A case of early gastric cancer arising from gastritis cystica profunda treated by endoscopic submucosal dissection

Abstract

Gastritis cystica profunda (GCP) consists of hyperplasia and cystic dilatation of the gastric glands extending into the submucosa. It occurs in the residual stomach post surgery and in the unoperated stomach. GCP is considered a benign lesion, but there is controversy about its malignant potential. We report a case of early gastric cancer arising from GCP treated by endoscopic submucosal dissection (ESD) in a 55-year-old unoperated man. Upper gastrointestinal endoscopy revealed a 15-mm diameter submucosal tumor (SMT) in the upper corpus of the stomach. The surface had angiotelectasia and slight depression covered with normal mucosa. Neither ulceration nor erosion was seen. Narrow-band imaging endoscopy showed no abnormalities suggesting gastric cancer. Endoscopic ultrasonography visualized the internally low-echoic SMT, harboring tiny cystic lesions, mainly within the second and third layers of the gastric wall. The SMT was removed by ESD to avoid retention and allow for comprehensive diagnosis. It was diagnosed as GCP with partial well-differentiated adenocarcinoma without involvement of the lateral and deep margins, lymphatic invasion, vascular invasion and perineural invasion. The gastric epithelium comprised normal mucosa without dysplasia. ESD seems to be useful for the diagnosis of SMT, including GCP harboring gastric cancer, and avoids unnecessary surgical procedures.

Keywords: Endoscopic submucosal dissection; Endoscopic ultrasonography; Gastric cancer; Gastritis cystica profunda; Submucosal tumor.

Fig. 1

a, b Endoscopic view showing the 15-mm diameter SMT with normal overlying mucosa in the giant curvature of the upper corpus of the stomach (a). The surface of the SMT had angiotelectasia (a) and slight depression covered with normal mucosa, stained with indigo carmine dye (b). However, neither ulceration nor erosion was seen (a, b). c Narrow-band imaging endoscopy showed no abnormal finding suggesting gastric cancer. The mucosa of the whole stomach was normal without chronic gastritis. d EUS visualized the SMT mainly within the second and third layers of the gastric wall. The tumor was internally low-echoic and harbored tiny cystic lesions.

Fig. 2

Pathological findings of the resected SMT. a Complete SMT resection was confirmed. The resected specimen was 35 × 20 mm and the tumor was 12 × 12 mm. b, c Cystic dilatation of the gastric glands extending into the submucosal layer was present, and the SMT was diagnosed as GCP. The gastric epithelium comprised normal mucosa without any dysplasia (c). d Inset of c. Well-differentiated adenocarcinoma was partially seen within the GCP. There was no involvement of the lateral and deep margins, lymphatic invasion, vascular invasion or perineural invasion. Original magnification: ×10 (b), ×100 (c), ×400 (d).