Endoscopic full-thickness resection of IgG4-related gastric submucosal tumor-like lesion

IgG4-related disease (IgG4-RD) is an immune-mediated disorder in which abundant IgG4-positive plasma cells infiltrate the affected organs. IgG4-RD presenting as a submucosal tumor of the stomach is rare, and preoperative diagnosis is difficult. Herein, we demonstrate endoscopic full-thickness resection (EFTR) of IgG4-RD presenting as a submucosal stomach tumor for the first time.

Our patient (a 77-year-old man) had a 20-mm submucosal tumor in the posterior wall of the stomach, which was initially identified by upper gastrointestinal endoscopy ([Fig. 1]). Endoscopic ultrasonography showed a low-echoic mass derived from the muscularis propria of the stomach ([Fig. 2]). Fine-needle aspiration biopsy could not confirm the diagnosis. Enhanced computed tomography showed neither lymph node enlargement nor metastasis.

Fig. 1 Endoscopic appearance of the 20-mm submucosal tumor-like lesion on the posterior wall of the middle part of the stomach on: a antegrade view; b retroflexed view.

Fig. 2 Endoscopic ultrasonography view of the submucosal tumor-like lesion showing an 18-mm low-echoic mass derived from the muscularis propria of the stomach.

A malignant gastrointestinal stromal tumor (GIST) was suspected and EFTR was performed with the patient under general anesthesia. The mucosa was incised around the submucosal tumor using a FlushKnife BT 2.5 (Fujifilm, Tokyo, Japan). After the lesion had been pulled towards the stomach lumen using two clips and a thread, the resection was completed using an IT-Knife 2 (Olympus, Tokyo, Japan). Fibrosis made this lesion unusually difficult to resect; therefore, two clips were required for sufficient traction. The perforation site was closed using SureClips (Micro-Tech, Nanjing, China) and a detachable snare (Olympus) ([Fig. 3]; [Video 1]). Histopathology showed a mass with lymphoplasmacytic infiltration, fibrosis, and IgG4-positive plasma cells ([Fig. 4]). A postoperative elevation of serum IgG4 levels was noted. No recurrence was observed within 1 year.

Fig.3 Appearances following endoscopic full-thickness resection of the gastric lesion showing: a the resection site with intraperitoneal fat visible; b closure of the perforation with hemostatic clips and a detachable snare.

Video 1 Endoscopic full-thickness resection of a 20-mm gastric submucosal tumor-like lesion.

Fig. 4 The pathological examination of the lesion showing: a macroscopically, a lesion of 22 × 20 × 18 mm; b microscopically on hematoxylin and eosin staining, a diffuse lymphoplasmacytic infiltration and fibrosis; c on immunostaining with IgG4, the presence of abundant IgG4-positive plasma cells.

This case was one of definite IgG4-RD presenting as a gastric submucosal tumor. EFTR allowed accurate diagnosis. IgG4-RD may present as a gastric lesion and often cannot be differentiated preoperatively from a GIST [1]. Patients with such lesions have undergone various types of surgery [2]; however, this is the first report of EFTR of gastric IgG4-RD. Minimally invasive endoscopic treatment should be considered for undiagnosed submucosal lesions.

Endoscopy_UCTN_Code_TTT_1AO_2AG

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Yamane T, Eto K, Morinaga T. et al. IgG4-related disease presenting as a submucosal tumor of the stomach resected with laparoscopic endoscopic cooperative surgery: a case report. Surg Case Rep 2020; 6: 93
• 2 Skorus U, Kenig J, Mastalerz K. IgG4-related disease manifesting as an isolated gastric lesion- a literature review. Pol Przegl Chir 2018; 90: 41-45

Publication History

Article published online:
25 August 2022