Resection Of Early Gastric Cancer Research Articles

Endoscopic Resection of Early Gastric Cancer with Undifferentiated-Type Histology.

Endoscopic Resection of Early Gastric Cancer with Undifferentiated-Type Histology.

Long-Term Effects of Helicobacter pylori Eradication on Metachronous Gastric Cancer Development.

Background/AimsGastric mucosal atrophy and intestinal metaplasia due to Helicobacter pylori infection are the main precursor lesions of gastric cancer. The aim of this study was to evaluate the long-term effects of H. pylori eradication on the progression of precancerous lesions to metachronous cancer after endoscopic resection of early gastric cancer (EGC).MethodsPatients who underwent endoscopic resection of EGC were retrospectively reviewed. Changes in precancerous lesions and development of metachronous cancer were compared according to H. pylori eradication and final infection status.ResultsIn total, 565 patients were followed for over 5 years after endoscopic resection of EGC. The grade of atrophy on corpus was significantly lower in the H. pylori-eradicated group than in the persistent group during follow-up (p=0.029). In patients <70 years of age, the cumulative incidence rate of metachronous cancer was significantly lower in the H. pylori-eradicated group than in the persistent group (p=0.018). Age was an independent risk factor for metachronous cancer development.ConclusionsH. pylori eradication might prevent the development of metachronous cancer in patients <70 years of age by delaying the progression of precancerous lesions after endoscopic resection of EGC.

Long-term outcomes after noncurative endoscopic resection of early gastric cancer: the optimal time for additional endoscopic treatment

We aimed to evaluate long-term outcomes with noncurative endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) and surveillance strategies such as the optimal time for additional endoscopic treatment in patients with noncurative ESD. Of 2527 patients who underwent gastric ESD for EGC, 512 (20.3%) patients with noncurative resection were reviewed. Noncurative resection is defined as positive resected margins on histology, lymphovascular infiltration, or beyond the expanded criteria for ESD. The mean ± standard deviation follow-up duration was 79.0 ± 55.7 months. A total of 264 patients (51.6%) and 50 patients (9.8%) underwent surgery and endoscopic treatment after noncurative resection, respectively, whereas 198 patients (38.7%) were observed. Cancer-specific survival and disease-free survival rates were significantly different among the surgery, other endoscopic treatment, and observation groups (96.7%, 86.8%, and 86.2%, respectively; P=.030; and 92.5%, 73.6%, and 63.0%, respectively; P< .001). When patients who underwent surgery were excluded, the disease-free survival rate of recurrence was not significantly different between the endoscopic treatment and observation groups (73.6% vs 63.0%; P= .548). To exclude the potential for the presence of lymph node metastasis, we further analyzed disease-free survival of local recurrence by comparing the patients with only a positive lateral resection margin. The disease-free survival rate was higher in the endoscopic treatment group than in the observation group (89.2% vs 69.1%; P= .023). Moreover, additional endoscopic treatment within 3 months showed significant associations with lower risk of local recurrence on multivariate analysis (hazard ratio, 0.017; 95% confidence interval, 0.002-0.260; P= .003). In patients with noncurative ESD, additional surgery showed a better long-term outcome; moreover, when a positive lateral resection margin was the only noncurative factor, additional endoscopic treatment within 3 months could be considered to improve disease-free survival.

The Incidence of Lymph Node Metastasis in Submucosal Early Gastric Cancer (EGC) According to the Expanded Criteria of the Japanese Gastric Cancer Association (JGCA): A Systematic Review

Introduction: Japanese criteria for curative endoscopic resection of early gastric cancer initially included non-ulcerated, well-differentiated mucosal lesions ≤2 cm in diameter, known as the absolute criteria. Subsequently, these indications were expanded to include non ulcerated differentiated lesions < 3 cm with submucosal invasion (SM1) μm. Whether patients meeting the expanded criteria can be safely managed without gastrectomy and lymph node dissection has been controversial. There are conflicting results regarding the risk of lymph node metastasis in patients with submucosal gastric lesions who met the expanded criteria. We performed a systemic review to evaluate the incidence of Lymph Node Invasion (LNM) in patients met the expanded criteria for SM1 lesions. Methods: We comprehensively searched main reference databases (MEDLINE, EMBASE, CINHAL) for any study that included patients who underwent gastrectomy and lymph node dissection for early gastric cancer through December 10, 2016. Patients with submucosal lesions that met the expanded criteria were included in the final analysis. We followed the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses(PRISMA). Article review was done by “MA” and “MB” and the final review was done by “MO.” Relative risk was used to compare the incidence of LNM in each group. CI of 95 and p Results: Our search yielded 1,775 studies, of which 1,705 studies were excluded after abstract or method, and result sections were reviewed. A total of 70 full-text articles were reviewed. 54 articles were excluded due to missing data on LN. 16 manuscripts (1 prospective and 15 retrospectives) from Japan, Korea, and China were included. 1392 patients with SM early gastric cancer met the expanded indication were included in the final analysis. The search strategy is summarized in Figure 1. The incidence of LNM was 41 out of 1392 patients (2.9%) table 1.FigureConclusion: The incidence of LNM for submucosal lesions met the expanded criteria is (2.9%). This is higher than the results in the landmark study by Gottoda et al. The increased risk of LNM should be considered in discussing surveillance versus surgical gastrectomy in patients who underwent Endoscopic Submucosal Dissection for EGC with SM1 invasion.Figure

Risk factors for early metachronous tumor development after endoscopic resection for early gastric cancer.

BackgroundMetachronous gastric tumor (MGT) is one of major concerns after endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). Optimal follow-up strategy has not been yet well-established. The aim of this study was to identify the different clinical features of the patients according to the time interval to development of MGT.MethodsAmong 1,780 consecutive patients with EGC who underwent ESD between 2005 and 2014, 115 patients with MGT were retrospectively reviewed. MGT was defined as secondary gastric cancer or dysplasia detected > 1 year after initial ESD. Clinicopathological factors associated with early development of MGT were evaluated.ResultsThe median interval to development of MGT was 37 months. In univariate analysis, the median interval to MGT was shorter if EGC lesion was non-elevated type (39.4 vs 57.0 months, p = 0.011), or synchronous primary lesion was absent (39.8 vs 51.4 months, p = 0.050). In multivariate Cox’s proportional hazards analysis, the hazard ratios for early occurrence of MGT were 1.966 (95% CI: 1.141–3.386, p = 0.015) and 1.911 (95% CI: 1.163–3.141, p = 0.011), respectively. There was no significant difference in overall survival after diagnosis of MGT between the early occurrence group and the late occurrence group.ConclusionsNon-elevated gross type and absence of synchronous gastric tumor were independent risk factors for early development of MGT. Meticulous endoscopic inspection is especially important for the detection of MGT during the early follow-up period in patients with these initial tumor characteristics.

Metachronous Gastric Cancer Following Curative Endoscopic Resection of Early Gastric Cancer.

This review article summarizes knowledge about metachronous gastric cancer (MGC) occurring after curative endoscopic resection (ER) of early gastric cancer (EGC), treatment outcomes of patients who developed MGC, and efficacy of Helicobacter pylori eradication to prevent MGC. The incidence of MGC following curative ER increases over time and is higher than in patients undergoing gastrectomy. Increasing age and multifocal EGC are independent risk factors for developing MGC. An MGC following curative ER is usually a small (<20 mm) and differentiated intramucosal cancer. Most MGC lesions are found at an early stage on semiannual or annual surveillance endoscopy and are successfully treated by further ER, with excellent long-term outcomes. Eradication of H. pylori may reduce the risk of MGC following ER of EGC, but further prospective studies with long-term outcomes are required. Surveillance endoscopy following gastric ER should be continued indefinitely, due to the risk of MGC even after successful H. pylori eradication. Risk stratification and tailored endoscopic surveillance schedules need to be developed.

Potential for peritoneal cancer cell seeding in endoscopic full-thickness resection for early gastric cancer

During endoscopic full-thickness resection (EFTR) for cancers, whether exposure of the lumen to the abdominal cavity during the procedure is acceptable is controversial because of the potential risk of tumor cell seeding. To assess the possibility of transplantation as a result of contact with tumor cells during the procedure, we prospectively investigated the ability of cancer cells to be detached by touching the tumor surface. In 48 patients with a single early gastric cancer resected by endoscopic submucosal dissection, stamp cytology was performed by touching the surface of the specimens to glass slides. Samples were obtained from cancerous and noncancerous areas, constituting the study and control groups, respectively. The detection rate of malignant class IV or V (C-IV/C-V) samples was investigated with Papanicolaou staining. The rate of CD44v9-positive cases, a cancer stem cell marker, was assessed in C-IV/C-V samples with immunohistochemical staining. Detection rates of C-IV/C-V samples in the cancerous group (53/192 slides, 27.6%) differed significantly from those of the C-IV/C-V samples in the noncancerous group (0/96 slides, 0%). Among the 53 slides of C-IV/C-V samples in the cancerous group, CD44v9 cells were expressed in 18 slides (34.0%). These data suggest that cancer cells, including cancer stem cells, in early gastric cancers are easily detached via contact with the tumor surface. In EFTR, a nonexposure approach is recommended to avoid the riskof iatrogenic cancer cell seeding via contact with and transplantation of cancer cells.

Predictors of Metachronous Neoplasia After Endoscopic Resection for Early Gastric Cancer

Patients with early gastric cancer (EGC) have a risk for developing metachronous neoplasia (MN; dysplasia or carcinoma) in the remaining stomach after

Tumour infiltrating lymphocytes are predictors of lymph node metastasis in early gastric cancers

Lymph node metastasis (LNM) is an important factor for predicting prognosis and selecting appropriate treatment in early gastric cancers (EGCs). We investigated the histopathological and microenvironmental predictors of LNM in EGCs. We retrieved 43 cases of EGC without LNM and 59 cases with LNM. Clinicopathological variables and tumour-infiltrating lymphocytes (TILs), Crohn's-like lymphoid reaction (CLR), tumour stromal percentage (TSP), and FOXA1 expression were evaluated and correlated with LNM. Among the 102 cases, 68 cases (66.7%) had low TILs and 34 cases (33.3%) had high TILs. High TILs were significantly correlated with the absence of LNM (p<0.001), less extent of invasion (p=0.004), absence of LVI (p=0.035), conspicuous CLR (p<0.001), and the absence of TSP (p=0.009). Conspicuous CLR was observed in 47 cases (46.1%) and TSP was present in 17 cases (16.7%) and neither was correlated with LNM. High FOXA1 expression was significantly associated with presence of LNM, low TILs, and submucosal invasion. In multivariate analysis, low TILs (p=0.023), LVI (p=0.008), and submucosal invasion (p=0.001) were independent predictive factors for LNM in EGCs. Evaluation of TILs in biopsied or endoscopically resected EGC specimens may help to predict LNM and select subsequent proper treatment modalities and follow-up.

Helicobacter pylori infection and serum level of pepsinogen are associated with the risk of metachronous gastric neoplasm after endoscopic resection

Patients who have undergone endoscopic resection of early gastric cancers (EGCs) are at risk for metachronous gastric neoplasm. To determine whether serum level of pepsinogen (PG), a marker of gastric atrophy, can determine which patients who have undergone endoscopic submucosal dissection for EGC are at risk for metachronous gastric neoplasm. We also investigated the effects of Helicobacter pylori eradication on metachronous gastric neoplasm incidence. We performed a retrospective study of 590 consecutive patients who underwent endoscopic submucosal dissection for EGC, from January 2008 to May 2013 at a tertiary centre in South Korea; serum levels of PG were measured at the time of endoscopic submucosal dissection and H. pylori infection status were recorded. In case of proven presence of current H. pylori infection, eradication treatment was provided. Patients underwent follow-up endoscopies at 3 months, 9 months, and each year after the procedure to detect neoplasms and were tested for H. pylori infection; serum levels of PG were measured at these time points from 442 of the patients. The main and sub-cohorts were assessed for baseline characteristics, H. pylori infection, serum level of PG, and metachronous gastric neoplasm lesions. During a median follow-up period of 47.7 months, 64 patients developed metachronous gastric neoplasms. In multivariate analysis of the main cohort (n = 590), risk factors for metachronous gastric neoplasm included persistent H. pylori infection (hazard ratio [HR], 2.532; P = .022) and serum ratio of PGI:PGII of three or less at the time of endoscopic submucosal dissection (HR, 1.881; P = .018). Among patients with serum PG measurements, persistent H. pylori infection (odds ratio [OR], 4.404; P = .009) and persistent decrease in mean serum ratio of PGI:PGII to 3 or less were associated with increased risk of metachronous gastric neoplasm (OR, 2.141; P = .039). In a retrospective analysis of patients who underwent endoscopic resection of EGCs, eradication of H. pylori infection reduced risk for metachronous gastric neoplasm. Serum ratio of PGI:PGII of 3 or less also increase risk of metachronous gastric neoplasm after endoscopic submucosal dissection. ClinicalTrials.gov. registry number, NCT02682446.

Therapeutic Outcomes of Endoscopic Resection of Early Gastric Cancer with Undifferentiated-Type Histology: A Korean ESD Registry Database Analysis.

Background/AimsTo assess the therapeutic outcomes of endoscopic resection (ER) of early gastric cancer (EGC) with undifferentiated-type histology. MethodsCases of ER of EGC with undifferentiated-type histology in the Korean endoscopic submucosal dissection (ESD) registry database were identified and reviewed. The immediate outcomes, including en bloc resection, complete resection, and curative resection rates, and long-term outcomes, including recurrence and survival rates, were extracted and analyzed. ResultsFrom 2006 to 2015, 275 EGCs with undifferentiated-type histology from 275 patients were identified. The immediate outcomes were as follows: en bloc resection rate: 92.4%; complete resection rate: 80%; and curative resection rate: 36.4%. Compared to patients with lesions that were beyond the expanded indication, those with expanded indication lesions showed better therapeutic outcomes. There was no difference in immediate outcomes between patients with poorly differentiated adenocarcinoma (PDC) and signet ring cell carcinoma (SRC). However, compared to ER of SRC, ER of PDC had a stronger association with submucosal invasion (41.9% vs. 23.6%, p=0.003). With regard to long-term outcomes, there was no difference between lesions with curative and non-curative resections in the recurrence and mortality rates. These rates also did not differ between PDC and SRC (median follow up: 3.96 years). ConclusionsER confined to expanded indication lesions can be considered for treatment of EGC with undifferentiated-type histology.

Surveillance strategy according to age after endoscopic resection of early gastric cancer.

Whether surveillance strategy after curative endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) differs in young patients is unclear. This study aimed to evaluate the risk of metachronous and extragastric recurrence in young patients with EGC after curative ESD. We retrospectively enrolled 1237 consecutive patients who underwent curative ESD for EGC from 2005 to 2014 at a single tertiary hospital. The patients were divided into group 1 (<50years of age, n=86), group 2 (age 50-74, n=985), or group 3 (≥75years of age, n=166). The clinical characteristics and outcomes were compared among the three age groups. Group 1 had more frequent Helicobacter pylori infection (P<0.001), less frequent intestinal metaplasia (P=0.021), and more frequent undifferentiated tumors (P=0.039). Although the 5-year risk of developing metachronous recurrence appeared to be lower in group 1 (2.7%) than in groups 2 (8.6%) or 3 (8.7%), the risk became quite similar at the 7-year follow-up (6.4, 12.7, and 8.7% for groups 1, 2, and 3, respectively; P=0.409 by log-rank test). Extragastric recurrences developed in only 2 cases in group 2 (0.2%). Surveillance for metachronous and extragastric recurrence after curative ESD in patients <50years of age should not be different from that in patients ≥50years of age. Endoscopic surveillance for metachronous recurrence should be continued for longer than 5years, even in young patients.

Long-Term Outcomes of Using Endoscopic Submucosal Dissection to Treat Early Gastric Cancer.

Endoscopic submucosal dissection (ESD) is becoming the main procedure for the resection of early gastric cancer (EGC). The absolute indications for treating EGC with endoscopic resection were established by the Japanese Gastric Cancer Association and have been generally accepted. However, the absolute indications for treating EGC are rather strict, and expanded indications have been developed. Many studies have reported favorable long-term outcomes for patients who received curative resection for the expanded indication. ESD preserves the stomach, thereby improving patients’ quality of life compared to surgery; however, a generally higher incidence of metachronous gastric cancer has been reported after ESD for EGC. Therefore, clinicians must pay careful attention during surveillance endoscopy, even after a curative ESD.

Clinical implications of pre-existing adenoma in endoscopically resected early gastric cancers.

BackgroundAlthough gastric adenoma is widely accepted as a precursor of gastric cancer, pre-existing adenoma is not always detected in gastric cancer patients.ObjectiveTo investigate the clinical characteristics of early gastric cancer (EGC) arising from adenoma, compared with those of EGC without pre-existing adenoma.MethodsPatients who underwent endoscopic resection for EGC at a single tertiary hospital were divided into two groups based on the presence (ex-adenoma group) or absence (de novo group) of pre-existing adenoma on pathologic specimens. Clinicopathologic characteristics, endoscopic features and long-term outcomes were analyzed.ResultsOf 1,509 patients, 236 (15.6%) were included in the ex-adenoma group. Mean age (P = 0.003) and Helicobacter pylori infection rate (P = 0.040) were significantly higher in the ex-adenoma than in the de novo group. Mean endoscopic size was significantly larger, elevated lesions were more prevalent (both P < 0.001), and carcinomas were more differentiated in the ex-adenoma group than in the de novo group (P = 0.037). The degree of atrophy (P = 0.025) or intestinal metaplasia (P < 0.001) was more advanced in the ex-adenoma group. Synchronous gastric neoplasia was significantly more prevalent in the ex-adenoma group (P < 0.001), whereas metachronous cancer recurrence rate was not significantly different between the two groups.ConclusionsEGCs with pre-existing adenoma show a greater association with H. pylori–related chronic inflammation than those without, which could explain the differences in the characteristics between groups. Potential differences in carcinogenic mechanisms between the groups were explored.

Nomogram for lymph node metastasis prediction with early gastric cancer patients: To decide additional gastrectomy after endoscopic dissection.

4045 Background: Accurate prediction of metastatic lymph node is critical to avoid unnecessary gastrectomy and improve quality of life for patients with early gastric cancer. The aim of this study was to develop and validate a nomogram for prediction of lymph node metastasis in early gastric cancer patients. Methods: We reviewed the clinicopathological data of 10595 patients who underwent curative resection for early gastric cancer from 2001 to 2015 at Samsung Medical Center. This model was externally validated by 2100 patients who underwent curative resection for gastric cancer in National Cancer Center. Multivariate analysis using the Cox proportional hazard regression model was performed to develop the nomogram, and discrimination and calibration were evaluated by external validation. Overall survival, disease free survival, and recurrence free survival were compared between gastrectomy groups of 6641 patients and endoscopic dissection group of 999 patients who was performed the treatment in Samsung Medical Center for early gastric cancer by risk on nomogram to demonstrate the efficacy of nomogram. Results: Multivariate analyses revealed that age, tumor size, lymphatic invasion, depth of invasion, and histologic differentiation were significant prognostic factors for lymph node metastasis. The nomogram had good discrimination with a concordance index of 0.845 [95% confidence interval 0.832-0.858], supported by an external validation point of 0.813[95% confidence interval 0.786-0.84]. In low risk on nomogram, endoscopic dissection group had similar overall survival (P = 0.319), disease free survival (P = 0.469) and recurrence free survival (P = 0.091) compared to gastrectomy group. Conclusions: We developed and validated a nomogram predicting lymph node metastasis for early gastric cancer based on a large database. This personalized nomogram is useful to avoid unnecessary gastrectomy after endoscopic dissection resulting in improved quality of life for early gastric cancer patients.

Exploring the Evidence of Expanded Criteria for Endoscopic Resection of Early Gastric Cancers.

Exploring the Evidence of Expanded Criteria for Endoscopic Resection of Early Gastric Cancers.

Additive endoscopic resection may be sufficient for patients with a positive lateral margin after endoscopic resection of early gastric cancer

No well-established treatment strategies exist for lateral margin positivity (LM+) alone after endoscopic resection (ER) of early gastric cancer (EGC). Thus, we aimed to clarify a treatment strategy for non-curative resection (non-CR) with LM+ alone after ER in EGC. Among 2065 patients with EGC treated by ER, 76 (3.6%) with only LM+ after non-CR of EGC were reviewed retrospectively. Of these, 28 underwent gastrectomy, 25 underwent argon plasma coagulation (APC), and 23 underwent repeat ER (re-ER). We analyzed the clinicopathologic characteristics of all patients and compared those who underwent additive surgery, APC, or re-ER. Of the 76 patients, 28 (36.8%) fulfilled the absolute criteria and 48 (63.2%) the expanded criteria for ER. Among the latter patients, the proportion undergoing additive surgery was 75.0%, higher than that of patients in the former group (P= .014). Residual cancer cells were observed in 70.6% of patients after additive surgery or re-ER. Residual cancer cells were observed significantly more often in patients with undifferentiated-type than in those with differentiated-type EGC (P= .02). However, no lymph node metastasis was observed in any patient after additive surgery. Our results suggest that endoscopic treatment may be a sufficient additive therapy for patients with LM+ alone after ER, irrespective of whether the absolute or expanded ER criteria are used. However, as complete ablation of remnant cells cannot be guaranteed, re-ER is a better additive treatment than APC.

Clinicopathological characteristics of patients who underwent additional gastrectomy after incomplete endoscopic resection for early gastric cancer.

To evaluate the clinicopathological characteristics and factors that lead to residual tumors in patients who underwent additional gastrectomy for incomplete endoscopic resection (ER) for early gastric cancer (EGC).Between 2003 and 2013, the medical records of patients underwent additional gastrectomy after incomplete ER were retrospectively reviewed. Those diagnosed with the presence of histologic residual tumor in specimens obtained by gastrectomy were assigned to the residual tumor (RT) group (n = 47); those diagnosed with the absence of histologic residual tumor were assigned to the nonresidual tumor (NRT) group (n = 33).In the multivariate analysis, endoscopic piecemeal resection, Helicobacter pylori infection, large tumor size (>2 cm), and both (lateral and vertical) marginal involvement were independent factors of the presence of residual tumor in additional gastrectomy after incomplete resection ER for EGC and the rates of independent factors were significantly higher in the RT group than in the NRT group (P < 0.05).Before ER, preexamination to accurately determine the GC invasion depth and the presence of LN metastasis is very important. During ER, surgeons should attempt to perform en bloc resection and to resect the mucous membrane with adequate safety margins to prevent tumor invasion into the lateral and vertical margins.

Risk-Stratification Model Based on Lymph Node Metastasis After Noncurative Endoscopic Resection for Early Gastric Cancer.

Patients with early gastric cancer (EGC) who have undergone noncurative endoscopic resection (ER) generally require additional surgery due to the possibility of lymph node metastasis (LNM). This study aimed to develop a reliable risk-stratification system to predict LNM after noncurative ER for EGC. A total of 2368 patients had a diagnosis of EGC and underwent ER. The study analyzed 321 patients who underwent additive gastrectomy and lymph node dissection after noncurative ER. Independent risk factors for LNM were identified and used to develop a risk-stratification system to estimate the relative risk of LNM. Of the 321 patients, 23 (7.2%) had LNM. A logistic regression analysis showed that female sex, lymphovascular invasion (LVI), and a positive vertical margin were significantly associated with LNM. The authors established a risk-stratification system using sex, LVI, and positive vertical margin (area under the receiver-operating characteristic [AUROC] curve, 0.811). The high-risk LNM group (score,≥2 points) showed a significantly higher risk of LNM than the low-risk LNM group (score, <2 points) (14.0 vs 1.2%). No LNM was found in patients with a risk score of zero. After internal and external validation, the AUROC curve for predicting LNM was 0.788 and 0.842, respectively. The risk-stratification system developed in this study will facilitate identification of patients who should undergo LN dissection after noncurative ER. Although additive surgery should be performed after noncurative ER for patients with a high risk of LNM, a close follow-up visit could be considered for low-risk patients with multiple comorbidities or high operative risks.

Pattern of extragastric recurrence and the role of abdominal computed tomography in surveillance after endoscopic resection of early gastric cancer: Korean experiences.

Although extragastric recurrence after endoscopic resection of early gastric cancer is rare, it is important because of its potentially fatal outcomes. We investigated the patterns of extragastric recurrence after endoscopic resection and evaluated the role of abdominal computed tomography in surveillance. Between July 1994 and June 2014, 4915 patients underwent endoscopic resection of early gastric cancer. Because of follow-up periods of less than 6months and consecutive surgery within 1year, 810 patients were excluded. Thus, 4105 patients were retrospectively reviewed. The median follow-up period was 37months(interquartile range 20-59.6months). The overall incidence of extragastric recurrence was 0.37% (n=15). In patients who underwent curative resection, the incidence was 0.14% (n=5). There were three recurrences in the absolute indication group, six in the expanded indication group, and six in the beyond expanded indication group. The median time to extragastric recurrence was 17months(interquartile range 16.5-43.2months). Of the 15 extragastric recurrences, 11 were in the regional lymph nodes and 4 were in the liver, adrenal gland, and peritoneum. Sixty percent (9/15) of the extragastric recurrences occurred without intragastric lesions. Eleven recurrences were detected by abdominal computed tomography, and eight patients underwent curative surgery. After endoscopic resection of early gastric cancer, regional lymph node recurrence is the predominant extragastric recurrence pattern, which can be detected via abdominal computed tomography and cured by rescue surgery. Abdominal computed tomography should be considered as a surveillance method, especially in patients with an expanded indication.