PMC6000760_01
Findings of gastroduodenal endoscopy and colonoscopy. (a) A 30 mm ulcerated lesion covered by regenerative epithelium with a smooth margin at the anterior wall of the upper-gastric body. This lesion suggested a benign ulcer. (b) An ulcerated lesion at the mid-gastric body. The biopsy specimen from this lesion revealed moderately differentiated adenocarcinoma. Multiple diffuse protuberances such as submucosal tumors were observed around the lesion. (c) Irregular ductal structures with deposition of white opaque substance at cancer lesion. (d) A 30 mm submucosal tumor at the posterior wall of the gastric angle. (e) Multiple protuberances around the submucosal lesion. (f) Multiple protuberances such as submucosal tumors were observed across almost the whole stomach. (g) Endoscopic ultrasonography of submucosal tumor. Circular low echoic lesion was observed. (h) Endoscopic ultrasonography of multiple diffuse protuberances. Multiple cystic low echoic lesions throughout almost the entire stomach were observed. These findings suggested heterotopic gastric glands. (i) Colonoscopy revealed an 8 mm submucosal tumor in the cecum. The biopsy specimen from this lesion revealed a granular cell tumor.
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A repeat upper gastrointestinal endoscopy was performed (Fig. 1). Colonoscopy revealed an 8 mm yellowish submucosal tumor in the cecum (Fig. 1).
Contrast study of the stomach. (a, b) An irregular ulcerated lesion surrounded by submucosal tuber at the anterior wall of the mid-gastric body (arrows). This lesion seemed to spread under the submucosal layer. Although the range of the lesion was indeterminate, it was suspected to be invading to a deeper submucosal layer or muscle layer. (c) An 18 mm submucosal tumor was observed at the posterior wall of the lower-gastric body (arrow). Multiple small polypoid lesions were observed near the submucosal lesion (arrow heads). (d) Multiple small polypoid lesions (arrow heads).
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Contrast study demonstrated an irregular ulcerated lesion surrounded by submucosal tuber at the anterior wall of the mid-gastric body (Fig. 2).
Findings of abdominal computed tomography. Thickening of the whole gastric wall was observed. Lymphadenopathies around the cardia and lesser curvature were observed and lymph node metastases were suspected (arrows).Thickening of the gastric wall was close to the liver and direct invasion to the liver was suspected (arrow head).
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Computed tomography demonstrated diffuse gastric wall thickening (Fig. 3).
Macroscopic findings of the resected specimen and its cut surfaces. Gastric wall was thickened diffusely to aproximately 10 mm. Gastric cancer lesion at the anterior wall of the mid-gastric body (arrows). Gastric ulcer scarring (arrow heads). Two yellowish submucosal tumors (surrounded by squares). Submucosal cystic changes were observed in the whole gastric wall (surrounded by circles).
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Macroscopic findings of the resected specimen revealed diffuse gastric wall thickening of approximately 10 mm (Fig. 4).
Microscopic findings of the resected specimen. (a) Moderately differentiated adenocarcinoma invading submucosal stroma (x100). (b) Heterotopic gastric glands penetrating into the submucosal layer through the muscularis mucosae (x100). (c) Submucosal heterotopic gastric glands were observed in the whole gastric wall (x200). (d) Microscopic findings of the submucosal tumor. Sheet of large and polygonal cells with round to oval, eccentrically located nuclei and eosinophilic granular cytoplasm with lower mitotic activity. This finding suggests a granular cell tumor (x200). (e) Immunohistochemical staining for S-100 protein in the submucosal tumor. Diffuse and strong expression of S-100 protein was observed.
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The pathological diagnosis was a moderately differentiated tubular adenocarcinoma invading submucosal stroma without lymph node metastasis, two GCTs, and diffuse HGGs affecting the whole stomach (Fig. 5).