Where has the tumor gone? The characteristics of cases of negative pathologic diagnosis after endoscopic mucosal resection

Background and study aims: Discrepancies can occur between the histopathological findings from forceps biopsy and endoscopic mucosal resection (EMR), and occasionally in embarrassing cases tumorous tissue is not found at EMR. The aim of the present study was to evaluate the clinical, endoscopic, and histological features of gastric tumors in patients with pathololgically negative findings at EMR.

Patients and methods: We retrospectively reviewed data from all patients with gastric tumor treated with EMR or endoscopic submucosal dissection (ESD) between August 1999 and April 2007 at our institution, and enrolled into the study patients with no tumor tissue found at mucosal resection. Their biopsy and EMR specimen slides were reviewed by a single pathologist. Patient characteristics, including demographic and clinical features, and the endoscopic appearance of mucosal lesions were evaluated.

Results: Out of 633 patients treated with EMR or ESD, 20 patients (3.2 %) were included. The mean ± SD maximal dimension of the mucosal lesions was 6.40 ± 2.19 mm (range 3 – 10). Mean number of forceps biopsy fragments was 3.80 ± 1.96 and mean sampling ratio was 2.08 ± 1.07 mm/fragment. Before resection, histological findings from forceps biopsy were: 13 low grade dysplasias (65.0 %), 2 high grade dysplasias (10.0 %), and 5 intramucosal carcinomas (25.0 %).

Conclusions: In the case of pathologically negative findings at EMR, tumors might have been small enough to have been removed by the previous forceps biopsy. However, the possibility of sampling error or of a different location should be considered. Furthermore, appropriate communication between endoscopists and pathologists is essential.

References

• 1 Rembacken B J, Gotoda T, Fujii T, Axon A T. Endoscopic mucosal resection.  Endoscopy. 2001;  33 709-718
• 2 Soetikno R M, Gotoda T, Nakanishi Y, Soehendra N. Endoscopic mucosal resection.  Gastrointest Endosc. 2003;  57 567-579
• 3 Tada M SM, Murakami F, Mizumachi M. et al . Development of strip-off biopsy [in Japanese with English abstract].  Gastroenterol Endosc. 1984;  26 833-839
• 4 Hirao M, Masuda K, Asanuma T. et al . Endoscopic resection of early gastric cancer and other tumors with local injection of hypertonic saline-epinephrine.  Gastrointest Endosc. 1988;  34 264-269
• 5 Inoue H, Takeshita K, Hori H. et al . Endoscopic mucosal resection with a cap-fitted panendoscope for esophagus, stomach, and colon mucosal lesions.  Gastrointest Endosc. 1993;  39 58-62
• 6 Suzuki Y, Hiraishi H, Kanke K. et al . Treatment of gastric tumors by endoscopic mucosal resection with a ligating device.  Gastrointest Endosc. 1999;  49 192-199
• 7 Gotoda T, Kondo H, Ono H. et al . A new endoscopic mucosal resection procedure using an insulation-tipped electrosurgical knife for rectal flat lesions: report of two cases.  Gastrointest Endosc. 1999;  50 560-563
• 8 Inoue H, Noguchi O, Saito N. et al . Endoscopic mucosectomy for early cancer using a pre-looped plastic cap.  Gastrointest Endosc. 1994;  40 263-264
• 9 Gotoda T. Endoscopic resection of early gastric cancer.  Gastric Cancer. 2007;  10 1-11
• 10 Kitamura T, Tanabe S, Koizumi W. et al . Argon plasma coagulation for early gastric cancer: technique and outcome.  Gastrointest Endosc. 2006;  63 48-54
• 11 Nagano H, Ohyama S, Fukunaga T. et al . Indications for gastrectomy after incomplete EMR for early gastric cancer.  Gastric Cancer. 2005;  8 149-154
• 12 Yano H, Kimura Y, Iwazawa T, Monden T. Laparoscopic management for local recurrence of early gastric cancer after endoscopic mucosal resection.  Surg Endosc. 2005;  19 981-985
• 13 Ishikawa S, Togashi A, Inoue M. et al . Indications for EMR/ESD in cases of early gastric cancer: relationship between histological type, depth of wall invasion, and lymph node metastasis.  Gastric Cancer. 2007;  10 35-38
• 14 Yoon W J, Lee D H, Jung Y J. et al . Histologic characteristics of gastric polyps in Korea: emphasis on discrepancy between endoscopic forceps biopsy and endoscopic mucosal resection specimen.  World J Gastroenterol. 2006;  12 4029-4032
• 15 Muehldorfer S M, Stolte M, Martus P. et al . Diagnostic accuracy of forceps biopsy versus polypectomy for gastric polyps: a prospective multicentre study.  Gut. 2002;  50 465-470
• 16 Schlemper R J, Riddell R H, Kato Y. et al . The Vienna classification of gastrointestinal epithelial neoplasia.  Gut. 2000;  47 251-255
• 17 Repici A. From EMR to ESD: A new challenge from Japanese endoscopists.  Dig Liver Dis. 2007;  39 572-574
• 18 Palli D, Bianchi S, Cipriani F. et al . Reproducibility of histologic classification of gastric cancer.  Br J Cancer. 1991;  63 765-768
• 19 Hakim N S, Sarr M G, van Heerden J A. Does endoscopy really help the surgeon evaluate gastric cancer?.  Can J Surg. 1989;  32 175-177
• 20 Namieno T, Koito K, Higashi T. et al . Assessing the suitability of gastric carcinoma for limited resection: histologic differentiation of endoscopic biopsy.  World J Surg. 1998;  22 865-868
• 21 Hull M J, Mino-Kenudson M, Nishioka N S. et al . Endoscopic mucosal resection: an improved diagnostic procedure for early gastroesophageal epithelial neoplasms.  Am J Surg Pathol. 2006;  30 114-118
• 22 Szaloki T, Toth V, Tiszlavicz L, Czako L. Flat gastric polyps: results of forceps biopsy, endoscopic mucosal resection, and long-term follow-up.  Scand J Gastroenterol. 2006;  41 1105-1109
• 23 Park D I, Rhee P L, Kim J E. et al . Risk factors suggesting malignant transformation of gastric adenoma: univariate and multivariate analysis.  Endoscopy. 2001;  33 501-506
• 24 Park S Y, Jeon S W, Jung M K. et al . Long-term follow-up study of gastric intraepithelial neoplasias: progression from low-grade dysplasia to invasive carcinoma.  Eur J Gastroenterol Hepatol. 2008;  20 966-970
• 25 Jung M K, Jeon S W, Park S Y. et al . Endoscopic characteristics of gastric adenomas suggesting carcinomatous transformation.  Surg Endosc. 2008;  22 2705-2711