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[Gastric cancer 808. EGC (fundus)]

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A slightly depressed discolorated EGC was found during a screening endoscopy. The initial biopsy was "atypical signet ring cells." After referral, the repeated biopsy was poorly differentiated adenocarcinoma, and radical total gastrectomy was done.

Stomach, radical total gastrectomy: early gastric carcinoma
1. Location : upper third, Center at fundus and posterior wall
2. Gross type : EGC type IIc
3. Histologic type : tubular adenocarcinoma, poorly (solid) differentiated
4. Histologic type by Lauren : diffuse
5. Size : 1.5x1.5 cm
6. Depth of invasion : invades mucosa (muscularis mucosae) (pT1a)
7. Resection margin: free from carcinoma, safety margin: proximal 5.0 cm, distal 20.1 cm
8. Lymph node metastasis : no metastasis in 56 regional lymph nodes (pN0)
9. Lymphatic invasion : not identified
10. Venous invasion : not identified
11. Perineural invasion : not identified
12. Peritoneal cytology : negative
13. AJCC stage by 8th edition: pT1a N0

When I reviewed the endoscopic images of the screening endoscopy, I found that the endoscopist has a very good routine pattern of examinations.

The time to the duodenal bulb was 46 seconds, which is quite adequate. During the insertion, the esophagus need to be observed, and the stomach is usually 50% inflated. Some parts of the stomach is also observed before duodenal observation, so the common duodenal insertion time less than 30 seconds is too short.
(1) The distal antrum was observed and than (2) the angle, and than (3) the lesser curvature of the body, and than (4) around the cardia. This sequence is the most common pattern, but I recommend to observe the greater curvature side of the proximal antrum before the angle.
After the observation around the cardia, the endoscope was re-introduced to the antrum. Greater curvature side was mostly observed during the withdrawal step.
Finally, the greater curvature side of the fundus (left side of the saddle area) was observed and the gastric cancer was found (examination time: 1' 59''). Great job!
Although the examination was near perfect, I have some comments. (1) The stomach examination time (1' 15'' to 1' 59'') is too short, which means the movement of the scope was quite fast. We need to move the endoscope slowly for better observation of the gastric mucosa, and for the comfort of the patients. (2) Close up view of the cancer lesion is required. (3) Even if a cancer is found, the whole stomach needs to be observed at least twice.

Thank you very much for your great job. You really did a lot to the patient.