Amiable for attack?
Previous sampling of this gastric nodule has confirmed HGD and an EMR has been organised.
WHAT IS THE MOST APPROPRIATE MANAGEMENT?
■ Take further set of Samples!
No, because it's unlikely to change anything!
■ Organise staging CT and EUS first!
YES! This may well be invasive cancer!
■ Go ahead and resect it!
The correct approach would be to slow down a little! Pathologists would always like more samples but actually, surface samples may not be a true reflection of what is nestling deep within this lesion! This lesion is a little over 3cm in diameter and it would be very surprising if it wasn't an invasive cancer after all. Furthermore, there is a suspicious looking red, flat patch close to the shaft of the endoscope in the bottom row image on the left.
Ultimately, this patient underwent a gastrectomy which confirmed that the large nodule was indeed an invasive adenocarcinoma invading as deep as the muscle propria layer (T1b). In addition, there was multifocal LVI and a nearby involved node (N1). That red patch turned out to be a spot of HGD. Because EUS found a suspicious node, a gastrectomy was the most appropriate therapy.
Of course, we don't normally organise a CT and EUS for endoscopically resectable lesions which are not thought to be malignant. Of course biopsies have indicated that this is HGD only. However, the lesion is chunky and its unthinkable that it's HGD only. More surface biopsies may or may not reveal the true nature of the lesion. And frankly it doesn't really matter because endoscopically this is likely to be an invasive cancer. It's a dysplastic nodule about 3cm in diameter and probably close to 2cm in height !!!
Of course, the pathologists always want more samples but with a lesion of this size, of borderline resectability, a CT and EUS is more reassuring than further samples. The EUS revealed a chunky node and the patient had an appropriate gastrectomy.
How about a a test-lift? Unfortunately, test-lifts are difficult to interpret in the stomach and is likely to be 'borderline' committing you to 'having a go' trying to resect the lesion endoscopically. Of course, there is nothing wrong with an 'attempt at EMR/ESD' but the point is that first you would like to have the reassurance of a normal CT and EUS. Of course, you would probably take another set of samples rather than just looking at the lesion but whatever the pathologists say, it will not trump the endoscopic diagnosis of; ' invasive cancer'.
But why not just 'lob it off' for a definite diagnosis as well as staging? The reason is that a ESD resection of a cancer is very difficult. This is because the semi-translucent lifting plane disappears due to the desmoplastic reaction and you end up cutting blindly through opaque beige coloured tissue.
Perforating during the resection of a cancer is potentially devastating for the patient as it can upstage the lesion to 'disseminated disease'. As the stakes are very high in cancer, it would be inappropriate to subject the patient to a significant risk with only a slim chance of benefitting.