Endoscopic submucosal dissection (ESD) for gastritis cystica profunda (GCP) with early gastric cancer: A propensity score matching analysis

Background and aim

Cystic dilatation of the gastric glands within the mucosal layer is the hallmark of the rare condition known as gastritis cystica profunda (GCP). Although it has been proved that GCP is the precursor lesion for early gastric cancer (EGC), the management strategy of GCP-related EGC is not well established.The purpose of this research was to determine if ESD is effective and safe for GCP-related EGC.

Methods

Patients with EGC who had ESD at Beijing Friendship Hospital between January 2015 and May 2023 were retrospectively included. All patients were divided into two groups: those with GCP-related EGC, and those with EGC alone. The two groups were matched 1:1 using the propensity score matching (PSM) method. Curative resection rate, postoperative adverse outcome rate (bleeding, perforation, stricture), and recurrence rate were the primary measures used to evaluate the efficacy and safety of ESD.

Results

There were a total of 386 participants (44 with GCP and 342 with EGC alone). Following PSM, 44 patients were paired and analyzed separately. Except for the presence of cysts in EUS (multiple/single/none cyst: 12/2/5 versus 1/0/25, P < 0.0001), there was no change in baseline characteristics, EUS appearance, or histology results between groups. Overall, there was no significant difference in curative resection rates between the GCP group (70.5 %) and the control group (81.8 %) (P = 0.211). Postoperative complications were comparative (9/44 vs 5/44, P = 0.244), as were rates of local recurrence (1/44 vs 0/44, P = 1.0), metachronous gastric cancer (1/44 vs 0/44, P = 1.0), and mortality (0/44 vs 0/44, P = 1.0).

Conclusions

Existence of cysts in EUS is a characteristic presentation to distinguish GCP-related EGC from EGC-alone lesions. ESD might be a safe and effective therapy for patients with GCP-related EGC.

Coexistence of early gastric cancer and benign submucosal lesions mimic invasive cancer: a retrospective multicenter experience

OBJECTIVE

To present a study to identify the characteristics of coexisting early gastric cancer (EGC) and benign submucosal lesions, with the aim of reducing the adverse consequences of overdiagnosis and overtreatment.

METHODS

In this retrospective study, we searched the endoscopic databases of three tertiary centers. We screened of patients suspected of early gastric cancer submucosal infiltration by conventional endoscopy and ultimately selected for endoscopic submucosal dissection treatment after endoscopic ultrasonography and magnifying endoscopy with narrow-band imaging examination. Patients with coexisting EGC and benign submucosal lesions in histological sections were included. Clinical data and endoscopic images were reviewed. To evaluate the precision of endoscopists' diagnoses for this type of lesion, eight endoscopists with different experiences were recruited to judge the infiltration depth of these lesions and analyze the accuracy rate.

RESULTS

We screened 520 patients and retrospectively identified 18 EGC patients with an invasive cancer-like morphology. The most common lesion site was the cardia (12/18, 66.67%). The coexisting submucosal lesions could be divided into solid (5/18, 27.78%) and cystic (13/18, 72.22%). The most common type of submucosal lesion was gastritis cystica profunda (12/18, 66.67%), whereas leiomyoma was the predominant submucosal solid lesion (3/18, 16.67%). Ten (55.56%) patients < underwent endoscopic ultrasonography; submucosal lesions were definitively diagnosed in 6 patients (60.00%). The accuracy of judgement of the infiltration depth was significantly lower in cases of coexistence of EGC with benign submucosal lesions (EGC-SML) than in EGC (38.50% versus 65.60%, P = 0.0167). The rate of over-diagnosis was significantly higher within the EGC-SML group compared to the EGC group (59.17% versus 10.83%, P < 0.0001).

CONCLUSIONS

We should be aware of the coexistence of EGC and benign submucosal lesions, the most common of which is early cardiac-differentiated cancer with gastritis cystica profunda.

Gastritis cystica profunda: clinical and pathologic study of seven cases and review of literature

Gastritis cystica profunda (GCP) is a rare lesion characterized by hyperplasia and cystic dilatation of the gastric glands in the submucosal layer. Here we report seven cases of GCP. The patients are 5 women and 2 men with a mean age of 62 (range, 42-82) years at the time of diagnosis. The patients presented with abdominal distension, sour regurgitation, and heartburn. One case had the previous gastric surgery and the other six cases had no special history. The lesions were located in the fundus (4/7), corpus (1/7), cardia (1/7), and antrum (1/7). Endoscopic analysis revealed pedunculated polyps, or a dome-shaped polyp. Histologically, all cases showed dilated tubular glands, mainly located in the submucosa, among the muscularis mucosa, and occasionally in the lamina propria. The glands were lined by bland single columnar epithelium with infolding features in some areas. Mitotic activity and marked cellular atypia were not present. The stroma in some cases was mildly edematous with infiltrated lymphocytes and plasma cells. There was no epithelial dysplasia in the overlying mucosa. Immunohistochemically, the Ki-67 index was < 1%. P53 immunostaining was generally characterized as wild type in all cases. Based on the morphology of the glands and the cells and the possible mechanism of hyperplasia and cystic dilatation of the gastric glands, it is easy to differentiate GCP from a well-differentiated adenocarcinoma.

Gastritis cystica profunda: a case report and literature review

Gastric cystica profunda (GCP) is a rare disease characterized by multiple cystic lesions in the mucosa and/or submucosal layer. Usually, GCP occurs in stomachs that have previously been operated on. If there is no postoperative pathological results, it is challenging to diagnose GCP based on nonspecific clinical symptoms and imaging findings. This report aimed to provide a comprehensive overview of all cases of GCP reported to date. A comprehensive literature search was conducted for all reported GCP cases between 1972 and 2014. The keywords searched included "gastritis cystica profunda", "submucosal cysts of the stomach", and "heterotopic submucosal gastric glands". One retrospective case from our group was also reported and compared with those from the existing literature. A total of 52 cases were found including 37 (71.2%) men and 15 (28.8%) women (M/F ratio =2.5). The mean age of the patients was 59.9 (range, 39-91) years old. Among the cases, 58.8% (n=30) of lesions were located in the gastric body, 25.5% (n=13) of lesions were located in the fundus, 19.6% (n=9) of lesions were located in the antrum, and 3.9% (n=2) of lesions were located in the cardia, while 1 case was in the prepyloric lesion and 1 case was at the anastomotic site. Of the patients, 52% (n=26) had previously received gastric surgery. The main manifestations of GCP included abdominal pain (n=14, 36.8%) and gastrointestinal bleeding (including hematemesis and melena, n=7, 18.4%). Only 4 of the 52 cases were diagnosed before surgery, and the rest were diagnosed through postoperative histopathologic examination. GCP is difficult to correctly diagnose preoperatively due to its relative rarity and lack of typical clinical symptoms. Histopathological examination should be used for correct diagnosis. Complete surgical removal of the GCP is widely considered as the best treatment option.

Multiple Gastritis Cystica Profunda in a Patient without Gastric Surgery History

Gastritis cystica profunda (GCP) is a rare condition characterized by polypoid cystic ectasia of the submucosal layer with cystic dilatation of the glandular structures of the stomach. The probable pathogenesis refers to degradation of the integrity of the muscularis mucosa and migration of epithelial cells to the submucosal layer. The most common cause known in the literature for this occurrence is previous stomach surgery. A case presented with two GCP lesions in different locations in the stomach without any history of previous surgery.

Well-differentiated adenocarcinoma may be misdiagnosed as gastritis cystica profunda

Gastric cancer (GC) is one of the most common malignant tumors in China. The low detection rate of early GC is one of the reasons for its high mortality rate. Thanks to the application of new gastroscopy technology, the detection rate of early GC has increased. Highly differentiated adenocarcinoma accounts for about 70% of all early GC cases; however, well-differentiated adenocarcinoma is difficult to diagnose because of its non-significant structural abnormality and cellular atypia. Gastritis cystica profunda is a rare disease characterized by the presence of the gastric intrinsic gland in the muscularis mucosa and/or submucosa, which is easily confused with highly differentiated adenocarcinoma. Therefore, attention should be paid to the identification of these two different entities in the clinical work.

Gastritis cystica profunda in a previously unoperated stomach: A case report

Gastritis cystica profunda is a relatively rare disease, usually observed at anastomotic sites in stomachs of patients that have undergone gastric procedures. We present the rare case of an elevated lesion in the anterior wall of the gastric antrum of a 43-year-old Chinese woman who had never undergone gastric surgery and had no gastrointestinal tract symptoms. Although the physical examination and laboratory data showed no abnormalities, endoscopic ultrasonography revealed an anechoic cystic structure. Abdominal computed tomography and magnetic resonance imaging showed the gastric wall of the greater curvature of the antrum was markedly and irregularly thickened, and mild to moderate enhancement was observed around the lesion with no enhancement in the central portion, suggestive of a gastrointestinal stromal tumor. The patient underwent a distal gastric resection of the 2.5 cm × 1.5 cm lesion. A postoperative pathologic examination showed dilated cystic glands in the muscularis mucosa and submucosal layers and erosion of the mucosal surface of the tumor, confirming the diagnosis of gastritis cystica profunda without malignancy.

A case of early gastric cancer arising from gastritis cystica profunda treated by endoscopic submucosal dissection

Gastritis cystica profunda (GCP) consists of hyperplasia and cystic dilatation of the gastric glands extending into the submucosa. It occurs in the residual stomach post surgery and in the unoperated stomach. GCP is considered a benign lesion, but there is controversy about its malignant potential. We report a case of early gastric cancer arising from GCP treated by endoscopic submucosal dissection (ESD) in a 55-year-old unoperated man. Upper gastrointestinal endoscopy revealed a 15-mm diameter submucosal tumor (SMT) in the upper corpus of the stomach. The surface had angiotelectasia and slight depression covered with normal mucosa. Neither ulceration nor erosion was seen. Narrow-band imaging endoscopy showed no abnormalities suggesting gastric cancer. Endoscopic ultrasonography visualized the internally low-echoic SMT, harboring tiny cystic lesions, mainly within the second and third layers of the gastric wall. The SMT was removed by ESD to avoid retention and allow for comprehensive diagnosis. It was diagnosed as GCP with partial well-differentiated adenocarcinoma without involvement of the lateral and deep margins, lymphatic invasion, vascular invasion and perineural invasion. The gastric epithelium comprised normal mucosa without dysplasia. ESD seems to be useful for the diagnosis of SMT, including GCP harboring gastric cancer, and avoids unnecessary surgical procedures.

A case of gastric inverted hyperplastic polyp found with gastritis cystica profunda and early gastric cancer

A gastric inverted hyperplastic polyp is a rare type of gastric polyp and is characterized by downward growth of a variety of mucosal components into the submucosa. The polyp consists of columnar cells resembling foveolar epithelium and pyloric gland epithelium and can coexist with gastritis cystica profunda. Frequently, adenocarcinoma can coexist, but the relation is not clear. A 77-year-old male underwent endoscopic submucosal dissection due to early gastric cancer. A gastric inverted hyperplastic polyp was found in the removed specimen and gastric cystica profunda was also found. We report a case of gastric inverted hyperplastic polyp coexisting with gastric cystica profunda and gastric adenocarcinoma.

Gastric adenocarcinoma arising in gastritis cystica profunda presenting with selective loss of KCNE2 expression

Gastritis cystica profunda (GCP) is a rare condition caused by ectopic entrapment of gastric glands, probably secondary to the disruption of muscularis mucosae. GCP is often associated with gastric adenocarcinoma, and loss of the KCNE2 subunit from potassium channel complexes is considered a common primary target molecule leads to both GCP and malignancy. In this study, we, for the first time, analyzed the expression of KCNE2 in surgically excised tissue from human gastric cancer associated with GCP and confirmed that reduced KCNE2 expression correlates with disease formation.