Submucosal Tumor-like-shaped Low-grade Well-differentiated Adenocarcinoma with Gastric Phenotype Arising in the <i>Helicobacter pylori</i>-negative Stomach at Medical Check-up: A Report of Three Cases

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<p>  We describe three cases of submucosal tumor (SMT)-like-shaped low-grade well-differentiated adenocarcinoma with gastric phenotype (LG-WDA-G) arising in the Helicobacter pylori-negative stomach that were revealed during esophagogastroduodenoscopy (EGD) screening. In Case 1, a whitish 7-mm-diameter SMT-like lesion in the fornix of a 42-year-old man was revealed. Dilated-branched vessels and pigmentation were also observed on the surface of the lesion. Biopsy specimens displayed a mild structural variant but no evidence of malignancy. Endoscopic submucosal dissection was performed as a diagnostic treatment. In Case 2, EGD revealed a gentle protrusion 7-mm in size in the fornix of a 49-year-old man. Dilated-branched vessels and prolongation of the intervening part between the crypts were observed at the surface of the lesion. Biopsy revealed adenocarcinoma. Histologically, in both cases, each tumor was located in the deep mucosal layer covered with the non-neoplastic foveolar epithelium formed by irregularly shaped glands composed of slightly atypical glandular cells resembling fundic glands cells. Immunostaining results revealed MUC6 and pepsinogen-I expression. These results confirmed the diagnosis of LG-WDA-G; specifically, gastric adenocarcinoma of the fundic gland type. In Case 3, a 10-mm SMT-like elevated lesion with central erosion was observed on the greater curvature of the middle gastric body in a 66-year-old man. Biopsy specimens showed atypical glands but indefinite for neoplasia. Endoscopic ultrasonography findings showed an isoechoic tumor with several cystic legions in the submucosal layer. According to immunohistochemistry, LG-WDA-G with MUC6, pepsinogen-I, and MUC5AC-positive tumor cells were invading the submucosal layer significantly along heterotopic gastric glands. Additional surgery revealed no lymph node metastasis.</p>

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