Endoscopic Mucosal Resection for Treatment of Multiple Early Gastric Cancer Complicating Familial Adenomatous Polyposis: A Case Report

Special Article - Current Endoscopic Therapy in Japan

Austin J Gastroenterol. 2015;2(2): 1035.

Endoscopic Mucosal Resection for Treatment of Multiple Early Gastric Cancer Complicating Familial Adenomatous Polyposis: A Case Report

Haruna Kawamura1*, Satohiro Matsumoto1, Hiroyuki Miyatani1, Yukio Yoshida1, Masaaki Saito2 and Yoh Dobashi3

1Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan

2Department of Surgery, Saitama Medical Center, Jichi Medical University, Japan

3Department of and Pathology, Saitama Medical Center, Jichi Medical University, Japan

*Corresponding author: Haruna Kawamura, Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma, Omiya, Saitama, Saitama 330-8503, Japan

Received: December 19, 2014; Accepted: February 23, 2015; Published: February 25, 2015

Abstract

Familial Adenomatous Polyposis (FAP) is a hereditary colorectal disorder characterized by multiple adenomas developing diffusely throughout the large intestine that frequently show malignant transformation even at a young age. In a 69-year-old woman who had undergone total colectomy for FAP, endoscopic surveillance for multiple gastric polyps revealed a pedunculated polyp measuring more than 2 cm in diameter in the fornix of the stomach? As histopathological examination revealed that the polyp was an adenocarcinoma, Endoscopic Mucosal Resection (EMR) was performed to remove this polyp and three 1cm polyps around it. All the lesions were histopathologically diagnosed to be adenocarcinomas, and the risk of the remaining multiple gastric polyps progressing to cancer was also determined to be high. Therefore, total gastrectomy was performed. Histopathology of the total-gastrectomy specimen showed multiple intramucosal carcinomas. At present, there are no established guidelines for either surveillance or treatment of gastric lesions in FAP patients. As exemplified by our case, there are lesions among gastric polyps that are difficult to diagnose as cancer based on the endoscopic findings alone. For surveillance in FAP patients with multiple gastric polyps, step biopsy as well as target biopsy may need to be performed.

Keywords: Familial adenomatous polyposis; Gastric cancer; Endoscopic mucosal resection

Introduction

Familial Adenomatous Polyposis (FAP) is a peculiar hereditary colorectal disorder characterized by multiple adenomas developing diffusely throughout the large intestine that frequently show malignant transformation even at a young age. This disorder is considered to be caused by mutations of the adenomatous polyposis coli gene located on the long arm of chromosome 5 [1,2]. Meanwhile, in regard to extracolonic lesions associated with FAP, the disorder is known to be frequently complicated by gastric lesions [3,4]. Gastric lesions complicating FAP were first reported by Hauser [5], and several reports have been published since. The frequency of such lesions has also been reported to be quite high [4]. In a family study conducted by Watanabe et al, associated gastric lesions were detected in 15 patients from 13 families out of 22 patients from 14 families with FAP [6]. The gastric lesions known to be associated with FAP include fundic gland polyps [7,8], gastric adenomas [9], and gastric cancers [4], which are histologically specific to the fundic gland area. A recent study in 73 FAP patients with gastric lesions in Japan showed that the lesions comprised fundic gland polyps, gastric adenomas and gastric cancers, in that order of frequency, while the age at the time of detection was older in the reverse order [4].

Case Presentation

In a 69-year-old woman who had undergone total colectomy for FAP, endoscopic surveillance for multiple gastric polyps revealed a pedunculated polyp measuring more than 2 cm in diameter in the fornix of the stomach (Figure 1). Histopathology showed that the polyp was an adenocarcinoma; three subpedunculated polyps measuring about 1 cm in diameter around it were also suspected to be adenocarcinomas. Endoscopic Mucosal Resection (EMR) of all the four lesions was performed. All of the tissue specimens showed well-differentiated adenocarcinomas; furthermore, the polyp that measured more than 2 cm in diameter also showed sub mucosal invasion (Figure 2). Thus, the patient was diagnosed as having multiple gastric cancer, and it was suspected that cancer might also have developed in the remaining multiple polyps. Thus, after obtaining informed consent from the patient, total gastrectomy was additionally performed.