Three synchronous lesions with different historical types diagnosed by endoscopic submucosal dissection in one patient

A 69-year-old man underwent gastroscopy owing to intermittent abdominal distension for over 4 months. The gastroscopy revealed two distinct lesions in the lower stomach body, which was highly atrophied (O-3) [1], and the background mucosa was infected with Helicobacter pylori. Lesion 1, labeled as 0-Is + IIa [2], measured 40 × 20 mm and had a nodular mixed-type appearance on the posterior wall of the stomach body ([Fig. 1 a, b]). Lesion 2, labeled as 0-IIb, measured 15 × 10 mm and was adjacent to lesion 1 on the oral side ([Fig. 2 a]). Biopsy pathology of both lesions showed atypical cells.

Fig. 1 Features of lesion 1 under white light endoscopy and magnifying endoscopy with blue-laser imaging (ME-BLI).

Fig. 2 Features of lesion 2 under white light endoscopy and ME-BLI.

Further investigation using magnifying endoscopy with blue-laser imaging (ME-BLI) revealed that lesion 1 had a distinct boundary and mimicked a colonic laterally spreading tumor with a villous surface pattern ([Fig. 1 d, e]). ME-BLI also revealed that the area of the lesion presenting noticeable redness had an intensive and irregular vascular pattern ([Fig. 1 f]). Lesion 2 also had a distinct boundary and presented a brownish area. ME-BLI further revealed an irregular vascular pattern and white globe appearance ([Fig. 2 d, e]). Both lesions were removed completely by endoscopic submucosal dissection (ESD). The histological diagnosis was intestinal adenoma with partial high-grade intraepithelial neoplasia for lesion 1 and crawling-type adenocarcinoma [3] (tub2) for lesion 2 ([Fig. 3, ] [Fig. 4 b, c]).

Fig. 3 Postoperative specimen and hematoxylin and eosin (H&E) stain of lesion 1. a Endoscopic submucosal dissection specimen. b H&E stain of the red area. c H&E stain of the anal side.

Fig. 4 Postoperative specimen and H&E stain of lesions 2 and 3.

The patient underwent a follow-up gastroscopy after 10 months, which revealed a 15 × 10-mm 0-IIc lesion ([Fig. 5]) with a clear boundary in the gastric antrum. Lesion 3 showed light redness, and further ME-BLI revealed increased density of the glandular ducts with an irregular surface and vascular pattern ([Fig. 5 d, e]). It was also removed by ESD and the final diagnosis was well-differentiated tubular adenocarcinoma (tub1) ([Fig. 4 e, f]).

Fig. 5 Features of lesion 3 under white light endoscopy and ME-BLI.

This case highlights the detection of three synchronous gastric lesions with different pathologic types ([Video 1]). Each one had a different macroscopical appearance.

Video 1 Three synchronous lesions with different historical types diagnosed by endoscopic submucosal dissection in one patient.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Kimura K, Takemoto T. An endoscopic recognition of atrophic border and its significance in chronic gastritis. Endoscopy 1969; 3: 87-97
• 2 Fujiyoshi MRA, Inoue H, Fujiyoshi Y. et al. Endoscopic classifications of early gastric cancer: A literature review. Cancers (Basel) 2021; 14: 100
• 3 Okamoto N, Kawachi H, Yoshida T. et al. “Crawling-type” adenocarcinoma of the stomach: A distinct entity preceding poorly differentiated adenocarcinoma. Gastric Cancer 2013; 16: 220-232

Publication History

Article published online:
21 September 2023