Objective: To investigate the expression of tumor-associated macrophages(TAMs) in early gastric carcinoma(EGC) and their clinicopathological significance. Methods: A retrospective analysis was conducted on 109 patients with EGC who underwent radical gastrectomy at the Second People's Hospital of Changzhou between January 2006 and December 2022. Expression of CD68 and CD163 was assessed by immunohistochemistry in tumor regions and paired adjacent non-tumor mucosa. Macrophage expression was compared between tumor and non-tumor regions, and the associations between TAMs and clinicopathological characteristics were further analyzed. The CD163/CD68 ratio was dichotomized using a receiver operating characteristic(ROC) derived cut-off value and included in logistic regression analyses to identify risk factors for lymph node metastasis(LNM) in EGC. ROC analysis was further performed to evaluate the discriminatory ability of the endoscopic curability assessment(eCura) system, both alone and in combination with the CD163/CD68 ratio, for predicting LNM, and the DeLong test was used to compare the area under the curve(AUC). Overall survival was analyzed using the Kaplan-Meier method. Results: Compared with paired adjacent non-tumor mucosa, CD163 and CD68 scores were significantly higher in tumor regions(CD163: 10% vs. 5%; CD68: 35% vs. 10%; P < 0.001 for both), whereas the CD163/CD68 ratio was significantly lower(0.33 vs. 0.50, P < 0.001). A high CD163/CD68 ratio was significantly associated with poor tumor differentiation, submucosal invasion, and LNM(P < 0.05). Multivariate logistic regression identified the CD163/CD68 ratio as an independent risk factor for LNM in EGC(P < 0.05). The discriminatory ability for LNM was significantly improved when the eCura system was combined with the CD163/CD68 ratio(AUC=0.774) compared with the eCura system alone(AUC=0.706, P=0.023). No significant association was observed between TAMs(CD163 and CD68 scores, CD163/CD68 ratio) and 5-year overall survival in patients with EGC. Conclusion: Tumor-associated macrophages may participate in the tumorigenesis of EGC. The CD163/CD68 ratio is closely associated with LNM in EGC and may serve as an indicator of the tumor immune microenvironment. When combined with the eCura system, the CD163/CD68 ratio provides additional information for risk stratification of LNM in EGC.