A unique case of well-differentiated gastric-type adenocarcinoma coexisting with a gastric adenocarcinoma of the fundic gland in a Helicobacter pylori-uninfected stomach

We herein report a unique case involving the coexistence of well-differentiated gastric-type adenocarcinoma and gastric adenocarcinoma of the fundic gland in a Helicobacter pylori-uninfected stomach.

An asymptomatic 51-year-old woman without H. pylori infection underwent a screening esophagogastroduodenoscopy at our hospital. The regular arrangement of collecting venules could be observed in the lower part of the stomach body and gastric angle under white-light endoscopy ([Fig. 1 a]), consistent with an H. pylori-uninfected mucosal background [1] [2].

Fig. 1 Endoscopic images showing: a no atrophy or intestinal metaplasia in the background gastric mucosa, with a regular arrangement of collecting venules visible in the lower part of the stomach body and gastric angle; b a type 0-IIa lesion on the anterior wall of the upper gastric body; c, d a clear demarcation line on narrow-band imaging (NBI) and indigo carmine dyeing; e, f an irregular microsurface pattern with a demarcation line on magnifying endoscopy with NBI.

On the anterior wall of the upper gastric body, a 15-mm slightly elevated (0-IIa) and whitish lesion (lesion A) was identified. Both narrow-band imaging (NBI) and indigo carmine dyeing revealed the lesion to have a clear boundary. Further examination using underwater magnifying endoscopy with NBI (ME-NBI) revealed an irregular microsurface pattern with a demarcation line ([Fig. 1 b–f]; [Video 1]), and a diagnosis of cancer was made [3]. A second 5-mm submucosal tumor-like elevated lesion (lesion B) with a discolored mucosal surface and dilatation of microvessels was seen at the greater curvature. ME-NBI showed a regular microsurface pattern without a demarcation line ([Fig. 2]). According to the magnifying endoscopy simple diagnostic algorithm for early gastric cancer (MESDA-G) [4], the diagnosis was noncancerous; however, as the endoscopic features on white-light imaging still strongly suggested a neoplastic lesion, lesion B was also diagnostically resected when endoscopic submucosal dissection (ESD) was performed for the lesion A.

Video 1 Two simultaneous gastric cancers are identified in a Helicobacter pylori-uninfected stomach.

Fig. 2 Endoscopic images of lesion B, which was seen at the greater curvature, showing: a a submucosal tumor-like elevated and discolored lesion with dilatation of microvessels on the surface; b a regular microsurface pattern without a demarcation line on underwater magnifying endoscopy with narrow-band imaging.

The final histologic examination showed that lesion A was a well-differentiated adenocarcinoma, which was confined to the mucosal layer without lymphatic or venous infiltration, and immunohistochemistry indicated the mucin genotype was gastric type. Lesion B was considered to be a gastric adenocarcinoma of the fundic gland (chief cell-predominant type) with a submucosal invasion depth of 800 μm, and negative vertical and horizontal margins.

The finding of simultaneous multiple gastric cancers in an H. pylori-uninfected stomach is extremely rare, so it is crucial that endoscopists are vigilant and pay more attention to minimize the risk of missed diagnosis.

Endoscopy_UCTN_Code_CCL_1AB_2AD_3AB

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Garces-Duran R, Galdin-Ferreyra M, Delgado-Guillena PG. et al. Diagnosis of Helicobacter pylori infection by the arrangement of collecting venules using white light endoscopy: evaluation of interobserver agreement. Dig Dis 2022; 3: 376-384
• 2 Machado RS, Viriato A, Kawakami E. et al. The regular arrangement of collecting venules pattern evaluated by standard endoscope and the absence of antrum nodularity are highly indicative of Helicobacter pylori uninfected gastric mucosa. Dig Liver Dis 2008; 1: 68-72
• 3 Yao K, Anagnostopoulos GK, Ragunath K. Magnifying endoscopy for diagnosing and delineating early gastric cancer. Endoscopy 2009; 5: 462-467
• 4 Muto M, Yao K, Kaise M. et al. Magnifying endoscopy simple diagnostic algorithm for early gastric cancer (MESDA-G). Dig Endosc 2016; 4: 379-393

Publication History

Article published online:
27 October 2023