This ASG video tip is sponsored by Braintree, maker of the newly approved Suflav and Sutab. We have a 60-year-old female who was referred to the GI clinic for family history of gastric cancer. She was originally from China, but moved to the United States 20 years ago. The only complaint is she has chronic dysplexia and intermittent bloating, but otherwise denied all the GI symptoms, no weight loss, never has an upper endoscopy, no family history, but she has a family history of gastric cancer in her mother and was diagnosed at age of 50. Her labs were unremarkable. So she is at an increased risk of gastric cancer because one, she's come from high eastern country and two is she has family history in her first degree relatives. So we recommend an upper endoscopy to first detect and risk stratify pre-cancerous gastric lesions, such as gastric atrophy and gastric intestinal metaplegia. And second is to detect gastric dysplasia and early gastric cancer and potentially treat them before they turn to advanced cancer. But to examine the stomach in these patients, we have to perform high quality endoscopy. First ensure mucosal visibility. We have to clean the stomach carefully, remove all the debris, bubbles, use mucolytic until you don't see any bubble or minimal bubbles or mucus left that does not obscure view. Like the lower pictures, it's still not adequate cleaning and we need to continue to clean more before we start examination. The second is ensure adequate distention of the stomach. Like in this picture, you can see a partial distention of the stomach and it looks okay. But when we fully distention the stomach, you can see advanced gastric cancer. So we can miss even advanced gastric cancer if we don't fully insufflate the stomach. Next is how long we have to examine the stomach. In this study, it showed that the endoscopies that spend at least seven minutes performing endoscopy in a high risk patients, there has been about two and a half fold increase in chance of detect high risk gastric lesions. So it's recommended that we at least spend seven minutes perform an upper endoscopy in this high risk patients. And we need to use enhanced imaging to improve detection of gastric metaplasia. And for this white light image, it looks normal. But when we apply NBI, you can see multiple whitish patches. And in close up view, you see rich pattern. This is suggestive of gastric metaplasia and targeted biopsy confirm gastric metaplasia. So in the combination of enhanced imaging and targeted biopsy increased detection of gastric metaplasia. So this patient underwent endoscopy. And first you see, so we cannot, okay. So you can see the large lesion, the place lesion at the incisor and above it, you can see gastric metaplasia. Come back to this place lesion, there's no ulcer. On the NBI, there's irregular surface pattern. So this is non-isolated lesion and depressed morphology. At least we concern that this is high grade dysplasia or early gastric cancer. So the biopsy of this lesion, in fact, show intramucosal adenocarcinoma in the background of gastric metaplasia. And targeted biopsy of other patient's lesion also confirm metaplasia somewhere else. And biopsy, gastric mapping biopsy was negative for H. pylori. CT scan and endoscopic ultrasound was negative for lymph node involvement or metastasis. So what we will do next, EMR, ESD, or gastrectomy. Endoscopic resection can be offered for gastric and nipple plasia that has a low or minimal risk of lymph node metastasis. And typically, we accept 1% or lower risk of lymph node metastasis to perform endoscopic resection and has a long-term clinical outcome of endoscopic resection comparable to surgery. So this guideline show that the absolute and expanded indications, this patient is look like to be mucosal lesion, no ulcer, and two centimeter or smaller. And this is a differentiated type lesion. So it's point to the red box category that we can offer endoscopic resection. And this category has a risk of lymph node metastasis less than 1%. So we elect ESD rather than EMR to increase chance of curative resection. And on-block resection was performed. And you can see the lesion in the center of the specimen. And the final pathology show intramucosal cancer, moderately differentiated type, tubular adenocarcinoma, negative deep and lateral margin, and no lymphovascular invasion. And on the pathology, also negative for evidence of ulcerations. So this fit the curative resection criteria. So the patient can avoid surgery. But what next? Because this patient has overall increased risk of synchronous, metachronous, or recurrent lesion after endoscopic resection. And most of these recurrent, local recurrent, occur in the first year. So it's recommended to perform surveillance endoscopy for T1A cancer. We perform endoscopy at six months, twice, and then annually. These patients need follow-up long-term. Thank you.

gastric cancer

upper endoscopy

pre-cancerous gastric lesions

endoscopic resection

surveillance endoscopy