Clin Endosc.  2013 Sep;46(5):436-440.

Tissue Acquisition in Gastric Epithelial Tumor Prior to Endoscopic Resection

• Kim CG

Abstract

Endoscopic forceps biopsy is essential before planning an endoscopic resection of upper gastrointestinal epithelial tumors. However, forceps biopsy is limited by its superficiality and frequency of sampling errors. Histologic discrepancies between endoscopic forceps biopsies and resected specimens are frequent. Factors associated with such histologic discrepancies are tumor size, macroscopic type, surface color, and the type of medical facility. Precise targeting of biopsies is recommended to achieve an accurate diagnosis, curative endoscopic resection, and a satisfactory oncologic outcome. Multiple deep forceps biopsies can induce mucosal ulceration in early gastric cancer. Endoscopic resection for early gastric cancer with ulcerative findings is associated with piecemeal resection, incomplete resection, and a risk for procedure-related complications such as bleeding and perforation. Such active ulcers caused by forceps biopsy and following submucosal fibrosis might also be mistaken as an indication for more aggressive procedures, such as gastrectomy with D2 lymph node dissection. Proton pump inhibitors might be prescribed to facilitate the healing of biopsy-induced ulcers if an active ulcer is predicted after deep biopsy. It is unknown which time interval from biopsy to endoscopic resection is appropriate for a safe procedure and a good oncologic outcome. Further investigations are needed to conclude the appropriate time interval.

Keyword

Forceps biopsy; Endoscopic resection; Histologic discrepancy; Ulcer

MeSH Terms

Biopsy
Fibrosis
Gastrectomy
Hemorrhage
Lymph Node Excision
Proton Pump Inhibitors
Selection Bias
Stomach Neoplasms
Surgical Instruments
Ulcer
Proton Pump Inhibitors

Figure

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  Fig. 1 Endoscopic photos of biopsy-proven low-grade adenoma according to risk factors indicating a finding of upgrade to high-grade adenoma or invasive carcinoma with postendoscopic resection pathologic results. (A) A 0.7-cm-sized, nonerythematous, elevated lesion was classified as low-grade adenoma after endoscopic resection. (B) A 2.2-cm-sized, whitish, flat, elevated lesion was proven and classified as high-grade adenoma after endoscopic resection. (C) A 3.5-cm-sized, erythematous, flat, elevated lesion was classified as invasive carcinoma after endoscopic resection.

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  Fig. 2 (A) Endoscopic finding which was obtained at initial endoscopy at a local clinic. No definite ulcer was found. (B) Endoscopic finding just after performing forceps biopsy at a local clinic. Biopsy was performed at the center of the tumor surface. (C) Endoscopic finding at the tertiary referral center. An ulcer was shown on the tumor surface. (D) Endoscopic finding at endoscopic resection. The previously noted ulcer was healed after treating with proton pump inhibitors for 15 days. (E) Microscopic findings of resected specimen (H&E stain, ×40). The center of the specimen (arrow) shows a healed ulcer with submucosal fibrosis.

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