This lesion was found in the mid-oesophagus.
Which of the following options is correct?
a) this is a benign lesion and as samples are unlikely to be diagnostic no biopsies are needed
b) this lesion is benign and biopsies will confirm this
c) this lesion is indeterminate and should be extensively sampled
d) this lesion is likely to be an early malignancy which can be removed endoscopically
e) this lesion is likely to be cancer which can not be removed endoscopically
This depressed (ulcer-like) lesion is very suspicious. Benign pathology such as granular cell tumours and leiomyomas will not be ulcerated. The two most likely causes are: 1) primary squamous cell carcinoma or 2) a metastases.
“Technically” it is possible to remove this lesion endoscopically. In fact, I was able to easily remove it using the “Cook Duette” kit. However, as I rather suspected, although the cancer was superficial there was invasion of the lymphatic channels and a positive deep margin. Subsequently, some of my peers thought that I should not have removed the lesion. They argued that instead I should have made an endoscopic diagnosis that the lesion was too advanced for endoscopic resection.
Unfortunately, the Multidisciplinary Cancer Teams in England always want precise histological confirmation before deciding on treatment. For example, even if a colonic lesion looks like a cancer on abdominal CT, endoscopy and biopsies are still required. The reason for this is that to subject a patient to potentially hazardous surgery to treat benign disease or to remove lesions which can be removed endoscopically is now becoming unacceptable practise.
In removing this lesion endoscopically (using the Duette kit), I probably subjected the patient to a less than 1:200 risk of a perforation and less than 1:50 risk of late bleeding. I believe that these are acceptable risks to achieve a precise diagnosis. After all, analysis of the EMR specimen provided more information than could have been obtained from surface biopsies, EUS and CT.
However, I agree that it would NOT have been acceptable to attempt to remove this lesion by ESD. This technique subjects the patient to a 1:20 risk of perforation which could lead to wide dissemination of cancerous cells throughout the chest.