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[Gastric cancer 780. Small P/D adenocarcinoma]

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A middle-aged woman visited my clinic due to a small gastric cancer detected in the screening endoscopy. The pathology was poorly differentiated adenocarcinoma, and surgery was recommended in the previous hospital. What's your opinion? Would you recommend surgery, or ESD?

ESD for undifferetiated type histology is still controversal. I strongly recommend ESD for flat signet ring cell carcinomas within 1cm. ESD for poorly differentiated adenocarcinoma is still a little bit worrisome. I usually explain in detail about the advantage and disadvantage of endoscopic treatment and give some time for consideration. One week later, the patient is usually choose ESD.

However, this patient chose surgery, and the final pathology was as follows.

Radical subtotal gastrectomy: Early gastric carcinoma
1. Location : middle third, Center at antrum and greater curvature
2. Gross type : EGC type IIc
3. Histologic type : tubular adenocarcinoma, poorly (solid) differentiated
4. Histologic type by Lauren : intestinal
5. Size : 1.0x0.7 cm
6. Depth of invasion : invades mucosa (lamina propria) (pT1a)
7. Resection margin: free from carcinoma, safety margin: proximal 6.0 cm, distal 8.0 cm
8. Lymph node metastasis : no metastasis in 39 regional lymph nodes (pN0)
9. Lymphatic invasion : not identified
10. Venous invasion : not identified
11. Perineural invasion : not identified
12. AJCC stage by 8th edition: pT1a N0

Patients are usually strongly influenced the opinion of the first doctor.

우리말 요약: 미분화조직형 (P/D 또는 SRC) 위암의 내시경 치료는 아직 controversal 합니다. 전문가들은 적응증을 확대하고자 하는데 정부에서는 아직 보수적인 기조를 유지하고 있습니다. 전문가들의 견해와 감독 당국의 견해가 일치하지 않는 것이 아무래도 마음에 걸립니다. 환자들은 선별급여 진료를 표준진료가 아닌 것으로 생각하는 경향이 있습니다. 이로 말미암아 과잉 치료가 유도되는 측면이 있는 것 같습니다.

© 일원내시경교실 바른내시경연구소 이준행. EndoTODAY Endoscopy Learning Center. Lee Jun Haeng. (2019-8-20)