Not every GI tumour can be removed through the endoscope, and the deciding factor is almost always depth. The digestive wall has layers, and I need to know which of them the tumour has reached. The biopsy gives us the cell type and grade. Size comes next. Most of us keep 2 cm in mind, yet a flat 3 cm lesion confined to the lining may suit endoscopy better than a 1.5 cm tumour already fixed to the wall. Where depth is still unclear after careful examination, I arrange an endoscopic ultrasound (EUS) before anything is cut.
According to Dr. Vipulroy Rathod, Gastroenterology Specialist in Mumbai, “The first thing I want to know is how deep the tumour goes. If it has not crossed the superficial layers and the cells look favourable, the endoscope can often achieve what an operation would otherwise do. Where we are unsure, we stage it properly before removing anything.”
How Do Doctors Assess Whether a GI Tumour Can Be Removed Endoscopically?
- Depth of invasion. This is the first of the criteria for endoscopic tumour removal. Tumours confined to the mucosa or the upper submucosa carry a low risk of lymph node spread, which is what allows removal through the scope to be curative. If the surface findings raise doubt, we use EUS to view the wall layers in cross-section. See Endoscopic Ultrasound (EUS).
- Surface pattern. High-definition and magnified views show the pit and vessel pattern of the tumour. A disorganised or destroyed pattern suggests deeper growth, and narrow band imaging helps us read it more clearly. See NBI Endoscopy.
- Size and shape. Tumours up to roughly 2 cm are usually the most straightforward to take out in one piece. Larger lesions are not ruled out, but they need a more advanced technique and closer planning.
- Tumour type and differentiation. A biopsy tells us the type of tumour and how closely the cells resemble normal tissue. Well-differentiated tumours are better candidates than poorly differentiated ones, which tend to spread earlier.
Which GI Tumours Are Usually Suitable for Endoscopic Removal?
- Early oesophageal and gastric tumours. Endoscopic removal of GI tumours works best here when the lesion is superficial. Many are removed whole by dissecting beneath them, which gives the pathologist a complete specimen. See Endoscopic Submucosal Dissection.
- Colon and rectal tumours. Large flat polyps and early cancers of the colon and rectum can often be cleared by mucosal resection or submucosal dissection, provided there is no sign of deep invasion.
- Neuroendocrine tumours. Small, low-grade tumours of the stomach, duodenum or rectum may be treated endoscopically when they sit in the upper wall layers. Read our post on What Is Carcinoid Tumor of the GI Tract?
- Tumours with early invasion. A tumour that has only just entered the superficial submucosa may still be managed endoscopically if the pathology after removal is favourable. If it is not, surgery is considered.
What Determines the Right Treatment Approach?
- Muscle layer involvement. A tumour that has reached the muscle layer cannot be removed completely through the scope and is generally referred for surgery.
- Spread beyond the wall. Staging with EUS and scans checks the nearby lymph nodes and distant organs. Evidence of spread moves treatment away from endoscopy alone.
- Poor lifting and scarring. When injected fluid fails to raise the tumour, or earlier procedures have left scar tissue fixing it to the wall, deeper invasion is suspected and the risk of perforation rises. These cases may need a more specialised approach. See Advanced Endoscopic Treatment for GI Tumors.
- The pathology report. After removal, the laboratory examines the depth, the margins and any lymphovascular invasion. A report showing deep or high-risk features may call for further treatment, including surgery.
Not sure whether your tumour can be treated through the scope? Contact us to book a consultation with Dr. Rathod.
Key Takeaways
- The muscle layer is the dividing line. Above it, the scope can usually finish the job. Once the tumour has gone through it, the scope cannot.
- Size on its own never settles the question. I read it alongside the shape, the biopsy and the grade of the cells.
- Ultrasound is not routine. We add it when the surface view leaves us guessing about depth.
- Enlarged lymph nodes on staging change the plan, however the surface of the tumour looks.
- Removal is not the end of it. The pathology report has the final say, and we scope the site again after a few months.
Not sure whether your tumour can be treated through the scope? Book a consultation with Dr. Rathod.
Frequently Asked Questions
No. Only those that stay in the inner layers of the wall and show favourable cells on biopsy.
No. We request it when the surface view leaves the depth in doubt.
That does happen. We go through the report with the patient and then decide between surgery and close watching.
Not a hard one. Bigger tumours are removed too, when their depth and cells allow it.
References
- Endoscopic submucosal dissection for superficial gastrointestinal lesions: ESGE Guideline, Update 2022, Endoscopy
- Endoscopic submucosal dissection: ESGE Guideline, Endoscopy
Disclaimer: The information shared in this content is for educational purposes only and is not a substitute for professional medical advice, diagnosis or treatment. Please consult a qualified gastroenterologist for guidance specific to your condition.
