Treatment modalities for early gastric cancer

Table 1 Treatments options in a patient with early gastric cancer

Histology	Mucosal cancer					Submucosal cancer
	≤ 10 mm	≤ 20 mm > 20 mm		≤ 30 mm > 30 mm		Into the upper third ( ≤ 30 mm)	Into the middle third (any size)
	(flat/depressed)	(No ulceration)		(Ulceration)
Intestinal type	EMR	EMR	ESD	ESD	Surgery	ESD	Surgery
Diffuse type	Surgery		Surgery	Surgery	Surgery	Surgery	Surgery
	ESD1

¹Treatment option if the patient decline surgery. EGC: Early gastric cancer; EMR: Endoscopic mucosal resection; ESD: Endoscopic submucosal dissection.

Table 2 Process steps in endoscopic submucosal dissection treatment of the early gastric cancer

Process steps	Technique/devices
Estimation of lateral extension	Chomoendoscopy (indigo carmine) ± NBI
Marking	Mucosal markings are placed 5 mm lateral to the lesion margin
Submucosal injection	Injection of saline mixed with diluted epinephrine (1:100000) and indigo carmine into the submucosal layer
Mucosal incision (precutting)	A small initial mucosal incision is made to gain access to the submucosal space without to injure the muscularis propria (e.g., by Dual knife)
Circumferential incisión	Carried out 5 mm lateral to the mucosal markings (e.g., IT knife)
Submucosal dissection	The technique varies among endoscopist
	Adequate reinjection of fluid into the submucosa
	The parallel movement for muscle layer with the IT2 is typically lateral
	With the Dual knife forward

NBI: Narrow band imaging.