Preoperative risk stratification of colorectal high-grade intraepithelial neoplasia based on endoscopic biopsy: superior performance of 18F-FDG positron emission tomography-computed tomography over contrast-enhanced computed tomography in guiding surgical decision-making

Sebaceous gland ectopia of the esophagus: A clinical, endoscopic, and pathologic study of a rare condition with literature review.

INTRODUCTION Over the past decade, the pathology of un differentiated sinonasal malignancies has undergone extensive study, leading to significant advancements in the depiction and histopathological classification of various entities. These entities are now recognized as subsets of "sinonasal undifferentiated carcinomas (SNUC)" and poorly differentiated unclassified carcinomas. Typically, these malignancies are detected at later stages, by which time they have often invaded the facial and cranial regions. Olfactory neuroblastoma, which arises from the olfactory neuroepithelium with neuroblastic immature differentiation, is one such malignancy. CASE REPORT We present a case involving a left-sided nasal mass with blood-tinged discharge that obscured the nasal cavity. Previous biopsies had been inconclusive. Imaging revealed a large heterogeneous mass with bone erosions and extension into the intraorbital and intracranial regions. The patient underwent an endoscopic nasal biopsy. CONCLUSION Olfactory Neuroblastoma is a rare ,highly malignant, often have a long history before diagnosis. Treatment utilises a combination of surgery, external beam radiation, and chemotherapy modalities. Immunohistochemistry plays a crucial role in establishing a definitive diagnosis.

Immunoglobulin G4 (IgG4)-related disease (IgG4-RD) is a systemic inflammatory disorder characterized by abundant infiltration of IgG4-positive lymphocytes and plasma cells with fibrosis in the involved organs. Periarterial lesions are relatively rare manifestations of IgG4-RD, and their clinical and imaging findings remain unclear. A 66-year-old man presented with persistent upper abdominal pain. Contrast-enhanced computed tomography (CECT) showed a gradually enhanced 47mm soft tissue mass lesion adjacent to the pancreatic uncinate and spreading around the superior mesenteric artery. Considering the imaging findings, pancreatic cancer could not be ruled out. We decided to perform an endoscopic ultrasound-guided fine-needle biopsy to confirm the histological diagnosis; however, we could not obtain a sufficient amount of tissue. Finally, the patient was diagnosed with IgG4-related periarteritis by performing a percutaneous biopsy of the lesion. The patient was treated with oral prednisolone (PSL) and approximately six months after PSL induction, CECT revealed marked shrinkage of the lesion. Although imaging findings are important for diagnosis, histopathological findings are essential for accurate clinical diagnosis. All possible means, including percutaneous targeted biopsy, should be attempted to acquire sufficient tissue to confirm the pathological diagnosis to enable appropriate treatment.

Abstract BACKGROUND Representing 0-4-3% of all intracranial tumors, pineal region tumors (PRTs) are exceedingly rare, histologically diverse lesions. Their rarity and varying responses to treatment have hampered the development of a uniform treatment protocol for these lesions. We aimed to examine our experience with GKRS in pineal parenchymal tumors (PPTs), determining the long-term neurological and radiological outcomes. METHODS All patients with PPT who underwent GKRS between 2015 and 2023 were included in the analysis. Details of clinical presentation and imaging, surgical procedures performed, histopathology, radiosurgical parameters and follow-up were recorded. Outcomes assessed were resolution of hydrocephalus, percentage regression of tumor volume and occurrence of complications. RESULTS Eight patients underwent GKRS for PPTs- Six pineal parenchymal tumors of intermediate differentiation (PPTID), one papillary tumor of pineal region (PTPR), and one radiologically diagnosed PPT. Seven patients had hydrocephalus, managed with an ETV in five cases and VP shunt in two cases. An endoscopic biopsy was performed in six cases, while microsurgical resection was performed in one. The mean dose delivered was 14.9 ± 2.1 Gy. After a mean follow-up of 40.38 ± 13.8 months, all lesions were noted to regress, with a mean 80.7% ± 10.7% reduction in volume. In all cases, hydrocephalus has resolved, and there were no persistent neurological deficits. CONCLUSIONS GKRS is safe and effective in pineal parenchymal tumors (PPTID and PTPR), with a consistent regression of tumor noted in all cases. Emergent management of hydrocephalus, with a biopsy of the lesion followed by GKRS, represent an effective treatment protocol for most pineal lesions, with sustained long-term neurological outcomes.

Abstract BACKGROUND Pineal region lesions are managed by various surgical options, including endoscopy, microsurgery and stereotactic biopsy. METHODS The details of all patients who underwent modified Poppen’s approach for pineal region lesions were retrieved from the department registry. The clinical details, surgical procedure details, post operative outcomes were tabulated from case records. Extent of resection was noted from the post-operative images. RESULTS Twenty three patients underwent modified Poppen’s approach in our Institute from 2016 till 2022. The age ranged from 9 – 69 years.. Eighteen patients had features of raised ICP at presentation. Eighteen patients had right sided approach and five had left sided approach. Gross / near total resection was possible in 10 patients(43.5%). Two patients developed hemiparesis post-operatively. Two patients developed worsening of upgaze restriction. One patient had left occipital hematoma causing difficulty in recognition of objects and color which gradually improved. One patient required VP shunt for hydrocephalus and another required thecoperitoneal shunt for pseudomeningocele. There was no operative mortality in this cohort. Histopathological examination revealed pineal parenchymal tumors were the most common (6/23), followed by meningioma (6/23), germ cell tumors (2/23), papillary tumor of pineal region (2/23), epidermoid (2/23). CONCLUSIONS Modified Poppen’s approach is a safe surgical approach for pineal region tumors which can result in near / gross total resection in 43.5% patients. Imaging features of non germ cell tumors and large tumors causing raised ICP can aid the surgeon in decision making for tumor decompression and plan further management.

Atypical teratoid/rhabdoid tumor (AT/RT) is a rare and highly malignant embryonal tumor of the central nervous system. It typically occurs in children younger than 3 years and is most commonly located in the posterior fossa. Intraventricular locations, such as the third ventricle, are extremely rare and pose significant diagnostic and therapeutic challenges. Here, we report the case of a 4-year-old girl presenting with symptoms of elevated intracranial pressure, including headache, nausea, and vomiting. She was neurologically intact at presentation. Neuroimaging revealed a heterogeneous mass within the third ventricle, obstructing the foramen of Monro. An endoscopic biopsy was performed to obtain diagnostic tissue, and a ventriculoperitoneal shunt was placed to manage hydrocephalus. Histopathological examination confirmed AT/RT. This rare case underscores the need to consider AT/RT in the differential diagnosis of intraventricular cystic-solid tumors in early childhood and offers insight into the diagnostic workup and surgical management of similar cases.

Claudin 18 isoform 2 (CLDN18.2) has emerged as a novel therapeutical target for HER2-negative, locally advanced, or metastatic gastroesophageal adenocarcinoma. However, reported prevalence rates vary widely (24-47%), underscoring the need for accurate population-specific data. This study investigates the CLDN18.2 prevalence in Spanish patients with gastroesophageal adenocarcinoma and explores its correlation with other biomarkers and clinicopathological factors. We retrospectively analyzed endoscopic biopsy samples from gastroesophageal adenocarcinoma patients across three Spanish institutions. CLDN18.2 expression was evaluated by immunohistochemistry using the Ventana CLDN18 (43-14A) assay and PS2+ scoring, with cases showing membranous 2+ or 3+ staining in ≥ 75% of tumor cells classified as positive. Clinicopathological and biomarker data were retrieved from medical records. CLDN18.2 was positive in 33% (89/270) of cases. Although histological type was not correlated with CLDN18.2 status, cases with poorly cohesive morphology exhibited heterogeneous staining, with a predominance of moderately and strongly stained cells. A weak to moderate inverse correlation was identified between signet ring cell content and CLDN18.2 staining (r = -0.29, p = 0.028). No significant differences were observed in clinical outcome. However, among patients with advanced-stage disease, CLDN18.2-positive intestinal tumors were associated with worse progression-free survival (HR 2.58, 95% CI 1.18-5.63; p = 0.029). These findings confirm a 33% prevalence of CLDN18.2 expression in the Spanish population, aligning with reports from other Western European cohorts. The significant heterogeneity in poorly cohesive cases and an inverse correlation with signet ring cell content pose diagnostic challenges for pathologists. Moreover, the association between CLDN18.2 positivity and worse progression-free survival in intestinal adenocarcinoma supports a potential role in tumor progression and metastasis, warranting further research.

Background: Alpha-feto-protein producing gastric adenocarcinoma is a rare and aggressive subtype of gastric cancer, associated with poor prognosis. Case Presentation: We report the case of a 66-year-old female with a history of hypertension and hypothyroidism who presented with severe anemia and abdominal pain. Initial imaging revealed a gastric lesion. Serum Alfa-Fetoprotein (AFP) was requested due to a suspicious lesion seen on initial liver imaging, and it was markedly elevated (>9000 ng/mL), raising suspicion for AFP-producing gastric cancer versus liver infarction due to venous thrombosis. Endoscopic biopsy of the gastric lesion confirmed Enteroblastic gastric adenocarcinoma. Subsequent MRI abdomen demonstrated hypermetabolic activity in the gastric lesion and in the abdominal lymph nodes without distant metastasis. Given her frailty and reluctance to undergo intravenous chemotherapy, she was offered oral chemotherapy (Capecitabine). Conclusion: Here, we present a case of AFP- producing gastric adenocarcinoma, a rare tumor that has not previously been reported from the Middle Eastern region, to the best of our current knowledge.

A transformer-based pathomics model using endoscopic biopsy WSIs for predicting pathological complete response to preoperative immunotherapy in colorectal cancer.

The utility of miRNA 221 & miRNA 199-a in the diagnosis of pancreatic adenocarcinoma.

Introduction: Gastroenteropancreatic Neuroendocrine Neoplasms (GEP-NENs) are a heterogeneous group of tumours with varying biological, functional and clinical characteristics. GEPNENs develop from the diffuse neuroendocrine system of the gastroenteropancreatic tract. Aim: To analyse the clinicopathological features and the distribution pattern of GEP-NENs. Materials and Methods: In this cross-sectional observational study, all cases of primary Gastrointestinal (GI) and pancreatobiliary tract NENs diagnosed in the Department of Pathology, Regional Cancer Centre, Trivandrum, Thiruvananthapuram, Kerala, India, from 1st January 2015 to 31st December 2020 were included. Pathological features, including tumour grade and stage, were analysed. The distribution pattern of NENs in different parts of the gastroenteropancreatic tract was noted and compared with tumour grade. Results: A total of 152 patients were included in the study. The age of patients ranged from 9 to 84 years. Gastrointestinal tract involvement was noted in 124 cases and pancreatic involvement in 28 cases. The most common site in the GI tract was the duodenum (25 cases), followed by the rectum (22 cases). There were 62 resection specimens and 90 endoscopic biopsies. The Well-Differentiated Neuroendocrine Tumour (WDNET) category accounted for 124 cases, of which the most common grade was G2 74 (48.7%). Grade 3 NET comprised 7.14% of GI tract (7 cases) and 26.9% of pancreatobiliary tract WDNETs. There were 28 cases of Neuroendocrine Carcinoma (NEC), of which 13 were Small Cell Neuroendocrine Carcinoma (SCNEC) and 15 were Large Cell NEC (LCNEC). The most common site of NEC involvement was the oesophagus. On Immunohistochemical (IHC) examination, synaptophysin positivity was noted in 96% of cases and chromogranin positivity in 76.11% of cases. A pathological Tumour (pT) stage was determined in 62 resection specimens and the most common stage was pT3 29 (46.77%). Among the 18 resection specimens of NET G1 tumours, three cases showed lymph node metastasis. Of the 32 cases of resected NET G2 tumours, seven showed lymph node metastasis and five showed liver metastasis. Conclusion: Morphology and the proliferation index play a crucial role in differentiating NET from NEC. WDNETs have metastatic potential, especially to lymph nodes and the liver. The differentiation of NET G3 from NEC is important for treatment decisions.

Rationale:Primary pancreatic lymphoma (PPL), representing 0.5% of pancreatic malignancies, poses diagnostic challenges due to overlapping clinical and imaging features with pancreatic adenocarcinoma. PPL is diagnosed by obtaining tissue samples via endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) or explorative laparotomy with biopsy. The R-CHOP regimen is the first-line chemotherapy protocol. This report presents a case initially misdiagnosed as pancreatic cancer, highlighting the critical role of histopathological confirmation.Patient concerns:A 55-year-old man presented with left upper abdominal pain for 20 days.Diagnoses:Computed tomography, magnetic resonance imaging, and fine needle biopsy suggested pancreatic cancer or neuroendocrine tumor. Postoperative pathology confirmed primary pancreatic lymphoma. The tumor was classified as CD20(+), BCL6(+), BCL2(+), and Ki-67(+, 60%).Interventions:The patient underwent laparoscopic distal pancreatectomy with splenectomy, followed by 6 cycles of R-CHOP chemotherapy.Outcomes:No recurrence was observed during a 2-year follow-up period.Lessons:This case highlights the diagnostic challenges associated with PPL and underscores the importance of histopathological confirmation for ambiguous pancreatic lesions. Although the role of surgery in localized disease requires further investigation, the R-CHOP regimen appears to be effective for managing PPL.

The diagnosis of microscopic colitis (MC) is based on endoscopic biopsy with histological assessment. Histological outcomes (remission, response or improvement) are important treatment targets in clinical trials. Although a substantial body of research on MC has been published in recent years, no standardized criteria currently exist for its histological outcomes. We sought to review and summarize the histological evaluation of MC in published systematic reviews (SRs) assessing the efficacy of interventions and to examine the heterogeneity in histological evaluation among the randomized controlled trials (RCTs) included in those SRs. We conducted an umbrella review (ie, an overview of systematic reviews) of published SRs. A literature search of the Cochrane Database of Systematic Reviews, MEDLINE, and Embase was performed up to May 2025. Definitions of histological evaluation and monitoring following interventions were extracted and summarized from the published SRs and the RCTs included within them. Fourteen SRs with meta-analyses that focused on interventions were included. Nineteen RCTs were included in these SRs. Of them, 12 fully published RCTs reported histological outcome data and met our inclusion criteria. The definitions for histological outcomes varied between RCTs but were generally based on reduction in lamina propria cellularity, intraepithelial lymphocytes, or collagen band thickness. This umbrella review highlights the heterogeneity in the definitions of histological outcomes in MC RCTs. The summarized evidence will support ongoing efforts to develop consensus definitions for histological outcomes in order to facilitate clinical trials of medical therapies for MC.

Disclosure: C. Rizk: None. G. Sydney: None. P. Gopal: None. S. Omay: None. P. Balasubramanian: None.Background: Ectopic salivary tissue within the sella is rare and mostly asymptomatic. Preoperative diagnosis is often challenging as they mimic pituitary neoplasms and the diagnosis is typically made after resection or biopsy. We present a case of ectopic intrasellar salivary gland tissue confirmed on histopathology in a patient who was presumed to have a meningioma on her initial imaging performed for the evaluation of headache. Case Presentation: A 61-year-old female presented with 4 month history of severe bifrontal headache and bilateral upper extremity weakness. Brain MRI was performed revealing a 2.8 x 2.6 x 1.9 cm mass along the left petroclival region extending into the sella, and into the left cavernous sinus with deviation of the pituitary stalk. The MR imaging characteristics were consistent with meningioma. Endocrine biochemical evaluation was unremarkable. Given the discordance between the patient’s clinical presentation and imaging characteristics and the short duration of her symptoms, endoscopic endonasal biopsy of the sellar lesion was performed for a definitive diagnosis. Histopathology was consistent with benign seromucinous salivary gland tissue with chronic inflammatory infiltrate. To rule out metastatic disease, DOTATATE PET scan was done which showed tracer uptake within the sella and the left cavernous sinus but no other abnormality. The patient was managed conservatively with improvement in her symptoms, and the lesion has remained stable on serial MRI imaging over the last one year. Conclusion: Ectopic salivary gland tissue in the sellar region is a rare finding and is typically asymptomatic. When symptoms do occur, they are often attributed to leakage of glandular secretions leading to localized inflammation. In uncommon instances, larger lesions may cause endocrine disturbances, including hyperprolactinemia or growth hormone deficiency. Definitive diagnosis generally relies on histopathological evaluation, and the overall prognosis is excellent.Presentation: Sunday, July 13, 2025

Disclosure: A. Barsegian: None. M. Kinaan: None.Background: Pancreatic heterotopia, the presence of pancreatic tissue outside its usual anatomical location, is rare with a prevalence of approximately 0.18% based on a large clinicopathological study of 99,544 surgical resections and upper endoscopic biopsies. Among these cases, the small intestine is a common site, accounting for 26% of the occurrences. We present a case of a patient who had undiagnosed pancreatic heterotopia in the small intestine that was unmasked by the use of semaglutide. Case Presentation: A 47-year-old female with a history of type 2 diabetes mellitus presented to our endocrine clinic for diabetes management. She was on metformin ER 500mg and glimepiride 4mg twice daily with inadequate control (HbA1C of 8.5%). We stopped glimepiride and advised her to start semaglutide. She had no pre-existing pancreatic disease at that time. She titrated semaglutide to a dose of 1mg weekly over the course of 8 months and achieved HbA1C of 6.9%. The patient was tolerating the medication well for several months. After 1 year of semaglutide use, she started developing subacute abdominal pain. CT imaging revealed an intestinal mass causing small bowel obstruction. She underwent surgical resection. Postoperative pathology revealed benign pancreatic heterotopia embedded in the wall of the small intestine. Based on these findings, we decided to stop semaglutide due to its possible growth stimulating effect on pancreatic tissue. Discussion: The effect of GLP-1 receptor agonists on pancreatic heterotopia is not documented in medical literature. However, there is evidence that GLP-1 receptor agonists are associated with an increase in pancreatic mass in general due to acinar cell hypertrophy. Therefore, we hypothesize that the use of semaglutide in this patient caused growth of the dormant heterotopic pancreatic tissue in the intestine. This is the first case report in literature linking use of semaglutide, or any GLP-1 receptor agonist, to growth of pancreatic heterotopic tissue. Conclusion: Clinicians should be vigilant about the potential effects of GLP-1 RAs on pancreatic tissue. In patients with known anatomic pancreatic abnormalities, such as pancreatic heterotopia, careful consideration and individualized treatment strategies are essential to balancing glycemic control and safety.Presentation: Monday, July 14, 2025

Disclosure: A.S. Alvelo Aviles: None. M. Gines Rosario: None. A.C. Franjul: None.Hyperthyroidism affects up to 1.4% of the global population, with Graves’ disease accounting for a 2% in women and 0.5% in men. Agranulocytosis is a rare adverse effect of antithyroid medications, while pancytopenia is even more uncommon. The prevalence of these hematologic complications is estimated to range from 0.1% to 0.5% among patients receiving antithyroid treatment. This can lead to life-threatening conditions, particularly in the setting of severe infections. Methimazole is a widely used medication in the management of hyperthyroidism, including Graves’ disease. We report a case in which an initially highly suspected hematologic malignancy, upon further evaluation, raised the possibility of pancytopenia induced by antithyroid medication.A 56-year-old female with a medical history of systemic lupus erythematosus and Graves’ disease previously on methimazole therapy, presents with fever, shortness of breath, and progressively worsening productive cough. She appeared critically ill—tachycardic, tachypneic, and requiring oxygen supplementation. Initial laboratory results were notable for pancytopenia: WBC count of 0.8 with an absolute neutrophil count (ANC) of 0, consistent with severe neutropenia; severe thrombocytopenia of 4,000/μL; and anemia of 8.0 g/dL. Thyroid function tests were within normal limits. Physical examination revealed generalized hematomas, and several non-painful, non-bleeding oral mucosa ulcers. Broad-spectrum antibiotics initiated and admitted to the ICU with a diagnosis of neutropenic fever and community-acquired pneumonia. ENT evaluation for glossodynia included nasal endoscopy biopsy confirming fungal infection. Further history revealed an ongoing workup for suspected medication-induced pancytopenia versus lymphoma. Bone marrow biopsy showed marked hypocellularity with plasma cell predominance, without evidence of malignancy—findings seen in methimazole-induced pancytopenia. Treatment with granulocyte colony-stimulating factor (G-CSF) initiated; however, slow bone marrow response, developing severe infectious complications, including bacteremia. Pancytopenia induced by antithyroid medications is a rare complication of an otherwise commonly used treatment. It carries a significant mortality risk and should be promptly considered and ruled out in patients presenting with new-onset pancytopenia. The underlying pathogenesis remains unclear, however current research points to an autoimmune mechanism involving interleukins. At present no clear consensus has been reached due its rarity. Furthermore, additional research into the pathophysiology of this condition is necessary to guide effective treatment.Presentation: Sunday, July 13, 2025

Introduction: A new core biopsy needle with a novel tapered stylet tip has been introduced for endoscopic ultrasound-guided fine needle biopsy (EUS-FNB). The tapered point stylet is purported to improve ease of puncture, leading to improved tissue acquisition and accuracy. However, there are no data available in the published literature. The aim of this study was to compare the diagnostic performance of the tapered stylet needle with conventional end-cutting FNB needles for tissue acquisition from solid lesions. Methods: Patients who underwent EUS-FNB of a solid lesion using the tapered stylet FNB needle across four tertiary hepatopancreaticobiliary centres in the UK were included in the study. Demographic, clinical, and performance outcomes were included in the analysis. Diagnostic performance was compared with a similar cohort of patients who underwent EUS-FNB using standard end-cutting FNB needles with a blunt-tipped stylet. The primary outcome was accuracy for the diagnosis of malignancy. Results: A total of 270 patients were included for analysis; 129 patients (48%) had sampling with the novel tapered stylet tip needle, among which 50% were female, the median age was 69, 74% had pancreatic lesions, and 80% had a final diagnosis of malignancy; 141 control cases (52%) were included for comparison, among which 48% were female, the median age was 68, 67% had pancreatic lesions, and 72% had a final diagnosis of malignancy. The tapered stylet needle demonstrated a sensitivity of 90% and an NPV of 72% for the diagnosis of malignancy compared with 88% and 77% for controls (p = 0.147). The overall diagnostic accuracy of the tapered stylet needle was 92.2% compared with 91.5% for controls (p = 0.634). Conclusions: The novel tapered tip stylet FNB needle demonstrated comparable sensitivity, NPV, and diagnostic accuracy to conventional FNB needles. This is the first and largest study reporting results for this new needle. However, further large comparative studies are warranted to validate our results and to determine if the tapered stylet offers an advantage over the conventional design.

BACKGROUNDThe concept of “duodenal-type follicular lymphoma (FL)” has already been established as a disease entity. On the other hand, because FL that develops in the colorectum is a rare disease, its clinical characteristics, including its treatment and outcome, are poorly understood.AIMTo clarify the characteristic clinical features of colorectal FL.METHODSWe identified 5 patients with FL from December 2010 to July 2022 whose colorectal lesions were confirmed by endoscopic biopsy at our hospital and retrospectively examined their clinical features, including endoscopic findings, treatment, and long-term outcomes.RESULTSThe median age of the patients was 70 years (range 62-74 years, 3 males and 2 females), and 2 patients were considered to have systemic FL lesions. Endoscopic findings revealed elavated lesions in all 5 patients (polypoid 3, flat elavated 1, papular 1). Only 1 patient underwent therapeutic intervention, and 4 patients chose watchful waiting. Except for 1 patient in which the lesion spontaneously regressed, the disease recurred or progressed in 4 patients, 3 of whom eventually achieved near complete remission with the administration of rituximab and bendamustine (± polatuzumab vedotin). The 5 patients in this study were still alive or exhibited long-term survival before death; the survival time ranged from 8-29 years after the onset of lymphoma.CONCLUSIONIn the present study, colorectal FL progressed slowly, and overall survival was good because it was sensitive to anticancer drugs even after the disease progressed without initial therapeutic intervention.

Background Endoscopic biopsies are insufficient for the correct diagnosis of gastric lesions since there has been described a discrepancy rate between endoscopy biopsies and endoscopic resection specimens of 25–32%. The aim of this study was to evaluate factors associated with upstaging and downstaging of biopsy results following gastric endoscopic submucosal dissection (ESD). Methods Retrospective, cohort study including consecutive patients who underwent gastric ESD after an initial upper endoscopy with the diagnosis of a gastric lesion harboring dysplasia or adenocarcinoma, confirmed by forceps biopsy. Results A total of 215 patients were included, most patients were male (66.0%), with a mean age of 68 ± 8 years. Most lesions were located in the antrum (62.3%). Upstaging was observed in 70 patients (32.6%): 43 patients from low-grade dysplasia (LGD) to high-grade dysplasia (HGD); 9 from LGD to adenocarcinoma; and 18 patients from HGD to adenocarcinoma. Patients with upstaging had significantly larger lesions (18 vs 15 mm, p < 0.001) and had more frequently ulcerated lesions (10.0% vs 2.9%, OR 3.778, p = 0.045). Five patients (2.3%) had downstaging, from HGD to LGD. Patients with downstaging were significantly younger (61 ± 8 vs 68 ± 8 years, p = 0.035) and were more frequently active smokers (60.0% vs 14.3%, OR 9.000, p = 0.028). Conclusion The diagnostic discrepancy rate between the initial forceps biopsy and the ESD specimen was 34.9%. Patients with larger or ulcerated lesions were more likely to have an upstaging pathological result. Therefore, it is essential to perform a thorough evaluation of the lesions, including chromoendoscopy and magnification.