Five gastric ulcers!

Just a bit of fun!  Five 'gastric ulcers', three of which are malignant. 
WHICH 3 ULCERS ARE CANCEROUS?

■ ABC

Bloody hell ! You are good!!!

■ BCD

Good guess but one is of these is benign

■ CDE

Good guess but two of these are benign

■ ACE

Good guess but one is of these is benign

explanation

Image A is a diffuse type gastric adenocarcinoma, which is strictly speaking not an ulcer (they rarely ulcerate of course). These are notoriously difficult to pick up and only show up as either a tiny pale submucosal spot, a red patch as in this case or as a more extensive patch of inflamed gastric mucosa. 

Image B was a T2 gastric cancer in which initial biopsies had been entirely benign, only reporting 'reactive atypia'.  However, endoscopically there is a rim of thickened, red indurated mucosa surrounding the ulcer. 

Image C is an early gastric cancer pulling on the nearby gastric folds. It was removed endoscopically and turned out to be intramucosal only. 

Image D is of an entirely benign 'giant' gastric ulcer. ‘Giant gastric ulcers’ are (arbitrarily) what we call ulcers which are ≥3cm in size.  In our  Leeds series of 111 ulcers, 42 were malignant (34 adenocarcinomas and 5 lymphomas as well 3 rare tumours).    In our series, logistic regression revealed that the (predictable) predictors for malignancy were;  1) increasing patient age, 2) larger size of giant the gastric ulcer and 3) the endoscopist making a diagnosis of a likely malignant ulcer.  

Finally E is an ulcerated fibroid polyp and not an ulcerated GIST!  Of course you can't tell the two apart on endoscopic grounds!