In these COVID-19 pandemic times, waiting times become even more relevant than those caused before by organizational issues in a multistep referral system. Waiting times could be accepted for high-grade dysplasia but much less for early cancer. Here we present 2 cases of early cancer of the stomach with variable progression.
An 81-year-old woman was given the diagnosis of early flat gastric body G2 adenocarcinoma (A) at the end of October 2019 and was treated by endoscopic submucosal dissection (ESD) at the end of January 2020 for several organizational reasons; at that time, the tumor showed macroscopically massive progression (B). The decision for ESD was made because of the patient’s wish to avoid surgery within expanded ESD criteria, but this proved to be very difficult. Histologic examination showed T1sm1 with positive basal margins. Histologic examination of a subsequent gastrectomy specimen showed no residual tumor, but 1 of 24 lymph nodes was positive.
Another patient, a 65-year-old woman, presented with a slightly bulky lesion at the cardia (C), which was histologically positive for adenocarcinoma, at the end of November 2019. Endoscopy at the time of ESD in February 2020 showed macroscopic progression of the lesion (D), and after ESD that showed a T1sm G2 R0 V0 but basal R1 lesion, surgery was indicated. Histopathologic analysis of the resection specimen showed it to be free of tumor, with negative lymph nodes (0/41).
In conclusion, our 2 cases showed variable progression during 3 to 4 months, the first from a IIb to a IIc or III lesion and the other to an increase in size by an estimated 20% to 30%. Even if we cannot prove the exact histologic extent of progression, we strongly suggest that we not wait too long—especially now!
Disclosure
All authors disclosed no financial relationships.
Commentary The COVID-19 pandemic has led to an ongoing severe shortage of personal protective equipment and a significant strain on healthcare systems across the world. To preserve healthcare resources to combat the pandemic and to limit the spread of the infection, healthcare systems universally resorted to canceling elective procedures for the time being. Although some procedures are considered clearly elective and can be postponed for 2 to 3 months, such as screening colonoscopy, other procedures could be elective but are time sensitive. Elective but time-sensitive procedures are those that could be postponed for a short time; however, beyond a certain point, delaying these procedures can result in a significant increase in morbidity or mortality for these patients.
Unfortunately, these distinctions cannot be made by a healthcare authority for providers all across the board because of patient-specific factors and procedural technical factors. The Centers for Medicare and Medicaid Services (CMS) in the United States issued a notice to limit all nonessential planned surgeries and procedures until further notice. In the CMS recommendation, procedures were divided into 3 tiers based on acuity (low, intermediate, and high). EGD and colonoscopies were considered tier 1 procedures (low acuity), and the recommendation was to cancel all endoscopies for both healthy and unhealthy patients. However, the CMS recommendation made an exception for the continuance of performing procedures on highly symptomatic patients. The statement did not issue further clarifications on who would be considered highly symptomatic.
This current case highlights the dilemma we are faced with as gastroenterologists during this COVID-19 crisis. The authors present 2 cases of high-grade gastric dysplasia with delayed intervention for 3 months, which resulted in lesion progression on both cases and lymph node invasion on the surgical specimen in 1 patient. Both cases are considered elective but time sensitive. Delay in performing these types of procedures may be acceptable for as long as 4 to 8 weeks, but beyond that point we should consider performing these procedures without further delay.
Table 1 shows examples of certain indications that could be elective but time sensitive. We encourage our readers to use their own judgement about when to delay or proceed with endoscopy, based on indication for the procedure and the potential for harm associated with long-term delay.
Table 1.
Examples of elective but time-sensitive procedures by indication
| Procedure | Elective but time-sensitive indications |
|---|---|
| EGD/colonoscopy/enteroscopy | Portal hypertensive gastropathy or arteriovenous malformations causing severe anemia and/or intermittent bleeding GI treated by chemotherapy/radiotherapy in need of follow-up endoscopy EMR or endoscopic submucosal dissection for early cancer or high-grade dysplasia of the GI tract Progressive dysphagia due to benign esophageal stricture |
| EUS | Large pancreatic pseudocyst with minimal symptoms at the time of presentation Abnormal nonspecific findings on pancreatic imaging studies such as “fullness of the head of the pancreas” in mildly symptomatic patients Suspected neuroendocrine tumor such as insulinoma with normal imaging in mildly symptomatic patients |
| ERCP | Possible stricture of the common bile duct seen on imaging with normal liver function test results Scheduled bile duct and pancreatic duct stent removal/exchange |
Michael B. Wallace, MD, MPH, FASGE, GIE Editor-in-Chief
Mohamed O. Othman, MD, Associate Editor for Focal Points
Mohamed O. Othman, MD, Associate Editor for Focal Points