Cancer of unknown primary inside the gastric wall identified by endoscopic submucosal dissection
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CASE REPORT
Cancer of unknown primary inside the gastric wall identified by endoscopic submucosal dissection Ippei Tanaka1 · Dai Hirasawa1 · Hiroaki Saito1 · Junichi Akahira2 · Tomoki Matsuda1 Received: 7 October 2020 / Accepted: 4 November 2020 © Japanese Society of Gastroenterology 2020
Abstract We report the rare and interesting case of cancer of unknown primary (CUP) detected by endoscopic submucosal dissection (ESD). A 67-year-old man with a gastric adenoma was referred to our hospital for endoscopic treatment. Esophagogastroduodenoscopy revealed a 15-mm submucosal tumor (SMT) at the lesser curvature of the lower gastric body, near the gastric adenoma. Both lesions were resected by ESD. Pathological examination showed that the SMT was a poorly differentiated adenocarcinoma with lymphatic tissue. Additional surgical resection was performed, and the lymph nodes were found to have the same pathological findings as the SMT. These lesions were diagnosed as CUP because the obvious primary site was not detected with additional examination. The patient has been followed up for 24 months without recurrence. Keywords Cancer of unknown primary · Endoscopic submucosal dissection · Submucosal tumor
Introduction
Case report
Cancer of unknown primary (CUP) is a metastatic malignancy with unknown origin of the primary tumor. The most frequent sites of metastasis are the lymph nodes, lungs, and liver. In the present study, however, we found a rare case of CUP that had metastasized to the lymphatic tissues within and outside the gastric wall. In addition, there have been no previous reports of CUP identified by endoscopic resection. The current case is considered to be highly suggestive and informative, because it illustrates the importance of detailed endoscopic observation and the efficacy of endoscopic resection.
A 67-year-old man with a gastric adenoma was referred to our hospital for endoscopic treatment. He had no notable prior medical or family history other than a history of Helicobacter pylori eradication. He had smoked half a pack of cigarettes per day since the age of 20 years. Physical examination revealed no abnormalities and no lymphadenopathy. The laboratory examination results were within the normal ranges, including tumor markers. Esophagogastroduodenoscopy revealed a 10-mm flat-elevated lesion at the lesser curvature of the lower gastric body, which was diagnosed as an adenoma by biopsy (Fig. 1a, green arrow). In addition, a 15-mm submucosal tumor (SMT) was observed near the gastric adenoma (Fig. 1a, yellow arrow). Endoscopic ultrasound sonography showed that the SMT, derived from the submucosal layer, appeared homogeneous low echoic area (Fig. 1b). We performed endoscopic submucosal dissection (ESD) for both the adenoma and the SMT (Fig. 2a). Histopathological examination revealed that the adenoma was completely resected with negative margin, and the SMT consisted of a poorly differentiated adenocarcinoma in the lymphatic tissue (Fig. 2b, c). A contrast-enhanced computed tomography showed an 8-mm enl
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