Two endoscopic submucosal dissection procedures ...

[Downloaded free from http://www.cancerjournal.net on Wednesday, September 28, 2016, IP: 95.49.95.63]

Original Article

Two endoscopic submucosal dissection procedures for stripping huge segment of the gastric mucosa to treat early gastric signet ring cell carcinoma ABSTRACT Aim: To introduce the method of stripping of early gastric signet ring cell carcinioma by two ESD procedures. Methods: A lesion of early gastric signet ring cell carcinoma in an elderly was removed by two consecutive ESD procedures. The pathology was analyzed and the patient was followed-up. Results: The lesion removed by first ESD procedure, which was 10cm in diameter, has tumor tissue on its edge, and the second lesion which was 5cm in diameter had an edge without tumor. There was no metastasis or recurrence during 24-month follow-up. Conclusion: We first described the method using two consecutive ESD procedures in man with gastric signet ring cell carcinoma, and the procedure was proved to be safe and efficient. KEY WORDS: Early gastric cancer, endoscopic submucosal dissection, gastric signet ring cell carcinoma

INTRODUCTION

PATIENT, METHODS AND RESULTS

Early gastric cancer (EGC) is a commonly encountered clinical problem in cases undergoing gastroscopy. There are constant improvements of gastroendoscopic treatment technology, which has led to endoscopic submucosal dissection (ESD) being more widely used. This technology completely strips the gastric mucous membrane using an endoscope to treat cases of gastric cancer, including cases that are detected in the early stages. Before the procedure, the extent of the tumor must be determined. The normal mucosa surrounding the lesion is marked at least 5 mm away from the tumor. The entire mucous membrane is stripped, followed by pathological examination. In the present study, we are the first to describe a case involving the use of case of two consecutive ESD procedures in an elderly man with gastric signet ring cell carcinoma who underwent surgery for colon cancer 20 days previously. The patient was followed‑up for 24 months, and there were no signs of recurrence or metastasis. We first used ESD to strip off the mucosa in an area with a 10 cm diameter. However, the pathological analysis showed residual malignant cells at the mucosal edge; therefore, we performed a second ESD.

In the present study, we describe a case of EGC in an 81‑year‑old man complaining of epigastric discomfort who was diagnosed with signet ring cell carcinoma by gastroscopy 20 days after he had undergone colon cancer surgery. The patient agreed to undergo gastroscopy, which indicated a lesion in the stomach that was histopathologically diagnosed as signet ring cell carcinoma confined to the mucosal region. The lesion is in the gastric body, and gastric antrum junction was red, had a patchy distribution, and an easily bleeding mucous membrane [Figure 1]. The lesion was 6 cm × 7 cm in diameter, and demarcation of the lesion was not clearly visible by normal endoscopy. The patient was diagnosed with EGC and underwent two ESD procedures using This is an open access article distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as the author is credited and the new creations are licensed under the identical terms.

Shengxi Li, Meidong Xu1, Chu Yuan1 Digestive Endoscopy Center, People’s Hospital of Liaoning Province, Shenyang, Liaoning 110016, 1 Digestive Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China For correspondence: Prof. Meidong Xu, Digestive Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China. E‑mail: xumeidong@ aliyun.com

Shengxi Li and Chu Yu a n c o n t r i b u t e d equally to this work. Access this article online Website: www.cancerjournal.net DOI: 10.4103/0973-1482.170532 PMID: *** Quick Response Code:

For reprints contact: [email protected]

Cite this article as: Li S, Xu M, Yuan C. Two endoscopic submucosal dissection procedures for stripping huge segment of the gastric mucosa to treat early gastric signet ring cell carcinoma. J Can Res Ther 2015;11:C253-7.

© 2015 Journal of Cancer Research and Therapeutics | Published by Wolters Kluwer - Medknow

C253


Li, et al.: Two ESD procedures for stripping huge segment to treat early gastric signet ring cell carcinoma

endoscopy after narrow‑band imaging (NBI) [Figure 2]. We obtained five pieces of tissue for pathological examination, which led to a diagnosis of signet ring cell carcinoma. Pathological analysis confirmed that the lesions only invaded the mucosal layer [Figure 3]. Because the lesion area was large, we suggested that the patient should undergo surgical removal of the lesions. However, the patient chose to undergo the ESD procedure. The patient was placed under general anesthesia using a breathing tube inserted intravenously. An Olympus gastroscope with an attached water channel along with NBI was used to determine the extent of the lesions, which were marked with an argon knife [Figure 4]. Prior to the surgical procedure, we performed a submucosal injection with indigo carmine at the lesion, and the lesion could be appropriately lifted. The mucosa that contained the lesions was gradually peeled off with a hook knife and insulation‑tipped (IT) knife [Figure 5]. The stripped mucous membrane was approximately 10 cm in diameter [Figure 6]. We performed a pathological examination of the entire section of peeled mucosa, which indicated the presence of tumor tissue at an edge of the peeled 10 cm of mucous membrane [Figure 4]. The 10 cm diameter section of the mucous membrane that was removed revealed that the tumor tissue was limited to the intramucosal layer [Figure 4]. However, we did not mark the location of the stripped mucosa in relation to the gastric body. The edge of the stripped mucous membrane revealed residual carcinoma tissue. Since the patient refused to undergo surgery, the physician proposed an alternative method. Along the edge of the cut gastric mucosa, we marked a total of 38 blocks at 5‑mm intervals from the edge; accordingly, samples were removed and were stored and sent for pathologic examination [Figure 7]. Pathological results showed that heterocyst was detected on the anterior wall of the gastric mucosa residual margin (block 15) [Figure 8]. We decided to perform another ESD stripping procedure, including the atypical cells of the gastric mucosa. The patient was placed under intravenous anesthesia, and a region of the gastric mucosa comprising differently shaped cells of approximately 5 cm in diameter was stripped away by ESD [Figure 9]. The wound was cleaned with argon gas before completion of the surgery, and the specimens were sent for pathological examination, which indicated no abnormal results. Four months after the patient received ESD, a gastroscopy examination indicated that the gastric antrum junction formed a false pylorus [Figure 10]. After that, the patient underwent gastroscopy examination in 3‑month intervals, and no abnormal results were detected until 24 months [Figures 11 and 12] since the first ESD procedure. DISCUSSION With the development of digestive endoscopic diagnosis and treatment technology, early cancer can be treated by endoscopic C254

Figure 1: Gastroscopy examination revealed that the mucous membrane was patchy, red, and bled easily (arrow)

Figure 2: Gastroscopy revealed that the mucous membrane was patchy, red, and bled easily (arrow)

a

b

c

d

Figure 3: (a-d) Pictures of (H and E, ×100); images for immune SP staining, ×100, CK (+ + +) CEA (+ + +). Pathological diagnosis: Chronic superficial gastric mucosal inflammation (chronic superficial gastritis) with partial erosion of the focal area. The cancer nest can be seen (poorly differentiated adenocarcinoma and a portion of the signet ring cell carcinoma) Journal of Cancer Research and Therapeutics - Volume 11 - Special Issue 3- 2015


Li, et al.: Two ESD procedures for stripping huge segment to treat early gastric signet ring cell carcinoma

Figure 4: Marking with Argon knife

Figure 6: The stripped mucosa was approximately 10 cm in diameter

Figure 8: The anterior wall of the gastric mucosa residual margin where the shaped cells were detected. Pathological diagnosis: Gastric signet ring cell carcinoma, carcinoma tissue in the mucosal layer, edge out 4, the third surface of the edge within the cancer nest (block 2–11)

resection and does not require traditional laparotomy.[1,2] At present, the best method for endoscopic resection of EGC is ESD.[3,4] ESD is indicated for the treatment of EGC in cases involving: (1) A differentiated intramucosal carcinoma, without any ulcer formation, regardless of size; (2) an ulcer