Management of Gastric Adenoma
All gastric adenomas should be endoscopically resected due to their significant malignant potential, with sessile polyps ≥15 mm requiring en bloc excision via endoscopic submucosal dissection (ESD) rather than endoscopic mucosal resection (EMR). 1
Pathologic Features and Cancer Risk
Gastric adenomas are premalignant lesions with concerning transformation rates:
- 50% of adenomas >2 cm harbor foci of adenocarcinoma 1
- 30% of patients with gastric adenoma have synchronous gastric adenocarcinoma elsewhere in the stomach 1
- Adenomas are typically single (82%), small (<2 cm), and located in the antrum and incisura angularis 1
- They appear as velvety pink lobulated lesions, either sessile or pedunculated 1
- Nearly always associated with background gastric atrophy (GA) and gastric intestinal metaplasia (GIM) 1
Pre-Resection Evaluation
Before any therapeutic intervention, perform comprehensive gastric assessment:
- Obtain histologic confirmation of adenoma diagnosis and grade of dysplasia 1
- Carefully evaluate the entire stomach for synchronous neoplasia (present in 30% of cases), extent of GA, and GIM 1
- Test for H. pylori infection status 1
Resection Technique Based on Size and Morphology
For Sessile Polyps ≥15 mm:
- Perform en bloc excision with ESD because the probability of invasive neoplasia is high and ESD reduces recurrence risk compared with EMR 1
For Smaller or Pedunculated Polyps:
- Complete endoscopic resection is appropriate 1
Post-Resection Surveillance Protocol
Follow-up gastroscopy at 6-12 months after endoscopic resection is mandatory 1
Subsequently, continue surveillance gastroscopy at yearly intervals, with frequency adjusted based on: 1
- Number of polyps
- Polyp size
- Highest grade of dysplasia present
The surveillance interval should also account for the stage of chronic atrophic gastritis in the background mucosa 1
Critical Pitfalls to Avoid
Never adopt a "wait and see" approach for gastric adenomas, as they carry significant cancer risk requiring definitive resection 1. The British Society of Gastroenterology explicitly states that gastric adenomas "carry a significant risk of progression to cancer and should be resected where appropriate" 1.
Do not overlook synchronous lesions—30% of patients harbor concurrent gastric adenocarcinoma elsewhere, necessitating meticulous examination of the entire stomach 1.
Avoid confusing gastric adenomas with hyperplastic polyps, which have different management algorithms including potential H. pylori eradication before resection 2. Adenomas require immediate resection regardless of H. pylori status 1.
For large sessile lesions ≥15 mm, do not use EMR—ESD is superior for reducing recurrence and ensuring complete resection given the high likelihood of invasive disease 1.