Gastric cancer. EndoTODAY

[Gastric cancer 800. Superficial spreading-type early gastric cancer - Initial diagnosis: 2 EGCs, Final diagnosis: 1 large EGC]

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A small gastric cancer was found at a local clinic. The initial biopsy was moderately differentiated adenocarcinoma and signet ring cell carcinoma.

When I reviewed the initial endoscopy pictures, the lesion was a 1cm sized ill-defined depressed lesion at anterior wall of the proximal antrum. Usually, endoscopic resection can be tried for 1cm sized small depressed type EGC. However, the border was so unclear, and the antral mucosal was very uneven with some hyperemic depressed lesion. I recommended repeating endoscopy for further evaluation.

In the repeated endoscopy, two lesions were found. The first lesion was a small EGC IIc at the anterior wall of the antrum, and the histology was signet ring cell carcinoma. The second lesion was a ovoid hyperemic EGC IIb at the lesser curvature of the proximal antrum. I recommended surgery for the two synchronous cancers.

In the operation room, the surgery team's impression for the resected specimen was also two synchronous cancers.

However, the final pathology was a single large EGC.

Stomach, radical subtotal gastrectomy: Early gastric carcinoma
1. Location : lower third, Center at antrum and anterior wall
2. Gross type : EGC type IIb+IIc
3. Histologic type : tubular adenocarcinoma, poorly (solid) differentiated >> signet-ring cell carcinoma (30%)
4. Histologic type by Lauren : mixed
5. Size : 9.0x7.5 cm
6. Depth of invasion : invades submucosa (sm1) (pT1b)
7. Resection margin: free from carcinoma
8. Lymph node metastasis : no metastasis in 53 regional lymph nodes (pN0)
9. Lymphatic invasion : not identified
10. Venous invasion : not identified
11. Perineural invasion : not identified
12. AJCC stage by 8th edition: pT1b N0

We usually call it a 'superficial spreading-type early gastric cancer'.

Followings are some more examples of superficial spreading-type early gastric cancer.

Stomach, radical total gastrectomy: Early gastric carcinoma
1. Location : middle third, Center at body and anterior wall
2. Gross type : EGC type IIa+IIb
3. Histologic type : tubular adenocarcinoma, mixed well and poorly differentiated (WHYX type)
4. Histologic type by Lauren : mixed
5. Size : 7.5x5.5 cm
6. Depth of invasion : invades mucosa (muscularis mucosae) (pT1a)
7. Resection margin: free from carcinoma, safety margin: proximal 2.0 cm, distal 9.0 cm
8. Lymph node metastasis : no metastasis in 19 regional lymph nodes (pN0) (0/19: "2", 0/1; "3", 0/4; "4", 0/4; "5", 0/0; "6", 0/4; "7", 0/1; "9", 0/1; "8a", 0/1; "11p", 0/0; "12a", 0/3; "4sb", 0/0; "1", 0/0)
9. Lymphatic invasion : not identified
10. Venous invasion : not identified
11. Perineural invasion : not identified
12. AJCC stage by 8th edition: pT1a N0

Early gastric carcinoma :
1. Location : lower third center at antrum and lesser curvature
2. Gross type : EGC type IIb
3. Histologic type : tubular adenocarcinoma, poorly differentiated
4. Histologic type by Lauren : intestinal
5. Size : 7.5x3.0 cm
6. Depth of invasion : extension to mucosa (muscularis mucosa) (pT1a)
7. Resection margin: free from carcinoma, safety margin: proximal, 8.5 cm; distal, 1.5 cm
8. Lymph node metastasis : no metastasis in 20 regional lymph nodes (pN0)
9. Lymphatic invasion : not identified
10.Venous invasion : not identified
11.Perineural invasion : not identified

Stomach, subtotal gastrectomy: Early gastric carcinoma
1. Location : middle third, Center at body and lesser curvature
2. Gross type : EGC type IIc
3. Histologic type : tubular adenocarcinoma, poorly (solid) differentiated with signet ring cell component (20%)
4. Histologic type by Lauren : mixed
5. Size : 9x5 cm
6. Depth of invasion : invades submucosa (SM1) (pT1b)
7. Resection margin: free from carcinoma, safety margin: proximal 2.5 cm, distal 5.5 cm
8. Lymph node metastasis : metastasis to 8 out of 57 regional lymph nodes (pN3a) (perinodal extension: absent) (8/57: "3", 6/13; "4", 0/7; "5", 0/1; "6", 0/11; "7", 0/3; "9", 2/10; "8a", 0/5; "11p", 0/2; "12a", 0/4; "4sb", 0/0; "1", 0/1)
9. Lymphatic invasion : present
10. Venous invasion : not identified
11. Perineural invasion : not identified
12. Peritoneal cytology : negative
13. AJCC stage by 7th edition: pT1b N3a
* EB virus (-), c-erbB-2 (-)