PMC9280801_01
Gastrointestinal endoscopic examination findings. (a, b, c) Endoscopy revealed a gastric body without atrophy of the background mucosa. The lesion was seen as a whitish, flattened, elevated lesion with depressions extending from the esophagogastric junction to the lesser curvature of the upper body, white light endoscopy. (d, e, f) Magnifying endoscopy with narrow-band imaging revealed a papillary or villous-like fine mucosal pattern with intra-structural irregular vessels in all lesions of unequal size and an enlarged white zone.
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The lesion was approximately three-quarters the circumference of the cardia (Figure 1(a)-(c)). Magnifying endoscopy with narrow-band imaging (NBI) showed granular and papillary micro-mucosal patterns of unequal size and an enlarged white zone (Figure 1(d)-(f)). The microvascular structure showed dilated and tortuous atypical vessels, which were more distinct on the anal side (Figure 1(e)).
Stomach tissue specimen from endoscopic submucosal dissection. The location and extent of the tumor (red line) and submucosal invasion (white lone) in the resected specimen are shown. The area shown in yellow was cut up by pathology. Histopathological examination shows that the deepest part reaches more than 3500 mum below the lower edge of the muscle plate.
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The lesion was a type 0-IIa + IIc tumor that measured 75 mm x 60 mm (Figure 2).
Representative histological images of a hematoxylin-eosin-stained, paraffin-embedded surgical specimen. (a) The tumor grew mainly in the stomach and extended into the esophagus. (b) The center of the cancer is growing in all layers, is exposed at the vertical margin, and has undergone thermal degeneration. Original magnification 20x. (c) Image of a moderately differentiated ductal adenocarcinoma with proliferation of fused atypical gland ducts and pale cytoplasm. Original magnification 40x. (d) Cancer cells with faint cytoplasm are floating in the lymphatic vessels, indicating endolymphatic tumor emboli. Original magnification 20x.
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Pathological examination revealed tubular adenocarcinoma in the submucosal layer, with a maximum depth of more than 3500 mum (Figure 3(a) and (b)), mild lymphatic invasion (Figure 3(c) and (d)), and venous invasion. Atypical epithelial cells with round, enlarged, and well-defined nuclei proliferated in the form of differentiated glandular ducts, irregular glandular ducts, fused glandular ducts, and papillae, forming the tumor (Figure 3(b)).
DAB-stained immunohistochemistry for MUC6, MUC5AC, pepsinogen-I, ki-67, p53, proton pump (proton pump/H+/K+-ATPase alpha subunit) in the same gastric cancer. Tumor showed focal positive staining for MUC6 (a) and MUC5AC (b), proton pump (f), and negative staining for pepsinogen-I (c). Ki-67 (d) and p53 (e) were both weakly positive, but the positivity rate was low. Original magnification 20x.
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Immunohistological examination revealed that the tumor was positive for MUC5AC, MUC6, and proton pump (proton pump/H+/K+-ATPase alpha subunit), but negative for MUC2, CD10, CDX2, and pepsinogen (Figure 4).
Hematoxylin and eosin staining of paraffin-embedded lymph node specimen after surgery. (a) Representative histologic images are shown. There are no tumor remnants, but there is metastasis in lymph nodes 1, 7, and 9. Original magnification 20x. (b) Enlarged image of the area indicated by the yellow square. Original magnification 40x.
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Postoperative pathological examination revealed adenocarcinoma with lymph node metastasis (Figure 5) but no residual lesion in the ESD scar.