Long-term and second recurrence following curative ESD for synchronous multiple early gastric neoplasia: a...

Synchronous multiple early gastric neoplasia (SM-EGN) is increasingly detected with advanced endoscopic imaging. However, long-term recurrence dynamics after curative endoscopic submucosal dissection (ESD), particularly second recurrence, remain insufficiently defined.

We retrospectively analyzed 987 patients who underwent ESD for early gastric neoplasia between 2012 and 2024, including 91 SM-EGN and 896 solitary cases. Among 766 patients with curative resection and ≥ 1 year follow-up, clinical outcomes and recurrence patterns were compared. Logistic regression identified independent predictors of recurrence, and Kaplan-Meier analysis assessed long-term outcomes.

SM-EGN patients were older, more often male, and had higher rates of prior malignancy and family history. Procedure time was longer for SM-EGN (116.8 vs 80.8 min, p < 0.0001), but complication rates were similar. SM-EGN patients had a higher recurrence rate (11.7% vs. 4.8%, p = 0.011) and a higher rate of second recurrence (3.9% vs. 0.7%, p = 0.033). Multivariate regression identified SM-EGN as an independent predictor of recurrence (OR 2.162, p = 0.048). Among recurrent patients, no independent predictors of second recurrence were found, and OS/DFS did not differ between single and double recurrence. In curative patients with ≥ 1 year follow-up, SM-EGN showed higher synchronous (p = 0.019) and metachronous (p = 0.027) recurrence, and shorter DFS to both first (p = 0.002) and second recurrence (p = 0.041).

SM-EGN confers a persistently higher recurrence risk after curative ESD, consistent with the phenomenon of field cancerization. No significant difference in survival was observed in the limited second recurrence cohort, likely due to intensive monitoring and timely intervention. That hints to us that SM-EGN patients require lifelong, risk-adapted surveillance.