Gastric cancer mimicking a submucosal tumor diagnosed by laparoscopic excision biopsy

Case Report: Clinicopathological characteristics of patients with gastric cancer with features of a submucosal tumour

Purpose

To investigate the clinicopathological characteristics, diagnosis and key points in the differential diagnosis of patients with gastric cancer (GC) with features of a submucosal tumour (GCSMT).

Methods

The clinical presentation and imaging findings of four GCSMT cases diagnosed at our centre from 2016 to 2021 were observed and their clinicopathological outcomes were analysed. The related literature was reviewed. Based on our collected data and the related literature, a total of 31 cases of GCSMT can be summarized.

Results

22 out of 31 cases did not present obvious symptoms and were accidentally discovered during gastroscopic examination. Only 10 patients experienced symptoms such as gastric discomfort, upper abdominal swelling and pain, haematemesis, or haematochezia. The male to female ratio was 22:9 and the age of onset ranged from 40 to 81 years (median age: 63 years). Tumours were located in the upper and middle third of the stomach (24/31), and in the lower third(7/31). The tumour diameter ranged from 0.6 to 7.3 cm, with an average value of 2.5 cm. Endoscopically, the disease manifested as SMTs, with the gastric mucosal surface appearing normal. Most patients underwent radical gastrectomy for GC (80.6%, 25/31). The pathological diagnoses of the 31 cases of GCSMT included well- and moderately-differentiated adenocarcinoma (6/31), poorly differentiated adenocarcinoma or signet ring cell carcinoma 6/31), mucinous adenocarcinoma (9/31), lymphoepithelioma-like carcinoma (7/31), gastric adenocarcinoma of the fundic gland type (3/31). Stage T1b and T2 tumours accounted for 56.7% (17/30) and 26.7% (8/30) of all cases. Lymph node metastases were found in six cases (20.0%, 6/30), whereas distant metastasis was not observed in any of the cases. For the 16 patients whose follow-up data were available, the follow-up time was 5-66 months, during which recurrence or metastasis was not observed.

Conclusion

GCSMT is a rare disease that is often difficult to accurately diagnose through endoscopic biopsy. The importance of gaining an understanding of this disease lies in differentiating it from other SMTs (mostly mesenchymal tumours) to avoid misdiagnosis and missed diagnosis and enable the early diagnosis and treatment of patients.

Early gastric cancer presenting as a typical submucosal tumor cured by endoscopic submucosal dissection: A case report

BACKGROUND

Submucosal tumor (SMT)-like gastric cancer is rare, and almost all cases undergo curative surgical treatment because the submucosal layer is usually deeply invaded by tumor cells or because histopathologic types of SMT-like gastric cancer are undifferentiated or poorly differentiated. No report has been issued on an SMT-like gastric cancer cured by endoscopic resection alone or on changes in the endoscopic features of this type of tumor over several years.

CASE SUMMARY

We describe an exceptional case of a 53-year-old male with a 1.5 cm-sized SMT-like lesion covered by normal-appearing mucosa discovered by esophagogastroduodenoscopy (EGD) at the gastric antrum. Endoscopic ultrasound (EUS) visualized a homogeneous, well-circumscribed hypoechogenic lesion arising from the second sonographic layer with associated subtle obliteration of the third sonographic layer. Initial endoscopic biopsy was negative for neoplasm. The patient refused to undergo an invasive procedure and was subsequently lost to follow-up. Three years after initial detection, EGD revealed the lesion had become markedly erythematous, and at 4 years after initial EGD it had increased in size to 1.8 cm and developed a central ulcer and a heterogeneous EUS echo. Finally, endoscopic submucosal dissection (ESD) was performed, and histopathologic examination revealed a moderately differentiated adenocarcinoma had minutely invaded the submucosal layer (invasion depth 169 μm) but without lymphovascular invasion and with negative resection margins. Fortunately, no additional surgical treatment was required. He has been followed for 4 years after ESD without any evidence of local or distant recurrence.

CONCLUSION

This report describes an extremely rare case of early gastric cancer presenting as SMT that was cured by ESD after a treatment delay of 4 years and the endoscopic changes that occurred during this period. The report highlights the importance of considering the possibility of gastric cancer when SMT is encountered in clinical practice.

Laparoscopic and endoscopic cooperative surgery for gastric cancer mimicking a submucosal tumor

Abstract

Background

Gastric cancer that mimics a submucosal tumor (SMT) is infrequently encountered in routine clinical settings, and histopathological analysis is often negative for malignant cells. In such cases, excisional biopsy of the entire tumor may be necessary to make a definitive pathological diagnosis, and laparoscopic and endoscopic cooperative surgery (LECS) is a viable method of excisional biopsy.

Case presentation

An 80-year-old male patient diagnosed with stomach wall irregularities at routine medical check-up was referred to our facility, and consequent endoscopic examination detected a 20-mm protruded lesion in the greater curvature at the middle third of the stomach. Endoscopic ultrasound (EUS) showed a thick, low echoic lesion with an irregular margin in the second layer of the gastric wall. Further, a nodular part of the lesion had infiltrated into the submucosa, with an appearance similar to that of linitis plastica of the stomach. The lesion was highly suspected to be a gastric carcinoma with submucosal invasion. However, mucosal-incision-assisted biopsy revealed no malignant cells. Computed tomography (CT) identified no metastatic lymph nodes. Therefore, an excisional biopsy using LECS was performed, and to avoid peritoneal dissemination, we used a modified version, namely, combination of laparoscopic and endoscopic approaches to neoplasia with non-exposure technique (CLEAN-NET). The procedure ended without any complications, and post-operative course was uneventful. As histopathology returned a diagnosis of adenocarcinoma pT4a, we performed radical gastrectomy and D2 lymphadenectomy. Post-operative course was unremarkable and the patient underwent follow-up examinations without adjuvant chemotherapy because of old age.

Conclusions

Local resection using LECS for gastric tumors with a high suspicion of malignancy is useful and feasible. LECS could be used in similar cases.

Gastric adenocarcinoma mimicking a submucosal tumor: A case report

BACKGROUND

Submucosal tumor (SMT)-like early-stage gastric cancer (GC) has rarely been reported. It is difficult to consider the possibility of GC and differentiate it from other submucosal lesions.

CASE SUMMARY

We present the case of a 50-year-old male patient with a 1.6 cm SMT-like flat elevated lesion covered by congested mucosa on the gastric angle. Magnifying endoscopy with narrow-band imaging, endoscopic biopsy, endoscopic ultrasound, and computed tomography were performed for diagnosis. Endoscopic submucosal dissection and gastrectomy with lymph node dissection were performed. The post-resection pathological analysis led to a final diagnosis of GC (Bormann type I, T1bN2M0).

CONCLUSION

GC should be considered when detecting an SMT-like lesion in the stomach.

Advanced gastric cancer with features of a submucosal tumor diagnosed by endoscopic ultrasound-guided fine needle aspiration and boring biopsy preoperatively: A case report and literature review

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Gastric carcinoma with features of a submucosal tumor is a rare condition.

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Gastric carcinoma with features of a submucosal tumor has unique features.

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Tissue sampling must be performed if gastric malignant submucosal tumor is suspected.

Introduction

Gastric cancer with features of a submucosal tumor (GCSMT) is rare, and the preoperative diagnosis is very difficult. We present a case of GCSMT diagnosed by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and boring biopsy (deeper biopsy), successfully treated with distal gastrectomy and lymph node dissection.

Presentation of case

An 81-year-old man with a history of myocardial infarction and type 2 diabetes mellitus was admitted to our hospital for further examination of a gastric submucosal tumor. Endoscopic examination of the gastrointestinal tract showed a 30-mm submucosal tumor at the lower gastric body. Enhanced computed tomography revealed a tumor located at the lower body of the stomach and pyloric lymph node swelling. EUS-FNA and boring biopsy from the tumor revealed adenocarcinoma. Accordingly, distal gastrectomy with lymph node dissection was performed. Histopathological examination showed a poorly differentiated adenocarcinoma. Postoperative diagnosis was GCSMT with lymph node metastasis (T2, N1, M0, stage IIA).

Conclusion

We report a rare case of GCSMT with lymph node metastasis. Preoperative diagnosis of GCSMT is necessary to guide surgical management. EUS-FNA and boring biopsy could aid in obtaining adequate quantities of the specimens for histopathological and immunohistochemical diagnosis.

Lymphoepithelioma-like gastric carcinoma in a patient with rectal laterally spreading tumor: A case report

Lymphoepithelioma-like gastric carcinoma (LELGC) is a rare neoplasm of the stomach that accounts for 1-4% of all gastric cancer cases. It is characterized by the presence of a lymphoid stroma with cells arranged primarily in micro alveolar, thin trabecular and primitive tubular patterns or isolated cells. In the present study, the case of a 50-year-old male patient with LELGC and rectal laterally spreading tumor is presented. Following endoscopic submucosal dissection, a diagnosis of carcinoma was reached and the patient underwent total radical gastrectomy. The postoperative pathological stage was IA T1bN0cM0 according to the Tumor-Node-Metastasis classification of gastric carcinoma, and the patient recovered well. The present case is reported to summarize the endoscopic and pathological characteristics of LELGC.

Signet-ring cell carcinoma mimicking gastric gastrointestinal stromal tumor confirmed by endoscopic ultrasound-guided trucut biopsy

A submucosal gastric adenocarcinoma, especially the signet ring cell type, is rare. The histologic evaluation techniques for this lesion has not been established; however, histologic confirmation is very important for decision of treatment method. Here, we report a 57-year-old man with a 12-cm gastric submucosal signet ring cell type adenocarcinoma, diagnosed by an endoscopic ultrasound-guided Trucut biopsy and immunochemical studies. This case suggests that the endoscopic ultrasound-guided Trucut biopsy might be a useful diagnostic method in cases of gastric adenocarcinoma with features of gastrointestinal stromal tumor.

Minimally invasive treatment of gastric gastrointestinal stromal tumors: laparoscopic and endoscopic approach

PURPOSE

This study aimed to verify the long-term outcome of a minimally invasive endoscopic or laparoscopic approach for the treatment of gastric gastrointestinal stromal tumor (GIST).

METHODS

This single-center study involved a retrospective review of gastric tumors that were pathologically confirmed as GIST. A total of 84 patients who underwent minimally invasive endoscopic or laparoscopic resection for gastric GIST were enrolled from February 2002 to June 2007. These demographics, tumor characteristics, and outcomes were analyzed for identification of outcomes and feasibility of endoscopic or laparoscopic resection.

RESULTS

Of 84 patients, 27 and 57 patients underwent endoscopic and laparoscopic resection, respectively. The average tumor size was 3.1 ± 1.7 cm. With a mean follow-up of 40.5 ± 20.7 months, 82 (97.7%) patients were disease free. Two patients, both of whom underwent laparoscopic resection, were alive with peritoneal recurrence. Two (7.4%) and 6 (10.5%) patients, respectively, had postoperative complications after endoscopic resection and laparoscopic resection. There was no significant difference in the operative morbidity according to tumor size. There was no postoperative mortality.

CONCLUSIONS

Laparoscopic surgery for gastric GIST is safe and feasible, even in large (>5 cm) tumors. Because endoscopic resection showed good results without recurrence, this approach can be useful in selected cases with a high operative risk or a need for preservation of organ function.

Lymphoepithelioma-Like Carcinoma of the Stomach with Epithelioid Granulomas

An 83-year-old Japanese man was admitted to our hospital for gastric adenocarcinoma mimicking a submucosal tumor in the gastric body. Considering his general condition, partial resection of the stomach and dissection of regional lymph nodes were performed; a dome-shaped tumor that was largely covered by normal mucosa and having a shallow central stellate ulcer was removed. Histopathologically, the carcinoma cell nests were surrounded by prominent lymphoid stroma. Sarcoid-like epithelioid granulomas were noted both in the tumor stroma and in the regional lymph node with metastasis. Epstein-Barr virus (EBV)-encoded RNA (EBER) in situ hybridization showed an intense and diffuse positive reaction in the carcinoma cells and no reaction in the surrounding gastric and lymphoid tissues. While the presence of lymphoid stroma is a characteristic finding in EBV-associated lymphoepithelioma-like carcinoma, sarcoid-like epithelioid granulomas might be associated with latent EBV infection.