Feasibility of endoscopic treatment and predictors of lymph node metastasis in early gastric cancer

BACKGROUND Endoscopic submucosal dissection (ESD) has been routinely performed in applicable early gastric cancer (EGC) patients as an alternative to conventional surgical operations that involve lymph node dissection. The indications for ESD have been recently expanded to include larger, ulcerated, and undifferentiated mucosal lesions, and differentiated lesions with slight submucosal invasion. The risk of lymph node metastasis (LNM) is the most important consideration when deciding on a treatment strategy for EGC. Despite the advantages over surgical procedures, lymph nodes cannot be removed by ESD. In addition, whether patients who meet the expanded indications for ESD can be managed safely remains controversial. AIM To determine whether the ESD indications are applicable to Chinese patients and to investigate the predictors of LNM in EGC. METHODS We retrospectively analyzed 12552 patients who underwent surgery for gastric cancer between June 2007 and December 2018 at the Affiliated Hospital of Qingdao University. A total of 1262 (10.1%) EGC patients were eligible for inclusion in this study. Data on the patients’ clinical, endoscopic, and histopathological characteristics were collected. The absolute and expanded indications for ESD were validated by regrouping the enrolled patients and determining the positive LNM results in each subgroup. Predictors of LNM in patients were evaluated by univariate and multivariate analyses. RESULTS LNM was observed in 182 (14.4%) patients. No LNM was detected in the patients who met the absolute indications (0/90). LNM occurred in 4/311 (1.3%) patients who met the expanded indications. According to univariate analysis, LNM was significantly associated with positive tumor marker status, medium (20-30 mm) and large (>30 mm) lesion sizes, excavated macroscopic-type tumors, ulcer presence, submucosal invasion (SM1 and SM2), poor differentiation, lymphovascular invasion (LVI), perineural invasion, and diffuse and mixed Lauren’s types. Multivariate analysis demonstrated SM1 invasion (odds ration [OR]= 2.285, P = 0.03), SM2 invasion (OR = 3.230, P < 0.001), LVI (OR = 15.702, P < 0.001), mucinous adenocarcinoma (OR = 2.823, P = 0.015), and large lesion size (OR = 1.900, P = 0.006) to be independent risk factors. CONCLUSION The absolute indications for ESD are reasonable, and the feasibility of expanding the indications for ESD requires further investigation. The predictors of LNM include invasion depth, LVI, mucinous adenocarcinoma, and lesion size.

Gastric adenocarcinoma of fundic gland type after Helicobacter pylori eradication:A case report

BACKGROUND Gastric adenocarcinoma of fundic gland type (GA-FG) has recently been proposed as a novel histological type of gastric cancer. CASE SUMMARY We report a case of GA-FG in a 77-year-old Chinese woman with epigastric distention who was referred to endoscopy for the management of an incidentally found submucosal tumor-like elevated lesion in the lower part of the gastric body. The tumor occurred after Helicobacter pylori (H. pylori) eradication therapy without long-term use of proton pump inhibitors. Complete and curable removal of the tumor was performed by endoscopic submucosal dissection. Histopathological findings showed numerous cells with basophilic cytoplasm and mildly atypical nuclei-like chief cells of the fundic gland. The tumor was observed to have the so-called “endless glands” pattern of the well-differentiated mixed phenotype. A safe resection margin without lymphatic and venous invasion was observed. As the tumor occurred after H. pylori eradication therapy, it is unknown whether there was a relationship with H. pylori eradication. The patient will be followed up by periodic gastroscopic observation. CONCLUSION In conclusion, we report a case of GA-FG after H. pylori eradication therapy without long-term proton pump inhibitors use. Further analysis of similar cases will reveal the clinical behavior of GA-FG.

Laterally spreading tumor-like primary rectal mucosa-associated lymphoid tissue lymphoma:A case report

BACKGROUND Colorectal mucosa-associated lymphoid tissue(MALT)lymphoma is a rare disease,and only a few cases have been reported to date.It has no specific clinical presentations and shows various endoscopic appearances.There is no uniform consensus on its treatment.With the advancement of endoscopic technology,endoscopic treatment has achieved better results in individual case reports of early-stage patients.CASE SUMMARY We report a case of rectal MALT in a 57-year-old Chinese man with no symptoms who received endoscopy as part of a routine physical examination,which incidentally found a 25 mm×20 mm,laterally spreading tumor(LST)-like elevated lesion in the rectum.Therefore,he was referred to our hospital for further endoscopic treatment.Complete and curable removal of the tumor was performed by endoscopic submucosal dissection.We observed enlarged and dilated branch-like vessels similar to those of gastric MALT lymphoma on magnifying endoscopy with narrow-band imaging.And immunopathological staining showed hyperplastic capillaries in the mucosa.Histopathological findings revealed diffusely hyperplastic lymphoid tissue in the lamina propria,with a visible lymphoid follicle structure surrounded by a large number of diffusely infiltrated lymphoid cells that had a relatively simple morphology and clear cytoplasm.In addition,immunohistochemical analysis suggested strongly positive expression for CD20 and Bcl-2.Gene rearrangement results showed positivity for IGH-A,IGH-C,IGK-B,and IGL.Taking all the above findings together,we arrived at a diagnosis of extranodal marginal zone B-cell lymphoma of MALT lymphoma. Positron emission tomography-computed tomographyexamination showed no other lesions involved. The patient will be followed byperiodic endoscopic observation.CONCLUSIONIn conclusion, we report a case of rectal MALT with an LST-like appearancetreated by endoscopic submucosal dissection. Further studies will be needed toexplore the clinical behavior, endoscopic appearance, and treatment of rectalMALT.

Lymphangiomatosis associated with protein losing enteropathy:A case report

BACKGROUND Lymphangiomatosis is a multisystem disorder that is rarely localized to the gastrointestinal tract.Lymphangiomatosis usually has no specific clinical presentation and is easily misdiagnosed.A case report and review of the literature on lymphangiomatosis associated with protein-losing enteropathy will help to improve the overall understanding of this disease.CASE SUMMARY We report a case of lymphangiomatosis of the bowel and other solid organs.A 78-year-old man presented with recurrent bowel bleeding and protein-losing enteropathy,as well as cystic lesions in the spleen,liver,and kidney.Imaging examinations revealed many cystic lesions on the spleen,liver,kidney,and thickened wall of the ascending colon,as well as pleural effusion and ascites.Colonoscopy revealed a strawberry mucosa,variable spontaneous bleeding,and surface erosion located in the terminal ileum.Several cystic masses with a translucent and smooth surface as well as diffuse white spots were located in the colon.A laterally spreading tumor(LST)was located in the ascending colon.Pathology indicated highly differentiated adenocarcinoma(LST)and lymphangiomatoid dilation,and D2-40 was positive.The final diagnosis was lymphangiomatosis.The patient underwent surgery for LST and then was administered thalidomide 75-150 mg/d.His condition,however,did not improve.He eventually died 6 mo after the initial diagnosis.CONCLUSION Lymphangiomatosis usually occurs diffusely and can involve many organs,such as the spleen,kidney,liver,lung,mesentery,and bowel.Recurrent bowel bleeding or protein-losing enteropathy is an important indicator that should alert clinicians about the possibility of this disease when it afflicts the bowel.Doctors should improve the medical understanding of lymphangiomatosis.

Atypical aggressive vertebral hemangioma of the sacrum with postoperative recurrence:A case report

BACKGROUND Aggressive vertebral hemangioma(VH)is an uncommon lesion in the adult population.The vast majority of aggressive VHs have typical radiographic features.However,preoperative diagnosis of atypical aggressive VH may be difficult.Aggressive VHs are likely to recur even with en bloc resection.CASE SUMMARY A 52-year-old woman presented with a 3-mo history of numbness and pain in her right lower extremity.Physical examination showed sacral tenderness and limited mobility,and the muscle strength was grade 4 in the right digital flexor.Computed tomography revealed osteolytic bone destruction from S1 to S2.Magnetic resonance imaging(MRI)showed that the mass was compressing the dural sac;it was heterogeneously hypointense on T1-weighted MRI and hyperintense on T2-weighted MRI,and gadolinium contrast enhancement showed that the tumor was heterogeneously enhanced and invading the vertebral endplate of S1.The patient developed progressive back pain and numbness in the bilateral extremities 6 mo postoperatively,and MRI examination showed recurrence of the mass.The mass was larger in size than before the operation,and it was extending into the spinal canal.CONCLUSION The radiographic findings of atypical aggressive VH include osteolytic vertebral bone destruction,extension of the mass into the spinal canal,and heterogeneous signal intensity on T1-,T2-,and enhanced T1-weighted MRI.These characteristics make preoperative diagnosis difficult,and biopsy is necessary to verify the lesion.Surgical decompression and gross total resection are recommended for treatment of aggressive VH.However,recurrence is inevitable in some cases.