LAUSR

Although well established for classic indications [1–3], the use of endoscopic submucosal dissection (ESD) can help to solve rare clinical situations [4–5]. A 35-year-old woman without medical history underwent an esophagogastroduodenoscopy for progressive epigastralgia that was unresponsive to proton pump inhibitors (PPIs) for 12 months. A 10-mm subepithelial lesion in the antrum was reported (▶Fig. 1). Biopsies revealed an extramedullary plasmacytoma, confirmed by expert pathology. Apart from weight loss, attributed to epigastralgia, no other B symptoms were present. Diagnostic work-up disclosed a unique gastric hypermetabolic focus on positron emission tomography (▶Fig. 2). There were no biological anomalies. Bone marrow biopsy was normal. Endoscopic evaluation 1 month after radiotherapy, administered with curative intent (40Gy), suggested a non-responding lesion (▶Fig. 3). Endosonography evaluation showed a homogeneous, hypoechoic mass (12.0 ×5.7mm) limited to the submucosa (▶Fig. 4). ESD was proposed as a treatment option in a multidisciplinary team. Lesion delineation was obtained using narrow-band imaging (NBI) and texture and color enhancement imaging. ESD was performed by expert hands (▶Video 1) with a GIF-HQ-190 gastroscope, using an electrosurgical knife and glycerol solution. The conventional ESD technique was applied, taking 1-cm lateral margins, dissecting alongside the proper gastric muscular layer under near focus and texture and color enhancement. En bloc resection (60×40mm) was obtained in 150 minutes. No post-radiotherapy fibrosis was noted. Pathology confirmed the presence of a 21-mm submucosal lambda monoclonal plasmacytoma infiltrating up to 1 071micrometers. Lateral and vertical margins were free, even though free deep submucosa was only 50 micrometers on the specimen (▶Fig. 5). Endoscopic evaluation at 6 months showed post-ESD scarring without signs of relapse (▶Video 1), while the patient reported minor residual epigastralgia but regained normal weight. Albeit the outcome is reassuring, close endoscopic and imaging follow-up is proposed. Although rare, ESD (alone or complementary to other treatment modalities) can serve as an adequate treatment for digestive plasmacytoma beyond the scope of its classic indications.