A cardia lesion for surgery?

This was found at the gastric cardia in a previously well 75 yr old woman. Biopsies have reported 'at least intramucosal cancer'.
Fortunately, both EUS and CT were reassuring
WHAT IS NOW THE MOST APPROPRIATE ACTION?

a) Recommend an attempt at endoscopic resection

CORRECT!

b) Recommend surgery

INCORRECT!

c) Recommend chemo-radiotherapy

INCORRECT!

Explanation

This proved to be a difficult question as 90% of our FB group actually thought that surgery would be necessary.  This is because cardia cancer is difficult to stage both endoscopically and by EUS.  This IIa+IIc lesion (i.e. flat elevated lesion with a central depression) does indeed look concerning for invasion into the deepest part of the submucosal space (sm3 invasion).  By the way, test-lifts are difficult to interpret in the stomach and are better done as 'test-resections'.  Naturally, if you find that the submucosal plane is obliterated by the pale, fibrous tissue of 'desmoplasia', you'll have to bail out. 

Although the chances of a cure may be a little slim, a total gastrectomy at the age of 75 is a lifechanging decision (and may be a life-ending decision) and should only be considered if absolutely necessary. 

The 'half-way house' of radiotherapy was not on offer. This is because the stomach usually don't cope well to 'full dose' radiotherapy (i.e. given with a curative intent).

In the end, the lesion was removed by ESD and histology confirmed as mainly HGD and IMca but with a central invasive focus extending into the middle of the submucosal space (sm2 invasion).  Fortunately, the differentiation was good and most importantly there was no LVI !!!    This was 7 years ago and the patient remains well, aged 82 yrs  !