A Case of Early Gastric Carcinoma with Lymphoid Stroma: Diagnostic Usefulness of Endosonography

Abstract: A case of early gastric carcinoma with lymphoid stroma (GCLS) showing features of submucosal tumor is reported here. A characteristic endoscopic ultrasonographic (EUS) finding was helpful for preoperative diagnosis. The patient, a 75-year-old woman without any previous complaints, visited our hospital for detailed examination of a small gastric lesion. Upper Gl studies revealed a submucosal tumor-like lesion measuring about 1.8 cm with a central slight depression on the greater curvature of the middle gastric body. Histologic findings of the specimens obtained by conventional biopsy indicated a poorly differentiated adenocarcinoma, although the possibility of malignant lymphoma was not completely ruled out. EUS examination was, therefore, performed in order to obtain further detailed information about the tumor. EUS disclosed that the tumor, which existed in the third layer, was composed of many small round clustered lesions, the echogenicity of which was lower than that of the muscle layer, and was almost covered with a normal mucosal layer. Taking these findings into consideration, a gastric cancer with lymphoid stroma whose invasion would be limited within the submucosa was highly suspected. It was proven by histological analysis of a surgically resected specimen that this peculiar multiple small round hypoechoic lesion was equivalent to the lymphoid aggregates infiltrating the GCLS. Since it has been reported that the prognosis of GCLS is better than that of common gastric cancers, accurate diagnosis is important for the selection of optimal treatment. While it is still not definitively proven that EUS is useful for diagnosis of GCLS, this procedure may potentially provide an excellent image of this special tumor and be of use for preoperative diagnosis.     

A patient with rectal cancer associated with ulcerative colitis in whom endoscopic ultrasonography was useful for diagnosis

Endoscopic ultrasonography (EUS) was helpful for the diagnosis of rectal cancer associated with ulcerative colitis. The patient was a 38-year-old Japanese man with a 19-year history of relapsing-remitting type ulcerative colitis involving the entire colon. Routine colonoscopy revealed multiple polypoid prominences in the upper portion of the rectum. EUS revealed a hypoechoic mass in the submucosa beneath and around the polypoid lesion on the most oral side. Signet ring cells were found in a biopsy specimen from this lesion. Subtotal colectomy was performed. A depressed lesion was observed around the prominence on the most oral side; histologically, this lesion was poorly differentiated mucinous and signet ring cell carcinoma extending into the subserosa. The polypoid lesion on the most anal side was well differentiated adenocarcinoma, which was limited to the mucosa. Our findings suggest that EUS is helpful for detecting invasive cancer associated with ulcerative colitis. Received: April 22, 1998 / Accepted: January 22, 1999     

A rare case of gastric lipoma with early gastric cancer

An 84-year-old man was admitted to our hospital with a 1-month history of epigastralgia. Upper gastrointestinal endoscopy revealed gastric cancer and a gastric submucosal tumor (SMT) on the greater curvature of the gastric body. By endoscopic ultrasonography, SMT was demonstrated as a well-circumscribed, smooth-bordered and hypoechoic mass localized in the submucosal layer. Total gastrectomy was performed. The histology of the resected specimen revealed a gastric lipoma and an early gastric cancer widespread to the surface on the lipoma. Two lesions were present in the same lesion, but not linked. We report a rare case of gastric lipoma complicated with early gastric cancer.     

内镜下十二指肠乳头切除术在乳头部肿瘤诊断中的价值

目的:评价内镜下十二指肠乳头切除术(endos-copic papillectomy,EP)在乳头部肿瘤诊断中的临床价值.方法:分析2008-01/2012-03来我院的16例经病理检查确诊的十二指肠乳头部肿瘤患者的相关资料,评价EP在十二指肠乳头部肿瘤诊断中的临床价值.结果:16例患者中,内镜活检诊断为腺瘤者12例,慢性炎症改变者4例.EP将乳头部肿瘤组织切除后整体送检行病理学检查确诊为低分化腺癌者2例,高分化腺癌1例,腺瘤13例(其中1例腺瘤恶变,4例常规内镜活检诊断为慢性炎症改变者术后均确诊为腺瘤),EP术后准确率明显高于内镜活检法(P<0.05).超声内镜(endoscopic ultrasonography,EUS)检查提示病变均起源于黏膜层,胰胆管扩张者9例,未见黏膜下层连续性中断及胰胆管受累者,无腹膜后淋巴结肿大者;12例高回声病变者术后病理检查结果均为腺瘤,1例高回声病变局部见低回声区者术后病理检查结果为腺瘤恶变,3例低回声病变者术后病理检查结果均为腺癌.EP术后2例低分化腺癌者、1例腺瘤恶变者及1例腺瘤者胆管开口处见病变残留,提示胆管受累,但术前EUS检查均未提示胆管受累;1例高分化腺癌及11例腺瘤者病灶均完整切除,术后切缘阴性.EP术后除2例出现黑便外,无急性胰腺炎、穿孔及其他并发症发生,无患者死亡.结论:EP术将乳头部肿瘤组织切除后整体送检行病理学检查可提高诊断准确率,为治疗方法的抉择提供科学依据.     

Gastric adenocarcinoma of fundic gland (chief cell predominant type) coexisting with well differentiated intestinal adenocarcinoma: A case report

Rationale:Gastric adenocarcinoma of fundic gland (chief cell predominant type) (GA-FG-CCP) is a new, rare variant of gastric adenocarcinoma, which is characterized by mild nuclear atypia and specific immunohistochemical markers.Patient concerns:An 84-year-old Chinese man was referred to our hospital for endoscopic resection of a gastric lesion.Interventions:We performed endoscopic submucosal dissection, and successfully removed the lesion.Diagnosis:Esophago gastroduodenoscopy showed a slightly elevated lesion with a diameter of 22 mm in the posterior wall of cardia. Magnifying endoscopy with narrow band imaging revealed an abnormal microsurface and microvessels on the tumor surface. Endoscopic ultrasonography revealed a hypoechoic mass located in the first layer. The pathological diagnosis of the biopsy specimens indicated that the tumor was high grade intraepithelial neoplasia. The pathological diagnosis differed between the superficial and deeper part of the lesion. The superficial part was composed of a tubular structure with prominent atypia and was diagnosed as well differentiated intestinal adenocarcinoma. The deeper part was composed of a well-differentiated tubular adenocarcinoma mimicking the fundic gland cells, mainly the chief cells. The tumor cells showed mild nuclear atypia and was positive for pepsinogen-I (PG-I) and mucin-6 (MUC6). This deeper part was diagnosed as GA-FG-CCP.Outcomes:The tumor was successfully removed. This patient had no discomfort during the follow-up period (10 months).Lessons:We present a rare case of GA-FG-CCP coexisted with well-differentiated tubular adenocarcinoma. GA-FG-CCP exists in the deep mucosal layer and the muscularis mucosa, which could not be found under endoscopy, but could be discerned in pathology with mild nuclear atypia and special biomarkers.     

A case of a protruded lesion formed by a poorly differentiated intramucosal adenocarcinoma of the stomach: an immunohistochemical analysis

A 70-year-old woman underwent upper gastrointestinal endoscopy and was found to have a 25-mm protruded lesion in the gastric body. A biopsy revealed malignant cells. Endoscopic submucosal dissection was performed. Histopathologically, the tumor was mainly composed of poorly differentiated adenocarcinoma (PDA), while moderately differentiated adenocarcinoma was observed on its superficial layer. The tumor was located within the mucosal layer. PDAs rarely form a protruded lesion. Here, the presence of a moderately differentiated adenocarcinoma element in the superficial layer of the tumor might have protected the tumor cells from erosion, and solid proliferation of the PDA also contributed to its outward growth.     

Primary minute invasive de novo colonic adenocarcinoma appearing as submucosal tumor

A 4 mm white-yellow submucosal tumor-like lesion was detected in the sigmoid colon of an asymptomatic 52-yr-old Japanese man. Because the lesion was unexpectedly suspicious for adenocarcinoma by pathological examination of the biopsy specimen, it was treated by endoscopic mucosal resection. The specimen obtained demonstrated well-differentiated adenocarcinoma without any adenomatous element, and was located principally in the submucosal layer with a maximum depth of 1600 mum from the muscularis mucosae. The cancer exposed to the luminal surface was pathologically concluded to be diminutive. Intriguingly, aggregation of lymphocytes was found beneath the mucosal layer, which might have compromised the integrity of the muscularis mucosae. Because of deep submucosal infiltration and the latent aggressive nature of de novo cancer, the patient underwent an additional partial sigmoidcolectomy, which demonstrated no residual cancer and no regional lymph node metastasis. The lesion in this patient exhibited a previously undescribed appearance of de novo colon cancer as submucosal tumor in an early phase of growth.     

Endoscopically Resected Granular Cell Tumor of the Stomach

Abstract: We report a rare case of granular cell tumor of the stomach resected endoscopically. The patient was a 53-year-old man who visited our clinic because of a protruding lesion incidentally found by X-ray examination of the stomach at a mass screening. Endoscopic examination revealed an apparent submucosal tumor at the anterior wall of the upper body of the stomach. An endoscopic ultrasonographic (EUS) study showed that the tumor was a hypoechoic lesion localized in the third layer (submucosal layer). On resection, a lesion measuring 6X5X3 mm was found to be localized in the submucosa. It was histologically diagnosed as granular cell tumor, which is quite uncommon in the stomach with only 44 cases having been reported to date.     

Early gastric cancer with lymphoid stroma presenting as a subepithelial lesion diagnosed by endoscopic submucosal dissection

A 53-year-old man underwent an esophagogastroduodenoscopy that showed a 20-mm subepithelial lesion in the middle gastric body. Endoscopic ultrasound revealed a hypoechoic mass located in the submucosa. Biopsy specimens revealed a benign gastric mucosa with severe lymphocytic infiltration in the submucosa. Malignant lymphoma or gastric cancer with lymphoid stroma was suspected. We performed endoscopic submucosal dissection for definitive diagnosis. Histological examination showed undifferentiated adenocarcinoma, which showed positive Epstein–Barr virus-encoded RNA in situ hybridization results, invading the submucosa mixed with dense lymphocytic infiltration. Thus, Epstein–Barr virus-positive gastric cancer with lymphoid stroma was diagnosed. Gastric cancer with lymphoid stroma is a rare subtype of gastric cancer, which is associated with Epstein–Barr virus infection; it sometimes appears as a subepithelial lesion, which makes it difficult to diagnose using standard biopsy. Endoscopic submucosal dissection was useful in obtaining a sufficient tissue for full histological assessment, including immunostaining.     

Lymphoepithelioma-like esophageal carcinoma with macroscopic reduction

Esophageal lymphoepithelioma-like carcinoma(LELC) is extremely rare. We report the first case of esopha-geal LELC showing macroscopic reduction. A 67-year-old male presented with dysphagia and, by endoscopic examination, was found to have a significantly raised tumor of 10 mm in diameter in the thoracic esophagus. The biopsied material showed esophageal cancer. We performed endoscopic submucosal dissection. However, the tumor became flattened, similar to a scar, in only 2 mo. Histologically, the carcinoma cells had infiltrated the submucosal layer. Prominent infiltration of T lymphoid cells that stained positive for CD8 was observed aroundthe carcinoma cells. Therefore, this lesion was consid-ered to be an LELC with poorly differentiated squamous cells. Because the margin was positive, an esophagec-tomy was performed. Carcinoma cells were detected in the neck in one lymph node. The staging was T1N0M1 b. However, the patient has been well, without adjuvant therapy or recurrence, for more than 5 years.     

SUCCESSFUL ENDOSCOPIC SUBMUCOSAL DISSECTION FOR MUCOSAL CANCER OF THE DUODENUM

We report a case of mucosal duodenal cancer in a 62‐year‐old woman, which was successfully removed en bloc by endoscopic submucosal dissection (ESD). The patient underwent an upper gastrointestinal endoscopy at our hospital, which revealed an elevated flat mucosal lesion (type IIa) measuring 10 mm in diameter in the second portion of the duodenum. Histopathological examination of a biopsy specimen revealed features suggestive of a tubulovillous adenoma with severe atypia. As the findings suggested that the lesion had an adenocarcinoma component but was confined to the mucosal layer, we decided to carry out ESD and successfully removed the tumor in one piece. The resected tumor was 20 × 15 mm in size. Histopathological examination revealed that the lesion was a well‐differentiated mucosal adenocarcinoma with no lymphovascular invasion. Mucosal duodenal cancer is extremely rare, and ESD of a lesion in the duodenum requires a high level of skill. To the best of our knowledge, this case is the first report of successful ESD carried out in a case of mucosal duodenal cancer.     

A Case of Poorly Differentiated Early Adenocarcinoma of the Stomach Forming a Protruded Type Lesion

Abstract: A case of poorly differentiated adenocarcinoma (undifferentiated type by Nakamura, diffuse type by Lauren) of the stomach infiltrating the submucosa and forming a protruded type lesion is reported. A 60-year-old man underwent endoscopic examination, which revealed a protruded type lesion with a nodular configuration and shallow ulceration accompanied by slough along the greater curvature of the upper gastric body, which was proved to be poorly differentiated adenocarcinoma by endoscopic biopsy. The patient underwent radical surgery, consisting of total gastrectomy with pancreato-splenectomy. Macroscopic observation of the resected specimen revealed a protruded type lesion, measuring 30 mm in diameter, in the fundus along the greater curvature. The surface of the lesion had an irregular and nodular configuration with erythema and superficial erosions. Although, in the setting of early gastric cancer, poorly differentiated adenocarcinomas are usually macroscopically depressed or ulcerated type, this case presented a protruded type lesion (polypoid type). We report this unusual case because of its extremely important implications in the discussion of gastric cancer therapy.     

Diagnosis of small flat early gastric cancer by flexible spectral imaging color enhancement

Current conventional endoscopy often misses flat early gastric cancers (0–IIb) because they are sometimes invisible. We experienced a case of small flat early gastric cancer that had been missed by normal-caliber conventional endoscopy. By small-caliber endoscope, conventional endoscopy showed a subtle reddish change of gastric mucosa, but the image with flexible spectral imaging color enhancement clearly showed a flat reddish lesion with 10 mm diameter, distinct from the surrounding mucosa. Flat early gastric cancer was suspected even though the lesion was not clearly described by conventional endoscopy. Histological examination of biopsy specimen revealed atypical glands. Endoscopic submucosal dissection of the lesion was performed. Pathological examination of the resected specimen confirmed well-differentiated adenocarcinoma localized in the mucosal layer without any depression or protrusion compared with the surrounding mucosa, consistent with the endoscopic finding. The small flat early gastric cancer became clearly visible with the new endoscopic technology.     

Clinical Evaluation of Endoscopic Ultrasonogrphy in Diagnosis of Submucosal Tumor of the Upper Alimentray Tract

Abstract: The usefulness and the problems of endoscopic ultrasonograpy (EUS) in the diagnosis of submucosal tumors (SMT) of the upper alimentary tract were evaluated in this study. EUS was carried out in 86 cases with SMT of the stomach. Tumors of 13 cases was confirmed histologically (leiomyoma in 7 cases, leiomyosarcoma in one, lipoma in 2, gastric cyst in one, aberrant pancreas in one and Schwannoma in one case). In only one out of 22 cases with SMT of the esophagus, the tumor was surgically resected and a pathological examination revealed leiomyoma EUS was useful in estimating the histological origin of SMT by observation of the relationship between the location of the tumor and each layer in the gastric or esophageal wall. However, it was imposible to differentiate leiomyoma from leiomyosarcoma in myogenic tumors through the echoic pattern of the tumor by EUS alone at the present time. EUS was also useful in distinguishing the cause of extragastric compression showing similar findings with SMT, which could not be clarified by X-ray or endoscopic examination. In fact, organs compressing the stomach were easily clarified by EUS. It was decided that EUS should be performed in all cases whenever there is any doubt of SMT existing after an X-ray or endoscopic examination.     

GASTRIC SUBMUCOSAL HETEROTOPIA OF THE IMMATURE GASTRIC GLANDS WITH ENDOSCOPIC FEATURE MIMICKING CARCINOID TUMOR

We describe a rare case of gastric submucosal heterotopia of the immature gastric glands mimicking carcinoid tumor shown by endoscopic examination, which was successfully treated by endoscopic tumor resection. A 66‐year‐old woman was admitted to our hospital for further examination of the gastric abnormality. Endoscopic examination of the upper gastrointestinal tract revealed a flat, rounded elevated lesion with a central erosion in the anterior wall of the upper gastric body. Endoscopic ultrasonography revealed a poorly demarcated, slightly hypoechoic lesion located in the third layer of the gastric wall. Based on these findings, a submucosal tumor, particularly a carcinoid tumor, was suspected. Endoscopic tumor resection, which provides a significant benefit for accurate final diagnosis and eradication of submucosal lesion, was performed. Histological study showed the gastric gland heterotopia of immature type in the submucosa.     

Esophageal intramural spreading from an adenocarcinoma of the esophagogastric junction

Although intramural spreading from gastric carcinoma to the esophageal wall is occasionally reported, longitudinal intramural lesion of the esophagus is very rare. We herein report the case of a patient found to have a carcinoma of the gastric cardia with intramural spreading to the esophagus approximately 7.0 cm in length. A 65-year-old man was admitted to our department suffering from a persistent midthoracic pain and mild dysphagia during the previous 3 months. Upper gastrointestinal studies revealed an oval submucosal tumor of the lower esophagus and a flare irregular lesion on the esophagogastric junction. An endoscopic ultrasonography showed the main tumor was in the submucosal layer and invaded beyond the muscularis propria. Histopathological examination of the resected specimen confirmed a poorly differentiated adenocarcinoma, 7.0 cm in length, which penetrated through the gastric wall, and invaded the submucosal layer of the esophagus. When only a few scattered carcinoma cells infiltrate only the mucosa or submucosa, it is difficult to diagnose the extent of esophageal invasion. In treating patients with gastric cancer with esophageal invasion, it is important to determine the safety of the proximal margin for esophageal resection. Histological examination using frozen sections obtained during surgery is essential for deciding the operative safety margin.     

Minute Rectal Cancer Associated with Nodular Involvement —A Case Study—

Abstract: This study presents the case of a patient with minute type Ha rectal cancer with a diameter at its largest of only 5 mm, with infiltration as far as the submucosal layer (sm) and positive parietal lymph node metastasis. The patient was a 54 year-old male who visited Yasuda Medical Hospital because of diarrhea which appeared in early May 1988. During sigmoidscopy, a small protruding lesion was seen in the rectum (Rs) about 12 cm from the margin of the anus, and the patient was referred to the authors' surgical service for an endoscopic polypectomy because of a biopsy diagnosis of adenocarcinoma. The polyp had a smooth, shiny surface, and had a well demarcated hemispherical shape. A histopathological examination of the polypectomized specimen, showed that it was an invasive carcinoma extending into the submucosal layer without any adenoma component. Since the cut end of the specimen strongly suggested positive cancer cells and lymphatic permeation was also confirmed from the polypectomized specimen, a low anterior resection was performed on August 4, 1988. The postoperative histological examination revealed a small amount of residual cancer cells in the submucosal layer which appeared to be at the cut end of the resected polyp. One metastatic focal point was seen in the pararectal lymphnode, and this patient's case provided valuable suggestions for deciding upon therapeutic policies for early cancer of the large intestine.     

Fatal submucosal invasive gastric adenosquamous carcinoma detected at surveillance after gastric endoscopic submucosal dissection

An 80-year-old man was under annual surveillance esophagogastroduodenoscopy after endoscopic submucosal dissection(ESD) for early gastric cancer(EGC).Two years after the initial ESD, a 0-Ⅱc type metachronous EGC lesion, 8 mm in size, without an ulcer scar, was found in the gastric antrum.The estimated tumor depth was up to the mucosa, and biopsy revealed well and poorly differentiated adenocarcinoma.ESD was performed for this lesion and en bloc resection with negative margins was achieved.Histopathological examination revealed an adenosquamous carcinoma 8 mm in size invading the deep submucosal layer(1600 μm), with lymphovascular invasion, consistent with the diagnosis of non-curative resection.Additional gastrectomy was recommended for this patient; however, two months after the ESD, preoperative computed tomography revealed multiple liver metastases, and the patient was considered as an unsuitable candidate for surgical resection.Systemic chemotherapy was therefore started; however, the patient died of gastric cancer 27 mo after the second ESD.Early gastric adenosquamous carcinoma localized to the mucosa and submucosa is extremely rare and its clinical behavior is not well known.The present report is very significant in that it underscores the distinct possibility of gastric adenosquamous carcinoma being very aggressive and fatal even when detected at an early cancer.     

The utility of endoscopic ultrasonography and endoscopy in the endoscopic mucosal resection of early gastric cancer

OBJECTIVE: To clarify the usefulness of endoscopic ultrasonography (EUS) and endoscopy in the endoscopic mucosal resection (EMR) of early gastric cancer. Patients/Methods-EMR was performed in 61 patients with early gastric cancer over the past five years. The accuracy of the assessment of the depth of cancerous invasion was studied in 49 patients who had EUS before EMR. Forty eight patients were treated with endoscopy alone; in these patients, EUS and endoscopic findings correlated with the clinical course. RESULTS: Forty six patients showed no changes in the submucosal layer or deeper structures on EUS. Pathologically these included 37 patients with mucosal cancer and nine with submucosal cancer showing very slight submucosal infiltration. Three patients showed diffuse low echo changes in the submucosal layer on EUS; pathologically, these included two with submucosal cancer and one with mucosal cancer with a peptic ulcer scar within the tumour focus. Of 48 patients receiving endoscopic treatment alone, 45 showed no tumour recurrence or evidence of metastases on EUS and endoscopy. Three cases of recurrence were observed. Two of these patients had a surgical gastrectomy, and one was re-treated endoscopically. In the former cases, the surgical results correlated well with assessment by EUS and endoscopy. In addition, the latter patient who was re-treated endoscopically after evaluation with EUS and endoscopy has so far had no recurrence. CONCLUSION: The combined use of EUS and endoscopy is effective in diagnosing the depth of cancerous invasion in patients undergoing EMR as well as in clarifying changes both within and between anatomic levels during follow up.     

A case of arteriovenous malformation in the submucosal layer of the stomach

Arteriovenous malformation (AVM) of the stomach is extremely rare. We report a patient with asymptomatic gastric AVM detected during mass screening of the upper gastrointestinal tract. The patient, a 69-year-old female, had no history of gastro-intestinal bleeding. Endoscopy revealed a gastric submucosal tumor (3 cm in diameter) at the posterior wall below the esophago-cardiac junction. Endoscopic ultrasonography (EUS) showed a hypoechoic structure in the third layer of the stomach, suggesting gastric AVM in the submucosal layer. Complete resection of the AVM tissue was performed by strip biopsy with surgical resection. Histological examination showed AVM in the submucosal layer. EUS examination was useful for the diagnosis of gastric AVM in this case.