A solitary gastric nodule

This suspicious looking 3cm gastric nodule was referred for an endoscopic removal after a CT and EUS had been reassuring. No samples have been taken as not to impede the resection
WHAT WOULD YOU DO NEXT?

■ First sample the nodule

Good idea but not good enough!

■ Sample nodule, antrum and gastric body

YES! To tell if this is a type III NET

■ Go ahead and resect as planned

NET's >2cm should be considered for surgery first!

explanation

This is a gastric neuroendocrine tumour (NET). You can tell because of the dilated vessels along its side (see below).  A typical feature of all gastric NET's.  

To remind you, gastric NET's are classified as; type I (70% - 80% of gastric NET's) linked with hypergastrinaemia secondary to an atrophic gastritis and classically appearing as multiple, small gastric nodules.  The rare type II gastric NET account for about 5-8% is associated with hypergastrinaemia from a gastrin-secreting tumour such as in the MEN-1 syndrome or the Zollinger–Ellison syndrome.  Finally, the type III NET (20%) is solitary, larger nodules with a high mitotic index arising in a healthy gastric mucosa.  These are the ones not to miss as they need a cancer-like gastric resection particularly if 2cm or larger in size ! 

Sampling the nodule will confirm that it's a NET and give you it's 'mitotic index'.  Grade III lesions (20% mitotic index) should  certainly be resected surgically.  However, also sampling the antrum and body is even better because if the mucosa is found not to be atrophic, this confirms that the lesion is a type III gastric NET !