Journal of Cancer Research and Therapeutics

: 2015  |  Volume : 11  |  Issue : 8  |  Page : 253--257

Two endoscopic submucosal dissection procedures for stripping huge segment of the gastric mucosa to treat early gastric signet ring cell carcinoma

Shengxi Li1, Meidong Xu2, Chu Yuan2,  
1 Digestive Endoscopy Center, People's Hospital of Liaoning Province, Shenyang, Liaoning 110016, China
2 Digestive Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China

Correspondence Address:
Meidong Xu
Digestive Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai 200032


Aim: To introduce the method of stripping of early gastric signet ring cell carcinioma by two ESD procedures. Methods: A lesion of early gastric signet ring cell carcinoma in an elderly was removed by two consecutive ESD procedures. The pathology was analyzed and the patient was followed-up. Results: The lesion removed by first ESD procedure, which was 10cm in diameter, has tumor tissue on its edge, and the second lesion which was 5cm in diameter had an edge without tumor. There was no metastasis or recurrence during 24-month follow-up. Conclusion: We first described the method using two consecutive ESD procedures in man with gastric signet ring cell carcinoma, and the procedure was proved to be safe and efficient.

How to cite this article:
Li S, Xu M, Yuan C. Two endoscopic submucosal dissection procedures for stripping huge segment of the gastric mucosa to treat early gastric signet ring cell carcinoma.J Can Res Ther 2015;11:253-257

How to cite this URL:
Li S, Xu M, Yuan C. Two endoscopic submucosal dissection procedures for stripping huge segment of the gastric mucosa to treat early gastric signet ring cell carcinoma. J Can Res Ther [serial online] 2015 [cited 2020 Dec 1 ];11:253-257
Available from:

Full Text


Early gastric cancer (EGC) is a commonly encountered clinical problem in cases undergoing gastroscopy. There are constant improvements of gastroendoscopic treatment technology, which has led to endoscopic submucosal dissection (ESD) being more widely used. This technology completely strips the gastric mucous membrane using an endoscope to treat cases of gastric cancer, including cases that are detected in the early stages. Before the procedure, the extent of the tumor must be determined. The normal mucosa surrounding the lesion is marked at least 5 mm away from the tumor. The entire mucous membrane is stripped, followed by pathological examination. In the present study, we are the first to describe a case involving the use of case of two consecutive ESD procedures in an elderly man with gastric signet ring cell carcinoma who underwent surgery for colon cancer 20 days previously. The patient was followed-up for 24 months, and there were no signs of recurrence or metastasis. We first used ESD to strip off the mucosa in an area with a 10 cm diameter. However, the pathological analysis showed residual malignant cells at the mucosal edge; therefore, we performed a second ESD.

 Patient, Methods and Results

In the present study, we describe a case of EGC in an 81-year-old man complaining of epigastric discomfort who was diagnosed with signet ring cell carcinoma by gastroscopy 20 days after he had undergone colon cancer surgery.

The patient agreed to undergo gastroscopy, which indicated a lesion in the stomach that was histopathologically diagnosed as signet ring cell carcinoma confined to the mucosal region. The lesion is in the gastric body, and gastric antrum junction was red, had a patchy distribution, and an easily bleeding mucous membrane [Figure 1].{Figure 1}

The lesion was 6 cm × 7 cm in diameter, and demarcation of the lesion was not clearly visible by normal endoscopy. The patient was diagnosed with EGC and underwent two ESD procedures using endoscopy after narrow-band imaging (NBI) [Figure 2]. We obtained five pieces of tissue for pathological examination, which led to a diagnosis of signet ring cell carcinoma. Pathological analysis confirmed that the lesions only invaded the mucosal layer [Figure 3]. Because the lesion area was large, we suggested that the patient should undergo surgical removal of the lesions. However, the patient chose to undergo the ESD procedure.{Figure 2}{Figure 3}

The patient was placed under general anesthesia using a breathing tube inserted intravenously. An Olympus gastroscope with an attached water channel along with NBI was used to determine the extent of the lesions, which were marked with an argon knife [Figure 4]. Prior to the surgical procedure, we performed a submucosal injection with indigo carmine at the lesion, and the lesion could be appropriately lifted. The mucosa that contained the lesions was gradually peeled off with a hook knife and insulation-tipped (IT) knife [Figure 5]. The stripped mucous membrane was approximately 10 cm in diameter [Figure 6]. We performed a pathological examination of the entire section of peeled mucosa, which indicated the presence of tumor tissue at an edge of the peeled 10 cm of mucous membrane [Figure 4].{Figure 4}{Figure 5}{Figure 6}

The 10 cm diameter section of the mucous membrane that was removed revealed that the tumor tissue was limited to the intramucosal layer [Figure 4]. However, we did not mark the location of the stripped mucosa in relation to the gastric body. The edge of the stripped mucous membrane revealed residual carcinoma tissue. Since the patient refused to undergo surgery, the physician proposed an alternative method. Along the edge of the cut gastric mucosa, we marked a total of 38 blocks at 5-mm intervals from the edge; accordingly, samples were removed and were stored and sent for pathologic examination [Figure 7].{Figure 7}

Pathological results showed that heterocyst was detected on the anterior wall of the gastric mucosa residual margin (block 15) [Figure 8]. We decided to perform another ESD stripping procedure, including the atypical cells of the gastric mucosa. The patient was placed under intravenous anesthesia, and a region of the gastric mucosa comprising differently shaped cells of approximately 5 cm in diameter was stripped away by ESD [Figure 9]. The wound was cleaned with argon gas before completion of the surgery, and the specimens were sent for pathological examination, which indicated no abnormal results.{Figure 8}{Figure 9}

Four months after the patient received ESD, a gastroscopy examination indicated that the gastric antrum junction formed a false pylorus [Figure 10]. After that, the patient underwent gastroscopy examination in 3-month intervals, and no abnormal results were detected until 24 months [Figure 11] and [Figure 12] since the first ESD procedure.{Figure 10}{Figure 11}{Figure 12}


With the development of digestive endoscopic diagnosis and treatment technology, early cancer can be treated by endoscopic resection and does not require traditional laparotomy.[1],[2] At present, the best method for endoscopic resection of EGC is ESD.[3],[4] ESD is indicated for the treatment of EGC in cases involving: (1) A differentiated intramucosal carcinoma, without any ulcer formation, regardless of size; (2) an ulcer <3 cm in diameter, with differentiated intramucosal carcinoma; (3) a differentiated adenocarcinoma that has invaded the submucosa, without any ulcer formation, regardless of size, lymph, or blood vessel involvement, and <3 cm in diameter; and (4) a low differentiated intramucosal carcinoma <2 cm in diameter, without any ulcer formation.[5]

In Japan, ESD is used to treat EGC that meets these conditions: (1) Tumor diameter is <2 cm, and no mucosal ulcer formation within undifferentiated cancer;[6],[7] (2) differentiated carcinoma without ulcer formation, regardless of the size; (3) tumor diameter <3 cm, with differentiated mucosa and ulcer formation; (4) tumor diameter <3 cm, without ulcer formation or differentiated submucosal carcinoma. For the elderly, in cases where surgery is contraindicated, or there is suspected lymph node metastasis in the submucosal carcinoma, ESD may be used to treat the patients.[8],[9] In the present study, we describe the case of an 81-year-old man in whom ESD was performed based on these relative indications. Twenty days after colon surgery, he experienced epigastric discomfort and bilge full. Gastroscopy revealed that the mucosa between the gastric antrum, and the gastric body had become red and had lost the luster of normal mucosa. The mucosa was prone to bleeding on touching, and the boundary was not clear. The pathological results indicated signet ring cell carcinoma. We suggested that the patient undergoes surgical removal of the lesion, indicating the need for re-surgery. The patient refused to undergo another surgery, and therefore, we proposed the use of ESD as an alternative based on the patient's relative indications. The patient and his family agreed to the ESD procedure.[10],[11] As mentioned earlier, the patient was intubated with a breathing tube and placed under intravenous anesthesia in order to undergo surgery by ESD in the operating room. First, we examined the patient using an amplified gastroscope and NBI [12] to determine the extent of the preliminary lesion. An argon knife was used to mark a 2 cm area outside the border of the lesion.[13],[14] As mentioned above, using a submucosal injection, hook knife, and IT knife stripping, the entire piece of mucous membrane was finally stripped away. The removed piece was approximately 10 cm in diameter. The stripped mucosa underwent pathological examination, and the results indicated the presence of cancer cells at the border. However, we did not know what position of the stomach corresponded to the peeled gastric mucosa that had the cancerous tissue. As the patient still refused to undergo re-surgery, we obtained more tissue by biopsy to determine which part of the stripped gastric mucosa had residual carcinoma tissue. After performing the biopsy to determine the location of residual cancer in the gastric mucosa, we stripped away the residual carcinoma tissue during a second ESD procedure.[15],[16],[17] To our knowledge, this is the first report to describe the case of an elderly patient with signet ring cell carcinoma of the gastric mucosa in which 15 cm of the gastric mucosa was stripped away after the patient refused surgical treatment. In addition, two examinations following the ESD indicated that the gastric antrum junction formed the pylorus.[18],[19] This case was different from previous reports in the fact that the patient underwent two ESD procedures within a short period. Early cancer treatment by ESD that complies with ESD indications is a reliable and safe procedure when it is performed by skilled endoscopists, and it has a high healing rate and low level of significant complications. However, the effectiveness of ESD for the treatment of early cancer that satisfies relative indications has been affected by a large range of cancers, such as cancers with a low level of differentiation. Therefore, repeated use of ESD treatment 2 or 3 times may be effective. From our experience, we noted that a key factor is that physicians should mark the positional relationship between the peeled gastric mucosa and the whole gastric mucosa for the second ESD procedure. Regular follow-up is another key point in this case.


We reported our experience with an elderly man who underwent removal of gastric mucosa with signet ring cell carcinoma in two ESD procedures that involved removal of a section of 15 cm in diameter. The patient was followed-up for 24 months, with gastroscopy and measurement of carcinoembryonic antigen and carbohydrate antigen 19–9 levels at 3-month intervals, and no abnormal results were noted. Thirteen months after the ESD, the patient underwent a full abdominal computed tomography (CT) scan, lung CT scan, and head CT scan, and there were no abnormal results.

To our knowledge, this is the first clinical report of the use of a second ESD for the treatment of signet ring cell carcinoma by two ESD procedures that involved stripping of 15 cm of gastric mucosa. No abnormal events were noted during the 24-month follow-up.[20]

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Con SA, Con-Chin GR, Kishimoto G, Con-Wong R. Endoscopic submucosal dissection (ESD) for the curative treatment of early gastric cancer: Initial experience in Costa Rica. Rev Gastroenterol Peru 2009;29:276-80.
2Kume K, Yamasaki M, Yoshikawa I, Otsuki M. Grasping-forceps-assisted endoscopic submucosal dissection using a novel irrigation cap-knife for large superficial early gastric cancer. Endoscopy 2007;39:566-9.
3Ahn JY, Jung HY. Long-term outcome of extended endoscopic submucosal dissection for early gastric cancer with differentiated histology. Clin Endosc 2013;46:463-6.
4Abe S, Oda I, Suzuki H, Nonaka S, Yoshinaga S, Odagaki T, et al. Short- and long-term outcomes of endoscopic submucosal dissection for undifferentiated early gastric cancer. Endoscopy 2013;45:703-7.
5Coman RM, Gotoda T, Draganov PV. Training in endoscopic submucosal dissection. World J Gastrointest Endosc 2013;5:369-78.
6Oka S, Tanaka S, Higashiyama M, Numata N, Sanomura Y, Yoshida S, et al. Clinical validity of the expanded criteria for endoscopic resection of undifferentiated-type early gastric cancer based on long-term outcomes. Surg Endosc 2014;28:639-47.
7Kim YY, Jeon SW, Kim J, Park JC, Cho KB, Park KS, et al. Endoscopic submucosal dissection for early gastric cancer with undifferentiated histology: Could we extend the criteria beyond? Surg Endosc 2013;27:4656-62.
8Nasu K, Maeshiro T, Shida D, Miyamoto S, Inoue S, Umekita N, et al. A case of elder gastric cancer patient who relapsed at the local stomach wall and the regional lymph node at the time of six months after endoscopic submucosal dissection (ESD). Gan To Kagaku Ryoho 2009;36:2067-9.
9Walter B, Probst A, Märkl B, Wagner T, Anthuber M, Messmann H. Fulminant metastatic spread in a patient with an early gastric cancer. Endoscopy 2009;41:907-9.
10Chiu PWY. International digestive disease forum master series: East meets west novel endoscopic therapeutics for early gastric cancer. Clin Gastroenterol Hepatol 2013. pii: S1542-3565(13) 01176-2.
11Yada T, Yokoi C, Uemura N. The current state of diagnosis and treatment for early gastric cancer. Diagn Ther Endosc 2013;2013:241320.
12Yamada S, Doyama H, Yao K, Uedo N, Ezoe Y, Oda I, et al. An efficient diagnostic strategy for small, depressed early gastric cancer with magnifying narrow-band imaging: A post-hoc analysis of a prospective randomized controlled trial. Gastrointest Endosc 2014;79:55-63.
13Chang CC, Tiong C, Fang CL, Pan S, Liu JD, Lou HY, et al. Large early gastric cancers treated by endoscopic submucosal dissection with an insulation-tipped diathermic knife. J Formos Med Assoc 2007;106:260-4.
14Han JP, Hong SJ, Choi MH, Song JY, Kim HK, Ko BM, et al. Clinical outcomes of early gastric cancer with lateral margin positivity after endoscopic submucosal dissection. Gastrointest Endosc 2013;78:956-61.
15Oda I, Oyama T, Abe S, Ohnita K, Kosaka T, Hirasawa K, et al. Preliminary results of multicenter questionnaire study on long-term outcomes of curative endoscopic submucosal dissection for early gastric cancer. Dig Endosc 2014;26:214-9.
16Choi YY, Kwon IG, Lee SK, Kim HK, An JY, Kim HI, et al. Can we apply the same indication of endoscopic submucosal dissection for primary gastric cancer to remnant gastric cancer? Gastric Cancer 2014;17:310-5.
17Tanabe S, Ishido K, Higuchi K, Sasaki T, Katada C, Azuma M, et al. Long-term outcomes of endoscopic submucosal dissection for early gastric cancer: A retrospective comparison with conventional endoscopic resection in a single center. Gastric Cancer 2014;17:130-6.
18Zhang J, Yang JM, Xu QS, Shigetomo M, Fei BY, Lou GC, et al. The accumulating appreciation of endoscopic submucosal dissection in the treatment of gastrointestinal neoplasms: Preliminary experience in local eastern China. Hepatogastroenterology 2013;60:1257-62.
19Oda I, Suzuki H, Nonaka S, Yoshinaga S. Complications of gastric endoscopic submucosal dissection. Dig Endosc 2013;25 Suppl 1:71-8.
20Imai K, Kakushima N, Tanaka M, Takizawa K, Matsubayashi H, Hotta K, et al. Validation of the application of the Japanese curative criteria for superficial adenocarcinoma at the esophagogastric junction treated by endoscopic submucosal dissection: A long-term analysis. Surg Endosc 2013;27:2436-45.