keywords
- gastric one-point cancer
- early gastric cancer
- endoscopic mucosal resection
- endoscopic submucosal dissection
Introduction
Carcinoma of the stomach is the most common malignant tumor in China. Due to advanced endoscopic techniques and equipment, the detection of early gastric carcinoma (EGC) has increased worldwide. Yet gastric one-point cancer is rarely detected.
Case Report
A 55-year-old male patient was admitted for surgery with a 30-year history of gastrodynia, and a 20-day history of blunt epigastric pain, nausea, heartburn, and loss of body weight without haematemesis or dark stools. His, and his family medical history was unremarkable. He visited a local hospital due to epigastric pain on January 7, 2008.
Gastroscopy disclosed a 1.0 cm × 0.8 cm ulcer in the pyloric antrum of the greater curvature, and another duodenobulbar ulcer at the healing stage measuring 0.4 cm × 0.3 cm. Light microscopic examination of an endoscopic biopsy specimen showed adenocarcinomas with severe atypical hyperplasia in the gastric mucosa (Fig.1).
Light microscopic examination of the endoscopic biopsy specimen (H&E stain, × 100).
The patient subsequently underwent subtotal gastrectomy with a Roux-en-Y esophagojejunostomy and lymphoadenectomy on January 31, 2008. During surgery, no ascites or peritoneal dissemination was seen. The serosal surface of the stomach was smooth. There was no histological evidence of invasion into the veins or lymphatics.
Postoperative microscopic examination showed severe atypical hyperplasia in the gastric mucosa, but no cancer cells (Fig.2). Also there was no micrometastasis in the perigastric lymph nodes. The postoperative course of this patient was uneventful, and about 40 days later he was discharged without further therapy.
Light microscopic examination of the postoperative specimen (H&E stain, × 100).
Discussion
Early gastric cancer (EGC) was first defined in 1962 by the Japanese Society of Gastroenterological Endoscopy as adenocarcinoma confined to the mucosa or submucosa irrespective of lymph node involvement. Lesions with a maximum diameter of 5 mm or less are classified as minute, and those with a diameter of between 6 and 10 mm as small.
Microscopic examination of endoscopic biopsy specimens show carcinomas, but with a postoperative histopathologic examination no cancer cells can be detected. This type of early gastric cancer is defined as one-point cancer, which is fairly rare in EGC.
Despite only minor local invasion in EGC, lymph node invasion is still relatively common. Lymph node metastasis is one of the most important prognostic factors for EGC. Favorable therapeutic effects on EGCs have been obtained with regional lymphadenectomy[1]. Recently, less invasive treatments have been performed for EGC, including endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD)[2-7]. There are theoretical risks, however, in such approaches. First, EGC is frequently associated with synchronous tumours that are not detected during endoscopic examination, and would therefore not be removed at the time of EMR. Second, even if there are no synchronous cancers, the remaining stomach is likely to contain areas of premalignant change, such as intestinal metaplasia or dysplasia that would confer a high risk of carcinoma in the future. Third, it is difficult to be sure of the depth of invasion preoperatively, even with endoscopic ultrasound, making it extremely difficult to confidently exclude node metastasis preoperatively. In general, the most widely and successfully performed operation for EGC is gastrectomy (distal, proximal or total) with radical D2 lymphadenectomy[8-15].
- Received February 29, 2008.
- Accepted May 22, 2008.
- Copyright © 2008 by Tianjin Medical University Cancer Institute & Hospital and Springer