Two-stage endoscopic resection for a huge gastric tumor at the fornix

We report a case of two-stage endoscopic resection (TSER) of a huge tumor at the duodenal bulb.¹ When the tumor is large, endoscopic resection becomes difficult because of insufficient working space. TSER is a two-phase method to safely resect large protruding tumors endoscopically while ensuring accurate pathologic evaluation of tumor invasion. In the first stage, the head of the tumor is resected by piecemeal polypectomy to reduce its volume without damaging the base. In the second stage, the base is resected en bloc through endoscopic submucosal dissection (ESD). En bloc resection of the base is necessary for accurate pathologic evaluation of tumor infiltration.² After piecemeal polypectomy, there is enough space for ESD.

Achieving R0 resection endoscopically is possible for large differentiated gastric cancer if the lesion is intramucosal cancer without ulceration and lymphovascular invasion. The tumor must be resected en bloc with negative margins.³ However, large lesions are a risk factor for difficult gastric ESD.⁴ Thus, TSER can ensure accurate pathologic evaluation and R0 resection of large tumors that are difficult to resect en bloc through conventional ESD. Here, we report a case of a huge gastric tumor treated with TSER (Video 1, available online at www.videogie.org).

An 84-year-old man was diagnosed with a protruding tumor at the fornix (Fig. 1). The surface of the tumor had a villous structure, and the size exceeded 10 cm. Biopsy results led us to suspect pyloric gland adenoma. The tumor was highly likely to be cancerous owing to its size⁵ and was diagnosed endoscopically as a gastric-type adenocarcinoma with low-grade atypia corresponding to intramucosal depth. Thus, the tumor should be resected en bloc for accurate pathologic evaluation.

Figure 1.

The large protruding tumor at the fornix. A, Forward view. B, Retroflex view.

The base margin was not visible because of the huge head portion. Observation with grasping forceps was attempted, but a full view of the base could not be obtained because of the tumor's weight. The traction method was considered ineffective for the same reason. Considering the endoscopic diagnosis, we decided to perform TSER to reduce the tumor volume, clarify the lesion margins, and enable the use of the traction method afterward. In the first stage, piecemeal polypectomy was performed (Fig. 2). During polypectomy, we used a Dualoop snare (Medicos Hirata, Osaka, Japan), and the setting used on the VIO3 electrical unit (Erbe, Tübingen, Germany) was Endocut Q (effect 3, duration 2, and interval 3). The first-stage procedure time was 35 minutes. The base margin was unclear immediately after piecemeal polypectomy because of bleeding and edema. Therefore, we prescribed antacids and performed ESD as the second stage 2 weeks later. At this time, the basal margin was clear, and the tumor became lighter, making the traction method effective (Fig. 3). The base was resected en bloc by ESD (Fig. 4). During ESD, after injecting 0.4% hyaluronic acid or saline solution, we used a Teck knife (Micro-Tech, Nanjing, China) and an ITknife2 (Olympus, Tokyo, Japan), and the settings on the VIO3 electrical unit were Endocut I (effect 2, duration 2, and interval 2) and Spray Coag (effect 4.5). The procedure time was 450 minutes (ESD: 330 minutes, closure: 120 minutes). The mucosal defect was closed using 2 OTSC clips (Ovesco Endoscopy, Tübingen, Germany) and hemostatic clips. Both stages were completed without any adverse events. The patient was discharged 2 days after the polypectomy and 5 days after the ESD. Pathology revealed an 82 × 35-mm intramucosal differentiated and papillary adenocarcinoma, with no lymphovascular invasion, within a 112 × 76-mm gastric adenoma, resected R0. Because the base was resected en bloc, precise pathologic evaluation of tumor infiltration was possible (Figs. 4 and 5).

Figure 2.

The first stage: piecemeal polypectomy. A, At the start of the polypectomy. B, After the polypectomy.

Figure 3.

The second stage: endoscopic submucosal dissection (ESD). A, At the start of the ESD, the margin could be observed. B, Using a clip-with-line traction method. C, Post-ESD mucosal defect. D, After closure of the mucosal defect. E, The specimen was resected in the second stage, and the base of the tumor was resected en bloc.

Figure 4.

A, The resected specimen of the endoscopic submucosal dissection. B, The area of the carcinoma in situ.

Figure 5.

A, Pathologic specimen of the base. H&E, orig. mag. ×20. B, Pathology results revealed intramucosal differentiated and papillary adenocarcinoma in gastric adenoma. H&E, orig. mag. ×100.

We believe this is the first report of TSER successfully applied for a huge gastric tumor. TSER could also be applied for huge gastric protruding lesions.

Disclosure

None of the authors have any disclosures to make.

Supplementary data

Video 1

Two-stage endoscopic resection for a huge gastric tumor at the fornix.