the efficacy of the observational method. Their examination of a larger sample of 3,515 patients undergoing ESD – with special focus on 123 individuals with non-curative ESD due to pLM – revealed a remnant cancer occurrence of 25.9% in the observational group versus 0% in the curative resection group. Intriguingly, overall survival rates did not differ significantly between groups (P=0.577), indicating the feasibility of an observational strategy under rigorous follow-up for patients with pLM.

Alternatively, the study by Yang et al. [2] casts light on management strategies after ESD for undifferentiated-type EGC, especially among high-risk patients. The eCura system predicts cancer-specific survival in patients who do not meet the curative criteria after ESD for EGC by assessing the potential risk of lymph node metastasis (LNM) [6]. The revised eCura system (eCuraU) delineates patient categorization based on LNM risk following non-curative endoscopic resection, revealing significant survival benefits for high- versus low-risk patients following surgical intervention. The eCuraU system showed a significantly superior ability to identify high-risk patients with LNM than the eCura system (66.7% vs. 22.2%, respectively; McNemar’s test, P<0.001); moreover, surgery outperformed no treatment in terms of overall mortality (hazard ratio, 3.26; P=0.015) in the high-risk category. This highlights the importance of surgical action in high-risk patients identified by the eCuraU system, advocating for a customized surgical response to address the threat of LNM. Furthermore, evidence from Yang et al. [2] underscores the necessity for surgical action under specific conditions, particularly within scenarios involving undifferentiated-type EGC and a significant risk of LNM.

A thorough plan is required to implement these findings. For patients with solitary pLM similar to those in the Lee et al.’s study [1], a rigorous and organized monitoring approach may be sufficient to avoid the need for early invasive treatments. Conversely, for those with a high-risk profile as in the Yang et al.’s study [2], a shift toward advocating for additional surgical interventions after ESD is recommended to manage the increased LNM risk as delineated by the eCura and eCuraU system evaluations. In conclusion, the juxtaposition of the findings of Lee et al. [1] and Yang et al. [2] offers a unified strategy for addressing EGC following non-curative ESD that emphasizes a patient-oriented approach. This strategy facilitates patient-centered care and refines EGC treatment efficacy and precision after non-curative ESD.