Gastric cancer. EndoTODAY

[Gastric cancer 786. ESD for EGC at prepyloric antrum, 10 years after chemotherapy for retroperitoneal diffuse large B cell lymphoma]

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Ten years ago, a large retroperitoneal mass (biopsy: diffuse large B cell lymphoma) was found. After a successful course of the systemic chemetherapy, the patient has been in remission.

In a recent screening endoscopy, a flat elevated lesion with central depression (3x2cm, friability +) was found in the lesser curvature of the prepyloric antrum. Initial biopsy result at local clinic was adenoma with low grade dysplasia, but the repeated biopsy after referral confirmed moderately differentiated tubular adenocarcinoma.

left: DLBCL (10 years ago), right: recent screening endoscopy

ESD was performed. Because the lesion was very close to the pyloric ring, it was difficult to cut the distal part with sufficient cancer free margin. More than 80% of submucosal dissection, one piece complete snare resection was done.

ESD: Early gastric carcinoma
1. Location : prepyloric antrum, lesser curvature
2. Gross type : EGC type IIa
3. Histologic type : tubular adenocarcinoma, moderately differentiated (80%) + papillary adenocarcinoma, moderately differentiated (20%)
4. Histologic type by Lauren : intestinal
5. Size of carcinoma : (1) longest diameter, 28 mm (2) vertical diameter, 20 mm
6. Depth of invasion : invades mucosa (lamina propria) (pT1a)
7. Resection margin : free from carcinoma(N). safety margin : distal 4 mm, proximal 5 mm, anterior 8 mm, posterior 10 mm, deep 500 ㎛
8. Lymphatic invasion : not identified(N)
9. Venous invasion : not identified(N)
10. Perineural invasion : not identified(N)
11. Pre-existing adenoma : none
12. Microscopic ulcer : absent
13. Histologic heterogeneity: absent
14. Associated finding: Gastritis cystica superficialis

The final pathology was mixed differentiated adenocarcinoma (moderately differentiated and papillary). Papillary adenocarcinoma is considered as differentiated type by the Nakamura classification and intestinal type by the Lauren classification. The patient can be followed just like simple differentiated type EGC.

PDF 0.5M (2019-8-31. KIDEC 2019)

After the ESD, short-term oral steroid (4 weeks) was give for the prevention of the stricture.

ESD 후 협착 예방 경구 steroid 4주 코스

ESD 2일째 Pd 투약 시작
1주: 매일 30mg (5mg 6알)
2주: 매일 20mg (5mg 4알)
3주: 매일 10mg (5mg 2알)
4주: 매일 5mg (5mg 1알)
5주: 중단

병소의 위치와 절제 범위를 고려하여 협착 발생을 최소화하기 위하여 다음과 같은 경구 스테로이드 복용을 추천합니다. 시술 2일 후 prednisolone 투약을 시작해 주십시요. 첫 1주: 매일 Pd 30mg (5mg 6알) → 다음 주: 매일 Pd 20mg (5mg 4알) → 다음 주: 매일 Pd 10mg (5mg 2알) → 다음 주: 매일 Pd 5mg (5mg 1알) → 중단. 즉 시술 다음다음 날 시작하여 1주 간격으로 용량을 줄여나가는 스케쥴입니다 (매주 약을 줄여가며 총 4주 복용 후 중단).