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Table 1. Criteria for endoscopic submucosal dissection [19]
Criteria Absolute indication Extended indication Out of indication
European T1a (m) T1a (m) T1a (m) T1a (m) T1b (sm, < 500 µm)
guidelines < 2 cm > 2 cm < 2 cm < 3 cm < 3 cm
Differentiated Undifferentiated Differentiated Differentiated Differentiated
Ul (-) Ul (-) Ul (-) Ul (+) Ul (-)
Japanese T1a (m) T1a (m) T1a (m) T1a (m) Any submucosal
guidelines < 2 cm > 2 cm < 2 cm < 3 cm invasion (> T1b)
Differentiated Differentiated Undifferentiated Differentiated
Ul (-) Ul (-) Ul (-) Ul (+)

m: intramucosal; sm: submucosal; Ul: ulceration

MANAGEMENT OF LOCAL/LOCOREGIONAL DISEASE
Endoscopic treatment
Only around 10%-15% of gastric cancers in Europe are diagnosed as early gastric cancers. Although adop-
tion of endoscopic submucosal dissection (ESD) in the West has been slow, due to a lower incidence of early
gastric cancer, European Society of Gastrointestinal Endoscopy (ESGE) guidelines recommend ESD as the
[18]
treatment of choice for most superficial neoplastic gastric lesions . Guidelines from the National Cancer
Center in Tokyo have expanded these criteria based on a large number of patients [2,19] . ESD should be consid-
ered for lesions with very low risk of lymph node metastasis, no matter if it meets the absolute or expanded
indication criteria [Table 1]. Western studies have demonstrated an en-bloc and R0 resection rate of 98.4%
[20]
and 90.2%, respectively, which are comparable to corresponding results from Eastern Asian institutions .
The delayed bleeding rate was 6% and perforation rate was 1% which are also equivalent to Eastern Asian
rates [21-24] . The potential benefits of ESD are now acknowledged and ESD has become a promising treatment
option, alongside conventional endoscopic mucosal resection (EMR), for early gastric cancer in Western
countries.

Surgical treatment
Surgical resection remains the only treatment modality that is potentially curative for locally advanced gas-
tric cancer. However, the extent of surgical resection and lymph node dissection is still, to some degree, con-
[15]
troversial. Most European guidelines, nevertheless, recommend D2 dissection for stage II and III disease .
[25]
At the same time, minimally invasive gastrectomy is becoming more and more common .
Extent of gastric resection
The extent of resection is basically determined by the tumor location as well as the tumor stage, the type
and extension of stomach resection has a direct impact on patient’s postoperative quality of life (QOL) [26,27] . In
Western, in contrast to Far Eastern countries, most gastric cancers are diagnosed in the proximal stomach
as locally advanced tumors, which subsequently usually require total gastrectomy with D2 lymph node dis-
section for optimized prognosis. Therefore, the number of suitable cases for function preserving surgical
techniques, such as proximal and pylorus-preserving gastrectomy, which have been popularized in Eastern
[28]
Asia due to advantages of improved postoperative QOL, are very few in European populations . The vast
majority of diagnosed European gastric cancer cases are instead more suitable for subtotal or total gastrec-
tomy. Several studies have shown some functional advantages and comparable overall survival (OS) rate in
subtotal gastrectomy compared with total gastrectomy [26,27,29,30] . ESMO/ESSO/ESTRO guidelines recommend
macroscopic proximal margins of 5 cm between the proximal tumor margin and esophagogastric junction
[15]
(EGJ) for subtotal or distal gastrectomy, and of 8 cm for the diffuse histological type of gastric cancer .
Nonetheless, some studies reported equivalence regarding oncological outcome with shorter proximal
margin [31,32] .