Gastric cancer. EndoTODAY

[Gastric cancer 824. ESD for serrated adenocarcinoma of the stomach]

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A patient was referred due to tubulovillous adenoma with high grade dysplasia of the antrum. The result of the outside pathology slide was "serrated adenocarcinoma, well differentiated." ESD was done.

ESD: Early gastric carcinoma
1. Location : antrum, lesser curvature
2. Gross type : EGC type IIa
3. Histologic type : serrated adenocarcinoma, well differentiated
4. Histologic type by Lauren : intestinal
5. Size of carcinoma : (1) longest diameter, 6 mm (2) vertical diameter, 4 mm
6. Depth of invasion : invades mucosa (lamina propria) (pT1a)
7. Resection margin : free from carcinoma(N), safety margin : distal 10 mm, proximal 6 mm, anterior 16 mm, posterior 16 mm, deep 800 ㎛
8. Lymphatic invasion : not identified(N)
9. Venous invasion : not identified(N)
10. Perineural invasion : not identified(N)
11. Microscopic ulcer : absent
12. Histologic heterogeneity: absent

[보충 설명]

대장 serrated adenoma는 비교적 개념이 정리되어 있지만 위 serrated adenoma는 새로운 개념입니다. 2001년 Sweden의 Carlos Rubio의 첫 보고 이후 2013년까지 20예 정도만 보고되었습니다. 아래 표의 Kwon et al의 논문이 삼성서울병원 병리과에서 발표한 것입니다.

World J Gastrointest Endosc. 2013 May 16;5(5):261-4

제가 병리학자가 아니므로 정확한 특성을 설명드리기 어려워 Kwon 등의 논문에 나온 부분을 그대로 옮기겠습니다. "The gastric serrated adenoma has elongated fronds with lateral crenated, saw tooth-like notches as a result of scalloped epithelial indentations. The serrated crypts are lined by overtly dysplastic epithelial cells containing abundant eosinophilic cytoplasm and stratified elongated penicillate nuclei. These microscopic features mimic traditional serrated adenoma found in the colorectum." 병리학적으로 톱니모양을 보이는 것이고 임상적 특성에 대한 규명은 좀 더 기다려야 할 듯합니다. 현 단계에서 우리 내시경 의사들은 그냥 "그런 병이 있구나" 정도만 알면 되는 것 같습니다. (Histol Histopathol. 2013 Apr;28(4):453-62)

2013년 제가 처음 경험한 serrated adenocarcinoma의 내시경 사진을 소개합니다.

2018년 ESD 후 수술하였던 환자입니다.

ESD : Early gastric carcinoma
1. Location : high body, posterior wall
2. Gross type : EGC type IIc
3. Histologic type : tubular adenocarcinoma, moderately differentiated with serrated feature
4. Histologic type by Lauren : intestinal
5. Size of carcinoma : (1) longest diameter, 6 mm (2) vertical diameter, 6 mm
6. Depth of invasion : invades submucosa, (depth of sm invasion : 1200 ㎛) (pT1b)
7. Resection margin : involved deep resection margin by carcinoma with cauterized artifact negative other resection margins; safety margin : distal 3 mm, proximal 2 mm, anterior 16 mm, posterior 4 mm, deep 0 ㎛
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

Becuase of the deep SM invasion and positive vertical margin, additional surgical treatment was recommended.

The meaning of the serrated feature in the gastric neoplasm is still unclear.