Lymph Node Recurrence after Endoscopic Resection of Early Gastric Cancer Previously Classified as eCura B

Q: Why was post-ESD imaging surveillance not routinely recommended in this patient?

The lesion was reclassified from the former eCura B criteria to eCura A under updated Japanese guidelines, which do not recommend routine imaging follow-up.

Q: When was lymph node recurrence detected after curative ESD?

A solitary swollen lymph node was detected on computed tomography 19 months after curative resection.

Q: How was the recurrence treated and what was the surgical outcome?

After chemotherapy, the patient underwent total gastrectomy with D2 lymphadenectomy; histology showed no residual carcinoma in the resected area.

Sep 23, 2026

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A 63-year-old woman underwent endoscopic submucosal dissection (ESD) for early gastric cancer and the lesion initially satisfied former eCura B criteria. After updates to Japanese guidelines reclassified similar lesions as eCura A, routine imaging surveillance was not recommended. Nineteen months after curative resection, computed tomography identified a solitary swollen lymph node and metastasis was confirmed histopathologically. Post-chemotherapy total gastrectomy achieved no residual carcinoma, highlighting rare lymph node recurrence despite current criteria.

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Abstract

Introduction

Case Report

doi: 10.2169/internalmedicine.6409-25 Intern Med 65: 2096-2100, 2026 [http://internmed.jp](http://internmed.jp) 【CASE REPORT】 | Lymph Node Recurrence after Endoscopic Resection of Early Gastric Cancer Previously Classified as eCura B | | | --- | --- | | Kotaro Akita 1, Shinji Yoshii 1, Takakazu Miyake 1, Tsukasa Yamakawa 1, Tomoe Kazama 1,
Shintaro Sugita 2, Hiro-o Yamano 1 and Hiroshi Nakase 1 | | | Abstract:
A 63-year-old woman underwent endoscopic submucosal dissection for early gastric cancer. The lesion initially met the former eCura B criteria but was reclassified as eCura A under the updated Japanese guidelines, which do not recommend routine imaging follow-up. Nineteen months after curative resection, a solitary swollen lymph node was detected on computed tomography and metastasis was histopathologically confirmed. After chemotherapy, the patient underwent a total gastrectomy without residual carcinoma. While such recurrence is rare, this case suggests that clinicians should remain aware of the possibility of lymph node metastasis, even in lesions considered curative under the current criteria.
Key words: early gastric cancer, endoscopic submucosal dissection, lymph node recurrence, post-ESD surveillance, eCura A
(Intern Med 65: 2096-2100, 2026)
(DOI: 10.2169/internalmedicine.6409-25) | | |
Introduction
Endoscopic submucosal dissection (ESD) is widely accepted as a curative treatment for early gastric cancer (EGC) with negligible risk of lymph node metastasis (1) . In Japan, the curability of ESD is determined by histological features, such as depth of invasion, lymphovascular invasion, margin status, and tumor differentiation (1) . The eCura classification was introduced to stratify the post-ESD curability. Specifically, lesions with SM1 invasion (<500 μm), no lymphovascular invasion, and a tumor size 􀀂 3 cm were previously classified as eCura B (2) . However, both the second edition of the Japan Gastroenterological Endoscopy Society guidelines (1) and seventh edition of the Japanese Gastric Cancer Treatment Guidelines (3) have reclassified these lesions aseCura A based on large-scale studies demonstrating favorable long-term outcomes (4) . Under previous guidelines, routine imaging surveillance, including computed tomography (CT) or abdominal ultrasonography, is recommended for patients with lesions classified as eCura B. Nonetheless, this lesion criterion has been reclassified as eCura A under | the current guidelines, for which routine imaging follow-up is not recommended. Despite this reclassification, rare cases of lymph node metastasis have been reported (4-6) .
This report presents a case of isolated lymph node recurrence occurring 19 months after curative ESD for a lesion reclassified from eCura B to eCura A, based on the current guidelines. This case suggests that although the current guidelines classify similar lesions as eCura A with a very low risk of lymph node recurrence, such recurrence is still possible in rare cases. Therefore, clinicians should be aware that lymph node metastasis can occur even in lesions judged to be curative by the current criteria.

Case Report
A 63-year-old woman was referred to our department for the evaluation of a gastric lesion detected during esophagogastroduodenoscopy screening. White-light endoscopy revealed a 20-mm reddish-depressed lesion on the lesser curvature of the middle gastric body (Fig. 1a, b) .
The patient underwent ESD without any complications (Fig. 1c) . Histopathological examination of the resected | 1 Division of Gastroenterology and Hepatology, Department of Internal Medicine, Sapporo Medical University School of Medicine, Japan and 2 Department of Diagnostic Pathology, Hakodate Goryoukaku Hospital, Japan Received: August 18, 2025; Accepted: November 16, 2025; Advance Publication by J-STAGE: January 2, 2026 Correspondence to Dr. Shinji Yoshii, [shinjiyoshii@yahoo.co.jp](shinjiyoshii@yahoo.co.jp) Figur

FAQs

Why was post-ESD imaging surveillance not routinely recommended in this patient?

The lesion was reclassified from the former eCura B criteria to eCura A under updated Japanese guidelines, which do not recommend routine imaging follow-up.

When was lymph node recurrence detected after curative ESD?

A solitary swollen lymph node was detected on computed tomography 19 months after curative resection.

How was the recurrence treated and what was the surgical outcome?

After chemotherapy, the patient underwent total gastrectomy with D2 lymphadenectomy; histology showed no residual carcinoma in the resected area.

Sep 23, 2026

Uploaded by LangkahRina