Endoscopic submucosal dissection for the diagnosis and therapy of pedunculated gastric cancer with prolapse into the duodenal bulb: A case report.

INTRODUCTION: Preoperative diagnosis of gastric cancer invasion is not always sufficiently accurate. Diagnostic endoscopic submucosal dissection (ESD) can be performed for the purpose of accurate decision making and to avoid partial treatment vs aggressive over-treatment. We present a patient with the gastric cancer with indeterminate pre-operative diagnosis for depth of the invasion.

CASE PRESENTATION: A 70-year-old man presented at our hospital because both anti-Helicobacter pylori (Hp) IGG antibody and serum pepsinogen (PG) levels were classified as positive. Upper gastrointestinal endoscopy was performed, and a large (3.5 cm) pedunculated polyp-shaped gastric cancer with prolapse into the duodenal bulb was found. [fluorine-18]-fluorodeoxy-glucose (18F-FDG)-positron emission tomography (PET)/computed tomography (CT) imaging showed high 18F-FDG uptake, suggesting the possibility of advanced gastric cancer. Since the pre-operative diagnosis of the cancer invasion was indeterminable, diagnostic ESD was performed. The pathohistological diagnosis was early gastric cancer (33 × 35 × 20 mm, well differentiated tubular adenocarcinoma [tub1], pT1a[M], ly[--], v[--], UL[--], pHM0, pVM0) according to the Japanese classification of gastric carcinoma.

DISCUSSION AND CONCLUSION: It was reported that ESD for early gastric cancers that met the expanded criteria was acceptable and should be the standard treatment instead of gastrectomy. The expanded criteria included cancer confined to the mucosa (cT1a), a single primary intestinal-type gastric adenocarcinoma, an ulcer-negative lesion of any size. We reported a case of pedunculated gastric cancer with prolapse into the duodenal bulb that could be treated by ESD. The present case is a good example of diagnostic ESD being used to minimize the damage of gastric cancer treatment.