PMC4073029_01
(A, B) Conventional white light endoscopy shown a totally flat, type "0-IIb" lesion (white window) at the oral side of a type "0-IIa" lesion (Paris classification). Type "0-IIb" lesion is above the isolated dot (yellow circle). Image (B) corresponds to white window of Fig. 1A. (C) Chromoendoscopy with indigo carmine shown clearly the type "0-IIa" early gastric cancer, especially the proximal margin (arrows), and no further additional abnormalities. (D) Narrow band imaging magnifying image revealed an additional type "0-IIb" lesion proximal to type "0-IIa" lesion, which was not recognized by standard white light endoscopy as well as indigo carmine chromoendoscopy. Isolated dot (yellow circle) is situated just at the oral side (white arrows) of the type "0-IIa" lesion
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Systems) and an electric endoscopic system (EVIS 260 LUCERA SPECTRUM; Olympus Medical Systems) were used for examination. Standard white light endoscopy showed a slightly red and elevated gastric lesion at the middle gastric body along the lesser curvature type "0-IIa" lesion (Fig. 1A, B). Indigo carmine chromoendoscopy resulted in better delineation of the type "0-IIa" lesion and no other abnormalities (Fig. 1C). NBI-ME findings, including irregular microvascular and mucosal microsurface pattern, were also found in a flat area, "0-IIb", at the oral side of the "0-IIa" lesion (Fig. 1D). Precise tumor margin marking of both lesions was followed (Fig. 1A, B, D).
(A) NBI-magnifying image shown a demarcation line of the proximal borders (arrows) of the type "0-IIa" early gastric cancer. (B) NBI-magnification image of the type "0-IIb" lesion showing irregular white zone in the demarcation line (white line) between normal metaplastic mucosa and tumorous Narrow band imaging mucosal pattern. (C) NBI with maximum (x80) magnification of the center of the type "0-IIb" lesion clearly showed an irregular inter-lobular loop pattern 1 (ILL-1 pattern). (D) NBI magnifying image after acetic acid spray showed tumorous pattern microstructures (fusion and increased intensity of villous structures) in the second type "0-IIb" lesion
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NBI-ME showed the type "0-IIa" tumor as a brownish area, with clear demarcation line of the proximal and distal tumor margins (Fig. 2A). NBI-ME also showed a demarcation line between normal metaplastic mucosa and tumorous NBI mucosal pattern with irregular white zone (Fig. 2B). NBI-ME of the type "0-IIb" tumor enabled the observation of an irregular mucosal microsurface inter-lobular loop pattern 1 (ILL-1) (Fig. 2C). B, according to our recent classification (Fig. 2D). Based on the above-mentioned NBI findings the type "0-IIb" lesion was diagnosed as mucosal gastric adenocarcinoma of probable differentiated type.
(A) Endoscopic submucosal dissection specimen showing cancer extension (red line) of both type "0-IIa" a) and b) type "0-IIb" (black arrows) lesions (yellow circle shows the isolated dot between IIa and IIb lesions). (B) Histology of the rejected tumor with HE stain of the type "0-IIa" lesion, showing moderately differentiated gastric adenocarcinoma (tub1>>por), with complete pathological rejection (R0, T1a(M), UL (+) Ly (-) v(-) pHM0 PVM0). (C) Well-differentiated low-grade adenocarcinoma (tub 1) with complete pathological rejection of the small IIb lesion. (R0, pT1a(M), UL (-),v(-), Ly(-), PHM 0 pVM0)
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Histopathologic examination of the ESD specimen (Fig. 3A) showed double mucosal gastric adenocarcinoma, with moderate differentiation of the "0-IIa" lesion and a small area of low-grade well-differentiated adenocarcinoma of the type "0-IIb" gastric lesion, category 5 according to the revised Vienna classification (Fig. 3B, C). Marking point placed at 1 mm outside the borders was confirmed in the histological findings (Fig. 3A).