Clinical Scorecard: Recurrence Rates and Long-Term Outcomes After Curative Endoscopic Submucosal Dissection for Synchronous Multiple Early Gastric Neoplasms: Insights from a Single-Center Study

At a Glance

Key Highlights

• Synchronous multiple early gastric neoplasms (SM-EGN) occur in 5–15% of early gastric cancer cases and can be treated with simultaneous ESD in a single session.
• SM-EGN patients have comparable short-term ESD outcomes to solitary lesion patients but exhibit higher long-term risk of metachronous recurrence.
• Field cancerization underlies the predisposition to multiple and recurrent gastric neoplasms in SM-EGN patients.

Guideline-Based Recommendations

Diagnosis

• Use high-definition and image-enhanced endoscopy (chromoendoscopy, magnifying narrow-band imaging) for lesion detection and characterization.
• Perform biopsy for histologic confirmation before ESD.
• Conduct preoperative CT to exclude lymph node or distant metastasis in biopsy-proven carcinoma.

Management

• Perform en bloc endoscopic submucosal dissection (ESD) under general anesthesia for curative resection of EGN without lymph node metastasis.
• Remove all synchronous lesions in a single ESD session when feasible.
• Ensure curative resection criteria (eCura A or B) are met according to Japanese Gastric Cancer Treatment Guidelines.

Monitoring & Follow-up

• Schedule follow-up esophagogastroduodenoscopy (EGD) at 3, 6, and 12 months, then every 6–12 months for EGC patients.
• For LGD patients, schedule EGD at 6 and 12 months, then annually.
• Examine the entire gastric mucosa with white-light and image-enhanced endoscopy during follow-up to detect metachronous lesions.

Risks

• Recognize increased risk of metachronous gastric neoplasia in SM-EGN patients due to field cancerization.
• Monitor for local recurrence at resection sites and new lesions outside initial resection areas.
• Be aware of procedure-related risks such as perforation and delayed bleeding.

Patient & Prescribing Data

810 patients with early gastric neoplasia undergoing curative ESD, including 77 with synchronous multiple lesions and 733 with solitary lesions

Simultaneous ESD for SM-EGN is feasible and safe with comparable short-term outcomes; however, SM-EGN patients require vigilant long-term surveillance due to higher recurrence risk.

Clinical Best Practices

• Perform ESD by experienced endoscopists (>100 ESDs/year) to ensure technical success and minimize complications.
• Use comprehensive endoscopic imaging modalities pre- and post-ESD for accurate lesion assessment and detection of synchronous/metachronous lesions.
• Adopt strict follow-up protocols tailored to lesion histology to enable early detection and management of recurrences.
• Consider the concept of field cancerization when counseling patients on recurrence risk and surveillance strategies.

References

• Japanese Gastric Cancer Treatment Guidelines
• Moertel CG. Multiple primary malignant neoplasms: historical perspectives.