Gastric adenocarcinoma of fundic gland type spreading to heterotopic gastric glands

Gastric adenocarcinoma of the fundic gland type: A review of the literature

Background and Aim

Gastric adenocarcinoma of the fundic gland type (GA-FG) is a newly described tumor entity but lacking consensus. This review summarizes the key features and controversies regarding this uncommon neoplasm.

Methods

We reviewed studies on GA-FG published in English from 2007 to 2021.

Results

We found that 327 cases (340 lesions) have been reported. GA-FG lesions originate from deep layers of the gastric mucosa, with the following characteristics on conventional white-light endoscopy examination. These lesions, macroscopically identified as submucosal tumor-like 0-IIa, tend to have a whitish discoloration without inflammation, atrophy, or intestinal metaplasia in the background mucosa. Tumors located in the upper third of the stomach are usually solitary, with an average size <10 mm. Contrastingly, magnifying endoscopy with narrow-band imaging mostly shows the absence of any demarcation line, with a regular microvascular pattern and regular microsurface pattern. GA-FGs are covered with normal foveolar epithelium, forming a so-called endless glands pattern in the deeper region, which are mainly composed of chief cells or parietal cells. Most tumors exhibit submucosal invasion, but lymphovascular invasion and nodal metastasis are rare. Regarding the treatment of GA-FG, endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) are effective treatment methods.

Conclusions

GA-FG is a rare tumor that typically follows a benign course. This neoplasm has distinct endoscopic and pathological features and could be treated by ESD or EMR.

Endoscopic Treatment for Submucosal Heterotopic Gastric Gland in a Case Observed over Nine Years from Development to Enlargement

A 70-year-old Japanese man with a submucosal gastric mass that continued to increase in size underwent endoscopic submucosal dissection using the pocket creation method. Histologically, some epithelial cell nuclei were enlarged, but there was little atypia overall and no sign of malignancy, suggesting a diagnosis of submucosal heterotopic gastric gland (SHGG). SHGG that enlarges over time has been associated with gastric cancer, but a preoperative diagnosis is difficult. This case was very valuable, as it enabled us to follow the course of SHGG over a period of about nine years, from the onset to enlargement.

Twenty cases of gastric adenocarcinoma of the fundic gland type

BACKGROUND

Gastric adenocarcinoma of the fundic gland type is a new subtype of gastric adenocarcinoma. In 2019, the World Health Organization (WHO) listed gastric adenocarcinoma of the fundic gland type (GA-FG) as a new and rare gastric tumour with a low incidence due to the small number of cumulative cases worldwide. Twenty cases of GA-FG found in our centre were retrospectively analysed to improve the diagnostic ability of endoscopy and pathology in this disease.

OBJECTIVE

To investigate the clinicopathological features of fundus-derived gastric tumours and to improve the understanding of and diagnostic accuracy of endoscopy for this disease.

METHODS

The clinicopathological characteristics of 20 GA-FG cases between 2018 and 2022 were analysed using clinical and follow-up data and endoscopic, immunohistochemical, and pathological morphology characteristics.

RESULTS

In all cases, GA-FG was found in the fundus and the body of the stomach. In total, there were 19 patients with 20 lesions, with most of the patients having a single lesion. One patient had multiple lesions, and another patient had complications from signet ring cell carcinoma (SRCC). All lesions occurred in non-atrophic areas, and 10 patients had gastric fundic gland polyps simultaneously. There were 14 cases of gastric fundus adenocarcinoma and 6 cases of acid-secreting adenoma. Fourteen lesions were treated with endoscopic submucosal dissection (ESD), without recurrence or metastasis during the follow up; 6 patients were followed up for observation, 2 of whom showed no lesions after the first biopsy by gastric endoscopy, and 4 of whom showed no significant changes.

CONCLUSIONS

The incidence rate for GA-FG lesions may be underestimated due to their benign course. ESD seems to be an adequate treatment for GA-FG.

MAIN POINTS

Gastric adenocarcinoma of the fundic gland type (GA-FG) is located in the fundus and body of the stomach. All lesions occur in non-atrophic areas, and almost one-half involve gastric fundus polyps simultaneously. GA-FG lesions typically follow a benign disease course. ESD seems to be an adequate treatment for GA-FG.

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.

Gastric adenocarcinoma of the fundic gland: A review of clinicopathological characteristics, treatment and prognosis

Gastric adenocarcinoma of the fundic gland is a rare, well-differentiated gastric cancer entity, and very few patients transition to poorly differentiated tubular adenocarcinoma during progression. Gastric adenocarcinoma of the fundic gland originates from the mucosa of the gastric fundic gland, usually without chronic gastritis or intestinal metaplasia. Histologically, the tumor cells are closely arranged to form anastomosing tubular glands, and more than 95% of tumor cells differentiate towards chief cells. Most gastric adenocarcinoma of the fundic gland cases are characterized by submucosal involvement, but the tumor volume is usually small, with lymphatic and vascular invasion rarely observed. Therefore, endoscopic submucosal dissection can be an ideal treatment, leading to a favorable prognosis, and recurrence and metastasis of the disease are uncommon.

Gastric adenocarcinoma appearance in leiomyoma: A case report

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Gastric adenocarcinoma arising from a leiomyoma which is diagnosed by pathological evidence as heterotopic glands carcinoma within it.

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Pathological evidences diagnosed heterotopic gastric glands within the leiomyoma, then adenocarcinoma arose from the heterotopic gastric glands.

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This is the first report that describes a case of gastric adenocarcinoma arising from leiomyoma.

Introduction

We experienced an extremely rare case of gastric adenocarcinoma wrapped by leiomyoma.

Presentation of case

A 65-year-old man had an abnormality (filling defect) of the upper gastrointestinal series in his first medical checkup five years prior. Esophagogastroduodenoscopy detected a 10 mm submucosal tumor-like lesion in the greater curvature of the upper gastric remnant body. Despite repeated biopsy from the lesion, there was no sign of malignancy. A delle was observed on the top of the tumor at another visit five year after the first and a biopsy specimen revealed poorly differentiated adenocarcinoma. Therefore, laparoscopic gastrectomy was performed. Histological assessment revealed a 28 × 22 mm elevated lesion with a slight depression. Microscopically, papillary adenocarcinoma was observed at the submucosa with a solitary heterotopic gastric gland adjacent to the lesion. The final diagnosis was papillary adenocarcinoma arising from a solitary heterotopic gastric gland in the leiomyoma. No recurrence has occurred during a follow-up of two and a half years after surgery.

Conclusions

This is the first report of gastric adenocarcinoma arising from a submucosal tumor.

Gastric adenocarcinoma of fundic gland type arising from heterotopic gastric glands during a 19-year follow-up period

A 73-year-old man with prior history of duodenal ulcer has been undergoing periodic upper gastrointestinal endoscopy since 1999. In 2017, a 25-mm submucosal tumor-like protrusion was detected in the lesser curvature of the upper stomach; histological examination of the lesion revealed gastric adenocarcinoma of fundic gland type. En bloc resection was achieved using endoscopic submucosal dissection. The patient was histopathologically diagnosed with gastric adenocarcinoma of fundic gland type arising from heterotopic gastric glands. Immunohistochemical staining was positive for MUC5AC, MUC6, pepsinogen I, and proton pump but negative for MUC2 and CD10. Moreover, the patient's Ki-67 labeling index score was extremely low. The presence of MUC5AC indicated that the tumor differentiated to the foveolar epithelium and fundic glands. Gastric adenocarcinoma of fundic gland type that differentiates to several directions has a higher malignant potential than the disease that differentiates to chief cells. A retrospective review of the patient's previous endoscopic examination revealed that the submucosal tumor-like protrusion existed since 2000; tumor size increased from 8 mm in 2000 to 25 mm in 2017. The present case is rare in that the carcinoma arose from heterotopic gastric glands. Moreover, the 19-year follow-up revealed that the tumor differentiated to the foveolar epithelium, considered as having high-grade malignancy.

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.

Early gastric cancer with multiple submucosal heterotopic gastric gland: A case report

A case of early gastric cancer involving multiple submucosal gastric glands that was treated by distal gastrectomy was described in the present case report. An 85-year-old man was referred to our hospital for the treatment of gastric cancer. Esophagogastroduodenoscopy revealed an irregular, nodular, elevated lesion on the posterior wall of the middle third of the stomach, and biopsy specimens indicated well-differentiated tubular adenocarcinoma. Submucosal tumor (SMT)-like lesions were detected in the area adjacent to the nodular lesion, in the anterior wall side of the middle third of the stomach. Abdominal contrast-enhanced computed tomography showed cystic lesions in the middle part of the stomach, and no mass lesions in the liver. The patient underwent distal gastrectomy with regional lymphadenectomy. Macroscopic examination of the resected specimen showed an SMT-like lesion measuring 2.8×2.6 cm in contact with a superficial, depressed lesion measuring 1.7×0.9 mm in the middle third of the stomach, and another SMT-like lesion measuring 1.5×1.4 cm in diameter, which was also in the middle third of the stomach. The pathological diagnosis was well-differentiated tubular adenocarcinoma invading the gastric submucosal layer without lymph node metastasis, but with nearby submucosal heterotopic gastric gland (SHGG) detected. Following surgery, the patient remained symptom-free without evidence of recurrence for 3 months. The finding of SHGG remains a rare entity, and further studies are warranted to clarify the association between these submucosal lesions and the development of cancer.

Gastric adenocarcinoma of fundic gland mucosa type localized in the submucosa: A case report

RATIONALE

Gastric adenocarcinoma of fundic gland type (GA-FG) is a new histological type of gastric cancer manifesting with differentiation into a fundic gland. Furthermore, gastric adenocarcinoma of fundic gland mucosa type (GA-FGM) is a tumor that shows differentiation into not only a fundic gland but also foveolar epithelium and a mucous gland. These tumors tend to invade the submucosal layer. However, no cases of these tumors being localized only in the submucosa have been reported. Here, we present a case of GA-FGM localized in the submucosa and describe the cytological features of this tumor. To our knowledge, this is the first reported case of GA-FGM localized in the submucosa.

PATIENT CONCERNS

A man in his early 70s was referred to our institution because of the detection of a gastric submucosal tumor during a health checkup.

DIAGNOSES

Gastric adenocarcinoma of fundic gland mucosa type.

INTERVENTIONS

Endoscopic ultrasound-guided fine-needle aspiration (FNA), endoscopic submucosal dissection (ESD), and total gastrectomy with lymph node dissection were performed.

OUTCOMES

The FNA specimen showed epithelial cells with low-grade atypia. In the ESD specimen, adenocarcinoma showing a gastric fundic gland mucosa-like morphology was observed. Immunohistochemical analysis showed positive staining for pepsinogen I, H+/K+-adenosine triphosphatase, MUC6, and MUC5AC and negative staining for MUC2 and CD10, indicating tumor differentiation into fundic gland mucosa. Therefore, the tumor was diagnosed as GA-FGM, with localization in the submucosal layer. Total gastrectomy and lymph node dissection were performed because of the positive margins of the ESD specimen. Neither residual tumor nor lymph node metastasis was detected; however, many foci of heterotopic gastric glands (HGGs) were observed in the gastric wall, suggesting that GA-FGM arose from an HGG. After treatment, no recurrence was observed during a 1-year follow-up period.

LESSONS

Various tumors may arise from HGGs. Furthermore, when an FNA specimen shows gastric fundic gland mucosa-like epithelial cells with weak atypia, the possibility of GA-FG and GA-FGM should be considered.

Gastric adenocarcinoma of fundic gland type with signet-ring cell carcinoma component: A case report and review of the literature

A depressed lesion was found at a gastric angle of 76-year-old Japanese woman by esophagogastroduodenoscopy. Four years prior, she was diagnosed with a Helicobacter pylori infection but no eradication was performed. The pathological diagnosis of biopsy specimens was signet-ring cell carcinoma. Endoscopic submucosal dissection (ESD) was performed. Histopathological examination of the ESD specimen revealed proliferation of well-differentiated tubular adenocarcinoma mimicking fundic gland cells at the deep layer of the lamina propria mucosae. These tumor cells expressed focally pepsinogen-I, diffusely MUC6, and scattered H⁺/K⁺ ATPase according to immunohistochemistry. Therefore, we diagnosed this tumor as gastric adenocarcinoma of fundic gland type (GA-FG). Adjacent to the GA-FG, proliferation of signet-ring cell carcinoma which diffusely expressed MUC 2 and MUC 5AC was observed. Intestinal metaplasia was focally observed in the surrounding mucosa of the signet-ring cell carcinoma. To the best of our knowledge, this is the first case report of GA-FG with a signet-ring cell carcinoma component. The origin of signet-ring cell carcinoma, i.e., whether it accidentally arose from a non-neoplastic mucosa and coexisted with the GA-FG or dedifferentiated from the GA-FG is unclear at present. We expect the accumulation of similar cases and further analysis to clarify this issue.