1. Contribution by Prof. Dr. B.L.A.M. Weusten
St. Antonius Hospital, Nieuwegein
“How to treat a patient in case of incomplete histopathological assesment?”

2. Case
A 59 year old woman was referred from a community hospital because of a visible lesion in a C0M1 Barrett’s oesophagus. The past medical history reveals no relevant comorbidity

3. Endoscopy Upper endoscopy showed:
a large hiatal hernia (diaphragm at 40 cm, gastric folds at 32 cm)
C0M1 Barrett’s oesophagus with 2 visible lesions:
Lesion I: Paris type 0-Is, 20 mm Ø, at 6 o’clock at the z-line.
Lesion II: Just proximal to lesion I, 5mm Ø.

4. Lesion I

5. Lesion I (narrow-band imaging)

6. Lesion II (narrow-band imaging)

7. Endoscopy Both lesions fully lifted after submucosal injection
Both lesions were successfully removed with endoscopic resection. Because the size of the lesion and aiming at en bloc resection ER was performed using the cap technique with a large, flexible oblique cap

9. The problem
The resection specimen of lesion I (the largest lesion) was lost and could not be sent for histological examination.
Pathology lesion II:
Well to moderately differentiated adenocarcinoma (G1-G2), maximal diameter 6 mm.
Infiltration depth: muscularis mucosae (m3).
Deep resection margins free (R0).

10. What to do?
The smallest lesion (II) turned out to be a T1m3 cancer, but no histological assessment was available for the larger and thus possibly more advanced lesion (I).
Should you refer this patient for surgery or conduct a wait and see policy?

11. Considerations
It is important to weigh up the pro’s and con’s of both strategies:
Lesion I is larger than lesion II, but this does not automatically mean that it is more advanced.
Lesion I showed complete lifting after submucosal injection.
Furthermore, taking the morbidity and mortality of oesophagectomy in consideration, surgery might not be justified in this particular case.

12. Advise
Perform staging after 6 weeks with three-monthly follow with EUS thereafter.
Of course these arguments should be discussed with the patient.