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Endoscopic ultrasonography (EUS) is a useful method for visualizing features of gastric cancer. However, a previously reported classification system tended to result in overstaging. We investigated the usefulness of EUS for evaluation of the depth of gastric cancer invasion and indications for endoscopic treatment.Accuracy of EUS for determining the depth of invasion and incidences of a positive basal margin were assessed in 235 patients who underwent endoscopic treatment or surgery for gastric cancer. The EUS-determined depth of invasion was classified as follows: EUS-M (lesion confined to sonographic layers 1 and 2); EUS-M/SM border (lesion with changes in sonographic layer 3 but no deeper than 1 mm); EUS-SM (lesion with changes in sonographic layer 3 deeper than 1 mm); or EUS-AD (lesion with changes in sonographic layer 4 or 5).Accuracy of EUS for determining the depth of invasion was as follows: EUS-M, 99% were M and SM1 lesions; EUS-M/SM border, 87% were M and SM1 lesions; EUS-SM, 91% were SM2 lesions; EUS-AD, 100% were muscularis propria or deeper lesions. There was no EUS-M or EUS-M/SM border lesion for which endoscopic treatment resulted in a positive basal margin.EUS is useful for accurately determining the depth of invasion of gastric cancer. When there are no endoscopically determined ulcerous changes, endoscopic treatment should be considered for EUS-M and EUS-M/SM border lesions, and EUS-SM lesions should be treated surgically.