© Georg Thieme Verlag KG Stuttgart · New York
Depressed-type early adenocarcinoma of the terminal ileum
08 August 2007 (online)
Depressed-type neoplasm of the jejunum and the ileum has not yet been recognized. To the best of our knowledge, this is the first case of depressed-type primary adenocarcinoma of the ileum.
A 62-year-old man underwent total colonoscopy. A small reddish depressed lesion with marginal elevation, 5 mm in diameter, was detected in the terminal ileum ([Fig. 1 a]). A chromoendoscopic view with indigo carmine dye showed a star-shaped demarcation line of the depressed lesion ([Fig. 1 b]). A magnifying endoscopic view with crystal violet staining showed small round and tubular pit patterns ([Fig. 1 c]). With these findings, we diagnosed intramucosal neoplasm.
Fig. 1 a Conventional endoscopic view showed a shallow depressed lesion in the terminal ileum. b Chromoendoscopic view with indigo carmine dye showed a star-shaped demarcation line of the depressed lesion. c Magnifying endoscopic view with crystal violet staining showed regular arrangement of small round and tubular pit patterns.
An endoscopic mucosal resection was performed, and the resected lesion measured 5 × 4 mm. Stereomicroscopic view showed a star-shaped, depressed lesion with marginal elevation ([Fig. 2 a]). A histopathologic cross section revealed an intramucosal depressed neoplasm with lamina propria invasion ([Fig. 2 b]). A high-power view revealed well-differentiated adenocarcinoma ([Fig. 2 c]). Cancer-cell nuclei were positive in p53 immunohistochemical staining. A polymerase chain reaction-single strand conformation polymorphism (PCR-SSCP) study of p53 genes revealed some mutations of exon 6, 7, and 8. K-ras codon 12 mutations (PCR-restriction fragment length polymorphism [RFLP]) were not observed.
Fig. 2 a Stereomicroscopic view showed a star-shaped depressed lesion with marginal elevation. b Histopathologic cross section revealed an intramucosal depressed neoplasm with lamina propria invasion (H & E, original magnification × 10). c High-power view revealed well-differentiated adenocarcinoma (H&E, original magnification × 200).
Morphological appearance was classified as type 0-IIc in the Paris endoscopic classification , and mimicked a depressed-type colorectal cancer advocated by Kudo . It had been reported that K-ras mutations were absent in depressed-type colorectal cancers  . It was reported that rates of p53 positivity in depressed-type colorectal neoplastic lesions were higher in carcinomas and high-grade neoplasms than in low-grade neoplasms . Therefore the characterizations of the genetic change, such as p53 and K-ras, were mimicking depressed-type colorectal cancer.
- 1 The Paris endoscopic classification of superficial neoplastic lesions. Esophagus, stomach and colon: November 30 to December 1, 2002. Gastrointest Endosc. 2003; 58 S3-S43
- 2 Kudo S. Endoscopic mucosal resection of flat and depressed type of early colorectal cancer. Endoscopy. 1993; 25 455-461
- 3 Saito K, Arai K, Mori M. p53 overexpression and K-ras codon 12 mutations in submucosal invasive depressed-type colorectal cancer. Oncol Rep. 2000; 7 741-744
- 4 Kaneko K, Kurahashi T, Makino R. et al . Pathological features and genetic alterations in colorectal carcinomas with characteristics of nonpolypoid growth. Br J Cancer. 2004; 91 312-318
- 5 Hayakawa M, Shimokawa K, Kusugami K. et al . Clinicopathological features of superficial depressed-type colorectal neoplastic lesions. Am J Gastroenterol. 1999; 94 944-949
K. Hotta, MD
Department of Gastroenterology
Saku Central Hospital
Saku, Nagano 384-0301