A 65-year-old man undergoes endoscopy revealing a 1.5 cm elevated lesion in the gastric antrum. Biopsy shows well-differentiated adenocarcinoma confined to the mucosa (pT1a). Endoscopic ultrasound confirms no submucosal invasion. There is no ulceration, lymphovascular invasion, or perineural invasion. What is the recommended treatment?

• A Total gastrectomy with D2 lymphadenectomy
• B Distal gastrectomy with D1+ lymphadenectomy
• C Perioperative FLOT chemotherapy followed by surgery
• D Endoscopic submucosal dissection (ESD) ✓

Explanation

This meets the absolute indication for ESD according to Japanese gastric cancer guidelines: differentiated-type adenocarcinoma, intramucosal (pT1a), ≤2 cm, without ulceration. ESD is curative with 5-year survival exceeding 95%. Surgery is reserved for lesions exceeding these criteria or with lymphovascular invasion. Chemotherapy is not indicated for early gastric cancer.

Reference: Japanese Gastric Cancer Association Treatment Guidelines, 6th ed.

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Written and medically reviewed by the StethoPrep medical team.