Anastomotic findings !

This patient is undergoing a gastroscopy because of abdominal pain. Some 20 years ago he underwent a distal gastrectomy for peptic ulcer disease.
WHAT IS THE DIAGNOSIS?

■ a) Large hyperplastic polyp

No, there is more going on!

■ Atrophic gastritis with hyperplastic polyp

INCORRECT

■ atrophic gastritis with malignant polyp

Closer to the truth but not the whole truth!

■ atrophic gastritis with malignant polyp as well as a flat cancer

CORRECT!

■ None of the above

What else could there be??!

explanation

You can tell that the mucosa must be atrophic by the mucosal xanthelasma at about 25seconds into the video. The polyp dangling at about 12 O'clock is covered with the same irregular surface as the base from which is arises.

Finally, there is a large plaque-like area extending between 3-10 O'clock which does look concerning. It goes all the way up to the small bowel anastomosis. In general, large plaque-like cancers in the stomach do look intimidating but is usually intramucosal disease, provided that the appearance is uniform. The subpedunculated polyp indicate more 'heterogenous' disease.

The obvious question is now, should we offer the patient an attempt at endoscopic resection or a 'completion gastrectomy'? The second part of that particular question is of course, 'is the patient actually a candidate for a completion gastrectomy?'

At the time of my endoscopy, I didn't like the wide extend of the cancer and its heterogenous appearance. To also convince our MDT, I removed that subpedunculated polyp which was confirmed as intestinal-type intramucosal adenocarcinoma which was mainly 'moderately well differentiated' but with 'focal poor differentiation'. Predictably, the deep margin was positive, as the surface structure of both the polyp and the underlying gastric mucosa look the same.

Although both an EUS and CT were reassuring, because the patient was a surgical candidate and also because of the large area of heterogenous disease, extending all the way up to the small bowel anastomosis, the patient was in the end offered a gastrectomy rather than an endoscopic resection.

Ultimately, histology confirmed a very 'heterogenous disease' with areas within this 13cm lesion containing:

1. both intestinal and diffuse type cancer - even with signet ring formation!
2. both intramucosal and superficially invasive cancer (sm1 invasion only though)
3. areas with both well differentiated and poorly differentiated cancer
4. areas with and without LVI

Is there any evidence that heterogenous gastric cancers (i.e. cancers with a mixed histology) are less likely to be cured by endoscopic resection?   Actually there is!  Ozeki et al looked at more than 3000 endoscopic resections for early gastric cancer and found that lesions with a mixed histology was significantly less likely to be cured by ESD (35-42% cure rate vs 76-92% cure rate).   Ozeki Y. Mixed histology poses a greater risk for noncurative endoscopic resection in early gastric cancers regardless of the predominant histologic types. Eur J Gastro Hep 2021;32(2);186-193

Fortunately, there was no nodal disease.  Almost everyone got this right when first published on our FoE facebook group.