Abstract
BackgroundGastric cancer that mimics a submucosal tumor (SMT) is infrequently encountered in routine clinical settings, and histopathological analysis is often negative for malignant cells. In such cases, excisional biopsy of the entire tumor may be necessary to make a definitive pathological diagnosis, and laparoscopic and endoscopic cooperative surgery (LECS) is a viable method of excisional biopsy.Case presentationAn 80-year-old male patient diagnosed with stomach wall irregularities at routine medical check-up was referred to our facility, and consequent endoscopic examination detected a 20-mm protruded lesion in the greater curvature at the middle third of the stomach. Endoscopic ultrasound (EUS) showed a thick, low echoic lesion with an irregular margin in the second layer of the gastric wall. Further, a nodular part of the lesion had infiltrated into the submucosa, with an appearance similar to that of linitis plastica of the stomach. The lesion was highly suspected to be a gastric carcinoma with submucosal invasion. However, mucosal-incision-assisted biopsy revealed no malignant cells. Computed tomography (CT) identified no metastatic lymph nodes. Therefore, an excisional biopsy using LECS was performed, and to avoid peritoneal dissemination, we used a modified version, namely, combination of laparoscopic and endoscopic approaches to neoplasia with non-exposure technique (CLEAN-NET). The procedure ended without any complications, and post-operative course was uneventful. As histopathology returned a diagnosis of adenocarcinoma pT4a, we performed radical gastrectomy and D2 lymphadenectomy. Post-operative course was unremarkable and the patient underwent follow-up examinations without adjuvant chemotherapy because of old age.ConclusionsLocal resection using LECS for gastric tumors with a high suspicion of malignancy is useful and feasible. LECS could be used in similar cases.
Highlights
Gastric cancer that mimics a submucosal tumor (SMT) is infrequently encountered in routine clinical settings, and histopathological analysis is often negative for malignant cells
laparoscopic and endoscopic cooperative surgery (LECS) is routinely performed for local resection of gastric submucosal tumors (SMTs), including gastrointestinal stromal tumors (GIST) [1]
Case presentation An 80-year-old male patient who was found to have stomach wall irregularities during routine medical check-up was referred to Keio University Hospital
Summary
Laparoscopic and endoscopic cooperative surgery (LECS) is a procedure that combines laparoscopic gastric resection and endoscopic submucosal dissection (ESD) with appropriate but minimal surgical resection. LECS is routinely performed for local resection of gastric submucosal tumors (SMTs), including gastrointestinal stromal tumors (GIST) [1]. As the lesion was histopathologically determined to be advanced gastric cancer, radical gastrectomy was subsequently performed. On the basis of the above findings, we suspected the tumor to be gastric cancer mimicking SMT, similar to linitis plastica of the stomach with SM invasion or a lymphoproliferative disorder such as a malignant lymphoma. The technical details of this surgery involve (1) detecting the lesion and performing an endoscopic submucosal injection, (2) performing seromuscular dissection around the tumor under laparoscopic view, (3) cutting the mucosal layer using a mechanical stapler (Fig. 3), (4) and suturing the seromuscular layer. The procedure duration was 51 min, blood loss was 0 mL, and there is no perforation of the gastric wall. At the time of the final pathological diagnosis, there was no metastasis in the regional lymph nodes and no residual carcinoma in the resected (2020) 6:99
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