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Endoscopic curative resection of undifferentiated early gastric cancer
High definition endoscopy has improved the diagnosis of early gastric cancer but still has a miss rate of 20 % – 25 %. Magnification endoscopy with narrow-band imaging (NBI) helps to further characterize histology in early gastric cancer   .
A 62-year-old woman attended screening esophagogastroduodenoscopy, and white-light endoscopy showed a slightly depressed lesion of size 10 × 5 mm (Paris type 0-IIc) on the anterior wall of the stomach in the antrum. NBI showed a line of demarcation with absent microsurface pattern and irregular microvascular pattern . Near focus showed a dilated and tortuous corkscrew type of microvascular pattern and intralobular loop type 2 pattern ([Fig. 1]), as described by Nakayoshi et al., which was suggestive of poorly differentiated adenocarcinoma  . Biopsies showed a signet cell type of carcinoma.
Intramucosal undifferentiated type adenocarcinoma of size ≤ 2 cm is a candidate for endoscopic resection under expanded criteria in Japanese guidelines 2018.
Circumferential marking was done using a noninsulation-tipped endoscopic submucosal dissection knife under Forced Coag mode ([Video 1]). Submucosal injection using a 25-gauge needle with indigo carmine was performed to lift the lesion ([Fig. 2 a]). An initial mucosal incision was performed on the proximal side of the lesion with the same knife and incision was completed using Endocut I ([Fig. 2 b]). Bleeding was controlled using Coagrasper. Dissection was completed using the ITknife2 (Olympus Corp., Tokyo, Japan) ([Fig. 2 c]).
Video 1 Endoscopic curative resection of undifferentiated early gastric cancer.
The resected specimen measured 40 × 25 × 2 mm and revealed a signet ring cell carcinoma, with the deepest invasion confined to the mucosa and negative margins ([Fig. 3]). Follow-up esophagogastroduodenoscopy after 1 year showed resolution of the lesion with no recurrence.
Magnification endoscopy with NBI is a useful modality that helps to characterize and manage early gastric carcinoma, and in our case prevented gastrectomy.
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11 September 2020 (online)
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