Three synchronous lesions with different historical types diagnosed by endoscopic submucosal dissection in one patient

A 69-year-old man underwent gastroscopy owing to intermittent abdominal distension for over 4 months. The gastroscopy revealed two distinct lesions in the lower stomach body, which was highly atrophied (O-3) ¹ , and the background mucosa was infected with Helicobacter pylori. Lesion 1, labeled as 0-Is + IIa ² , measured 40 × 20 mm and had a nodular mixed-type appearance on the posterior wall of the stomach body ( Fig. 1 a, b ). Lesion 2, labeled as 0-IIb, measured 15 × 10 mm and was adjacent to lesion 1 on the oral side ( Fig. 2 a ). Biopsy pathology of both lesions showed atypical cells.

Fig. 1.

 Features of lesion 1 under white light endoscopy and magnifying endoscopy with blue-laser imaging (ME-BLI).

Fig. 2.

 Features of lesion 2 under white light endoscopy and ME-BLI.

Further investigation using magnifying endoscopy with blue-laser imaging (ME-BLI) revealed that lesion 1 had a distinct boundary and mimicked a colonic laterally spreading tumor with a villous surface pattern ( Fig. 1 d, e ). ME-BLI also revealed that the area of the lesion presenting noticeable redness had an intensive and irregular vascular pattern ( Fig. 1 f ). Lesion 2 also had a distinct boundary and presented a brownish area. ME-BLI further revealed an irregular vascular pattern and white globe appearance ( Fig. 2 d, e ). Both lesions were removed completely by endoscopic submucosal dissection (ESD). The histological diagnosis was intestinal adenoma with partial high-grade intraepithelial neoplasia for lesion 1 and crawling-type adenocarcinoma ³ (tub2) for lesion 2 ( Fig. 3, Fig. 4 b, c ).

Fig. 3.

 Postoperative specimen and hematoxylin and eosin (H&E) stain of lesion 1. a Endoscopic submucosal dissection specimen. b H&E stain of the red area. c H&E stain of the anal side.

Fig. 4.

 Postoperative specimen and H&E stain of lesions 2 and 3.

The patient underwent a follow-up gastroscopy after 10 months, which revealed a 15 × 10-mm 0-IIc lesion ( Fig. 5 ) with a clear boundary in the gastric antrum. Lesion 3 showed light redness, and further ME-BLI revealed increased density of the glandular ducts with an irregular surface and vascular pattern ( Fig. 5 d, e ). It was also removed by ESD and the final diagnosis was well-differentiated tubular adenocarcinoma (tub1) ( Fig. 4 e, f ).

Fig. 5 .

Features of lesion 3 under white light endoscopy and ME-BLI.

This case highlights the detection of three synchronous gastric lesions with different pathologic types ( Video 1 ). Each one had a different macroscopical appearance.

Video 1  Three synchronous lesions with different historical types diagnosed by endoscopic submucosal dissection in one patient.

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