Over the past decade, there have been substantial advances in endoscopic therapies for superficial neoplasia of the upper and lower gastrointestinal tract, including polypectomy, endoscopic mucosal resection (EMR), and endoscopic submucosal dissection (ESD). Among these, ESD has emerged as a superior technique, allowing for en-bloc resection of superficial gastrointestinal lesions irrespective of size, thereby enabling comprehensive pathological evaluation and accurate staging [1,2]. This facilitates the potential for curative treatment of early-stage malignancies while preserving organ function and avoiding morbidity associated with major surgery. Histopathological assessment of ESD specimens is critical for risk stratification and guiding subsequent management, as it allows for precise evaluation of resection margins and identification of adverse prognostic features such as depth of invasion (DOI), poor differentiation, lympho-vascular invasion (LVI), and tumour budding [1,3].

As ESD techniques have evolved, meticulous pathological examination, from specimen grossing to microscopic assessment has become imperative to ensure accurate reporting as well as the completeness and curative status of the resection [1,3]. The adequacy of endoscopic resection is determined not only by margin status but also by the risk of lymph node metastasis, which is influenced by several histopathological factors [4]. Compared to larger surgical specimens, ESD specimens present unique challenges due to their limited margins and smaller size, underscoring the crucial role of the pathologist in their evaluation [1]. Despite the existence of established international guidelines for the handling and reporting of endoscopic resection specimens, the implementation of these protocols remains limited to select centres in developing countries, including India [2,[5], [6], [7]].

In this study, we aim to document the spectrum of ESD specimens received at our centre over a five-year period. We also review the key gross and histopathological findings, the subsequent clinical course of patients with malignant lesions, and discuss pertinent diagnostic challenges and pitfalls.