Superficial Depressed Lesions Research Articles

Gastric dysplastic lesions in Helicobacter pylori-naïve stomach: Foveolar-type adenoma and intestinal-type dysplasia.

Reports of Helicobacter pylori (Hp)-naïve gastric neoplasm (HpNGN) cases have been rapidly increasing due to the recent increase in the Hp-naïve population in Japan. Most HpNGNs exhibit the gastric immunophenotype and a low malignant potential regardless of histological type. Especially, foveolar-type gastric adenoma (FGA) and intestinal-type gastric dysplasia (IGD) rarely progress to invasive carcinoma. FGA is a foveolar epithelial neoplasm that occurs in the fundic gland (oxyntic gland) mucosa and is classified as the flat type or raspberry type (FGA-RA). The flat type is a large, whitish flatly elevated lesion while FGA-RA is a small reddish polyp. Genomically, the flat type is characterized by APC and KRAS gene mutations and FGA-RA by a common single nucleotide variant in the KLF4 gene. This KLF4 single-nucleotide variant reportedly induces gastric foveolar epithelial tumorigenesis and activates both cell proliferation and apoptosis, leading to its slow-growing nature. IGD consists of an intestinalized epithelial dysplasia that develops in the pyloric gland mucosa, characterized as a superficial depressed lesion surrounded by raised mucosa showing a gastritis-like appearance. Immunohistochemically, it exhibits an intestinal or gastrointestinal phenotype and, frequently, p53 overexpression. Thus, IGD shows unique characteristics in HpNGNs and a potential multistep tumorigenic process.

Atypical intrapapillary capillary loops in early-stage basaloid squamous cell carcinoma of the esophagus.

Basaloid squamous cell carcinoma of the esophagus (BSCCE) is rare and extremely difficult to identify at early stage.We herein presented a superficial depressed lesion at early stage.

Three Cases of Synchronous Laparoscopic Resection for Gastric and Colonic Cancer

Case 1 was an 84-year-old female who suffered from a superficial elevated lesion within depressed area (0 IIc+IIa) from the lesser curvature to the posterior wall at the middle corpus of the stomach and a depressed lesion with a circumferential embankment (type 2) at the sigmoid colon. Case 2 was a 70-year-old male who suffered from a superficial depressed lesion (0 IIc) at the lesser curvature of the gastric angle and a superficial elevated lesion (0 IIa) at the cecum. Case 3 was a 58-year-old male who suffered from a superficial depressed lesion (0 IIc) from the lesser curvature to the posterior wall at the middle corpus of the stomach, and an elevated lesion (type 1) and a depressed lesion with a circumferential embankment (type 2) at the sigmoid colon. In 3 cases, we first inserted 5 or 6 trocars and performed laparoscopic distal gastrectomy with groups 1 and 2 lymph node dissection according to the Japanese Classification of Gastric Carcinoma. Subsequently, in case 1, 1 additional port was inserted at the right lower quadrant for sigmoidectomy; in case 2, two trocars were added for ileocecal resection; and in case 3, one additional port was inserted at the median hypogastric region for sigmoidectomy. In cases 1 and 2, Billroth II reconstruction was performed using a laparoscopic linear stapling device (endo-GIA) and, in case 3, Roux-en-Y reconstruction was performed using endo-GIA, after distal gastrectomy. The double stapling technique using a conventional circular stapling device was performed after pulling out the specimen from the paraumbilical port after colectomy in case 1, whereas an end-to-end triangular suture using endo-GIA was used extracorporeally through the paraumbilical port in case 2 and the median hypogastric port in case 3. The operative durations of cases 1, 2, and 3 were 315, 340, and 495 minutes and the amounts of blood loss were 80, 300, and 440 mL, respectively. Except for the need to retain the drain until the tenth postoperative day because of serous discharge in case 1, no postoperative complications occurred. The postoperative commencement of oral feeding was on the fifth day in case 1 and on the third day in cases 2 and 3. All cases made a quick recovery and they were discharged from hospital on the nineteenth, thirteenth, and tenth day after operation, respectively. Double cancer patients with gastric and colonic carcinomas were thought to be very suitable for laparoscopic surgery because by avoiding a total median skin incision, there is less wound pain and quicker postoperation recovery.

Gastrointestinal: Gastric mucosa‐associated lymphoma presented with unique vascular features on magnified endoscopy combined with narrow‐band imaging

Gastric lymphoma arising from mucosal associated lymphoid tissue (MALT) has distinct clinical and histological characteristics compared with nodal B-cell lymphoma. Magnified endoscopy (ME) combined with narrow band imaging (NBI) is widely used and the usefulness is well recognized for the diagnosis of gastritis and gastric cancer. However, there has been no report on ME combined with NBI for gastric MALT lymphoma, despite the necessity of differentiating it from gastric cancer. We report a case ofgastricMALTlymphomainwhichMEcombinedwithNBIcould detectuniquevascularfeaturesdifferentfromthoseseenincircumscribed atrophic gastritis or poorly differentiated adenocarcinoma. A 66-year-old woman underwent endoscopic screening of the upper gastrointestinal tract revealed ill-defined, brownish, superficial depressed lesion in the anterior wall of the upper gastric body (Fig. 1). ME combined with NBI system, consisting of an image processor (CV-260SL, Olympus Medical Systems, Tokyo, Japan), a light source (CLV-260SL), and a zoom endoscope (GIF-Q240Z) showed the disappearance of the surface structure and the appearance of abnormal blood vessels.Abnormal vessels were defined as new vessels that were not seen in the adjacent mucosa. They were large vessels like a tree trunk with long, bare branches that can be called as ‘tree like appearance’ (Fig. 2). Biopsy was taken from this abnormal portion and revealed hyperplasia of atypical centrocyte-like cells with small to medium-sized, ovoid nuclei and clear cytoplasm in the lamina propria mucosae and their infiltration among glandular epithelial cells, suggesting lymphoepithelial lesion. The atypical lymphocytes were immunohistochemically CD20+ ,C D10-, and CD5-. These findings were consistent with gastric MALT lymphoma. In this case report, we have shown that the tree-like appearance of the abnormal blood vessels, clearly observed by ME with NBI, could be one of the unique features suggestive of gastric MALT lymphoma. This finding could be helpful because superficial depressed type lesion potentially include circumscribed atrophic gastritis and poorly differentiated adenocarcinoma. Of note, these vascular findings are relatively easy to detect by using NBI, because NBI can present clearly defined vascular image. Therefore, our data also suggest the importance of NBI for the endoscopic evaluation of gastric MALTlymphoma.The combination of ME with NBI may also reduce the number of biopsy of gastric MALT lymphoma because it can provide precise information about the distribution of MALT lymphoma in the stomach.

A CASE OF EARLY GASTRIC CANCER ACCOMPANIED BY DIEULAFOY ULCER IN A YOUNG WOMAN

A case of early gastric carcinoma accompanied by Dieulafoy ulcer is presented. The patient, a 26‐year‐old female, visited our emergency room with chief complaints of massive hematemesis and tarry stool. The initial endoscopic examination revealed a superficial depressed lesion with a faded color accompanied by a tiny ulcer with converging folds at the anterior wall of the middle gastric body. Although no active bleeding vessel was found at that time, the patient was admitted to our hospital for further check‐ups and treatment. On the 6th hospital day, she developed massive hematemesis resulting in shock. Urgent endoscopy, this time, disclosed an exposed bleeding vessel at the small ulcer floor previously mentioned, and endoscopic hemostasis was achieved. Since, however, a biopsy at initial examination from the surrounding depressed area proved carcinoma, a partial distal gastrectomy was subsequently carried out. Histological examination of the resected specimen confirmed the diagnosis of carcinoma limited to the mucosa and submucosa along with findings consistent with Dieulafoy ulcer. This is a rare case of combination of early cancer and Dieulafoy ulcer particularly in such a young patient. A review of the literature is also presented.

Retrospective radiographic analysis of nonpedunculated colorectal carcinomas with special reference to tumor doubling time and morphological change

OBJECTIVE: Our aim was to characterize the development of nonpedunculated colorectal carcinomas by retrospective radiographic analysis, with special reference to tumor doubling time and morphological change. METHODS: Eleven colorectal carcinomas, which were observed for >6 months by barium enema examinations, were collected and retrospectively reviewed. There were five early and six advanced carcinomas, including submucosally invasive, superficial depressed carcinomas. RESULTS: Mean diameter of lesions at initial barium enema examination was 13.5 mm (early, 10.4 mm; advanced, 16.0 mm) and that at final barium enema examination was 30.9 mm (early, 18.2 mm; advanced, 41.5 mm). Initial morphology of the lesions was superficial in three, sessile in seven, and semipedunculated in 1. There was no pedunculated lesion. Macroscopic morphology of the five early carcinomas was superficial depressed (IIc) in two cases, mostly depressed but partly elevated (IIc+IIa) in one case, and superficial elevated with a depressed component (IIa+IIc) in two cases; all of the advanced carcinomas were of the ulcerated type. Mean doubling time was 6.8 months (early, 9.4 months; advanced, 4.7 months). Early carcinomas had significantly longer doubling times than advanced carcinomas ( p = 0.017, Wilcoxon’s text). The lesions with the longest doubling times were superficial depressed lesions. CONCLUSIONS: Early carcinomas have longer doubling times than advanced carcinomas. Most nonpedunculated colorectal carcinomas grow without significant morphological changes. Superficial depressed type tumors grow slowly, maintaining their macroscopic morphology.

TWO CASES OF CARCINOMA IN THE DISTAL GASTRIC REMNANT AFTER PROXIMAL GASTRECTOMY

This paper presents two cases of carcinoma occurred in the distal gastric remnant. Case 1; A 68-year-old woman, who underwent proximal gastrectomy with esophagogastrectomy and pyloroplasty for a gastric leiomyosarcoma 4 years before, was found to have a Borrmann III type carcinoma at the antrum of the remnant stomach on upper GI series and endoscopy. No distant metastases were detected. Then, total gastrectomy and splenectomy with lymphnode dissection were performed. Histological findings of the resected material were pT3 pN3 and poorly differentiated adenocarcinoma.Case 2; A 76-year-old man, who underwent the same surgery as Case 1 for an early gastric carcinoma in the cardiac region 13 years before, was found to have a superficial depressed lesion at the posterior wall just under the esophagogastrostomy on recent examination. Biopsied specimen disclosed that it was well differentiated adenocarcinoma of the remnant stomach. Operation is suspended at present, because the patient disagreed with surgical treatment.It is though that the frequency of carcinoma in the distal gastric remnant is probably high after proximal gastrectomy. because the remnant portion is a common site for malignancy and it is exposed with regurgitation of duodenal juice. However, previously reported cases including our two cases numbered only 26 in the Japanese literature for 3 decades since 1968. This paper also presents some bibliographical discussion in terms of clinicopathological pictures and possible carcinogenic mechanisms.

Endoscopic and pathologic features of Epstein-Barr virus–associated gastric carcinoma

Background: Although the presence of Epstein-Barr virus has been documented in approximately 7% of patients with gastric carcinoma, the clinical features of Epstein-Barr virus–associated carcinoma have not been well documented. We studied the histologic and endoscopic characteristics of Epstein-Barr virus–associated gastric carcinoma. Methods: We tested 124 gastric carcinomas from 117 patients using in situ hybridization for Epstein-Barr virus encoded small RNA1. The histologic and endoscopic findings in the Epstein-Barr virus–associated groups and the negative control groups were analyzed and compared. Results: Twelve tumors (9.7%) were identified as Epstein-Barr virus associated. These lesions were located mainly in the upper part of the stomach (p < .05) and had a diffuse-type histology (p < .05) compared with those in the control group. Six of seven (85.7%) early Epstein-Barr virus–associated lesions were type 0 IIc (superficial depressed) or a combined type, and 42.9% were accompanied by submucosal nodules of carcinoma with lymphoid stroma. Four of five (80%) advanced Epstein-Barr virus–associated tumors were type 3 (ulcerated without definite limits), thought to be the advanced shape of superficial depressed lesions. Conclusions: Epstein-Barr virus–associated gastric carcinomas often appear as superficial depressed or ulcerated lesions in the upper part of the stomach and have a diffuse-type histology with lymphoid infiltration. (Gastrointest Endosc 1997;45:236-42.)

Natural history of superficial depressed colorectal cancer: retrospective radiographic and histologic analysis.

To characterize the growth and developmental changes of superficial depressed colon cancer by using retrospective radiographic and histologic data. In a retrospective study, the radiographs in patients with nine superficial depressed and those with 12 elevated (sessile or semipedunculated) colon cancers were analyzed. The initial superficial depressed lesions were 11.7 mm (mean) in diameter and took an average of 32.3 months to double in size. The initial elevated lesions were 15.7 mm (mean) in diameter and took an average of 8.6 months to double in size. The initial size of the former was not statistically significantly different from that of the latter; however, the doubling time of the superficial depressed cancers was statistically significantly slower than that of the elevated cancers. Superficial depressed cancers did not have concomitant adenomatous components, did not develop rapidly into advanced cancer, and did not change greatly from their original configuration; their growth rate was rather slow. Histologically, superficial depressed cancers showed a nonpolypoid growth pattern. Superficial depressed cancer develops more slowly than does elevated cancer, and this development follows a nonpolypoid growth pattern.

Endoscopic and Histopathological Study about 25 Cases of Minute Superficial Depressed Neoplastic Lesions in the Large Intestine

Abstract: We studied 25 cases of minute (less than 5 mm in a diameter) superficial depressed neoplastic lesions during the period of March 1990 to September 1991. These depressed neoplastic lesions were recognized by colonoscopy as asteroid redness with surrounding elevation. The thickness and height of the surrounding elevations were modified by air volume. Occasionally, they seemed according to the air volume to be elevated lesions, though their fundamental form was confirmed as being superficial depressed lesions from observations of histopathological sections and using a dissecting microscope. The endoscopic figures were emphasized by sprinkling them with Methylene Blue.All of the minute depressed neoplastic lesions were histopathologically diagnosed as being tubular adenoma. For the purpose of confirming the histopathological character of the depressed neoplastic lesions (n = 25) and distinguishing them from conventional elevated adenomas (n = 71) of the same diameter, we compared the incidences of glandular crowding, nuclear stratification, nuclear pleomorphism and loss of nuclear polarity in two groups. Glandular crowding and nuclear pleomorphism were recognized significantly more often in the depressed neoplastic lesions than in the elevated adenomas.Although most of the minute depressed neoplastic lesions were fundamentally adenomas, because of their unique histopathologic character, they could give new insight into the development of colon cancer.