Decision making after ESD may be tricky. A patient came to my clinic with outside ESD pathology (Poorly differentiated adenocarcinoma with 30% moderately differentiated adenocarcinoma, 2.2cm, muscularis mucosa invasion, resection margin negative, lymphatic negative). Surgery was recommended at the previous hospital.

Because the histology was poorly differentiated adenocarcinoma in 70%, it is EGC with undifferentiated type histology. I have a personal policy of recommending additional surgery for EGC with undifferentiated type histology larger than 2 cm in ESD specimen. The size of EGC in this case was slightly above the criteria.