PMC10165463_01
Esophagogastroduodenoscopy (EGD) and endoscopic ultrasonography (EUS) findings: (a) Previous physician's EGD findings reported a submucosal tumor-like lesion in the fornix of the stomach. (b) EGD findings at our institution showed that the tumor was approximately 2 cm in length, and had increased in its thickness, with a reddish mucosal surface and central depression. (c) EUS revealed a tumor with a maximum diameter of approximately 20 mm with hypovascularity in the fourth layer and partially heterogeneous internal structures (white arrow). (d) Abdominal computed tomography showed no lymph nodes or distant metastases, just a tumor with a contrast effect in the same region of the gastric wall noted at endoscopy (white arrow).
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Esophagogastroduodenoscopy findings from the previous physician reported a lesion in the fornix, which was reported to be less than approximately 2 cm (Figure 1a). Our institution showed that the tumor was approximately 2 cm long and had increased in thickness, with a reddish mucosal surface and central depression (Figure 1b). Endoscopic ultrasonography revealed a 1.9 cm lesion with poor vascularity in the fourth layer of the gastric wall (Figure 1c). Computed tomography showed no lymph nodes or metastases (Figure 1d).
Non-exposed endoscopic wall-invasion technique: (a) The tumor was observed endoscopically and the margin was determined. (b) The sero-musclar layer around the tumor was incised laparoscopically to the submucosa where hyaluronic acid solution colored with indigocarmine was endoscopically injected beforehand. (c) During laparoscopic sero-muscular suturing, the tumor was inverted into the intragastric cavity with a sponge spacer from the external wall of the stomach. (d) The tumor was endoscopically removed with a submucosal dissection technique and retrieved transorally. The mucosal defect was closed with clipping.
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During partial resection of the stomach using the NEWS method (Figure 2a-d), the tumor margins were identified. Moreover, ALK expression was negative (Figure 2d).
The resected specimen: (a) The tumor was 25 x 22 mm with sufficient margins of normal gastric wall tissue. The tumor cross-section was white and homogeneous, with no internal necrotic tissue. (b) Hematoxylin-stained loupe image showed a tumor with a mixture of cord-like spindle-shaped cells and inflammatory cells, with fully negative margins. (c) In the tumor, there was proliferation of spindle-shaped myogenic cells and fibroblasts, and infiltration of inflammatory cells such as plasma cells of similar round shape. (d) Immunohistochemical staining was negative for anaplastic lymphoma kinase 1.
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Macroscopically, the tumor was 2.5 x 2.2 cm in diameter, with a sufficient normal gastric wall tissue margin (Figure 3a). Pathologically, the tumor had an infiltrative growth pattern with spindle-shaped cells growing in a cord-like pattern and round cells with basophilic cytoplasm (Figure 3b,c).