An oesophageal stricture

This patient has been referred for an oesophageal dilatation after biopsies have been reassuring
WHAT WOULD YOU DO?

■ Abort and take more samples

You are a wise as a fox!

■ Dilate to 12mm

Hmm, cautious but not cautious enought !

■ Dilate to 15mm

Seems reasonable but you've missed something!

■ Dilate to 18mm

You are clearly brave but look again!

■ Dilate to 20mm

If this stricture was benign, I would also aim for 20mm but it isn't!

explanation

Of course this stricture doesn't look right! There is a peculiar plaque-like area in the 10 O'clock position. The dilatation was cancelled and another set of samples were requested together with a CT. Samples indicated that this was a case of poorly differentiated intramucosal cancer and an EMR was organised.  Have a look at the clip below. Clearly this lesion is firmly tethered to underlying structures and is beyond endoscopic cure.  Some options may pop into your head such as injecting some fluid below the lesion or using the 'pull-within-the-snare' EMR technique.  The problem is that these will not change the basic fact that endoscopically the lesion is beyond endoscopic cure!  You run the risk of 'muddying the waters' with scrappy histology reporting 'intramucosal cancer at least' and with uncertain margins. Far better is to recognised the endoscopic irresectability of the lesion which provides a clear steer towards the 'next treatment level'. In this case the patient wasn't a surgical candidate and was offered chemo-radiotherapy (CRT).