Fig. 1. A Corpus, lesser curvature (U-turn view). B Same site after spraying indigo carmine

Case Description

A man, aged 73 years, complaining of anorexia, cough, and rhinorrhea for a week, underwent a barium meal examination, which was followed up by an upper gastrointestinal (GI) endoscopic examination to rule out abnormalities. A lesion of about 5mm in diameter was found in the corpus and was biopsied. Two months later he underwent endoscopic ultrasonographic examination and shortly thereafter endoscopic resection was performed. The resection margins were free of tumor. On follow-up endoscopic examinations, no local recurrence was found.

Endoscopy Commentary

Anthony T.R. Axon (UK)1

History

A 73-year-old man complaining of anorexia, cough, and rhinorrhea for a week would not in the United Kingdom usually be referred for a barium meal. As a general rule patients with these symptoms would be seen first by their general practitioner, who would provide symptomatic treatment and review them again after about a month. If the symptoms persisted they would be investigated according to how the patient had responded. If the symptoms had settled they would be reassured and discharged; if they were still present a specialist ear, nose, and throat opinion, a chest X-ray, or an upper digestive endoscopy would have been requested. If it

endoscopists use chromoscopy more frequently than they did in the past and the number of centres performing endoscopic mucosal resection has risen.

*Endoscopic Classification Review Group (2005) Update on the Paris Classification of superficial neoplastic lesions in the digestive tract. Endoscopy 37:570–578

1The comments by Professor Axon in this chapter were based on an assessment of the cases in December 2001 and his comments relate to Western practice at that time. Since then Japanese techniques have been embraced in the West with greater enthusiasm, particularly since the Paris classification was published* which was based on the Japanese macroscopic classification of early malignancy. As a result of this, Western

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had been an upper digestive endoscopy it is likely in the UK that there would have been some delay in undertaking the procedure.

It is unclear from the history given why following the barium meal the patient was referred for upper gastrointestinal (GI) endoscopy. In the UK it is unlikely that endoscopy would have been requested unless an abnormality had been found on barium meal examination.

Endoscopic Appearance

The appearance of the stomach without dye spray appears to show evidence of chronic atrophic gastritis with intestinal metaplasia. No focal lesion is readily apparent. It is unlikely that dye spray would have been used in the West as this is not a routine procedure. It is possible that random biopsies would have been taken from the stomach.

Following dye spray there appears to be an oval lesion with a deeply stained base and slightly elevated hypostaining mucosa surrounding it. The stained appearances suggest a small ulcer. In retrospect the lesion may be apparent on close examination of the unstained photograph. Its nature is uncertain. Was this to be an early gastric cancer, I would agree that this appearance would be a IIc.

Histopathology

The Western pathologists in this case mainly reported high-grade dysplasia on the biopsy specimen. We know from experience that high-grade dysplasia is associated with invasive cancer in the majority of cases. In the UK this histology would have been reviewed with the histopathologists and with surgical colleagues, to come to a decision as to how to proceed.

Management

There is little experience in the West of endoscopic mucosal resection, and although this is being undertaken in a number of centers it is only within the last 2 or 3 years that endoscopists have been performing this procedure, usually in specialized centers.The most likely decision, therefore, would have been for a surgeon to be involved. It is likely that further endoscopy would have been requested with additional biopsies. Had this con-firmed the abnormality, it is likely that total or subtotal gastrectomy would have been performed.

Summary

In summary, it is unlikely in the West that this patient would have been referred for endoscopy. Had endoscopy been done it is unlikely that the lesion would To Be Continue...