Another gastric lesion...

This is an elderly patient undergoing an OGD because of IDA (iron deficiency anaemia). A lesion catches my eye on the anterior gastric wall
WHAT IS THE LIKELY HISTOLOGY?

■ Gastric xanthelasma

The colour is suggestive and gastric atrophy would be the link but it's not quite right...

■ Healed GU scar

But how about that funny crypt pattern?

■ Gastric adenoma

Yes, doesn't this look like a tubular adenoma?

■ Early gastric cancer

Wouldn't the crypt pattern then be very disorganised or perhaps very small?

explanation

The pale colour is odd and reminiscent of gastric xanthelasma which as you know is linked with gastric atrophy which is the likely cause of this patients IDA. However, when I zoom in on the area, the crypt pattern is different here. Of course, this does not fit with a xanthelasma or a scar from a healed gastric ulcer (GU) either for that matter. 

Interestingly, almost everyone thought that this was an EGC. However, THERE IS a distinct crypt pattern in the centre of the lesion. Furthermore, the lesion isn't red. Remember that cancers encourage the growth of small irregular capillaries which gives them a red colouration. Finally, it doesn't have the typical flat-elevated with a central depression (IIa+IIc) growth morphology.  Therefore, your first guess should be a gastric adenoma!

​This is actually a gastric tubular adenoma which we found in an elderly frail patient with atrophic gastritis some 10 years ago.  As she had some comorbidities and it was only harbouring LGD, we decided to keep an eye on the lesion on a yearly basis.  The risk of progression is supposedly only 5% with tubular adenomas in the stomach. In contrast, villous adenomas are much more likely to progress (40%).   The BSG gastric polyp guidelines have the references if you want to look this up. 

Of course, the issue is not entirely clear-cut as risk of progression also increases with the size of the lesion (and this is probably 2cm in size) and also with age (patient is now 86 yrs). In some ways, making an initial decision to either 'attack' or 'abort' would be easiest.  After all, regular surveillance drains valuable resources and leaves you open to the possibility that at some point in the future, the patient is no longer a candidate for anything more invasive than a haircut but now the lesion under surveillance shows evidence of progression. Then your patient could well ask the legitimate question why you didn't go ahead when he was younger and fit enough but instead wasted his time with pointless surveillance?! 

My own preferred way to navigate this minefield is to openly discuss the three options with the patient;

1. Remove the lesion now even though the lesion may never progress and the risk of immediate harm may be as great as the chance of benefitting some years in the future
2. Keep the lesion under regular surveillance until the patient is no longer a candidate for endoscopic resection
3. Simply forget about the neoplastic lesion, hope for the best and focus on the positives in those twilight years. 

I often wonder if its the personality type which dictates what patients prefer. Perhaps, those who think 'my glass is half empty' usually want to have their lesion resected immediately whilst people who regards their 'glass to be half full',  prefer to  hope for the best and get on with their lives?