Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Early gastric cancer: Epidemiology, clinical manifestations, diagnosis, and staging

Douglas Morgan, MD, MPH
Section Editors
Mark Feldman, MD, MACP, AGAF, FACG
Kenneth K Tanabe, MD
Deputy Editors
Anne C Travis, MD, MSc, FACG, AGAF
Diane MF Savarese, MD


Early gastric cancer (EGC) is defined as invasive gastric cancer that invades no more deeply than the submucosa, irrespective of lymph node metastasis (T1, any N). While EGC is of particular importance for patient care in Eastern Asia, its significance extends to other disciplines and patient populations:

Globally, gastric adenocarcinoma, with nearly one million incident cases annually, is the second leading cause of global cancer mortality and the leading cause of infection-associated cancer death [1,2]. EGC accounts for 15 to 57 percent of incident gastric cancer, depending upon the geographic region. (See 'Epidemiology' below.)

EGC has driven the development of novel imaging technologies for early neoplasia detection such as narrow band imaging and autofluorescence imaging. These technologies are now being used throughout the gastrointestinal tract.

The need for better approaches to the treatment of EGC has led to the development of advanced endoscopic resection techniques such as endoscopic mucosal resection and endoscopic submucosal dissection. (See "Early gastric cancer: Treatment, natural history, and prognosis", section on 'Endoscopic mucosal resection' and "Early gastric cancer: Treatment, natural history, and prognosis", section on 'Endoscopic submucosal dissection'.)

New surveillance guidelines are in evolution for gastric intestinal metaplasia, which may increase the frequency of detection of EGC in the western populations [3,4]. (See "Gastric intestinal metaplasia" and "Gastric cancer screening".)


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Aug 24, 2015.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Parkin DM. The global health burden of infection-associated cancers in the year 2002. Int J Cancer 2006; 118:3030.
  2. Ferlay J, Shin HR, Bray F, et al. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer 2010; 127:2893.
  3. Correa P, Piazuelo MB, Wilson KT. Pathology of gastric intestinal metaplasia: clinical implications. Am J Gastroenterol 2010; 105:493.
  4. Dinis-Ribeiro M, Areia M, de Vries AC, et al. Management of precancerous conditions and lesions in the stomach (MAPS): guideline from the European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter Study Group (EHSG), European Society of Pathology (ESP), and the Sociedade Portuguesa de Endoscopia Digestiva (SPED). Endoscopy 2012; 44:74.
  5. Wroblewski LE, Peek RM Jr, Wilson KT. Helicobacter pylori and gastric cancer: factors that modulate disease risk. Clin Microbiol Rev 2010; 23:713.
  6. Gotoda T. Endoscopic resection of early gastric cancer: the Japanese perspective. Curr Opin Gastroenterol 2006; 22:561.
  7. Alfaro EE, Lauwers GY. Early gastric neoplasia: diagnosis and implications. Adv Anat Pathol 2011; 18:268.
  8. Siegel R, Naishadham D, Jemal A. Cancer statistics for Hispanics/Latinos, 2012. CA Cancer J Clin 2012; 62:283.
  9. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2015. CA Cancer J Clin 2015; 65:5.
  10. Anderson WF, Camargo MC, Fraumeni JF Jr, et al. Age-specific trends in incidence of noncardia gastric cancer in US adults. JAMA 2010; 303:1723.
  11. Shimizu S, Tada M, Kawai K. Early gastric cancer: its surveillance and natural course. Endoscopy 1995; 27:27.
  12. Maehara Y, Orita H, Okuyama T, et al. Predictors of lymph node metastasis in early gastric cancer. Br J Surg 1992; 79:245.
  13. Noguchi Y, Yoshikawa T, Tsuburaya A, et al. Is gastric carcinoma different between Japan and the United States? Cancer 2000; 89:2237.
  14. Lee HJ, Yang HK, Ahn YO. Gastric cancer in Korea. Gastric Cancer 2002; 5:177.
  15. Kang HJ, Kim DH, Jeon TY, et al. Lymph node metastasis from intestinal-type early gastric cancer: experience in a single institution and reassessment of the extended criteria for endoscopic submucosal dissection. Gastrointest Endosc 2010; 72:508.
  16. Everett SM, Axon AT. Early gastric cancer in Europe. Gut 1997; 41:142.
  17. Eckardt VF, Giessler W, Kanzler G, et al. Clinical and morphological characteristics of early gastric cancer. A case-control study. Gastroenterology 1990; 98:708.
  18. Everett SM, Axon AT. Early gastric cancer: disease or pseudo-disease? Lancet 1998; 351:1350.
  19. Hamashima C, Shibuya D, Yamazaki H, et al. The Japanese guidelines for gastric cancer screening. Jpn J Clin Oncol 2008; 38:259.
  20. Pittayanon R, Rerknimitr R. Role of digital chromoendoscopy and confocal laser endomicroscopy for gastric intestinal metaplasia and cancer surveillance. World J Gastrointest Endosc 2012; 4:472.
  21. Biasco G, Paganelli GM, Azzaroni D, et al. Early gastric cancer in Italy. Clinical and pathological observations on 80 cases. Dig Dis Sci 1987; 32:113.
  22. Evans DM, Craven JL, Murphy F, Cleary BK. Comparison of "early gastric cancer" in Britain and Japan. Gut 1978; 19:1.
  23. Schlemper RJ, Riddell RH, Kato Y, et al. The Vienna classification of gastrointestinal epithelial neoplasia. Gut 2000; 47:251.
  24. Schlemper RJ, Itabashi M, Kato Y, et al. Differences in diagnostic criteria for gastric carcinoma between Japanese and western pathologists. Lancet 1997; 349:1725.
  25. Rugge M, Correa P, Dixon MF, et al. Gastric dysplasia: the Padova international classification. Am J Surg Pathol 2000; 24:167.
  26. Fenoglio-Preiser C, Carneiro F, Correa P, et al. Tumours of the stomach. In: Pathology and Genetics of Tumours of the Digestive System, Hamilton R, Aalthonen L (Eds), International Agency for Research on Cancer, Lyon 2000. p.48.
  28. Laurén PA, Nevalainen TJ. Epidemiology of intestinal and diffuse types of gastric carcinoma. A time-trend study in Finland with comparison between studies from high- and low-risk areas. Cancer 1993; 71:2926.
  29. . Japanese Classification of Gastric Carcinoma - 2nd English Edition -. Gastric Cancer 1998; 1:10.
  30. The general rules for The gastric cancer study in surgery. Jpn J Surg 1973; 3:61.
  31. The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointest Endosc 2003; 58:S3.
  32. Gong C, Mera R, Bravo JC, et al. KRAS mutations predict progression of preneoplastic gastric lesions. Cancer Epidemiol Biomarkers Prev 1999; 8:167.
  33. Sugai T, Nakamura S, Uesugi N, et al. Role of DNA aneuploidy, overexpression of p53 gene product, and cellular proliferation in the progression of gastric cancer. Cytometry 1999; 38:111.
  34. Shiao YH, Bovo D, Guido M, et al. Microsatellite instability and/or loss of heterozygosity in young gastric cancer patients in Italy. Int J Cancer 1999; 82:59.
  35. Xiangming C, Hokita S, Natsugoe S, et al. Cooccurrence of reduced expression of alpha-catenin and overexpression of p53 is a predictor of lymph node metastasis in early gastric cancer. Oncology 1999; 57:131.
  36. Kim JJ, Baek MJ, Kim L, et al. Accumulated frameshift mutations at coding nucleotide repeats during the progression of gastric carcinoma with microsatellite instability. Lab Invest 1999; 79:1113.
  37. Yamamoto H, Perez-Piteira J, Yoshida T, et al. Gastric cancers of the microsatellite mutator phenotype display characteristic genetic and clinical features. Gastroenterology 1999; 116:1348.
  38. Hasuo T, Semba S, Li D, et al. Assessment of microsatellite instability status for the prediction of metachronous recurrence after initial endoscopic submucosal dissection for early gastric cancer. Br J Cancer 2007; 96:89.
  39. Zhu C, Ren C, Han J, et al. A five-microRNA panel in plasma was identified as potential biomarker for early detection of gastric cancer. Br J Cancer 2014; 110:2291.
  40. Shah MA, Khanin R, Tang L, et al. Molecular classification of gastric cancer: a new paradigm. Clin Cancer Res 2011; 17:2693.
  41. Tang W, Morgan DR, Meyers MO, et al. Epstein-barr virus infected gastric adenocarcinoma expresses latent and lytic viral transcripts and has a distinct human gene expression profile. Infect Agent Cancer 2012; 7:21.
  42. Craanen ME, Dekker W, Ferwerda J, et al. Early gastric cancer: a clinicopathologic study. J Clin Gastroenterol 1991; 13:274.
  43. Tack J, Talley NJ, Camilleri M, et al. Functional gastroduodenal disorders. In: Rome III: The Functional Gastrointestinal Disorders, 3rd ed, Drossman DA, Corazziari E, Delvaux M, et al (Eds), Degnon Associates, Inc, McLean, Virginia 2006. p.419.
  44. Wanebo HJ, Kennedy BJ, Chmiel J, et al. Cancer of the stomach. A patient care study by the American College of Surgeons. Ann Surg 1993; 218:583.
  45. Longo WE, Zucker KA, Zdon MJ, Modlin IM. Detection of early gastric cancer in an aggressive endoscopy unit. Am Surg 1989; 55:100.
  46. Ballantyne KC, Morris DL, Jones JA, et al. Accuracy of identification of early gastric cancer. Br J Surg 1987; 74:618.
  47. Kajitani T. The general rules for the gastric cancer study in surgery and pathology. Part I. Clinical classification. Jpn J Surg 1981; 11:127.
  48. Ang TL, Khor CJ, Gotoda T. Diagnosis and endoscopic resection of early gastric cancer. Singapore Med J 2010; 51:93.
  49. Emura F, Gralnek I, Baron TH. Improving early detection of gastric cancer: a novel systematic alphanumeric-coded endoscopic approach. Rev Gastroenterol Peru 2013; 33:52.
  50. de Vries AC, Haringsma J, de Vries RA, et al. Biopsy strategies for endoscopic surveillance of pre-malignant gastric lesions. Helicobacter 2010; 15:259.
  51. Yantiss RK, Odze RD. Optimal approach to obtaining mucosal biopsies for assessment of inflammatory disorders of the gastrointestinal tract. Am J Gastroenterol 2009; 104:774.
  52. Muto M, Katada C, Sano Y, Yoshida S. Narrow band imaging: a new diagnostic approach to visualize angiogenesis in superficial neoplasia. Clin Gastroenterol Hepatol 2005; 3:S16.
  53. Kato M, Kaise M, Yonezawa J, et al. Magnifying endoscopy with narrow-band imaging achieves superior accuracy in the differential diagnosis of superficial gastric lesions identified with white-light endoscopy: a prospective study. Gastrointest Endosc 2010; 72:523.
  54. Tada K, Oda I, Yokoi C, et al. Pilot study on clinical effectiveness of autofluorescence imaging for early gastric cancer diagnosis by less experienced endoscopists. Diagn Ther Endosc 2011; 2011:419136.
  55. Ezoe Y, Muto M, Uedo N, et al. Magnifying narrowband imaging is more accurate than conventional white-light imaging in diagnosis of gastric mucosal cancer. Gastroenterology 2011; 141:2017.
  56. Li HY, Dai J, Xue HB, et al. Application of magnifying endoscopy with narrow-band imaging in diagnosing gastric lesions: a prospective study. Gastrointest Endosc 2012; 76:1124.
  57. Subramanian V, Ragunath K. Advanced endoscopic imaging: a review of commercially available technologies. Clin Gastroenterol Hepatol 2014; 12:368.
  58. Yao K, Doyama H, Gotoda T, et al. Diagnostic performance and limitations of magnifying narrow-band imaging in screening endoscopy of early gastric cancer: a prospective multicenter feasibility study. Gastric Cancer 2014; 17:669.
  59. American Joint Committee on Cancer Staging Manual, 7th, Edge SB, Byrd DR, Compton CC, et al (Eds), Springer, New York 2010. p.117.
  60. Seto Y, Nagawa H, Muto T. Impact of lymph node metastasis on survival with early gastric cancer. World J Surg 1997; 21:186.
  61. Folli S, Dente M, Dell'Amore D, et al. Early gastric cancer: prognostic factors in 223 patients. Br J Surg 1995; 82:952.
  62. Roviello F, Rossi S, Marrelli D, et al. Number of lymph node metastases and its prognostic significance in early gastric cancer: a multicenter Italian study. J Surg Oncol 2006; 94:275.
  63. Nakamura K, Morisaki T, Sugitani A, et al. An early gastric carcinoma treatment strategy based on analysis of lymph node metastasis. Cancer 1999; 85:1500.
  64. Gotoda T, Yanagisawa A, Sasako M, et al. Incidence of lymph node metastasis from early gastric cancer: estimation with a large number of cases at two large centers. Gastric Cancer 2000; 3:219.
  65. Lee HH, Yoo HM, Song KY, et al. Risk of limited lymph node dissection in patients with clinically early gastric cancer: indications of extended lymph node dissection for early gastric cancer. Ann Surg Oncol 2013; 20:3534.
  66. Nasu J, Nishina T, Hirasaki S, et al. Predictive factors of lymph node metastasis in patients with undifferentiated early gastric cancers. J Clin Gastroenterol 2006; 40:412.
  67. Sano T, Kobori O, Muto T. Lymph node metastasis from early gastric cancer: endoscopic resection of tumour. Br J Surg 1992; 79:241.
  68. An JY, Baik YH, Choi MG, et al. Predictive factors for lymph node metastasis in early gastric cancer with submucosal invasion: analysis of a single institutional experience. Ann Surg 2007; 246:749.
  69. Lee IS, Yook JH, Park YS, et al. Suitability of endoscopic submucosal dissection for treatment of submucosal gastric cancers. Br J Surg 2013; 100:668.
  70. Fujikawa H, Sakamaki K, Kawabe T, et al. A New Statistical Model Identified Two-thirds of Clinical T1 Gastric Cancers as Possible Candidates for Endoscopic Treatment. Ann Surg Oncol 2015; 22:2317.
  71. Shim CN, Song MK, Kang DR, et al. Size discrepancy between endoscopic size and pathologic size is not negligible in endoscopic resection for early gastric cancer. Surg Endosc 2014; 28:2199.
  72. Choi J, Kim SG, Im JP, et al. Endoscopic prediction of tumor invasion depth in early gastric cancer. Gastrointest Endosc 2011; 73:917.
  73. Yoshida S, Tanaka S, Kunihiro K, et al. Diagnostic ability of high-frequency ultrasound probe sonography in staging early gastric cancer, especially for submucosal invasion. Abdom Imaging 2005; 30:518.
  74. Yanai H, Fujimura H, Suzumi M, et al. Delineation of the gastric muscularis mucosae and assessment of depth of invasion of early gastric cancer using a 20-megahertz endoscopic ultrasound probe. Gastrointest Endosc 1993; 39:505.
  75. Yanai H, Tada M, Karita M, Okita K. Diagnostic utility of 20-megahertz linear endoscopic ultrasonography in early gastric cancer. Gastrointest Endosc 1996; 44:29.
  76. Choi J, Kim SG, Im JP, et al. Comparison of endoscopic ultrasonography and conventional endoscopy for prediction of depth of tumor invasion in early gastric cancer. Endoscopy 2010; 42:705.
  77. Kim JH, Song KS, Youn YH, et al. Clinicopathologic factors influence accurate endosonographic assessment for early gastric cancer. Gastrointest Endosc 2007; 66:901.
  78. Gotoda T, Yamamoto H, Soetikno RM. Endoscopic submucosal dissection of early gastric cancer. J Gastroenterol 2006; 41:929.
  79. http://www.nccn.org/professionals/physician_gls/pdf/gastric.pdf (Accessed on September 27, 2011).