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Superficial gastric carcinoma simulating polypoid hypertrophic gastritis
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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.
The 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 (Mach ida Fibre-gastroscope, 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 considered 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. Histologic examination also showed the same type of mucinsecreting cells, and the lesions were diagnosed as mucinous adenocarcinoma. (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 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 surrounding 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
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Many reports dealing with direct vision methods have recently been published, such as biopsy,1,5-9,12 lavage,Hl suction" and brushingY·13 In combination, these methods have provided an accuracy in diagnosis heretofore unattainable. These methods are now reasonably free of complications and suitable for routine clinical use. They afford a means of examining the entire stomach and of detecting minute mucosal lesions. Their place in the diagnostic armamentarium is now firmly established. ACKNOWLEDGEMENT: We are grateful to Dr. Tsutomo Kidokoro and Dr. Hiroyuki Tohma for their criticism and advice.
REFERENCES Figure 2: Histology of the biopsied specimen revealed mucinous adenocarcinoma (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 classified as Type lib, the superficial or flat form & early gastric cancer.,·2 DISCUSSION Early diagnosis of lesions which are limited to the mucosa or submucosa is an important means of improving results in the treatment of gastric canGer. However, little has been published about the type of case presented in this paper.J.4 This type of cancer has been hard to diagnose since examination usually reveals color changes which may simulate gastritis and only slight morphological changes, such as slight unevenness of the gastric mucosa. 2 In his extensive experience with early gastric cancer, Kidokoro informs us that he has very rarely and with difficulty diagnosed pure type 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, was found in association with extensive atrophic changes on gastrocamera fiberscope photographs. Kitamura et a/. 4 have reported a similar gastric carcinoma measuring 3 cm x 2.5 cm. The extensive use of biopsy for evaluating very small abnormalities undoubtedly accounts for this success incorrect diagnosis.
1. YAMAKAWA T, PANISH J. BERCI, G, MORGENSTERN L, SOHMA S, KIDOKORO T, HAYASHIDA T: The corellation of target biopsy and contact smear cytology under direct visual control in malignant gastric lesions. Gastrointestinal Endoscopy 17:164, 1971 2. PROLLA)C, KOBAYASHI S, KIRSNER jB: Gastric cancer. Arch Intern Med 124:238, 1969 3. 01 I, IWATSUKA Y, ICHIOKA S, YAMADA, A, SUZUKI H, SUZUKI S, NAGASAKO K, HAYAKAWA K, TAKEMOTO T: A case of small lib type early gastric cancer diagnosed by aiming biopsy. Stomach and Intestine (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 early gastric cancer. Stomach and Intestine (Japan) 3:83,1968 5. WEISS jB, GANG Mj, EKKERS Tj, GAETZ HP, MCCRAY RS: Direct vision 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 and Intestine (Japan) 2:93, 1967 8. TAKAGI F: Gastric biopsy under direct visual control (II). Stomach and Intestine (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 lavage and fibergastroscopy. Gastrointestinal Endoscopy 15:198, 1969 11. FUKUDA T, SHIDA S, TAKITA T; Exfoliative cyto-diagnosis of early gastric cancer by gastroendoscopical method with fibergastroscope.llap Soc Clin Cytol (Japan) 4: 172, 1965 12. KOBAYASHI S, PROLLA jC, WINANS CS, KIRSNER jB: Improved endoscopic diagnosis of gastroesophageal malignancy. Combined use of direct vision brushing and biopsy. lAMA 212:2086, 1970 13. KOBAYASHI S, PROLLA jC, jC, KIRSNER jB & Brushing cytology of the esophagus and stomach under direct vision by fiberscopes. Acta (ytol 14:219, 1970 14. KIDOKORO T, SOHMA S, SETO R, GOTO K, YAMAKAWA T, TANIAI A, KATAYANAGI T, ASAKURA R: On direct vision cytology with special reference 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
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.
The 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 (Mach ida Fibre-gastroscope, 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 considered 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. Histologic examination also showed the same type of mucinsecreting cells, and the lesions were diagnosed as mucinous adenocarcinoma. (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 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 surrounding 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
28
Many reports dealing with direct vision methods have recently been published, such as biopsy,1,5-9,12 lavage,Hl suction" and brushingY·13 In combination, these methods have provided an accuracy in diagnosis heretofore unattainable. These methods are now reasonably free of complications and suitable for routine clinical use. They afford a means of examining the entire stomach and of detecting minute mucosal lesions. Their place in the diagnostic armamentarium is now firmly established. ACKNOWLEDGEMENT: We are grateful to Dr. Tsutomo Kidokoro and Dr. Hiroyuki Tohma for their criticism and advice.
REFERENCES Figure 2: Histology of the biopsied specimen revealed mucinous adenocarcinoma (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 classified as Type lib, the superficial or flat form & early gastric cancer.,·2 DISCUSSION Early diagnosis of lesions which are limited to the mucosa or submucosa is an important means of improving results in the treatment of gastric canGer. However, little has been published about the type of case presented in this paper.J.4 This type of cancer has been hard to diagnose since examination usually reveals color changes which may simulate gastritis and only slight morphological changes, such as slight unevenness of the gastric mucosa. 2 In his extensive experience with early gastric cancer, Kidokoro informs us that he has very rarely and with difficulty diagnosed pure type 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, was found in association with extensive atrophic changes on gastrocamera fiberscope photographs. Kitamura et a/. 4 have reported a similar gastric carcinoma measuring 3 cm x 2.5 cm. The extensive use of biopsy for evaluating very small abnormalities undoubtedly accounts for this success incorrect diagnosis.
1. YAMAKAWA T, PANISH J. BERCI, G, MORGENSTERN L, SOHMA S, KIDOKORO T, HAYASHIDA T: The corellation of target biopsy and contact smear cytology under direct visual control in malignant gastric lesions. Gastrointestinal Endoscopy 17:164, 1971 2. PROLLA)C, KOBAYASHI S, KIRSNER jB: Gastric cancer. Arch Intern Med 124:238, 1969 3. 01 I, IWATSUKA Y, ICHIOKA S, YAMADA, A, SUZUKI H, SUZUKI S, NAGASAKO K, HAYAKAWA K, TAKEMOTO T: A case of small lib type early gastric cancer diagnosed by aiming biopsy. Stomach and Intestine (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 early gastric cancer. Stomach and Intestine (Japan) 3:83,1968 5. WEISS jB, GANG Mj, EKKERS Tj, GAETZ HP, MCCRAY RS: Direct vision 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 and Intestine (Japan) 2:93, 1967 8. TAKAGI F: Gastric biopsy under direct visual control (II). Stomach and Intestine (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 lavage and fibergastroscopy. Gastrointestinal Endoscopy 15:198, 1969 11. FUKUDA T, SHIDA S, TAKITA T; Exfoliative cyto-diagnosis of early gastric cancer by gastroendoscopical method with fibergastroscope.llap Soc Clin Cytol (Japan) 4: 172, 1965 12. KOBAYASHI S, PROLLA jC, WINANS CS, KIRSNER jB: Improved endoscopic diagnosis of gastroesophageal malignancy. Combined use of direct vision brushing and biopsy. lAMA 212:2086, 1970 13. KOBAYASHI S, PROLLA jC, jC, KIRSNER jB & Brushing cytology of the esophagus and stomach under direct vision by fiberscopes. Acta (ytol 14:219, 1970 14. KIDOKORO T, SOHMA S, SETO R, GOTO K, YAMAKAWA T, TANIAI A, KATAYANAGI T, ASAKURA R: On direct vision cytology with special reference 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