Histological upgrading from pre-ESD biopsy to resection and endoscopic curability after gastric ESD: a multicenter retrospective cohort study

Background Endoscopic submucosal dissection (ESD) enables organ-preserving treatment of gastric epithelial neoplasia while providing definitive histopathological assessment for subsequent risk stratification. Aims To evaluate multicenter clinical, technical, and histopathological outcomes of gastric ESD, assess histological concordance between pre-ESD biopsy and resection specimens, identify factors associated with histological upgrading, and characterize endoscopic curability according to the 2025 eCura criteria. Methods This multicenter retrospective cohort included 89 patients with 89 gastric epithelial neoplasms treated by ESD at three tertiary centers between January 2023 and January 2026. Histological concordance was assessed using the revised Vienna classification, and factors associated with upgrading were evaluated using Firth penalized logistic regression. Results En bloc and R0 resection rates were 94.4% and 84.3%, respectively. Post-ESD complications occurred in 10.1% of patients, including delayed bleeding in 9.0%, with no perforations. Among 70 lesions with pre-ESD biopsy, 29 (41.4%) were upgraded and one (1.4%) was downgraded. Increasing age (aOR 1.92 per 10 years; 95% CI 1.06–3.81) and lesion size (aOR 1.74 per 10 mm; 95% CI 1.04–3.07) were associated with upgrading. Among 30 carcinomas, 16 (53.3%) fulfilled the 2025 eCura criteria for curative resection, while six lesions classified as eCuraB under the 2021 criteria were reclassified as eCuraA. Conclusions In this multicenter cohort, gastric ESD achieved high en bloc and R0 resection rates with an acceptable safety profile. Histological upgrading after pre-ESD biopsy was common, particularly with increasing age and lesion size, underscoring the importance of definitive ESD histopathology for accurate assessment of endoscopic curability.