A flat gastric polyp

This polyp found on the lesser gastric curve. 
WHAT IS THE MOST LIKELY DIAGNOSIS?

a) Hyperplastic polyp

HP polyps are usually subpedunculated and angry red

b) Intestinal metaplasia

IM is also 'pale' but not 'flat elevated'

c) Gastric adenoma

Would be my first guess!

d) Early invasive cancer

This is a plaque without a depression or dominant nodule to suggest invasive cancer

explanation

Of course, this could have been rather easy to miss!  An insignificant pale, plaque-like lesion but with distinct borders best seen after indigo carmine dye spray (as usual). Endoscopically this is what a gastric adenoma looks like and it was removed endoscopically. Somewhat surprisingly, histology reported a small spot of IMca and therefore its at actually an early cancer - not invasive though!   

Most invasive, gastric EGC's are of course shallow depressions as in the example below.   In fact the lesion below was invading into the middle of submucosa and was confirmed as poorly differentiated.  Afterwards the patient underwent a distal gastrectomy where no further cancer was found.  'Poor differentiation' is the least reliable and lymphovascular invasion (LVI) is the most reliable predictor of nearby lymphnode micro-metastases.