Superficial gastric carcinoma simulating polypoid hypertrophic gastritis
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27 Superficial gastric carcinoma simulating polypoid hypertrophic gastritis Tatsuo Yamakawa, M.D. Leon Morgenstern, M.D. Los Angeles, California An unusual case of gastric carcinoma, classified as the superficial or flat form (type JIb) of early gastric cancer, is reported. The unusual endoscopic impression was polypoid hypertrophic gastritis. A correct diagnosis was made employing, concomitantly, direct vision biopsy and contact smear cytology. Other methods of examination failed to detect the malignancy. T he use of modern endoscopic instruments has significantly improved the accuracy of diagnosing gastric malignancy. A considerable number of small or superficial gastric cancers have been found by using the newer endoscopic techniques. An unusual and interesting case of superficial carcinoma, in which target biopsy played an important diagnostic role, is reported in this paper. The extent of the cancer in this particular case could not be determined macroscopically, despite its large size, because the lesion was not significantly elevated or depressed. The purpose of this report is to illustrate the endoscopic methods used in diagnosing this type of gastric cancer. CASE REPORT A 42-year-old Japanese male presented with mild postprandial epigastric pain of one year's duration. He smoked 1 pack of cigarettes daily and occasionally imbibed alcoholic beverages. Physical examination revealed slight epigastric tenderness. Endoscopic (Machida Fibre-gastro- scope, Type B) and radiographic examinations exhibited deformity and coarseness of the rugal pattern in the pyloric region. The endoscopic diagnosis was polypoid hyperplastic gastritis. Malignancy, however, was not suspected owing to absence of the usual criteria, such as wall rigidity, mucosal unevenness, bleeding and discoloration. (Figure 1) Direct visual biopsy of the antral lesion was performed 7 days later. In addition to the lesion, an area of erosion was noted endoscopically on the posterior wall of the antrum, but the mucosa surrounding this area of erosion was consi- dered normal. Although the erosion was unusual, malignancy was still not suspected. Three specimens from each lesion were taken under visual control and examined histologically and cytologically, contact smear cytology being used as an adjunct at the time of biopsy.' Contact smear cytology revealed atypical mucin-secreting cells, diagnosed as class V malignant cells according to the Papanicolaou criteria. His- tologic examination also showed the same type of mucin- secreting cells, and the lesions were diagnosed as mucinous adenocarcinoma. (Figure 2) laparotomy revealed no evidence of lymph node involve- ment by carcinoma or of palpable tumor in the antrum. The appearance of the serosal side was normal in all respects. Radical gastrectomy was performed, and histologic examina- tion of the resected stomach revealed its margins to be free of tumor. Macroscopic findings and the pattern of distribution of the cancer are shown in Figure 3. It was impossible to trace the margins of this cancer grossly because the lesion was not significantly elevated or depressed compared to the sur- rounding mucosa, with the exception of a few minute areas of slight depression. The lesion measured 9 em x 11 em, and practically all of the antrum was occupied by mucinous adenocarcinoma. Carcinoma was confined to the mucosa and submucosa without involvement of the muscular and serosal layers. Histologically, no difference was found in mucosal thickness between the extensive areas of infiltration and the surrounding normal areas. In retrospect, the lesion Figure 1: Endoscopic examination showed polypoid hyperplastic lesion at the prepyloric region and erosions on the posterior wall of the antrum. No bleeding, discoloration, or rigidity of the wall was seen in the antrum. From the Division of Surgery, Cedars-Sinai Medical Center, Cedars of Lebanon Hospital Division, Los Angeles, California. Reprint requests: Leon Morgenstern, M.D., 4833 Fountain Avenue, Los Angeles, California 90026. VOLUME 19, NO.1, 1972
Transcript of Superficial gastric carcinoma simulating polypoid hypertrophic gastritis
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Superficial gastric carcinoma simulating polypoidhypertrophic gastritis
Tatsuo Yamakawa, M.D.Leon Morgenstern, M.D.
Los Angeles, California
An unusual case of gastric carcinoma, classified as the superficial orflat form (type JIb) of early gastric cancer, is reported. The unusualendoscopic impression was polypoid hypertrophic gastritis. A correctdiagnosis was made employing, concomitantly, direct vision biopsyand contact smear cytology. Other methods of examination failed todetect the malignancy.
The use of modern endoscopic instruments has significantlyimproved the accuracy of diagnosing gastric malignancy. Aconsiderable number of small or superficial gastric cancershave been found by using the newer endoscopic techniques.
An unusual and interesting case of superficial carcinoma,in which target biopsy played an important diagnostic role,is reported in this paper. The extent of the cancer in thisparticular case could not be determined macroscopically,despite its large size, because the lesion was not significantlyelevated or depressed. The purpose of this report is to illustratethe endoscopic methods used in diagnosing this type of gastriccancer.CASE REPORT A 42-year-old Japanese male presented withmild postprandial epigastric pain of one year's duration. Hesmoked 1 pack of cigarettes daily and occasionally imbibedalcoholic beverages. Physical examination revealed slightepigastric tenderness. Endoscopic (Mach ida Fibre-gastroscope, Type B) and radiographic examinations exhibiteddeformity and coarseness of the rugal pattern in the pyloricregion. The endoscopic diagnosis was polypoid hyperplasticgastritis. Malignancy, however, was not suspected owing toabsence of the usual criteria, such as wall rigidity, mucosalunevenness, bleeding and discoloration. (Figure 1)
Direct visual biopsy of the antral lesion was performed7 days later. In addition to the lesion, an area of erosionwas noted endoscopically on the posterior wall of the antrum,but the mucosa surrounding this area of erosion was considered normal. Although the erosion was unusual, malignancywas still not suspected. Three specimens from each lesionwere taken under visual control and examined histologicallyand cytologically, contact smear cytology being used as anadjunct at the time of biopsy.' Contact smear cytologyrevealed atypical mucin-secreting cells, diagnosed as classV malignant cells according to the Papanicolaou criteria. Histologic examination also showed the same type of mucinsecreting cells, and the lesions were diagnosed as mucinousadenocarcinoma. (Figure 2)
laparotomy revealed no evidence of lymph node involvement by carcinoma or of palpable tumor in the antrum. The
appearance of the serosal side was normal in all respects.Radical gastrectomy was performed, and histologic examination of the resected stomach revealed its margins to be freeof tumor.
Macroscopic findings and the pattern of distribution of thecancer are shown in Figure 3. It was impossible to tracethe margins of this cancer grossly because the lesion wasnot significantly elevated or depressed compared to the surrounding mucosa, with the exception of a few minute areasof slight depression. The lesion measured 9 em x 11 em,and practically all of the antrum was occupied by mucinousadenocarcinoma. Carcinoma was confined to the mucosaand submucosa without involvement of the muscular andserosal layers. Histologically, no difference was found inmucosal thickness between the extensive areas of infiltrationand the surrounding normal areas. In retrospect, the lesion
Figure 1: Endoscopic examination showed polypoid hyperplasticlesion at the prepyloric region and erosions on the posterior wallof the antrum. No bleeding, discoloration, or rigidity of the wallwas seen in the antrum.
From the Division of Surgery, Cedars-Sinai Medical Center, Cedars of Lebanon HospitalDivision, Los Angeles, California. Reprint requests: Leon Morgenstern, M.D., 4833 Fountain
Avenue, Los Angeles, California 90026.
VOLUME 19, NO.1, 1972
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Figure 2: Histology of the biopsied specimen revealed mucinousadenocarcinoma (H & E, X 100).
could not have been detected endoscopically or macroscopically. According to the system adopted by the Japan Gastroenterological Endoscopy Society, this case should be classifiedas Type lib, the superficial or flat form & early gastric cancer.,·2DISCUSSION Early diagnosis of lesions which are limitedto the mucosa or submucosa is an important means of improving results in the treatment of gastric canGer. However, littlehas been published about the type of case presented in thispaper.J.4 This type of cancer has been hard to diagnose sinceexamination usually reveals color changes which maysimulate gastritis and only slight morphological changes, suchas slight unevenness of the gastric mucosa.2 In his extensiveexperience with early gastric cancer, Kidokoro informs usthat he has very rarely and with difficulty diagnosed puretype lib lesions.
Oi et a/. 3 reported a very small lib type of superficial carcinoma measuring only 4 mm x 4 mm. The small elevated,reddened lesion, preoperatively diagnosed by biopsy, wasfound in association with extensive atrophic changes on gastrocamera fiberscope photographs. Kitamura et a/. 4 havereported a similar gastric carcinoma measuring 3 cm x 2.5cm. The extensive use of biopsy for evaluating very smallabnormalities undoubtedly accounts for this success incorrectdiagnosis.
Many reports dealing with direct vision methods haverecently been published, such as biopsy,1,5-9,12 lavage,Hlsuction" and brushingY·13 In combination, these methodshave provided an accuracy in diagnosis heretofore unattainable. These methods are now reasonably free of complicationsand suitable for routine clinical use. They afford a meansof examining the entire stomach and of detecting minutemucosal lesions. Their place in the diagnostic armamentariumis now firmly established.
ACKNOWLEDGEMENT: We are grateful to Dr. Tsutomo Kidokoro and Dr.Hiroyuki Tohma for their criticism and advice.
REFERENCES1. YAMAKAWA T, PANISH J. BERCI, G, MORGENSTERN L, SOHMA S,
KIDOKORO T, HAYASHIDA T: The corellation of target biopsyand contact smear cytology under direct visual control in malignantgastric lesions. Gastrointestinal Endoscopy 17:164, 1971
2. PROLLA)C, KOBAYASHI S, KIRSNER jB: Gastric cancer. Arch InternMed 124:238, 1969
3. 01 I, IWATSUKA Y, ICHIOKA S, YAMADA, A, SUZUKI H, SUZUKIS, NAGASAKO K, HAYAKAWA K, TAKEMOTO T: A case of smalllib type early gastric cancer diagnosed by aiming biopsy. Stomach andIntestine (Japan) 5:61, 1970
4. KITAMURA R, KITAMURA T, KIMURA K, TAKEMOTO T, MAEDAK,15A)1 S, YAMAGUCHI M, KAWAI K: One case of lib (?) type earlygastric cancer. Stomach and Intestine (Japan) 3:83,1968
5. WEISS jB, GANG Mj, EKKERS Tj, GAETZ HP, MCCRAY RS: Directvision gastric biopsy using the Machida FGS-B6 gastroscope. Gastrointestinal Endoscopy 17:23, 1970
6. KASUGAI T; Gastric biopsy under direct vision by the fibergastroscope.Gastrointestinal Endoscopy 15:33, 1968
7. TAKAGI K: Gastric biopsy under direct visual control (I). Stomach andIntestine (Japan) 2:93, 1967
8. TAKAGI F: Gastric biopsy under direct visual control (II). Stomach andIntestine (Japan) 2:261, 1967
9. KIDOKORO T: Direct vision cytology and biopsy of the stomach. Gastroentero/. Endosc. (japan) 8:42, 1966
10. KOBAYASHI S, KASAUGAI T, YAMAOKA Y, YOSHII Y, NAITO Y:Improved technique for gastric cytology utilizing simultaneous lavageand fibergastroscopy. Gastrointestinal Endoscopy 15:198, 1969
11. FUKUDA T, SHIDA S, TAKITA T; Exfoliative cyto-diagnosis of earlygastric cancer by gastroendoscopical method with fibergastroscope.llapSoc Clin Cytol (Japan) 4: 172, 1965
12. KOBAYASHI S, PROLLA jC, WINANS CS, KIRSNER jB: Improvedendoscopic diagnosis of gastroesophageal malignancy. Combined useof direct vision brushing and biopsy. lAMA 212:2086, 1970
13. KOBAYASHI S, PROLLA jC, jC, KIRSNER jB & Brushing cytology of theesophagus and stomach under direct vision by fiberscopes. Acta (ytol14:219, 1970
14. KIDOKORO T, SOHMA S, SETO R, GOTO K, YAMAKAWA T, TANIAIA, KATAYANAGI T, ASAKURA R: On direct vision cytology with specialreference to suction method. Stomach and Intestine (Japan) 3: 1201, 1968
Figure 3: Gross surgical specimen, left, and pattern of distribution of cancer, right.
GASTROINTESTINAL ENDOSCOPY
