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[Gastric cancer 789. Would you do ESD?]

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A 71 years old gentleman was referred with the biopsy results of "proliferation of atypical glands and ulcer, suspicious for adenocarcinoma, well differentiated." Repeated endoscopic biopsy was "moderately differentiated adenocarcinoma." CT results were "neither hepatic metastasis nor metastatic lymphadenopathy demonstrated."

Would you recommend surgery or ESD?

I recommended surgery because it is an ulcerative type EGC. There was a lymph node metastasis in the station number 4 (greater curvature).

Stomach, radical subtotal gastrectomy: Early gastric carcinoma
1. Location : middle third, Center at body and greater curvature
2. Gross type : EGC type IIc
3. Histologic type : tubular adenocarcinoma, moderately differentiated
4. Histologic type by Lauren : intestinal
5. Size : 1.8x1.5 cm
6. Depth of invasion : invades submucosa (sm2) (pT1b)
7. Resection margin: free from carcinoma, safety margin: proximal 6.0 cm, distal 5.0 cm
8. Lymph node metastasis : metastasis to 1 out of 22 regional lymph nodes (pN1) (perinodal extension: present) (1/22: "3", 0/8; "4", 1/7; "5", 0/0; "6", 0/0; "7", 0/0; "9", 0/3; "8a", 0/2; "11p", 0/1; "12a", 0/1; "4sb", 0/0; "1", 0/0)
9. Lymphatic invasion : not identified
10. Venous invasion : not identified
11. Perineural invasion : not identified
12. AJCC stage by 8th edition: pT1b N1