Underestimation of Subserosal Invasion in Early Gastric Cancer-Like Advanced Gastric Carcinoma With Focal Enteroblastic Differentiation: A Case Report.
This case underscores the importance of integrating endoscopic and pathological findings to avoid underestimating tumor depth in gastric cancer assessments.
Where it sits
this study against the rest of the aod-9604 corpusSummary and findings
This case report discusses a rare instance of early gastric cancer-like advanced gastric carcinoma with focal enteroblastic differentiation. The study highlights the challenges in accurately assessing tumor depth preoperatively, revealing subserosal invasion that was underestimated due to superficial endoscopic features. Endoscopic submucosal dissection was performed, leading to further surgical resection and histopathological examination.
Abstract
Early gastric cancer (EGC)-like advanced gastric cancer (AGC) is a rare entity that mimics superficial disease despite deep invasion. We report a case of EGC-like AGC with focal enteroblastic differentiation in which subserosal invasion was underestimated because of its superficially appearing endoscopic features. A subtle submucosal tumor (SMT)-like change was recognized only retrospectively after clinicopathological correlation. Endoscopy revealed a depressed 0-IIc-appearing lesion with fold convergence toward a single point, leading to a diagnosis of UL1; however, no mound-like elevation was observed. Retrospective review identified a subtle SMT-like protrusion on the anterior wall, slightly apart from the main depression. Endoscopic submucosal dissection (ESD) was performed for presumed EGC. During ESD, a whitish cord-like structure extending from the muscularis propria was identified at the corresponding site. The ESD specimen showed submucosal invasion with a positive vertical margin, and additional surgical resection revealed subserosal invasion. Histopathological examination of the surgical specimen demonstrated tubular adenocarcinoma (tub2>por1/tub1) with focal enteroblastic differentiation and subserosal invasion (pT3 [SS]) without lymph node metastasis but with venous invasion (V1c). Immunohistochemistry showed CK7 positivity, CK20 negativity, and partial expression of CDX2, glypican-3, and SALL4, whereas AFP was negative. Clinicopathological correlation showed that the retrospectively recognized SMT-like change corresponded to the deepest invasive component. This case highlights the difficulty of preoperative depth assessment in EGC-like AGC. Careful integration of endoscopic, intraoperative, and clinicopathological findings may help avoid underestimation of tumor depth.
Background
The paper addresses the challenges in accurately assessing the depth of invasion in early gastric cancer-like advanced gastric carcinoma. Prior knowledge indicates that superficial features can obscure deeper invasion, complicating diagnosis and treatment. This case is significant as it underscores the importance of integrating various clinical findings to improve preoperative assessments.
Methods
This is a case report involving a patient with early gastric cancer-like advanced gastric carcinoma. The endoscopic examination and subsequent endoscopic submucosal dissection (ESD) were performed, followed by histopathological analysis of the resected specimens. Specific immunohistochemical markers were evaluated to characterize the tumor.
Results
The primary endpoint observed was subserosal invasion classified as pT3 (SS) without lymph node metastasis but with venous invasion (V1c). The endoscopic findings included a depressed lesion with fold convergence, and the histopathological examination revealed submucosal invasion with a positive vertical margin.
Interpretation
This case adds to the literature by illustrating the potential for underestimating tumor depth in early gastric cancer-like advanced gastric carcinoma. While the findings are statistically significant, the clinical implications may be limited due to the single case nature of the report. The retrospective nature and lack of broader population data may confound the conclusions drawn.
Key findings
- Endoscopic examination revealed a depressed 0-IIc-appearing lesion.
- During ESD, a whitish cord-like structure was identified extending from the muscularis propria.
- Histopathological examination showed submucosal invasion with a positive vertical margin.
- Surgical resection revealed subserosal invasion classified as pT3 (SS).
- No lymph node metastasis was observed, but venous invasion was noted (V1c).
Limitations
- Single case report limits generalizability.
- Retrospective analysis may introduce bias.
- No broader population data to support findings.
- Potential for misinterpretation of endoscopic features.