Scirrhous Carcinoma Research Articles

Diagnostic potential and pitfalls of ultrasound-guided fine-needle aspiration cytology for breast lesions.

Ultrasound (US)-guided fine-needle aspiration cytology (FNAC) is now widely accepted as a diagnostic procedure for breast lesions. Along with its advantages, US-guided FNAC also has some pitfalls. The recognition of these pitfalls for this procedure is extremely important for the strict management of the disease. We retrospectively investigated the diagnostic potential and pitfalls of US-guided FNAC in the diagnosis of breast lesions. This study consisted of 348 aspirated samples from 274 breast tumors. The rate of sufficient aspirates was 74% after a single aspiration, while sufficient materials were finally obtained from 93% of the tumors by repeated aspirations. The rate was lower in tumors measuring less than 10 mm in diameter (62%), and in sclerosing adenosis (25%). The sensitivity of FNAC was 65%, the specificity was 75%, the border diagnosis rate was 18%, and the positive predictive value was 92%. The false-negative rate was higher in noninvasive carcinoma (45%). The border diagnosis rate was also higher in scirrhous carcinoma (29%). There were also five false-positive cases. Limited to nonpalpable lesions, the sufficient aspirates rate was 70% and the accuracy was 67%.

Diffusely infiltrative squamous cell carcinoma of the esophagus.

This study was designed to clarify the clinical and pathologic features of diffusely infiltrative squamous cell carcinoma of the esophagus. Diffusely infiltrative squamous cell carcinomas were classified grossly into two types, namely, scirrhous carcinoma and nonscirrhous carcinoma. There were seven patients with the former type and three with the latter type. Scirrhous-type carcinoma was associated with a prominently thickened esophageal wall with strictures, whereas nonscirrhous-type carcinoma demonstrated thickening of the esophageal wall without strictures. Microscopically, all patients had lymph node metastases and lymphatic invasion. Blood vessel invasion was found in seven patients and extranodal invasion was found in seven. The prognosis of patients with both types of carcinoma was extremely poor. Only two patients who underwent curative surgery as well as chemoradiotherapy survived for more than 1 year. Therefore, further morphological studies on the early stages of diffusely infiltrating esophageal carcinoma should be performed. New treatment strategies such as intensive preoperative chemoradiotherapy based on sensitivity tests in individual patients will be required for treating the advanced stages of this disease.

A CLINICOPATHOLOGICAL STUDY ON THE PATIENTS WITH METASTASIS FROM BREAST CANCER

Breast cancer is a malignant tumor that commonly metastasizes to bones, but not a few long survivors can be seen after bone metastasis occurs. Appropriate selection of therapies would afford an improvement in the patient's quality of life and an effect of life-prolongation, and hence we should be careful to deal with such patients. Of 540 patients with primary breast cancer treated at the hospital in a recant 26-year period since 1971, 60 patients experienced bone metastasis were subjected to study of clinicopathological prognostic factors. As a result, patients with breast cancer who were liable to have bone metastasis had: (1) small tumor with solid-tubular carcinoma or scirrhous carcinoma, (2) papillotubular carcinoma with tumor lenge, and (3) n0 and negative vascular invasion with solid-tubular carcinoma. The patients with solid-tubular carcinoma had easily bone metastasis, but they were found the foci in an early stage and lived for a long time after bone metastasis occurred. It is necessary to examine carefully about bone metastasis for the patients with above mentioned, especially within 5 years after operation.

Correlation between expression of urokinase-type plasminogen activator receptor and metastasis in gastric carcinoma

To clarify the interrelationship between urokinase-type plasminogen activator receptor (uPAR) and the progression of gastric cancer, uPAR expression in gastric cancer was studied by the reverse transcription (RT)-PCR and immunohistochemistry. uPAR mRNA was expressed in 44 of 46 primary gastric cancers and uPAR immunoreactivity was found in 21 (14%) of 155 tumors. uPAR immunoreactivity was also observed in the fibroblast-like cells and the inflammatory cells including macrophages. The intensity of uPAR immunoreactivity of these cells was weaker than that of cancer cells. uPAR expression detected by RT-PCR may be from cancer cells and/or non-cancerous stromal cells. uPAR immunoreactivity in cancer cells was closely associated with histologic type, nodal status, and macroscopic type. The uPAR positive tumors were closely associated with the macroscopically infiltrating type, undifferentiated type and stage IV disease. Poorly differentiated carcinomas with rich intestitial fibrosis (scirrhous carcinoma) expressed uPAR with a significantly higher incidence than the other histologic types of carcinoma. Growth of scirrhous carcinoma may be a result of a concerted action of the players in the plasminogen activator system, consisting of cancer cells and stromal elements. Furthermore, there was an intimate relationship between the grade of lymph node metastasis and uPAR tissue status. Patients with a uPAR positive tumor had a significantly poorer prognosis than those with uPAR negative tumor. These results indicate that the immunohistochemical diagnosis of uPAR tissue status on the primary tumor of gastric cancer may be a good predictor for the prognosis of patients with gastric cancer.

Surgically curable and incurable scirrhous carcinomas of the stomach.

The purpose of this study was to identify a subgroup of patients with scirrhous carcinoma of the stomach who are more suitable for surgery by analysis of their clinicopathologic characteristics. Seventy-three patients with scirrhous gastric carcinoma who underwent gastrectomy between 1979 and 1994 were included in the study. Clinicopathological characteristics of 5-year survivors and nonsurvivors were compared. A multivariate analysis of various prognostic factors was performed. The 5-year survival rate was 31.4%; 78% (28/36) of nonsurvivors died of malignant ascites and only 8% (3/36) died of hepatic or lung metastasis. When clinicopathologic parameters of 5-year survivors and nonsurvivors were compared, age, tumor size, macroscopic appearance, pT, pN, pM, stage, peritoneal lavage cytology, residual tumor, extent of gastric resection, operation time, volume of blood loss, and transfusion were significantly different. By the multivariate analysis, residual tumor, pathological depth of tumor infiltration, blood transfusion, and histological type were the independent prognostic factors. The prognosis of scirrhous carcinoma of the stomach is mainly determined by the depth of penetration and curability. In order to obtain better survival, early detection of tumor while it is limited to T2 stage appeared most important. Aggressive surgery would be indicated for T3 tumors, but in the case of T4 tumors, extent of operation should be determined by other factors such as extent of nodal metastasis or presence of distant metastasis.

Surgically curable and incurable scirrhous carcinomas of the stomach

Background and Objectives The purpose of this study was to identify a subgroup of patients with scirrhous carcinoma of the stomach who are more suitable for surgery by analysis of their clinicopathologic characteristics. Methods Seventy-three patients with scirrhous gastric carcinoma who underwent gastrectomy between 1979 and 1994 were included in the study. Clinicopathological characteristics of 5-year survivors and nonsurvivors were compared. A multivariate analysis of various prognostic factors was performed. Results The 5-year survival rate was 31.4%; 78% (28/36) of nonsurvivors died of malignant ascites and only 8% (3/36) died of hepatic or lung metastasis. When clinicopathologic parameters of 5-year survivors and nonsurvivors were compared, age, tumor size, macroscopic appearance, pT, pN, pM, stage, peritoneal lavage cytology, residual tumor, extent of gastric resection, operation time, volume of blood loss, and transfusion were significantly different. By the multivariate analysis, residual tumor, pathological depth of tumor infiltration, blood transfusion, and histological type were the independent prognostic factors. Conclusions The prognosis of scirrhous carcinoma of the stomach is mainly determined by the depth of penetration and curability. In order to obtain better survival, early detection of tumor while it is limited to T2 stage appeared most important. Aggressive surgery would be indicated for T3 tumors, but in the case of T4 tumors, extent of operation should be determined by other factors such as extent of nodal metastasis or presence of distant metastasis. J. Surg. Oncol. 1997;65:194–200. © 1997 Wiley-Liss, Inc.

Adhesion polypeptides are useful for the prevention of peritoneal dissemination of gastric cancer.

We examined the effect of adhesion polypeptides on the adhesion and invasiveness of gastric cancer cell lines. We previously reported the establishment of an extensively peritoneal-seeding cell line, OCUM-2MD3, from a poorly seeding human scirrhous gastric carcinoma cell line, OCUM-2M. Both alpha2beta1 and alpha3beta1 integrin expression was markedly increased on OCUM-2MD3 cells compared with OCUM-2M cells, and the ability of OCUM-2MD3 cells to bind to the extracellular matrix (ECM) was also significantly higher than that of OCUM-2M cells. The adhesion polypeptides, YIGSR and RGD, and two RGD derivatives significantly inhibited the adhesion of OCUM-2MD3 cells to the submesothelial ECM, while not inhibiting the adhesiveness of OCUM-2M cells and two well differentiated human gastric cell lines, MKN-28 and MKN-74. The YIGSR and RGD peptides also significantly inhibited the invasiveness of OCUM-2MD3 cells. The survival of nude mice with peritoneal dissemination given YIGSR sequence intraperitoneally was obviously longer than that of untreated mice. The survival of mice treated with RGD was also improved, and this effect was increased using the RGD derivatives, poly(CEMA-RGDS) and CM-chitin RGDS. These polypeptides appear to block the binding of integrins, which are expressed on OCUM-2MD3 cells, to the submesothelial ECM, and consequently inhibit peritoneal implantation. The peritoneal injection of adhesion polypeptides may be a new therapy against the dissemination of scirrhous gastric cancer, and may be useful for the prevention of dissemination in high-risk patients.

頚部腫脹を初発症状としたスキルス胃癌例

A case of severe neck edema arising from Virchow's lymphnode metastasis of gastric scirrhous carcinoma was reported. A 69-year-old man complained of dysphagia and aggressive neck swelling in addition to severe swelling of both legs. Radiographic examination showed difilse subcutaneous swelling surrounding the trachea and esophagus, which corresponded to cancerous lymphangitis, and a multiple mass lesion on the iliopsoas muscle (celiac lymphnode metastasis). Fine needle aspiration biopsy revealed adenocarcinoma, and immunohistological examination showed rich CEA in the cytoplasm, which characterizes gastric cancer. Gastrography and a gastrofiberscopiy biopsy revealed gastric scirrhous carcinoma. When supraclavicular lymphnode metastasis of adenocarcinoma is encountered, further examination of the abdominal organs is very important.

TWO CASES OF PREGNANCY, DELIVERY AND LACTATION AFTER BREAST-CONSERVING THERAPY

We experienced two cases of pregnancy, delivery and lactation after breast-conserving therapy. Case 1: A 29-year-old woman with a T1aN0 left breast cancer underwent quadrantectomy and axillar dissection. Pathological findings revealed scirrhous carcinoma and no lymph node metastasis. She was injected with mitomycin C, 10 mg i.v. immediately after thd operation and treated with UFT, 300 mg/day p.o. for two postoperative years. She subsequently became pregnant and delivered five years after the operation. After delivery, leactation and breast-feeding from the treated breast was successful for 10 months. Case 2: A 32-year-old woman with right non-invasive ductal carcinoma arising from a fibroadenoma underwent partial mastectomy and axillar dissection. She had no lymphnode metastasis and received no adjuvant chemotherapy. Three years after the operation, she became pregnant and also delivered. Lactation from the bilateral breasts was present, but breast-feeding was continued for only two months because of low milk production. Neither of these two cases underwent radiation therapy. There were no abnormalities of pregnancy or delivery, and both babies were normal.

A CASE OF SCIRRHOUS CARCINOMA OF THE STOMACH PROBABLY DEVELOPED FROM A MINUTE LESION IN THE BODY ON THE GREATER CURVATURE

A 52-year-old man was seen at the hospital because of nausea after meals lasting for about 19 days. Fluoroscopic examination of the stomach showed abnormal folds in the body on the greater curvature. The definite diagnosis could not be achieved even by biopsies performed two times. With both fluoroscopic and endoscopic findings strongly suggesting scirrhous carcinoma of the stomach, an operation was carried out, shich disclosed that marked infiltration into the serosa had already occurred. The patient died of carcinomatous peritonitis after 13 months. Excised specimens revealed minute ulcer lesions 2mm in diameter between the gastric folds in the upper body on the greater curvature. A histopathological examination showed that a poorly differentiated adenocarcinoma exposed on the mucosal surface involved only the bottom of the minute ulcer, with extensive invasion into sm to ss, and partly into se, covering almost whole-circumferentially from the upper body to angular notch of the stomach. The site was diagnosed as the primary focus. Early diagnosis of scirrhous gastric carcinoma is considered difficult because of the common site and characteristics of growth and infiltration patterns. It is thought that careful endoscopic search for minute ulcer lesions between the gastric folds is important to make an early definitive diagnosis, particularly in cases involving the gastric body on the greater curvature.

Differential responses of scirrhous and well-differentiated gastric cancer cells to orthotopic fibroblasts.

Scirrhous gastric cancer cells proliferate rapidly with fibrosis, when the cancer cells invade into the submucosa of the stomach. To investigate the mechanisms responsible for the rapid proliferation, the growth interaction between gastric cancer cells and fibroblasts was examined. Human gastric cancer cell lines established from scirrhous carcinoma or well-differentiated adenocarcinoma were used. Human fibroblast cell lines were obtained from various organs. The growth interaction between gastric cancer cells and fibroblasts was examined by calculating the number of cancer cells or by measuring [3H]thymidine incorporation of cancer cells. Gastric fibroblasts specifically stimulated the growth of scirrhous gastric cancer cells, but not that of well-differentiated adenocarcinoma cells. The growth factor(s) produced from gastric fibroblasts were then partially purified and characterised. The growth-promoting factor(s) had apparent molecular weights of 10000 dalton and was sensitive both to heat and proteinase treatment. No inhibition for the factor(s) was achieved with defined anti-growth factor antibodies. In this study, differential responses of scirrhous and well-differentiated gastric cancer cells to orthotopic fibroblasts were shown. Rapid proliferation of scirrhous gastric carcinoma should be partly controlled by orthotopic fibroblasts. The growth factor(s) from gastric fibroblasts, which was distinct from various defined growth factors such as epidermal growth factor (EGF), basic fibroblast growth factor (b-FGF), transforming growth factor-alpha (TGF-alpha), keratinocyte growth factor (KGF), vascular endothelial growth factor (VEGF), insulin-like growth factor I (IGF-I), hepatocyte growth factor (HGF), platelet-derived growth factor (PDGF) and transforming growth factor beta 1 (TGF-beta 1) may play an important role in the progression of scirrhous gastric cancer cells.

Short communication: detection of early scirrhous carcinoma of the stomach by endoscopic ultrasonography.

The endoscopic ultrasonography (US) characteristics of early scirrhous carcinoma of the stomach (ESS) were evaluated in four patients. ESS was defined as the presence of poorly differentiated carcinoma cells spreading through the submucosa and muscularis propria in association with a marked desmoplastic reaction without serosal invasion. ESS was characterized by localized irregular hypoechoic enlargement of the third (submucosal) and the fourth (muscularis propria) layers. The fifth (serosal) layer was normal. The third and fourth layers showed a threefold increase in thickness compared with the thickness of these layers in healthy subjects. Our results suggest that endoscopic US is useful for diagnosis of ESS.

Production of matrix metalloproteinases and tissue inhibitors of metalloproteinases in human breast carcinomas.

We examined production and tissue localization of matrix metalloproteinase (MMP)‐1 (tissue collagenase), MMP‐2 (gelatinase A), MMP‐3 (stromelysin‐1), MMP‐9 (gelatinase B), tissue inhibitors of metalloproteinase (TIMP)‐1 and TIMP‐2 in human breast carcinomas. In more than half of the cases, MMP‐1, MMP‐2, MMP‐9, TIMP‐1 and TIMP‐2 were immunolocalized in carcinoma cells and MMP‐2 was on the carcinoma cell membranes as well, whereas MMP‐3 was positively stained in less than 15% of the cases. MMP‐1 staining in carcinoma cells was significantly higher in scirrhous carcinoma than in other types of carcinoma. MMP‐9 expression was remarkably higher in the carcinoma cases with lymphnode metastasis than in the non‐metastatic cases. MMP‐3 was mainly expressed in T‐lymphocytes infiltrated in the tumor stroma. Stromal fibroblasts were positive for all these MMPs except for MMP‐3. The TIMP‐1 levels released into the culture media by carcinoma tissues were significantly lower than those by fibroadenoma tissues, although there were no significant differences in the levels of MMP‐1, MMP‐2, MMP‐9 and TIMP‐2. Gelatin zymographical analyses showed that the activation rate of the zymogen of MMP‐2 (proMMP‐2) is significantly higher in the more advanced carcinoma group with lymphnode metastasis than in the metastasis‐negative and fibroadenoma groups. These data indicate that MMP‐1, MMP‐2 and MMP‐9 are highly expressed in human breast carcinoma tissue and suggest that activation of proMMP‐2 may be an indicator of lymphnode metastasis of the breast carcinoma.

Immunohistochemical analysis of the poorly differentiated stomach adenocarcinoma with medullary growth pattern.

Poorly differentiated gastric adenocarcinoma with medullary features (poor medullary) is distinguished by a propensity for hepatic metastasis. To classify it antigenically, we compared it to poorly differentiated adenocarcinoma with scirrhous growth pattern (poor scirrhous), well and moderately differentiated adenocarcinoma (differentiated adenocarcinoma), and normal gastric mucosa (foveolar and deep epithelium) using immunohistochemistry with antibodies against CEA, AFP, NSE, and Lewis-type antigens. Lewis(a) antigen was significantly associated with differentiated adenocarcinoma and foveolar epithelium, although Lewis(x) antigen was significantly expressed in poor medullary, poor scirrhous, and deep gland epithelium. From the viewpoint of expression of Lewis(a), there was no significant differentiation between poor medullary and differentiated adenocarcinoma, but it was definite between poor scirrhous and differentiated adenocarcinoma. Therefore, we conclude that in antigenic expression, poor medullary carcinoma is allied with differentiated adenocarcinoma rather than poorly differentiated scirrhous carcinoma.

Immunohistochemical analysis of the poorly differentiated stomach adenocarcinoma with medullary growth pattern

Poorly differentiated gastric adenocarcinoma with medullary features (poor medullary) is distinguished by a propensity for hepatic metastasis. To classify it antigenically, we compared it to poorly differentiated adenocarcinoma with scirrhous growth pattern (poor scirrhous), well and moderately differentiated adenocarcinoma (differentiated adenocarcinoma), and normal gastric mucosa (foveolar and deep epithelium) using immunohistochemistry with antibodies against CEA, AFP, NSE, and Lewis-type antigens. Lewisb antigen was significantly associated with differentiated adenocarcinoma and foveolar epithelium, although Lewisx antigen was significantly expressed in poor medullary, poor scirrhous, and deep gland epithelium. From the viewpoint of expression of Lewisa, there was no significant differentiation between poor medullary and differentiated adenocarcinoma, but it was definite between poor scirrhous and differentiated adenocarcinoma. Therefore, we conclude that in antigenic expression, poor medullary carcinoma is allied with differentiated adenocarcinoma rather than poorly differentiated scirrhous carcinoma. © 1996 Wiley-Liss, Inc.

TWO CASES OF ACCESSORY BREAST CANCER

Accessory breast cancer is rare. Two cases of accessory breast cancer are described here. [Case 1] A 58-year-old woman was referred to the hospital after biopsy of a right axillary tumor at elsewhere. The excisional biopsy of the tumor revealed papillo-tubular carcinoma with mammary gland, without connection to the proper mammary gland. Modified radical mastectomy was performed. No lymph node metastasis was recognized. She is doing well without any evidence of recurrence, as of 6 years after the operation. [Case 2] A 64-year-old woman was admitted to our hospital because of a right axillary tumor. The excisional biopsy of the tumor revealed scirrhous carcinoma with mammary gland, without connection to the proper mammary gland. A wide local resection with axillary and subclavian lymph node dissection was performed. Six axillary lymph nodes were involved. She is doing well without any evidence of recurrence, as of 7 months after the operation. Sixty-five reported cases of accessory breast cancer in the Japanese literature, including these cases, are reviewed and discussed.

CT in patients with scirrhous carcinoma of the GI tract: imaging findings and value for tumor detection and staging.

The purposes of this study were to analyze the CT features of scirrhous carcinoma of the gastrointestinal (GI) tract and to assess the usefulness of CT in detecting and staging these lesions. This is a retrospective evaluation of 31 proven cases of scirrhous carcinoma (linitis plastica) of the GI tract imaged in our institution from 1986 to 1994. Twenty-two patients had primary gastric carcinoma, and nine had carcinoma of the colon (rectosigmoid in eight and right colon in one). CT examinations were reviewed and correlated with pathologic and/or surgical findings in all patients and with barium examinations in 19 cases. A modified Dukes classification was used to stage these lesions without knowledge of the pathologic and surgical results. Four gastric lesions were missed during the initial CT examination. Seventeen patients had extensive circumferential lesions, and five had focal plaquelike lesions. The wall thickness ranged from 1 to 3 cm (mean, 1.8 cm). Homogeneous enhancement was seen in 17 patients, slightly heterogeneous enhancement was seen in one, a target configuration was present in two patients, and intramural calcification was present in one patient. All colonic lesions were circumferential, homogeneously enhancing with a wall thickness ranging from 1 to 3 cm (mean, 2 cm). CT scans showed limitations in evaluating local parameters. Compared with surgical and pathologic staging, CT correctly staged 26 patients, understaged four patients, and overstaged one patient. Among the 19 patients with pathologically proven stage D lesions (61%), CT correctly staged 17 patients (89%) and had a 100% positive predictive value. One case of hepatic metastases, 13 cases of malignant ascites, and 11 cases of omental and peritoneal metastases were found. CT is an important complimentary imaging technique to detect scirrhous carcinoma. The sensitivity of detection depends on the size of the lesion and the quality of the examination. CT has limitations in staging early lesions but shows a high sensitivity (89%) in detecting Dukes stage D lesions. Accurate CT staging in these individuals (61% in this series) allows a more adequate treatment strategy and avoids unnecessary exploratory laparotomies.

Prognostic Significance of c-e<italic>rb</italic>B-2 Expression in Invasive Ductal Carcinoma of the Breast

The expression of c-erbB-2 oncoprotein was studied in relation to the histological type of invasive ductal carcinoma. The expression of c-erbB-2 was found in 26 (17.6%) of 148 cases, and was a significant prognostic indicator in patients with lymph node metastasis, but not in those without. The patients were divided into a scirrhous group and a non-scirrhous group on the basis of histological type. There was no significant difference between the two groups in age, clinical stage, lymph node status, estrogen receptor status, operation method or c-erbB-2 expression. The expression of c-erbB-2 was a significant prognostic indicator in the scirrhous group, irrespective of lymph node metastasis, but not in the non-scirrhous group. We conclude that the prognostic significance of c-erbB-2 expression differs among histological types of invasive ductal carcinoma, and that c-erbB-2 expression is a prognostic indicator in patients with scirrhous carcinoma.

Molecular biology of gastric cancer.

Gastric cancer involves changes in multiple oncogenes and multiple suppressor genes, and it causes genetic instability. Aberrant expression and amplification of the c-met gene, inactivation of the p53 gene, and CD44 abnormal transcripts are common events of both well differentiated and poorly differentiated gastric cancers. Amplification of the cyclin E gene is also observed in gastric cancer regardless of histologic type. Decreased expression of the pic1 (p21) gene occurs independent of the p53 mutations. In addition, K-ras mutations, c-erbB-2 gene amplification, loss of heterozygosity (LOH) and mutations of the APC gene, LOH of the bcl-2 gene, and LOH at the DCC locus are preferentially associated with well differentiated gastric cancer. Moreover, LOH on chromosome 1q is involved in the progression of well differentiated cancer. Precancerous lesions, including hyperplastic polyp, intestinal metaplasia, and adenoma, share genetic changes found in well differentiated cancers. Conversely, genetic instability may be involved in the first step of stomach carcinogenesis of the poorly differentiated type. Reduction or loss of cadherin and catenins, K-sam gene amplification, and c-met gene amplification are necessary for the development and progression of poorly differentiated or scirrhous carcinoma. Interaction between cell-adhesion molecules in the c-met expressed tumor cells and hepatocyte growth factor from stromal cells is implicated in the morphogenesis of two types of gastric cancer.(ABSTRACT TRUNCATED AT 250 WORDS)

Endosonographic evaluation of giant gastric folds

Giant gastric folds develop in several benign and malignant diseases. We used endoscopic ultrasonography to evaluate giant gastric folds in 15 patients with Borrmann type IV scirrhous carcinoma, 8 patients with gastric lymphoma, 5 patients with anisakiasis, 1 patient with Menetrier's disease, and 6 normal subjects with simple gastric hyperrugosity. With a 7.5 MHz transducer, a five-layered gastric wall structure was imaged. The thickness of the gastric wall and each layer was measured and compared with the endosonographic findings of 16 healthy subjects. Endoscopic ultrasonography findings revealed that the second layer alone was thickened in Menetrier's disease, and the third layer alone enlarged in anisakiasis. Most of the patients with scirrhous carcinoma showed an abnormally enlarged third and fourth layer. The second layer together with the third layer was thickened in healthy subjects with simple hyperrugosity and also in patients with gastric lymphoma. However, the fourth ultrasound layer corresponding to the muscularis propria was significantly thickened only in malignant conditions. It is concluded that endoscopic ultrasonography can visualize the structure of giant gastric folds and may facilitate the differentiation of benign from malignant etiologies.