Endoscopic curative resection of undifferentiated early gastric cancer

High definition endoscopy has improved the diagnosis of early gastric cancer but still has a miss rate of 20 % – 25 %. Magnification endoscopy with narrow-band imaging (NBI) helps to further characterize histology in early gastric cancer [1] [2] [3].

A 62-year-old woman attended screening esophagogastroduodenoscopy, and white-light endoscopy showed a slightly depressed lesion of size 10 × 5 mm (Paris type 0-IIc) on the anterior wall of the stomach in the antrum. NBI showed a line of demarcation with absent microsurface pattern and irregular microvascular pattern [4]. Near focus showed a dilated and tortuous corkscrew type of microvascular pattern and intralobular loop type 2 pattern ([Fig. 1]), as described by Nakayoshi et al., which was suggestive of poorly differentiated adenocarcinoma [1] [5]. Biopsies showed a signet cell type of carcinoma.

Fig. 1 Magnification narrow-band imaging. Line of demarcation, irregular/absent microsurface pattern, and corkscrew microvascular pattern.

Intramucosal undifferentiated type adenocarcinoma of size ≤ 2 cm is a candidate for endoscopic resection under expanded criteria in Japanese guidelines 2018.

Circumferential marking was done using a noninsulation-tipped endoscopic submucosal dissection knife under Forced Coag mode ([Video 1]). Submucosal injection using a 25-gauge needle with indigo carmine was performed to lift the lesion ([Fig. 2 a]). An initial mucosal incision was performed on the proximal side of the lesion with the same knife and incision was completed using Endocut I ([Fig. 2 b]). Bleeding was controlled using Coagrasper. Dissection was completed using the ITknife2 (Olympus Corp., Tokyo, Japan) ([Fig. 2 c]).

Video 1 Endoscopic curative resection of undifferentiated early gastric cancer.

Fig. 2 Resection of the lesion. a Submucosal lift using indigo carmine mixed with (0.9 %) normal saline solution. b Submucosal dissection using the Dualknife ‘J’ (Olympus Corp. Tokyo, Japan). c Dissection was completed using the ITknife2 (Olympus Corp.).

The resected specimen measured 40 × 25 × 2 mm and revealed a signet ring cell carcinoma, with the deepest invasion confined to the mucosa and negative margins ([Fig. 3]). Follow-up esophagogastroduodenoscopy after 1 year showed resolution of the lesion with no recurrence.

Fig. 3 Histological analysis. a Periodic acid–Schiff-Alcian blue staining showed a poorly differentiated adenocarcinoma, with muscularis mucosae free from tumor invasion. b Signet ring cells infiltrated the lamina propria. c, d Specimen showed tumor-free vertical and horizontal margins (respectively 1.6 and 5.7 mm; Type 0 IIc, pT1a ULO, Ly0 V0, pHM0, pVMO).

Magnification endoscopy with NBI is a useful modality that helps to characterize and manage early gastric carcinoma, and in our case prevented gastrectomy.

Endoscopy_UCTN_Code_CCL_1AB_2AD_3AB

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Yokoyama A, Inoue H, Minami H. et al. Novel narrow-band imaging magnifying endoscopic classification for early gastric cancer. Dig Liver Dis 2010; 42: 704-708
• 2 Yu H, Yang AM, Lu XH. et al. Magnifying narrow-band imaging endoscopy is superior in diagnosis of early gastric cancer. World J Gastroenterol 2015; 21: 9156
• 3 Kaise M. Advanced endoscopic imaging for early gastric cancer. Best Pract Res Clin Gastroenterol 2015; 29: 575-587
• 4 Muto M, Yao K, Kaise M. et al. Magnifying endoscopy simple diagnostic algorithm for early gastric cancer (MESDA‐G). Dig Endosc 2016; 28: 379-393
• 5 Nakayoshi T, Tajiri H, Matsuda K. et al. Magnifying endoscopy combined with narrow band imaging system for early gastric cancer: correlation of vascular pattern with histopathology (including video). Endoscopy 2004; 36: 1080-1084

Publikationsverlauf

Artikel online veröffentlicht:
11. September 2020