This ASG video tip is sponsored by Braintree, maker of the newly approved Souflave and Soutab. So, this is a 74-year-old Korean female. This patient had an upper endoscopy that was performed by an outside physician for surveillance of gastrointestinal metaplasia. This physician saw a subtle erosion at the angularis of the stomach, took a biopsy, which showed adenocarcinoma. The patient had a staging CT scan with a whole-body CT PET scan, which was considered negative. The patient was referred to me for staging and underwent EGD and endoscopic ultrasound. Now what we saw here was this little area of nodularity at the angularis of the stomach, which could only really be seen properly in retroflection. And what we notice here, and you'll forgive the photo, this is before we had our magnifying imaging, our near-focus imaging, so I don't have beautiful pictures like Sawani had, but what you'll see here is that this, you see this central nodule here, and if you look at this under NBI, you'll see that the surface pattern is irregular, but it's not non-structural and it's not ulcerative. So we staged this as a T1A lesion on endoscopic ultrasound. Now on the actual endoscopic ultrasound, when you have intramucosal cancer and it's not going into the submucosa, it can actually be very difficult to see on the endoscopic ultrasound. It can almost look normal. So what we saw here was very slight thickening of the mucosal layer on endoscopic ultrasound, but really no evidence of invasion into the submucosa and no evidence of lymphadenopathy, which is really kind of the red flags that we're looking for on endoscopic ultrasound. Now interestingly, we have this little nodule here, but we consider this lesion much larger, about two to three centimeters, because you have this surrounding area of irregular appearing mucosa, which is probably just dysplasia, but it's very difficult to tell where the cancer stops and where the dysplasia starts and stops. So we end up taking a much wider margin. Now to add one more, aside from the position, to add another challenge here, you can see this darkness here, and that's a tattoo that's been placed previously next to that lesion, but these tattoos do migrate quite a bit, and often you could place them a few centimeters away and they'll still move and sort of diffuse and end up underneath your lesion once you go back in later to remove them and do therapy. So we repeated the biopsy, and generally I try to get these patients in very, very quickly for a staging endoscopic ultrasound, but not necessarily perform the ESD in that session. So I get my information, and then if I find that it is something resectable, then I try to get them in as quickly as possible for the ESD procedure. So on our repeat biopsy, we found moderately differentiated adenocarcinoma in a background of high-grade dysplasia with no LVI, EUS staging was T1A and zero. The patient was presented with the options of a local ESD resection versus a total gastrectomy. Obviously if possible, we like to preserve the organ. I think patients prefer that too. So the absolute indication for ESD, as Sawani mentioned, is a tumor less than or equal to two centimeters, well differentiated with no ulcer, no LVI. We felt that this was under the expanded indication of differentiated with intramucosal cancer greater than two centimeters, ulcer negative, no LVI. Now keep in mind, sometimes we do get this moderately differentiated from our pathologists, and it sort of falls in between a little bit, and you may not know what to do with that. Often I'll consider this as a differentiated cancer, and then the ESD sort of becomes like the ultimate staging, where you can stage that cancer and then decide what to do with the cancer once you have that specimen. So this is our ESD resection here. Apologies, it seems like the video is not functioning. But I'll sort of point out some of the challenges we face here. Obviously position at the angularis, difficult place to perform ESD. And the way we often will overcome that is with using traction. So there's different devices to use traction. In this situation, we used a clip with a suture, and we attached the clip to the distal end of the lesion. You do want to leave some extra normal mucosa around the margin of the lesion when it's dissected. And that allows you to attach your clip to normal mucosa, which is better than attaching it to the area of diseased mucosa. So you attach your clip distally, and you're able to pull traction with the suture coming out of the mouth in order to obtain proper traction, make it easier to dissect when you have significant fibrosis, which we had in this situation. Significant fibrosis from the tattoo and also from the tumor. You tend to see that fibrosis right underneath where the cancer is. And that not only makes it more difficult to dissect, but often you'll get more vascularization and more bleeding in that area as well. So the traction is very helpful in that situation. And apologies for the video not working, but we'll go ahead and move on here. So in terms of our pathology, we have a very nice image here of our tumor. And you can see this sort of circular nodule here, which goes right down to this muscular mucosa here, which you can see at the bottom, surrounded by dysplasia. But you can really see the central nodule is exactly where the tumor was. There's a closer image here of the cancer. So our pathological diagnosis was well-differentiated intramucosal adenocarcinoma. And we'll see this sometimes where initial biopsy shows moderately differentiated. And then once we resect it and we have the entire specimen, it becomes a well-differentiated intramucosal carcinoma in the background of high-grade dysplasia and intestinal metaplasia, no lymphovascular invasion. There were negative deep and lateral margins for carcinoma and for high-grade dysplasia. So we considered this a curative resection. EGD was performed, again, at intervals of three months, six months, and two years, and was negative for recurrence. So the patient continued on to have surveillance for persistent gastrointestinal metaplasia. Thank you very much.

74-year-old Korean female

upper endoscopy

gastrointestinal metaplasia

adenocarcinoma

staging procedures