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Abstract Background The combination of laparoscopic and endoscopic approaches to neoplasia with a non-exposure technique (CLEAN-NET) is a laparoscopic and endoscopic cooperative surgery (LECS). It combines laparoscopic gastric resection and endoscopic techniques for local resection of gastric tumors, such as gastrointestinal stromal tumors (GIST), with minimal surgical margins. A conventional CLEAN-NET surgical procedure is complex, requiring careful techniques to preserve the cardia, particularly in case of nearby lesions. We describe the case of a patient who underwent a modified CLEAN-NET approach with a semi-circular seromuscular layer incision surrounding the base of the tumor, different from a circular shape seromuscular layer in the conventional CLEAN-NET: around the tumor to preserve mucosal continuity, which acts as a barrier to avoid intraoperative tumor dissemination. Case presentation A 43-year-old woman was referred to our hospital because of a gastric submucosal tumor near the cardia, detected on medical examination. The patient was diagnosed with gastric GIST based on the results of endoscopic ultrasound-guided fine-needle aspiration. Modified CLEAN-NET was performed with a semicircular incision of the seromuscular layer on the opposite side of the cardia, making the surgical procedure simple and minimizing partial resection of the gastric wall, including the tumor, while preserving the cardia. The operative time was 147 min, preoperative blood loss volume was 3 mL, and postoperative hospital stay was 9 days. The resected specimen revealed a minimal resection of the gastric wall, including the tumor. The cardia and gastric nerves were preserved, and the postoperative food intake was good. Conclusions The modified CLEAN-NET with semicircular seromuscular layer dissection is a simple and reliable surgical procedure for GIST near the cardia.

Laparoscopic surgery has been used to treat gastric submucosal tumors (SMTs). Laparoscopic and endoscopic cooperative surgery (LECS) has been used when subtotal resection has been difficult, which enabled resection of these tumors. In this study, we reviewed the medical records of patients with gastric SMTs who underwent laparoscopic surgery in our hospital with the aim of reporting the surgical indications, procedures (especially for LECS), and outcomes of surgery. This study involved 55 patients who underwent laparoscopic surgery between April 2014 and March 2021. We classified the patients into two groups: laparoscopy-assisted surgery group (non-LECS group, n = 30) and LECS group (n = 25). LECS was performed in the upper stomach, in the greater curvature of the lower stomach, and in both intraluminal and intramural locations in the middle stomach. Non-LECS was selected for extraluminal and intramural tumors in the greater curvature of the upper stomach. There were no severe complications associated with the operation. There was one postoperative complication in the LECS group. The length of postoperative hospital stay did not significantly differ between the LECS and non-LECS groups. We reported the surgical procedures for gastric SMTs in our hospital. It is essential to make full use of the multiple techniques reported in this article and examine the location of the tumor to avoid excess or insufficient resection. Our review of the present case series allowed us to select the appropriate surgical approach for gastric SMTs based on the lesion location and type of development. [ABSTRACT FROM AUTHOR]

Implantation cyst is often reported to be a delayed complication after colorectal surgery. This report presents a 70-year-old man undergoing gastrectomy 33 years earlier for an acute gastric ulcer. His endoscopic finding showed a submucosal tumor about 20 mm in diameter at the gastro-jejunal anastomosis. Endoscopic ultrasonography showed that the tumor was a cystic mass that was continuous from the third layer, but there were no existences of internal substantial nodules, indicating that the tumor was diagnosed as implantation cyst. This is the first report showing that implantation cyst can occur at gastro-jejunal anastomosis. We should take into account the occurrence of implantation cyst, when we encounter a submucosal tumor at gastro-jejunal anastomosis after surgery even if a long period has passed. [ABSTRACT FROM AUTHOR]

Background: The combination of laparoscopic and endoscopic approaches to neoplasia with a non-exposure technique (CLEAN-NET) is a laparoscopic and endoscopic cooperative surgery (LECS). It combines laparoscopic gastric resection and endoscopic techniques for local resection of gastric tumors, such as gastrointestinal stromal tumors (GIST), with minimal surgical margins. A conventional CLEAN-NET surgical procedure is complex, requiring careful techniques to preserve the cardia, particularly in case of nearby lesions. We describe the case of a patient who underwent a modified CLEAN-NET approach with a semi-circular seromuscular layer incision surrounding the base of the tumor, different from a circular shape seromuscular layer in the conventional CLEAN-NET: around the tumor to preserve mucosal continuity, which acts as a barrier to avoid intraoperative tumor dissemination. Case presentation: A 43-year-old woman was referred to our hospital because of a gastric submucosal tumor near the cardia, detected on medical examination. The patient was diagnosed with gastric GIST based on the results of endoscopic ultrasound-guided fine-needle aspiration. Modified CLEAN-NET was performed with a semicircular incision of the seromuscular layer on the opposite side of the cardia, making the surgical procedure simple and minimizing partial resection of the gastric wall, including the tumor, while preserving the cardia. The operative time was 147 min, preoperative blood loss volume was 3 mL, and postoperative hospital stay was 9 days. The resected specimen revealed a minimal resection of the gastric wall, including the tumor. The cardia and gastric nerves were preserved, and the postoperative food intake was good. Conclusions: The modified CLEAN-NET with semicircular seromuscular layer dissection is a simple and reliable surgical procedure for GIST near the cardia. [ABSTRACT FROM AUTHOR]

Gastric calcifying fibrous tumor (CFT) is a rare benign mesenchymal tumor. Several previous studies have reported surgical resection for gastric CFT larger than 20mm for the difficulty in preoperative diagnosis. Here, we report a rare case of large gastric CFT treated with endoscopic submucosal excavation (ESE). A 70-year-old woman presented with recurrent epigastric pain and underwent endoscopy, which revealed a 35mm-sized submucosal tumor in the gastric body. ESE was performed after imaging examination and endoscopic ultrasonography. En bloc resection was achieved, but due to the specimen's substantial size and difficulty in mincing, it posed challenges for removal through the mouth. Finally, the specimen was temporarily placed in the stomach and was completely removed two days later. The diagnosis was confirmed based on pathological and immunohistochemical findings. There was no recurrence during the patient's 11-month follow-up. We provided a case report related to the diagnosis and endoscopic treatment for large gastric CFT. In addition, our experience of temporarily leaving a large postoperative specimen, considered a benign lesion, in the stomach for later removal was successful but requires appropriate timing to avoid blockage of the gastrointestinal tract. [ABSTRACT FROM AUTHOR]

Recent reports have described the practicality of laparoscopic intragastric surgery (l-IGS) as an alternative for resecting submucosal tumors (SMTs) near the esophagogastric junction (EGJ), where excision using an exogastric approach would be difficult. However, even using IGS to perform a full-thickness resection of SMTs that are in or extremely close to the EGJ is very difficult to do safely and avoid disrupting or causing stenosis of the EGJ, without advanced experience. This study retrospectively examined the usefulness of l-IGS for gastric SMTs located in or extremely close to the EGJ. Fourteen patients with gastric SMTs < 2 cm of the EGJ and underwent l-IGS were eligible for this study. We examined the tumor location, operative time, intraoperative hemorrhage, degree of deformation, gastroesophageal reflux disease, perioperative complications, and recurrence. Furthermore, we compared patients with tumors in the EGJ with those with tumors near the EGJ and patients in whom three-port l-IGS was performed with those who underwent single-incision laparoscopic surgery. The average tumor size, operative time, intraoperative hemorrhage, and postoperative hospitalization of the 14 patients were 30.9 ± 21.3 mm, 125.2 ± 31.1 min, 30.7 ± 103.3 mL, and 9.2 ± 3.1 d, respectively. No differences in these parameters according to the type of l-IGS or tumor location were observed. All patients underwent l-IGS without complications and were free from EGJ deformation or esophagitis. We believe that l-IGS is useful for gastric SMTs located < 2 cm of the EGJ as it can be safely performed for difficult tumor locations and does not cause deformation of the EGJ. [ABSTRACT FROM AUTHOR]

IntroductionGastric glomus tumor is a rare submucosal mesenchymal tumor with no distinct features on endoscopy. In clinical practice, it is often treated with laparoscopic partial gastrectomy. Here, we report a case of gastric glomus tumor successfully resected using a combination of gastroscopy and laparoscopy.Case descriptionThe patient was an elderly male who underwent gastroscopy, which revealed a submucosal mass in the gastric antrum. The lesion was suspected to be a stromal tumor. Further evaluation with computed tomography (CT) imaging indicated a space-occupying lesion in the gastric antrum, with the possibility of benign pathology. Endoscopic ultrasonography revealed that the tumor originated from the muscular layer and was approximately 28.8 mm ×22.5 mm. Blood flow was detected behind the lesion, suggesting the possibility of a gastric glomus tumor. The tumor was removed using a combination of gastroscopy and laparoscopy. Postoperative pathology suggested that it was a benign gastric glomus tumor. The patient recovered uneventfully and was discharged 7 days later.ConclusionGastric glomus tumor is a rare submucosal tumor that should be included in the differential diagnosis of gastric submucosal tumors. A combined approach using gastroscopy and laparoscopy offers a minimally invasive and effective treatment option.

Primary esophageal small cell carcinoma (PESC) is a rare, extremely aggressive malignancy characterized by rapid growth, early metastasis, and poor prognosis. This study presents a case of early-stage PESC that was initially misdiagnosed as an esophageal leiomyoma, which was observed as a submucosal tumor during gastroscopy. The patient subsequently underwent endoscopic submucosal dissection (ESD), which successfully achieved complete tumor resection. Histopathological analysis later confirmed the diagnosis of small cell carcinoma. Subsequent treatments were recommended; however, the patient declined these options and developed systemic metastases 16 months later, indicating progression to advanced disease and a poor prognosis. This case underscores the imperative to consider PESC in the differential diagnosis of submucosal esophageal lesions, especially when clinical suspicion is elevated, despite its rarity. Additionally, it highlights the challenges associated with the diagnosis and management of submucosal PESC and emphasizes the crucial role of early diagnosis in enhancing patient prognosis and survival rates.

Most of the swallowed foreign bodies pass through the gastrointenstinal tract (GIT) and only 1% of them are required surgery. Many authors have reported different cases of a foreign body migration deep into the layer of the gastrointestinal tract and their successful subsequent surgical treatment. However, there are some limited reports about the extraction of the embedded foreign bodies, when endoscopic techniques, such as endoscopic submucosal dissection, are used. We present the case of a 70-years old patient who was performed full-thickness resection of a duodenal neuroendocrine tumor. According to upper endoscopy, the submucosal gastric antral tumor was suspected. During the preoperative examination, esophagogastroduodenoscopy, endosonography and computed tomography were performed, but the nature of the formation was not determined. During the full-thickness resection, the embedded foreign body (a fish-bone) with the fistula around it was revealed and successfully extracted. This case demonstrates a rare pathological situation – the foreign body of the gastric wall, as well as the efficiency of flexible intraluminal endoscopy to extract it.

A 49-year-old man came to our hospital because of melena and was suspected to have advanced descending colon cancer by contrast-enhanced CT of the abdomen. Two days later, he was brought to the emergency department with fever and severe abdominal pain. A simple CT scan of the abdomen showed gas outside of the mass, which was diagnosed as a penetration into the retroperitoneum. Later, colonoscopy revealed a submucosal mass-like lesion with ulceration in the descending colon, which did not pass the scope, and biopsy showed no obvious malignancy. Since the colon was almost obstructed and also penetrated, we decided on a policy of surgery. After preoperative placement of an ICG fluorescent left ureteral stent, a laparoscopic left-hemi colectomy was performed. Though the left ureter was preserved, which was confirmed by a fluorescent stent, the left gonadal artery/vein was resected. because of direct invasion of the tumor. Histopathological examination revealed adenosquamous carcinoma, pT3N1a, Stage Ⅲb. Adenosquamous carcinoma of the colon is rare, and this is the first report of a similar case. [ABSTRACT FROM AUTHOR]

Background and Aim: Gastrointestinal stromal tumors (GISTs) are treated as malignant gastric subepithelial lesions (SELs), and resection is recommended. However, small gastric SELs < 20 mm with no malignant features are monitored without histopathological examination, and the frequency of malignancy is unknown. This study aimed to clarify the clinicopathological findings and clinical course of gastric SELs < 20 mm measured by endoscopic ultrasound (EUS). Methods: This retrospective cohort study included consecutive patients with small gastric SELs < 20 mm diagnosed using EUS at a tertiary referral center between 2009 and 2021. The clinical course after diagnosis using EUS‐guided fine‐needle aspiration (EUS‐FNA) was reviewed. Results: Among 333 patients with small gastric SELs, 104 patients with 105 lesions underwent EUS‐FNA. The pathological diagnosis was confirmed in 87 patients. GISTs were the most common pathology (47%). Among the 87 patients, 43 underwent therapeutic interventions, including tumor resection and chemotherapy. In groups of tumor resection, the pathological tumor size on the resected specimen was significantly larger than the size measured by EUS (19.5 mm vs 15.0 mm, P < 0.001), and 37% of resected SELs were 20 mm or over. No recurrence was observed after tumor resection during a mean follow‐up period of 40 months. Conclusions: Approximately 40% of small gastric SELs were malignant tumors, such as GIST, with most of them requiring treatment. Additionally, considering that the EUS measurement is 5 mm smaller than the pathological tumor diameter, further examinations, such as systematic EUS‐FNA, may be required for SEL, including those smaller than 20 mm. [ABSTRACT FROM AUTHOR]

Objectives: Early gastric cancer endoscopic resection (ER) is prominent in Japan. However, evidence regarding ER of gastric submucosal tumors (SMT) is limited. This prospective multicenter phase II study investigated the efficacy and safety of endoscopic full‐thickness resection (EFTR) for gastric SMT. Methods: Endoscopic full‐thickness resection indication for gastric SMT was 11–30 mm, histologically proven or clinically suspicious (irregular margin, increasing size, or internal heterogeneity) gastrointestinal stromal tumors (GIST), with no ulceration and intraluminal growth type. The primary end‐point was the complete ER (ER0) rate, with a sample size of 42. Results: We enrolled 46 patients with 46 lesions between September 2020 and May 2023 at seven Japanese institutions. The mean ± SD (range) endoscopic tumor size was 18.8 ± 4.5 (11–28) mm. The tumor resection and defect closure times were 54 ± 26 (22–125) min and 33 ± 28 (12–186) min, respectively. A 100% ER0 was achieved in all 46 patients. The EFTR procedure was accomplished in all patients without surgical intervention. One patient had delayed perforation and was managed endoscopically. GIST accounted for 76% (n = 35) of the cases. R0, R1, and RX rates were 33 (77%), 3 (6.5%), and 7 (15%), respectively. Conclusion: Endoscopic full‐thickness resection for gastric SMT of 11–30 mm is efficacious. It warrants further validation in a large‐scale cohort study to determine the long‐term outcome of this treatment for patients with gastric GIST. [ABSTRACT FROM AUTHOR]

Aim: To explore the feasibility and effectiveness of snare-assisted traction endoscopic full thickness resection (EFTR) on gastric fundus submucosal tumors (SMTs). Methods: The clinical and pathological data of patients with gastric SMTs who underwent EFTR treatment at the Endoscopy Center of Kaifeng Central Hospital from January 2018 to June 2023 were collected. Among them, 36 patients underwent snare-assisted traction EFTR (SAT-EFTR) and 46 patients underwent standard EFTR (S-EFTR). The clinical baseline data, operative data, adverse events, and follow-up results of the two groups were collected and compared. Results: All patients successfully completed EFTR technique. There were 34 male and 48 female patients, with an average age of (56.62 ± 11.31) years. The average operation time was shorter in the snare-assisted EFTR group than the S-EFTR group (73.39 ± 31.33 minutes versus 92.89 ± 37.57 minutes, P = .014). In addition, the resection speed of the snare-assisted EFTR group was also significantly faster than that of the S-EFTR group (4.04 ± 2.23 versus 2.48 ± 0.93 mm2/min, P < .001). There was no statistically significant difference in the age, gender, lesion size, postoperative fasting duration, and postoperative hospitalization stay between the two groups (P > .05). One patient in the SAT-EFTR group developed delayed postoperative perforation which was close with purse‑string suture technique. All patients were discharged successfully, and there was no recurrence or metastasis during the follow-up period. Conclusion: Snare-assisted traction of EFTR could shorten the operation time, reduce the difficulty of the operation, and improve the efficiency of the operation. At the same time, this method is simple and easy to learn, more suitable for beginners, and worthy of clinical promotion and application. [ABSTRACT FROM AUTHOR]

Intracholecystic papillary neoplasm (ICPN) of the gallbladder is a relatively new concept and a rare neoplasm. ICPNs are found in 0.4% of cholecystectomies. ICPNs are commonly associated with low-to high-grade dysplasia and can be found with invasive foci. To the best of our research, <100 cases (n = 92) are reported worldwide and only 27 cases have been reported in India. We present a case of ICPN with a detailed review of the literature to illuminate the pitfalls of this entity, which is rarely encountered in routine reporting. [ABSTRACT FROM AUTHOR]

Abstract Background Inflammatory myofibroblastic tumor (IMT) of the stomach is an uncommon mesenchymal neoplasm. We present a case of gastric submucosal tumor (SMT) where the final diagnosis was IMT. Case presentation A 69-year-old man presented with a 24-mm SMT on the posterior wall of the middle third of the stomach that was detected by screening upper gastrointestinal endoscopy. Abdominal contrast-enhanced computed tomography showed that the tumor was well-enhanced. Although endoscopic ultrasonography-guided biopsy was performed, the histological diagnosis was not confirmed preoperatively. Since the tumor was clinically suspected to be a gastrointestinal stromal tumor, we performed gastric wedge resection by laparoscopic–endoscopic cooperative surgery. Pathologically, proliferative spindle cells with a positive reaction for smooth muscle actin, negativity for c-kit, desmin, s-100, CD34, STAT-6, β-catenin and anaplastic lymphoma kinase 1 were identified. Hence, the tumor was finally diagnosed as an IMT originating from the stomach. Conclusions When an SMT of the stomach is identified, the possibility of gastric IMT should be considered.

We herein describe the rare case of a patient with a gastric duplication cyst who underwent laparoscopic resection. A 67-year-old man was referred to our hospital with an intra-abdominal lesion incidentally diagnosed on abdominal computed tomography. Esophagogastroduodenoscopy revealed normal esophageal and gastric mucosa without any lesions. Abdominal contrast-enhanced computed tomography revealed an 18 mm well-defined mass adjacent to the lesser curvature side of the esophagogastric junction. Following clinical diagnosis as an intra-abdominal mass, the patient underwent laparoscopic surgery in a five-port setting. The lesion originated from the stomach, near the muscular layer. The stomach muscle layer was partially resected; however, no communication between the mass and gastric mucosa was identified. Macroscopically, the resected specimen was 19 × 18 mm with a smooth surface and distinct margins. Microscopic examination confirmed the diagnosis of a gastric duplication cyst. The inner surface was covered with gastric gland pit-type columnar epithelial cells without atypia or neoplastic changes. The cyst wall presented layers of mucosa, muscularis mucosae, submucosa, muscularis propria, and subserosa. The patient's course after the procedure was uneventful, and he was discharged 8 days postoperatively. Gastric duplication cysts are rare and mostly asymptomatic, and their laparoscopic partial resection is safe and effective. [ABSTRACT FROM AUTHOR]

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Although heterotopic pancreas usually occurs in the stomach and rarely presents as a submucosal tumor, an accurate preoperative diagnosis is often difficult because of the variety of clinical symptoms and findings depending on the size and location of the lesion. We experienced a case of gastric type III heterotopic pancreas presenting as a gastric adenomyoma in the antrum of the stomach. A 62-year-old woman visited a local hospital for epigastric discomfort. An esophagogastroduodenoscopy study indicated a submucosal tumor in the greater curvature of the gastric antrum. The patient underwent surgical resection of the tumor because it was enlarged. The histological sections of the resected specimen showed that the tumor was composed of ductular structures lined by tall columnar epithelia and a prominent smooth muscle stroma with no atypical cells. The tumor was compatible with Heinrich's type III heterotopic pancreas, which presented as an adenomyoma of the stomach. These findings provide useful histological features and some insight into a better understanding of the embryonic origin and development of adenomyoma and heterotopic pancreas in the antrum of the stomach. [ABSTRACT FROM AUTHOR]

A 56-year-old woman was referred to our hospital due to dry mouth. Diagnostic upper gastrointestinal endoscopy showed slightly elevated lesions both on the anterior wall and lesser curvature in the upper part of the stomach. Biopsy-proven tuble-forming atypical cells in the two lesions led us to treat the presumed early gastric cancers with endoscopic submucosal dissection (ESD). Pathological examination of the ESD specimen showed well-differentiated malignant cells spreading widely in the submucosa with positive lateral and deep margins. On retrospective image re-evaluation after ESD, we noticed the correlation between the presumed early gastric cancers and the multiple submucosal cyst-like lesions in the gastric wall on computed tomography. Under the tentative diagnosis of gastric cancers originating not from orthotopic gastric mucosa but from submucosal ectopic gastric gland, the patient underwent laparoscopic total gastrectomy and regional lymph node dissection, revealing the tumor infiltration to the serosa and regional lymph node swelling. Postoperative pathological evaluation showed lymph node metastases, multiple submucosal cyst-like lesions lined with a single layer of presumably benign epithelium, papillary adenocarcinoma cells in the submucosa, and tubular adenocarcinoma cells both in the mucosal and subserosal regions. The patient was discharged on the postoperative 7th day without any events and completed adjuvant chemotherapy on an outpatient basis. General surgeons should note that cyst-like lesion(s) in the gastric wall might be a predictor of extensive submucosal cancer cell spreading even in a case of well-differentiated gastric adenocarcinoma.

Abstract Background An Inflammatory myofibroblastic tumor (IMT) is a rare intermediate malignancy characterized by myofibroblast proliferation and inflammatory cell infiltration. Various organs are the primary sites of origin. However, primary tumors originating in the stomach tend to be extremely rare, making the diagnosis difficult. Herein, we present a case of IMT originating in the stomach that was effectively managed using inverted laparoscopic endoscopic cooperative surgery (LECS). Case presentation A 47-year-old male who was admitted to the hospital because of a submucosal tumor that was discovered during upper gastrointestinal endoscopy. The diameter of the tumor was approximately 20 mm. A KIT-negative gastrointestinal stromal tumor was suspected based on the biopsy findings. Therefore, partial resection of the stomach was performed using inverted laparoscopic and endoscopic cooperative surgery. Histopathological examination revealed collagen fiber proliferation from the submucosal layer to the muscular layer, accompanied by infiltration of spindle-shaped cells, lymphocytes, and numerous inflammatory cells. Immunohistochemistry results were positive for SMA and negative for CD34, desmin, and c-kit. IgG4-positive cells were observed with an IgG4/IgG ratio > 50%, and specific nuclei were positive for ALK. Therefore, IMT was diagnosed. This condition may be difficult to diagnose both before and after surgery because of its rarity and submucosal tumor-like morphology. Conclusion When a submucosal tumor originating in the stomach is observed, IMT should be considered. Partial resection of the stomach with LECS and immunohistochemical diagnosis may be useful.

Abstract Background Metastatic esophageal cancer is rare. Its common primary lesions include lung cancer and breast cancer. Metastatic esophageal cancer originating from colorectal cancer is rarer. Case presentation A 79-year-old woman visited our hospital because of lower abdominal discomfort. She was endoscopically diagnosed with type 0–IIa + IIc cancer of the cecum, and biopsy of the lesion showed signet-ring cell carcinoma. With a preoperative clinical staging of cStage I (cT2, cN0, cM0), the patient underwent laparoscopic ileocecal resection with D3 lymphadenectomy. Histopathological examination of the resected specimens revealed signet-ring cell carcinoma [type 4, pT4a, pN3 (No. 203), M0, pRM1, stage IIIc, R1]. Despite radial margin positivity, the patient refused resection of the residual tumor and received oral tegafur and uracil. KRAS mutation test showed KRAS wild-type colon cancer, but she refused anti-epidermal growth factor receptor therapy. One year after surgery, her blood carcinoembryonic antigen concentration elevated. Colonoscopy showed anastomotic recurrence and biopsy of the lesion showed signet-ring cell carcinoma. Upper gastrointestinal endoscopy showed multiple longitudinal submucosal tumors with erosions on their surfaces in the esophagus. Tumor biopsy revealed signet-ring cell carcinoma. Immunohistochemistry showed that the histological type of the esophageal tumors was the same as that of the primary colon cancer. Based on these findings, the esophageal tumors were diagnosed with metastasis from signet-ring cell carcinoma of the cecum. The oral chemotherapy was replaced with FOLFOX plus bevacizumab. However, the patient’s condition required treatment discontinuation, and she died of cancer progression 1 year and 5 months after surgery. Conclusions To our knowledge, this is the first case report on metastatic esophageal cancer from signet-ring cell carcinoma of the cecum. Esophagoscopy showed multiple longitudinal submucosal tumors, which is similar to an endoscopic finding of intramural metastasis from primary esophageal cancer. We consider that the multiple longitudinal submucosal tumors are a notable feature of our case. When metastatic esophageal cancer is suspected, clinicians, endoscopists, and pathologists should consider signet-ring cell carcinoma of the colon as one of potential primary lesions. This consideration could lead the specialists to appropriate examinations and treatments, thereby improving clinical outcomes in patients with the metastasis.

Abstract An 83‐year‐old male underwent three transgastric punctures with endoscopic ultrasound‐guided fine‐needle aspiration for the examination of a pancreatic body tumor. After a diagnosis of resectable pancreatic cancer and undergoing distal pancreatectomy, the patient was administered postoperative adjuvant chemotherapy with oral S‐1 for 6 months, and carcinoembryonic antigen and carbohydrate antigen 19‐9 levels were bimonthly evaluated. Carbohydrate antigen 19‐9 levels continually increased to 4638.1 U/mL at 45 months post‐fine‐needle aspiration. Endoscopic ultrasound‐guided showed a 25 mm low‐echoic, irregularly shaped, and heterogeneous tumor with clear margins protruding from the mucosa outside the gastric wall, and biopsy confirmed adenocarcinoma. Since the immunostaining findings of the specimen matched those of the previously resected specimen, needle tract seeding (NTS) due to puncture of the pancreatic cancer was identified as the cause. After a pylorus‐preserving gastrectomy at 46 months post‐fine‐needle aspiration, postoperative chemotherapy initiation, comprising gemcitabine and nab‐paclitaxel, was initiated; however, the patient died despite these interventions as he developed multiple peritoneal dissemination. Although rare, the incidence of NTS will increase in the future owing to the expected extended survival in post‐pancreatic cancer resection cases. We suggest regular upper gastrointestinal endoscopy and endoscopic ultrasound‐guided evaluations for patients who are at risk for NTS can facilitate early detection. Furthermore, it is extremely relevant to share experiences of encountered NTS cases in practice and extend knowledge of its varying endoscopic appearances.

Abstract Background and aim Various techniques for direct biopsy from gastrointestinal subepithelial tumors (SETs) have been reported, although no standard method has been established. A common feature of these techniques is the removal of overlaying mucosa to enable direct biopsies from the SETs. These methods have been synthesized under the collective term “unroofing technique”. We conducted a multicenter retrospective study to assess its efficacy and identify potential complications. Methods This study was conducted in 10 hospitals and involved all eligible patients who underwent unroofing techniques to obtain biopsies for gastrointestinal SETs between April 2015 and March 2021. The primary endpoint was the diagnostic accuracy of the unroofing technique, and the secondary endpoints were the incidence of adverse events and the factors contributing to the accurate diagnosis. Results The study included 61 patients with 61 gastrointestinal SETs. The median tumor size was 20 mm, and the median procedure time was 38 min, with 82% successful tumor exposure. The rate of pathological diagnosis was 72.1%. In 44 patients with a pathological diagnosis, two showed discrepancies with the postresection pathological diagnosis. No factors, including facility experience, organ, tumor size, or tumor exposure, significantly affected the diagnostic accuracy. There was one case of delayed bleeding and two cases of perforation. Conclusion The diagnostic yield of the unroofing technique was acceptable. The unroofing technique was beneficial regardless of institutional experience, organ, tumor size, or actual tumor exposure.

Abstract A 51‐year‐old woman visited our hospital with the chief complaint of tarry stools. Contrast‐enhanced abdominal computed tomography revealed leakage of contrast medium into the lumen of the small intestine. Subsequently, a double‐balloon endoscopy was performed, which revealed a submucosal mass‐like lesion in the jejunum. Although hemostasis was attempted with clips, complete hemostasis was difficult to achieve, and angiographic embolization was performed. Nevertheless, the anemia progressed, and a small bowel resection was performed. Histopathological examination led to a diagnosis of a ruptured submucosal aneurysm of the small intestine. Endoscopic hemostasis is often difficult to achieve for submucosal aneurysms in the intestine. The submucosal tumor‐like finding observed on endoscopy in submucosal aneurysms is termed an “SMT‐like sign” and is considered an important finding to diagnose aneurysms.

Abstract A 25‐year‐old man was referred to our center for investigation of a gastric submucosal tumor and an ulcer that had developed on its oral side. Endoscopic ultrasonography findings suggested the presence of an ectopic pancreas, and treatment with an oral proton pump inhibitor was planned for the ulcer. Over the subsequent 3 years, the patient endured recurring epigastric pain and episodes of passing black stools. Emergency endoscopy revealed that the morphology of the gastric submucosal tumor had transformed into a pedunculated polyp‐like morphology with a bleeding ulcer at the apex of the lesion. Endoscopic hemostasis using hemostatic forceps was performed. However, the patient continued to pass black stools. In light of the persistent symptoms and unique morphology of the lesion, endoscopic resection was attempted as a curative approach. The lesion was excised by hot snare polypectomy. Post‐treatment, the patient exhibited no signs of recurrence, marking a successful resolution. Three months later, a gastroduodenal endoscopy showed that the excised site had undergone scar formation without recurrence of the lesion. This case holds significant clinical value as it demonstrates the efficacy of a minimally invasive treatment strategy in managing repeated bleeding ulcerations of an ectopic pancreas, ultimately achieving a complete cure.

Gastric duplication cysts (GDCs) are rare structural abnormalities, especially in adults. We first report a rare case of small multiple GDCs in a woman, which presents as a submucosal tumor (SMT) at the gastric antrum. In consideration of the patient's request for surgical treatment and minimally invasive resection, endoscopic submucosal dissection (ESD) was performed to remove the cyst. The case provides a reference for ESD surgery to remove small GDCs. So far, there is no consensus or practice guidelines for the diagnosis and management of GDCs. Herein we perform a comprehensive literature review and discussion on GDCs. GDCs are 'repetitive' cystic or tubular structures of gastric mucosa and muscularis mucosae, and share the muscularis propria and serous layer with the normal gastric wall. GDCs protruding into the stomach cavity can be diagnosed by endoscopic ultrasound (EUS), which has higher specificity and accuracy than CT and MRI. Some GDCs may cause complications, even cancerization. Therefore, we suggest that once found, the GDCs could be completely resected. For GDCs protruding into the stomach cavity, endoscopic surgery such as ESD can be adopted to remove the lesion. Endoscopic full-thickness resection (EFTR) may become an option for larger GDCs in the future. For extraluminal GDC, laparoscopic surgery is currently preferred. In this review, we summarized the structural and histopathological characteristics of GDCs and various treatment therapies, in order to provide experience and reference for the diagnosis and treatment of GDCs in the future. [ABSTRACT FROM AUTHOR]

Intracholecystic papillary neoplasm (ICPN) of the gallbladder is a relatively new concept and a rare neoplasm. ICPNs are found in 0.4% of cholecystectomies. ICPNs are commonly associated with low-to high-grade dysplasia and can be found with invasive foci. To the best of our research,

Background: Metastatic esophageal cancer is rare. Its common primary lesions include lung cancer and breast cancer. Metastatic esophageal cancer originating from colorectal cancer is rarer. Case presentation: A 79-year-old woman visited our hospital because of lower abdominal discomfort. She was endoscopically diagnosed with type 0–IIa + IIc cancer of the cecum, and biopsy of the lesion showed signet-ring cell carcinoma. With a preoperative clinical staging of cStage I (cT2, cN0, cM0), the patient underwent laparoscopic ileocecal resection with D3 lymphadenectomy. Histopathological examination of the resected specimens revealed signet-ring cell carcinoma [type 4, pT4a, pN3 (No. 203), M0, pRM1, stage IIIc, R1]. Despite radial margin positivity, the patient refused resection of the residual tumor and received oral tegafur and uracil. KRAS mutation test showed KRAS wild-type colon cancer, but she refused anti-epidermal growth factor receptor therapy. One year after surgery, her blood carcinoembryonic antigen concentration elevated. Colonoscopy showed anastomotic recurrence and biopsy of the lesion showed signet-ring cell carcinoma. Upper gastrointestinal endoscopy showed multiple longitudinal submucosal tumors with erosions on their surfaces in the esophagus. Tumor biopsy revealed signet-ring cell carcinoma. Immunohistochemistry showed that the histological type of the esophageal tumors was the same as that of the primary colon cancer. Based on these findings, the esophageal tumors were diagnosed with metastasis from signet-ring cell carcinoma of the cecum. The oral chemotherapy was replaced with FOLFOX plus bevacizumab. However, the patient's condition required treatment discontinuation, and she died of cancer progression 1 year and 5 months after surgery. Conclusions: To our knowledge, this is the first case report on metastatic esophageal cancer from signet-ring cell carcinoma of the cecum. Esophagoscopy showed multiple longitudinal submucosal tumors, which is similar to an endoscopic finding of intramural metastasis from primary esophageal cancer. We consider that the multiple longitudinal submucosal tumors are a notable feature of our case. When metastatic esophageal cancer is suspected, clinicians, endoscopists, and pathologists should consider signet-ring cell carcinoma of the colon as one of potential primary lesions. This consideration could lead the specialists to appropriate examinations and treatments, thereby improving clinical outcomes in patients with the metastasis. [ABSTRACT FROM AUTHOR]

Gastric glomus tumors are rare submucosal mesenchymal neoplasms that are difficult to diagnose preoperatively. We present a case of a 60‐year‐old woman who was diagnosed with a gastric glomus tumor using endoscopic ultrasonography‐guided fine‐needle aspiration biopsy. The tumor was successfully resected with laparoscopic endoscopic cooperative surgery (LECS). LECS could be an effective method for the resection of gastric glomus tumors. [ABSTRACT FROM AUTHOR]

BackgroundPlexiform fibromyxoma (PF) is a rare gastric tumor often confused with gastrointestinal stromal tumor. These so-called "benign" tumors often present with upper GI bleeding and gastric outlet obstruction. It was recently demonstrated that approximately one-third of PF have activation of the GLI1 oncogene, a transcription factor in the hedgehog (Hh) pathway, via a MALAT1-GLI1 fusion protein or GLI1 up-regulation. Despite this discovery, the biology of most PFs remains unknown.MethodsNext generation sequencing (NGS) was performed on formalin-fixed paraffin-embedded (FFPE) samples of PF specimens collected from three institutions (UCSD, NCI and OHSU). Fresh frozen tissue from one tumor was utilized for in vitro assays, including quantitative RT-PCR and cell viability assays following drug treatment.ResultsEight patients with PF were identified and 5 patients' tumors were analyzed by NGS. An index case had a mono-allelic PTCH1 deletion of exons 15-24 and a second case, identified in a validation cohort, also had a PTCH1 gene loss associated with a suspected long-range chromosome 9 deletion. Building on the role of Hh signaling in PF, PTCH1, a tumor suppressor protein, functions upstream of GLI1. Loss of PTCH1 induces GLI1 activation and downstream gene transcription. Utilizing fresh tissue from the index PF case, RT-qPCR analysis demonstrated expression of Hh pathway components, SMO and GLI1, as well as GLI1 transcriptional targets, CCND1 and HHIP. In turn, short-term in vitro treatment with a Hh pathway inhibitor, sonidegib, resulted in dose-dependent cell killing.ConclusionsFor the first time, we report a novel association between PTCH1 inactivation and the development of plexiform fibromyxoma. Hh pathway inhibition with SMO antagonists may represent a target to study for treating a subset of plexiform fibromyxomas.

Endoscopic ultrasonography (EUS) has been found to be of great advantage in the diagnosis of digestive tract submucosal tumors. However, EUS-based diagnosis is limited by variability in subjective interpretation on the part of doctors. Tumor classification of ultrasound images with the computer-aided diagnosis system can significantly improve the diagnostic efficiency and accuracy of doctors. In this study, we proposed a multifeature fusion classification method for adaptive EUS tumor images. First, for different ultrasound tumor images, we selected the region of interest based on prior information to facilitate the estimation in the subsequent works. Second, we proposed a method based on image gray histogram feature extraction with principal component analysis dimensionality reduction, which learns the gray distribution of different tumor images effectively. Third, we fused the reduced grayscale features with the improved local binary pattern features and gray-level co-occurrence matrix features, and then used the multiclassification support vector machine. Finally, in the experiment, we selected the 431 ultrasound images of 109 patients in the hospital and compared the experimental effects of different features and different classifiers. The results revealed that the proposed method performed best, with the highest accuracy of 96.18% and an area under the curve of 99%. It is evident that the method proposed in this study can efficiently contribute to the classification of EUS tumor images. [ABSTRACT FROM AUTHOR]

Gastric subepithelial lesions (SEL) are usually found incidentally during esophagogastroduodenoscopy. Most gastric SELs are benign lesions, such as leiomyoma and pancreatic rests. However, neoplastic lesions including neuroendocrine tumors, gastrointestinal stromal tumors, and certain types of gastric adenocarcinoma (GA), such as the recently WHO-classified fundic gland type adenocarcinoma, may be found. The lack of simple and established diagnostic methods for SEL remains a clinical challenge. Standard biopsy is suboptimal for diagnosis due to the subepithelial location of lesions and is therefore often omitted. Furthermore, guideline-based algorithmic approaches for diagnosing SEL also differ between Japan and the USA. In this case series, we describe three cases of gastric SEL that were subsequently diagnosed as GA. Case 1 was a fundic gland type (chief cell predominant type) adenocarcinoma; Case 2 was a poorly differentiated GA; Case 3 was an advanced GA, found after 4 serial years of endoscopic follow-up for SEL. While standard biopsy led to successful diagnosis in the first 2 cases, no standard biopsy was performed during surveillance in Case 3, making its diagnostic effectiveness unclear. The third case highlights the importance of longitudinal observation for endoscopic mucosal alterations that may suggest certain types of GA. Clinicians should be aware that standard biopsy may play an important role in the evaluation of malignant gastric SEL-like lesions. It is crucial to remain vigilant for surface changes in SEL and not to summarily omit standard biopsy.

Esophageal squamous cell carcinoma is an aggressive and globally prevalent malignancy that rarely presents as submucosal tumor-like lesions, leading to significant diagnostic challenges. We present two examples of primary esophageal squamous cell carcinoma in which complete intramural invasion mimicked submucosal tumor-like lesions. Initial biopsies suggested benign hyperplasia; however, subsequent endoscopic ultrasound-guided fine needle aspiration confirmed the diagnosis of esophageal squamous cell carcinoma. Both patients received appropriate treatment and showed favorable outcomes. The histopathological feature of intramural esophageal squamous cell carcinoma, characterized by growth confined within the esophageal wall without mucosal epithelial invasion, represents an exceedingly rare and complex pattern. The diagnostic challenges presented by this form of esophageal squamous cell carcinoma highlight the critical role of detailed histopathological examination, with endoscopic ultrasound-guided fine needle aspiration being indispensable for accurate diagnosis and effective management of submucosal tumor-like lesions. [ABSTRACT FROM AUTHOR]

Gastric plexiform fibromyxoma is extremely rare. In our case, upper gastrointestinal endoscopy of a 41-year-old woman patient revealed a 1-cm submucosal tumor (SMT) in the greater curvature of the lower body of the stomach. On contrast-enhanced computed tomography, the tumor was hypervascular in the arterial phase with continuous enhancement in the post-venous phase. On endoscopic ultrasonography, it had a low echo pattern. The preoperative diagnosis was a gastric SMT with a rich vasculature; however because the biosy specimen did not contain tumor tissue, a malignant tumor could not be excluded. The patient underwent nonexposed endoscopic wall-inversion surgery (NEWS), and the tumor was completely resected. Immunohistochemical examination revealed that the tumor was positive for D2-40 and α-smooth muscle actin, but negative for c-kit, discovered on gastrointestinal stromal tumor-1, desmin, S100, Melan-A, signal transducer and activator of transcription 6, insulinoma-associated protein 1, CXCL13, ETS transcription factor, follicular dendritic cell, anaplastic lymphoma kinase, human melanoma black, h-caldesmon, and CD1a, 10, 21, 23, 31, 34, 68, and 163. Approximately, 1–2% of the tumor cell nuclei were Ki-67-positive. Finally, we diagnosed the tumor as a plexiform fibromyxoma. In conclusion, NEWS is an effective method for the treatment of SMTs with a diameter of

Abstract Objectives A gastric hamartomatous inverted polyp (GHIP) is a rare submucosal tumor characterized histopathologically by a submucosal inverted proliferation of cystically dilated hyperplastic gastric glands. Only 42 GHIPs have been reported in English literature. Few GHIPs have been reported to accompany adenocarcinomas. We reported on three patients with a GHIP and reviewed the clinicopathological and endoscopic features of GHIPs. Methods This study included two men and one woman with a GHIP. The endoscopic, histopathological, and immunohistochemical features of the endoscopically resected specimens were analyzed. A gene mutation analysis was also performed. Results All the tumors were located in the body of the stomach, with a median size of 20 mm. Two tumors were sessile, and the remaining tumor had a pedunculated appearance. The overlying mucosa mainly appeared normal but was reddish in one tumor. The histopathological examination of the tumors revealed a well‐circumscribed and lobular submucosal proliferation of cystically dilated hyperplastic glands. The immunohistochemical analysis revealed that the MUC5AC‐positive foveolar epithelium was located in the center, and MUC6‐positive pseudo‐pyloric or pepsinogen‐I and H+/K+ ATPase‐positive fundic‐type glands were located at the periphery of two tumors. No carcinomatous components were noted in any of the tumors. Moreover, no significant mutations in oncogenes or tumor suppressor genes were noted. Conclusions Our review revealed that approximately three fourths of GHIP cases showed an submucosal tumor‐like feature, whereas endoscopic features, including the endoscopic ultrasonography findings, were not characteristic. Because an endoscopic diagnosis of a GHIP may be difficult, complete endoscopic resection may be required for a pathological diagnosis.

Abstract A 54‐year‐old man was referred to our hospital because of a suspected esophageal submucosal tumor on upper gastrointestinal radiography. Contrast‐enhanced computed tomography showed a 52 mm homogeneous mass attached to the lower thoracic esophagus. Esophagogastroduodenoscopy revealed a 50 mm submucosal tumor in the lower esophagus, and endoscopic ultrasonography (EUS) showed a continuous hypoechoic lesion in the esophageal muscularis propria. Contrast‐enhanced harmonic EUS revealed a non‐echogenic area. T1 and T2 magnetic resonance imaging revealed a high‐signal lesion. Based on imaging studies, an esophageal duplication cyst was diagnosed. Although asymptomatic, the patient underwent video‐assisted thoracic surgery because of the possibility of rupture and the appearance of symptoms due to a future infection or enlargement, although this was not noted before. In our case, the esophageal duplication cyst appeared as a hypoechoic mass, requiring differentiation from submucosal tumor other than the cyst. Histologically, the cyst was covered by two layers of muscle covered by the chorioepithelial columnar epithelium. EUS fine‐needle aspiration is effective in diagnosing submucosal tumor but also carries the risk of infection. Contrast‐enhanced ultrasonography was used in this case to observe the interior and reach a preoperative diagnosis. Contrast‐enhanced harmonic EUS appears to be effective in examining the interior of submucosal tumor lesions noninvasively.

Abstract Herein, we report two rare basaloid squamous cell carcinoma (BSCC) cases. Esophagogastroduodenoscopy revealed a submucosal tumor‐like lesion and a biopsied specimen showed a finding suspected of BSCC in both cases. Both lesions underwent endoscopic submucosal dissection with en bloc resection, and long‐term survival was achieved using additional chemoradiotherapy. The standard treatment for BSCC has not been determined, and there are few reports of esophageal BSCC treated using endoscopic resection. Endoscopic submucosal dissection and additional chemoradiotherapy for superficial BSCC may be effective treatment options.

Objectives: Limited information is available on the efficacy and safety of endoscopic resection (ER) of gastric submucosal tumors (SMTs) in Japanese endoscopic practice where ER for gastric tumors is extremely popular. Methods: We conducted this study to elucidate the current scenario of ER for gastric SMTs in Japanese endoscopic practice. Patients (from 12 institutions) with gastric SMTs who underwent ER were enrolled from the first case until August 2020. Results: We enrolled 117 patients with 118 lesions. The number of patients who underwent ER increased over the years. The mean endoscopic tumor size was 20 ± 7.2 (8–40) mm. The growth type was primarily intraluminal (90%). The mean resection and wound closure times were 58 ± 38 (range, 12–254) min and 31 ± 41 (range, 3–330) min, respectively. Complete ER was achieved for 117 (99%) lesions. Full‐thickness resection rate was 44%; however, only 12 (10%) patients required abdominal paracentesis for decompression. Endoscopic treatments were completed in 115 (97%) lesions, while three lesions required conversions to laparoscopic surgery due to luminal collapse, uncontrolled bleeding, and difficulty in defect closure. Gastrointestinal stromal tumors were the most common pathology (74%). No recurrence was observed during the mean follow‐up period of 4.3 ± 2.9 years. The 5‐year overall survival rate was 98.9% (95% confidence interval 97.8–100%). Conclusion: Performance of ER for gastric SMTs is increasing in Japan. The technique seems feasible in Japanese endoscopic practice, warranting further validation in a prospective study. Watch a video of this article. [ABSTRACT FROM AUTHOR]

A 56-year-old woman was referred to our hospital due to dry mouth. Diagnostic upper gastrointestinal endoscopy showed slightly elevated lesions both on the anterior wall and lesser curvature in the upper part of the stomach. Biopsy-proven tuble-forming atypical cells in the two lesions led us to treat the presumed early gastric cancers with endoscopic submucosal dissection (ESD). Pathological examination of the ESD specimen showed well-differentiated malignant cells spreading widely in the submucosa with positive lateral and deep margins. On retrospective image re-evaluation after ESD, we noticed the correlation between the presumed early gastric cancers and the multiple submucosal cyst-like lesions in the gastric wall on computed tomography. Under the tentative diagnosis of gastric cancers originating not from orthotopic gastric mucosa but from submucosal ectopic gastric gland, the patient underwent laparoscopic total gastrectomy and regional lymph node dissection, revealing the tumor infiltration to the serosa and regional lymph node swelling. Postoperative pathological evaluation showed lymph node metastases, multiple submucosal cyst-like lesions lined with a single layer of presumably benign epithelium, papillary adenocarcinoma cells in the submucosa, and tubular adenocarcinoma cells both in the mucosal and subserosal regions. The patient was discharged on the postoperative 7th day without any events and completed adjuvant chemotherapy on an outpatient basis. General surgeons should note that cyst-like lesion(s) in the gastric wall might be a predictor of extensive submucosal cancer cell spreading even in a case of well-differentiated gastric adenocarcinoma. [ABSTRACT FROM AUTHOR]

Introduction: Glomus tumor (GT) is a rare mesenchymal neoplasm that can be found anywhere throughout the body, including the stomach. Our goal was to present a case and a systematic review of the literature, reporting clinical, radiological, surgical, and pathological features of the disease. Methods: We reviewed Pubmed and SCOPUS for all case reports and case series published after 2000. Papers written in languages different from English and letters to the editor were excluded. Screening and data extraction were performed following the PRISMA guidelines. Results: A total of 89 studies were included in the systematic review, consisting of 187 cases of gastric glomus tumor. Mean age was 52 (18–90); most patients were female (61%). The most common clinical presentation was epigastric pain (33.9% of cases). The gastric antrum was the most frequently involved site (75.3%). Mean tumor size was 2.82 cm (0.8–17). Preoperative diagnosis was achieved in 22 cases, mostly by endoscopic ultrasound (EUS)-guided biopsy. Wedge resection was performed in 62% of treated patients. Smooth muscle actin was expressed in all cases with available immunohistochemistry. Malignant GT was reported in 11 cases. Discussion: Epigastric pain and bleeding were the most common symptoms at presentation in patients with diagnosis of glomus tumor. EUS-guided fine needle aspiration can be useful for preoperative diagnosis. Endoscopic elastosonography is a promising tool for the differential diagnosis of gastric submucosal lesions, including glomus tumors. The treatment of choice is wedge resection with adequate free margins. A laparoscopic approach is warranted when technically feasible. Since malignant gastric GTs have been described, long-term follow-up is suggested after surgical excision. [ABSTRACT FROM AUTHOR]

Background: The ability of endoscopists to identify gastric lesions is uneven. Even experienced endoscopists may miss or misdiagnose lesions due to heavy workload or fatigue or subtle changes in lesions under white-light endoscopy (WLE). This study aimed to develop an artificial intelligence (AI) system that could diagnose six common gastric lesions under WLE and to explore its role in assisting endoscopists in diagnosis. Methods: Images of early gastric cancer, advanced gastric cancer, submucosal tumor, polyp, peptic ulcer, erosion, and lesion-free gastric mucosa were retrospectively collected to train and test the system. The performance of the system was compared with that of 12 endoscopists. The performance of endoscopists with or without referring to the system was also evaluated. Results: A total of 29,809 images from 8947 patients and 1579 images from 496 patients were used to train and test the system, respectively. For per-lesion analysis, the overall accuracy of the system was 85.7%, which was comparable to that of senior endoscopists (85.1%, P = 0.729) and significantly higher than that of junior endoscopists (78.8%, P < 0.001). With system assistance, the overall accuracies of senior and junior endoscopists increased to 89.3% (4.2%, P < 0.001) and 86.2% (7.4%, P < 0.001), respectively. Senior and junior endoscopists achieved varying degrees of improvement in the diagnostic performance of other types of lesions except for polyp. The diagnostic times of senior (3.8 vs 3.2 s per image, P = 0.500) and junior endoscopists (6.2 vs 4.6 s per image, P = 0.144) assisted by the system were both slightly shortened, despite no significant differences. Conclusions: The proposed AI system could be applied as an auxiliary tool to reduce the workload of endoscopists and improve the diagnostic accuracy of gastric lesions. [ABSTRACT FROM AUTHOR]

Primary esophageal small cell carcinoma (PESC) is a rare, extremely aggressive malignancy characterized by rapid growth, early metastasis, and poor prognosis. This study presents a case of early-stage PESC that was initially misdiagnosed as an esophageal leiomyoma, which was observed as a submucosal tumor during gastroscopy. The patient subsequently underwent endoscopic submucosal dissection (ESD), which successfully achieved complete tumor resection. Histopathological analysis later confirmed the diagnosis of small cell carcinoma. Subsequent treatments were recommended; however, the patient declined these options and developed systemic metastases 16 months later, indicating progression to advanced disease and a poor prognosis. This case underscores the imperative to consider PESC in the differential diagnosis of submucosal esophageal lesions, especially when clinical suspicion is elevated, despite its rarity. Additionally, it highlights the challenges associated with the diagnosis and management of submucosal PESC and emphasizes the crucial role of early diagnosis in enhancing patient prognosis and survival rates., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Yan and Xiao.)

Abstract Background Leiomyosarcoma is a rare tumor that could originate from the gastrointestinal tract, uterus, kidney, retroperitoneum, and the soft tissues of the extremities. It accounts for only 1% of all gastrointestinal mesenchymal tumors and primary leiomyosarcoma of the stomach is extremely rare. Most cases reported as leiomyosarcoma of the stomach before the development of KIT immunohistochemistry might be gastrointestinal stromal tumors (GISTs) of the stomach and only 18 cases of leiomyosarcoma of the stomach have been reported since early 2000s. We report here a patient with leiomyosarcoma of the stomach treated by laparoscopic and endoscopic cooperative surgery (LECS). Case presentation A 59-year-old man was referred to our hospital for an early gastric cancer, which was initially treated by endoscopic submucosal dissection. Six months after his initial treatment, a follow-up esophagogastroduodenoscopy revealed a small polypoid lesion at the lesser curvature of the proximal stomach, which appeared to be a hyperplastic polyp. However, one and a half years later, the lesion grew and showed more irregular surface. Biopsy at the time revealed smooth muscle cell proliferation suggestive of leiomyoma. Three years later, the lesion grew even larger and biopsy showed pleomorphic spindle cells. Immunohistochemical study showed positive staining for alpha-smooth muscle actin and desmin, but negative for c-kit and CD34. Ki-67 labeling index was nearly 60%. Based on these findings, the diagnosis of leiomyosarcoma was established. The patient subsequently underwent a partial gastrectomy by LECS. The patient is currently in good condition without recurrence or metastasis at 12 months after surgery. Conclusions Leiomyosarcoma of the stomach is extremely rare. This is the first report of leiomyosarcoma of the stomach treated by LECS. We could also follow its appearance change through endoscopic examination for 3 years.

Objective To evaluate the clinical efficacy of endoscopic full thickness resection in treatment of small gastric submucosal tumors (diameter≤1 cm). Methods A total of 102 patients with small gastric submucosal tumors treated using endoscopic full thickness resection in Zhongshan Hospital, Fudan University between January 2015 and December 2015 were analyzed retrospectively. Tumor resection rate, procedure time, interoperative bleeding and postoperative complications were observed in the procedures. Patients had follow-up endoscopy for evaluation of efficacy and safety. Results Endoscopic treatment was successful and resection of tumor was complete for all 102 patients. The average procedure time was (34.8±7.5) (11-126) min, Tumor diameter was (0.50±0.36) (0.3-1.0) cm and located all at gastric fundus. Pathological diagnose showed that 51 cases were with stromal tumor(50%), 45 cases with leiomyoma(44.1%), 2 cases with fibroma (2.0%), 2 cases with neuroendocrine tumors(2.0%), 1 case with hamartoma(1.0%), and 1 case with lymphoma(1.0%). Bleeding and perforation were not found and lesion surface of stomach was repaired well shown by follow-up. Conclusions Endoscopic full thickness resection in treatment of gastric submucosal tumors is effective and safe.

Background and Aims: Noninvasive, imaging diagnosis of gastrointestinal mesenchymal tumors (GIMTs) is still difficult. This study aimed to develop a novel diagnostic method of GIMTs via endoscopic ultrasonography (EUS) using circularity. Methods: In a derivation series, we retrospectively collected 50 GIMTs 2–5 cm in diameter of two institutions. After selecting one EUS still image showing the maximal area per lesion, two endoscopists who were blind to the histological diagnosis assessed circularity, a surrogate indicator of roundness (range, 0–1; 1 = a true circle), with an image-analyzing software. Median circularity of three types of GIMT was compared, and the cutoff value to differentiate a group from other groups was presented by drawing a receiver operating characteristic curve. Subsequently, we assessed the diagnostic ability of circularity in 91 GIMTs which were retrospectively collected from the other two institutions by using the optimal cutoff value presented in the derivation series. Results: The circularity in leiomyomas indicated 0.70 and was significantly lower than that of gastrointestinal stromal tumors (0.89), schwannomas (0.90), and their combined group. When leiomyomas were diagnosed as the circularity of <0.8305, which was presented as the optimal cutoff value, the diagnostic accuracy, sensitivity, and specificity in the validation series were 73.6%, 80.0%, and 72.4%, respectively. Conclusion: The data demonstrated that leiomyomas significantly exhibited more distortion than other GIMTs. That implies that the difference in shape, which is objectively determined as circularity, is useful to noninvasively discriminate leiomyomas from other GIMTs. [ABSTRACT FROM AUTHOR]

Lymphangiomas are rare and benign vascular malformations of the lymphatic system. They may arise in any location and at all ages and have variable presentation. These lesions in the intestinal wall are reported very rarely. In the case of colonic lymphangiomas, it is more common in late adulthood and old age, which, in this age group is thought to be associated with local disturbances of lymphatic circulation secondary to inflammation, degeneration, surgical procedure, trauma or radiation. The clinical presentation of colonic lymphangiomas varies from incidental findings on imaging to presenting with acute abdomen. The imaging features are usually multilocular cyst in intramural colon and submucosal mass on endoscopy. However, in the case of symptomatic lesions with atypical image findings, and the fact that the disease is rare, preoperative diagnosis is often difficult. On the other hand, although these cystic tumors do not transform into malignancy, they can be locally invasive or complicated, and often require resection. We report a 53-year-old male who had a cystic lymphangioma of the transverse colon illustrated by imaging modalities and recognized via postoperative histopathological examination. [ABSTRACT FROM AUTHOR]