Retrospective Study
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Jun 25, 2015; 7(7): 741-746
Published online Jun 25, 2015. doi: 10.4253/wjge.v7.i7.741
Endoscopic features of early-stage signet-ring-cell carcinoma of the stomach
Chainarong Phalanusitthepha, Kevin L Grimes, Haruo Ikeda, Hiroki Sato, Chiaki Sato, Chananya Hokierti, Haruhiro Inoue
Chainarong Phalanusitthepha, Kevin L Grimes, Haruo Ikeda, Hiroki Sato, Chiaki Sato, Haruhiro Inoue, Digestive Disease Center, Showa University Koto-Toyosu Hospital, Tokyo 135-8577, Japan
Chainarong Phalanusitthepha, Chananya Hokierti, Minimally Invasive Surgery Unit, Division of General Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
Author contributions: All the authors contributed to this work.
Ethics approval: This study was conducted in accordance with the ethical standards of the Helsinki Declaration of 1964, as revised in 2013. Retrospective review of pathologic specimens is exempt from formal approval according to the policies and procedures of the Institutional Review Board (IRB) of Showa University Northern Yokohama Hospital, Yokohama, Japan.
Informed consent: All study participants, or their legal guardian, provided pre-operative informed written consent for the endoscopic or surgical procedures, as well as the collection and analysis of pathologic specimens.
Conflict-of-interest: Dr. Inoue has received fees for serving as an advisory committee member for Olympus Corporation, Tokyo, Japan. The other authors have no conflicts of interest or financial ties to disclose.
Data sharing: Technical appendix and dataset are available from the corresponding author at haruinoue777@yahoo.co.jp. Consent was not obtained but the presented data are anonymized and the risk of identification is low.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Haruhiro Inoue, MD, PhD, Digestive Disease Center, Showa University Koto-Toyosu Hospital, 5-1-38 Toyosu, Koto-ku, Tokyo 135-0061, Japan. haruinoue777@yahoo.co.jp
Telephone: +44-121-4142972 Fax: +44-121-6272384
Received: September 10, 2014
Peer-review started: September 11, 2014
First decision: November 14, 2014
Revised: March 9, 2015
Accepted: April 1, 2015
Article in press: April 7, 2015
Published online: June 25, 2015
Abstract

AIM: To identify the features of early signet ring cell gastric carcinoma using magnification endoscopy with narrow band imaging (NBI).

METHODS: A retrospective review was conducted of 12 cases of early signet ring cell gastric carcinoma who underwent treatment in a single institution between January 2009 and April 2013. All patients had magnification endoscopy with NBI and indigo carmine contrast to closely examine the mucosal architecture, including the microvasculature and arrangement of gastric pits. Histologic examination of the final endoscopic submucosal dissection or gastrectomy specimen was performed and compared with the endoscopic findings to identify patterns specific to signet ring cell carcinoma.

RESULTS: Twelve patients with early signet ring cell gastric carcinoma were identified; 75% were male, and average age was 61 years. Most of the lesions were stage T1a (83%), while the remainder were T1b (17%). The mean lesion size was 1.4 cm2. On standard endoscopy, all 12 patients had a pale, flat lesion without any evidence of mucosal abnormality such as ulceration, elevation, or depression. On magnification endoscopy with NBI, all of the patients had irregularities in the glands and microvasculature consistent with early gastric cancer. In addition, all 12 patients exhibited the “stretch sign”, an elongation or expansion of the architectural structure. Histologic examination of the resected specimens demonstrated an expanded and edematous mucosal layer infiltrated with tumor cells.

CONCLUSION: The “stretch sign” appears to be specific for signet ring cell carcinoma and may aid in the early diagnosis and treatment of this aggressive pathology.

Keywords: Signet ring cells, Early gastric cancer, Magnification endoscopy, Narrow band imaging, Stretch sign, Endoscopic submucosal dissection

Core tip: With aggressive screening, gastric cancer can be detected in the early stages, leading to the possibility of successful minimally invasive treatments, such as endoscopic submucosal dissection. A rare type of gastric cancer, signet ring cell carcinoma, has aggressive biological features, but patients treated in the early stages may actually fare better than those with adenocarcinoma. Here we present findings specific for signet ring cell carcinoma that can be identified on magnification endoscopy, potentially securing a diagnosis in the early stages of the disease without the need to rely on random biopsies.