Reply to Solís-Muñoz et al.

We have read the letter by Solís-Muñoz et al. with great joy. We deeply appreciate their comments and sharing of important opinions on vanishing or unfound gastric cancer cases. In their letter, they report on a very interesting case of a 55-year-old male who was diagnosed with signet ring-cell adenocarcinoma, which was incidentally found in one sample specimen from random endoscopic biopsies for evaluation of gastritis status and antibiogram of Helicobacter pylori. After the meticulous and elaborate evaluation with highly sophisticated methods, including genetic and molecular tests to ensure the specimen belonged to the patient, the patient had been carefully followed up for 4 years and had shown no evidence of disease. We absolutely agree with the authors’ opinion that the focus of tumor cells was eliminated with the forceps biopsy and that a close endoscopic follow-up schedule will be necessary to detect the development of new foci in the future.

Rabenstein et al. used the term “invisible gastric cancer” to refer to random biopsies that are taken from the gastric mucosa for histologic assessment of gastritis and H. pylori status and which show definite malignant neoplastic cells but are without the presence of any endoscopically visible lesions [1]. In a study by Cadman et al. this type of case occurred in one out of 8907 endoscopic examinations [2]. As there is no standard treatment strategy in these rare cases, total gastrectomy, a close surveillance strategy, “watch and wait” with the aim of detecting the confirmed neoplastic lesion, or photodynamic therapy of the entire region in which biopsy was taken could all be options for management [1]. As Solís-Muñoz et al. mention, endoscopic mucosal resection or endoscopic submucosal dissection could be a good alternative if the area from which the biopsy was taken is known. This endoscopic treatment has the advantage of being less invasive than radical operation. It also enables the complete removal of a suspicious area of tumor and the gathering of additional pathologic information on which to base a decision of whether subsequent surgery is necessary compared with just watching and waiting. Therefore, the endoscopic treatment could be a more reliable approach to the management of this surprising and embarrassing case. In our opinion, when biopsy of gastric mucosa is taken for any purpose, efforts should be made to identify or record the exact location. For instance, the moment of a forceps bite or the bleeding point at a biopsy site should be recorded as an image with adjacent landmarks such as angle, pylorus, or gastric folds.

The increase in the number of these embarrassing occasions might be due to the fact that the number of upper gastrointestinal endoscopies performed annually has increased greatly. In order to avoid unnecessary laborious efforts to confirm the location of the tumor and to make a more reliable management strategy for this vanishing or invisible cancer case, endoscopists need to be more responsible for the biopsies that they take, and intensive cooperation between endoscopists and pathologists should be a prerequisite.

Competing interests: None

References

• 1 Rabenstein T, May A, Gossner L. et al . Invisible gastric carcinoma detected by random biopsy: long-term results after photodynamic therapy.  Endoscopy. 2008;  40 899-904
• 2 Cadman B, Dixon M F, Wyatt J I. Value of routine, non-targeted biopsies in the diagnosis of gastric neoplasia.  J Clin Pathol. 1997;  50 832-834