A rare clinical case of a gastric adenocarcinoma of fundic gland-type associated with a second independent gastric signet-ring cell carcinoma

Gastric adenocarcinoma of fundic gland-type is a rare form of adenocarcinoma that develops from parietal or chief cells in the fundus [1]. It has mostly been reported in Asia (Japan and South Korea) since 2007 [2]. Gastric signet-ring cell adenocarcinoma is another histological form of gastric cancer, which is relatively uncommon and often has a poor prognosis due to its late discovery [3]. The coexistence of these two histological forms of gastric cancer in the same lesion is exceptional [4], and two independent lesions with those different histological types in the same stomach has never been described.

We report a rare case of this association in a 73-year-old woman. An initial gastroscopy performed for dyspeptic syndrome revealed a small (5 mm) polypoid, raspberry-like sessile lesion on the greater curvature of the fundic region near the cardia. It was resected using a cold snare. The histopathological examination showed an oxyntic gland adenoma but could not confirm the absence of submucosal infiltration. A second gastroscopy was performed for submucosal dissection (ESD) of the lesion’s scar ([Video 1]). During this endoscopy, ESD was performed for two atypical lesions located in the fundus, including the 15-mm scar area of the initial resection and a new additional lesion ([Video 1]). Histopathology confirmed the existence of oxyntic gland-type gastric adenoma superficially at the site of the first scar ([Fig. 1]). However, as it is frequently reported, the lesion was already invasive with a component inside the submucosae, changing the diagnosis to gastric adenocarcinoma of fundic gland-type. At the second scar site, a signet-ring cell gastric carcinoma was found without submucosal invasion ([Fig. 2]). A total gastrectomy was recommended in a multidisciplinary meeting as the ESD was noncurative for these two different histological types.

Fig. 1 Histopathological characterization of the first scar. a–c Low-power (a, ×100 hematoxylin phloxine saffron stain [HPS]) and high-power (b, ×400 HPS) magnification showed normal fundic mucosa to the right of the dotted line and oxyntic gland adenoma (OGA) to the left. Subtle architectural changes and mild atypia can be seen differentiating those two areas. The infiltrating component of gastric adenocarcinoma of fundic-gland type (GA-FG) is shown by black arrows at the low-power magnification (a, ×100 HPS) and is associated with oxyntic glands (in brown) invading beyond the muscularis mucosae (in pink) (c, ×100, double staining against desmin in pink and keratin AE1/AE3 in brown). d Both the OGA and GA-FG components showed low proliferation rates (Ki67, ×100). e, f They exhibited strong expression of MUC6 (e, ×100) but were negative for MUC5AC staining (f, ×100).

Fig. 2 Histopathological characterization of the second scar. a Low-power magnification (×100 hematoxylin phloxine saffron stain [HPS]) showed fibrous deposition between gastric glands. b Higher magnification (×400 HPS) allowed independent cells with signet-ring cell features to be recognized. c These carcinomatous cells were better seen with anti-EA1/AE3 staining (×400) between normal glands in the lamina propria. d The signet-ring cells retained E-cadherin expression (×400).

Endoscopic imaging of the two atypical scarred fundic lesions and their submucosal dissections.Video 1

Endoscopy_UCTN_Code_CCL_1AB_2AD_3AB

Publication History

Article published online:
09 April 2025

• References

• 1 Ueyama H, Yao T, Nakashima Y. et al. Gastric adenocarcinoma of fundic gland type (chief cell predominant type): proposal for a new entity of gastric adenocarcinoma. Am J Surg Pathol 2010; 34: 609-619
• 2 Miyazawa M, Matsuda M, Yano M. et al. Gastric adenocarcinoma of the fundic gland (chief cell-predominant type): a review of endoscopic and clinicopathological features. World J Gastroenterol 2016; 22: 10523-10531
• 3 Fung BM, Patel M, Patel N. et al. Signet ring cell gastric carcinoma: clinical epidemiology and outcomes in a predominantly Latino county hospital population. Dig Dis Sci 2021; 66: 1240-1248
• 4 Kai K, Satake M, Tokunaga O. et al. Gastric adenocarcinoma of fundic gland type with signet-ring cell carcinoma component: a case report and review of the literature. World J Gastroenterol 2018; 24: 2915-2920