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INTRODUCTION:A 67-year-old-male with history of dysphagia was found to have a subepithelial mass in the gastric cardia. It was located anterolaterally along the greater curvature and had normal overlying mucosa. Endoscopic ultrasound demonstrated a 17 mm hypoechoic homogenous lesion arising from the muscularis propria without malignant features (Figure 1). It was most consistent with a leiomyoma. After discussion of the findings and management options, our patient elected to proceed with endoscopic resection.CASE DESCRIPTION/METHODS:A single-channel endoscope identified the lesion on retroflexion. After submucosal injection of 0.9% normal saline, methylene blue, and epinephrine, a transverse incision was made in the midsection of the bulging mass, exposing the submucosa. Repeated injections lifted the submucosa for dissection using a T-type hybrid knife. An IT-2 knife (Olympus®) was used to cut the submucosa in a circumferential fashion around the tumor. It was bilobar in appearance (Figure 2) and significantly larger than seen on EUS. All bleeding vessels were cauterized, and a large snare was used to perform en bloc resection of the tumor. We used a transverse midline incision to facilitate resection while minimizing disruption of the overlying mucosa. No mucosa was excised, and the incision was easily approximated for closure using multiple endoclips. The tumor was pale in appearance with an intact capsule. It measured 25 mm at its greatest diameter, which was 8 mm larger than EUS measurement. Histologic examination revealed bland spindle cell proliferation (Figure 3). Immunohistochemical staining was positive for actin and desmin and negative for CD117 and CD34, features consistent with leiomyoma.DISCUSSION:Endoscopic surgery is rapidly advancing, providing safe and feasible alternatives to more invasive therapies. We describe successful endoscopic full-thickness resection (EFTR) of a gastric cardia mass whose size and shape were significantly underestimated on pre-operative EUS. We have encountered this in prior cases, most notably lesions originating in the third and fourth gastric layers. Resection of our patient's gastric cardia tumor made this discrepancy particularly challenging, and it is a pitfall of EUS that even the most experienced endosonographers must be cognizant of.