Managing crawling-type gastric adenocarcinoma with endoscopic techniques and postoperative monitoring

Abstract

Crawling-type gastric adenocarcinoma is a rare subtype of gastric cancer with diagnostic and therapeutic challenges due to its flat, ill-defined lesions. Advanced diagnostic techniques, such as narrow-band imaging and linear endoscopic ultrasonography, improve detection, but endoscopic submucosal dissection poses a risk of incomplete resection. Despite negative resection margins, vigilant postoperative monitoring is crucial due to the potential for recurrence. This letter highlights the importance of refined diagnostic criteria, individualized treatment approaches, and continuous follow-up to optimize management of this unique gastric cancer subtype.

Key Words: Crawling-type gastric cancer; Superficial flat tumor; Positive resection margin; Multiple biopsies; Endoscopic submucosal dissection; Postoperative monitoring

Core Tip: Crawling-type gastric adenocarcinoma is a rare subtype of gastric cancer with diagnostic challenges due to its flat, ill-defined appearance. Advanced endoscopic techniques like narrow-band imaging and endoscopic ultrasonography are critical for accurate detection. Despite negative resection margins, the potential for recurrence highlights the need for vigilant postoperative monitoring. Multiple biopsies across mucosal layers and re-biopsies can aid in achieving a more precise diagnosis, optimizing management, and improving patient outcomes.

TO THE EDITOR

Gastric adenocarcinoma, particularly the rare “crawling-type,” characterized by ill-defined, flat appearance and indistinct borders[1], presents unique challenges in diagnosis and treatment due to its subtle endoscopic characteristics. In a article recently published by Xu et al[2], a case of “crawling-type” gastric cancer (GC) is discussed in detail, highlighting the complexities involved in its recognition and management. Xu et al[2] performed a detailed examination to identify the nature of the tumor and then resected it by endoscopic submucosal dissection (ESD). Pathological and immunohistochemical examinations revealed the diagnosis as "crawling-type" gastric adenocarcinoma.

This letter emphasizes the significance of advanced diagnostic techniques and tailored therapeutic strategies in addressing this elusive subtype of GC.

CHALLENGES IN DIAGNOSIS AND ROLE OF ADVANCED ENDOSCOPIC TECHNIQUES

“Crawling-type” GC often manifests as superficial concave or flat lesions, making it difficult to diagnose through standard endoscopic procedures. The lack of early symptoms and the indistinct borders of these lesions further complicate their identification. Thus, advanced diagnostic techniques such as narrow-band imaging, acetate-indigo carmine staining, and linear endoscopic ultrasonography (EUS) are crucial in accurately recognizing this subtype[3,4]. These methods can provide a more detailed examination of the gastric mucosa, enhancing the detection of subtle lesions with "crawling-type" GC.

Moreover, multiple biopsies of all mucosal layers can improve the detection rate of suspicious concave or flat lesions on gastroscopy[1]. We believe that more efforts are needed to refine diagnostic criteria and treatment strategies, to facilitate managing this rare GC subtype. This case improved endoscopists’ understanding of specific endoscopic properties of “crawling-type” GC. In addition, the detailed diagnostic steps described in the case report by Xu et al[2] provide a valuable framework for clinicians when encountering similar cases in their practice.

NEED FOR TAILORED TREATMENT AND VIGILANT POSTOPERATIVE MONITORING

The management of “crawling-type” GC requires a careful balance between accurate diagnosis and effective treatment. In this case, ESD was performed for “crawling-type” GC and postoperative pathology showed that the resection margin was negative, and the patient was followed for 1 year without tumor recurrence. Xu et al[2], recognizing the distinctive features of this GC subtype, advocated for ESD as an effective treatment approach. However, it is still necessary to be aware of the possible high risk of recurrence and needs of additional ESD interventions because such endoscopically ill-defined lesions might be associated with a higher rate of positive margins.

Since “crawling-type” GC often resides in the epithelial proliferative layer and presents with superficial depression or flatness, defining the lesion's borders during ESD is particularly challenging[5]. Such characteristics can make endoscopists usually unable to evaluate submucosal invasive lesions, leading to misdiagnosis or a high margin positive rate after endoscopic resection[6]. A previous study reported that the positive rate of resection margins of such GC is as high as about 30%[6]. In addition, Haruta et al[1] reported that even if the surgical margin was negative after the ESD, the tumor recurred during the postoperative follow-up and at last laparoscopic distal gastrectomy was added. Therefore, although Xu et al[2] followed the patient for 1 year and no recurrence was observed, continued monitoring may be still worth considering. It is recommended to perform four-quadrant mapping biopsy and extensive labeling during ESD to achieve a curative resection and reduce the risk of recurrence[7]. In conclusion, preoperative evaluation and individualized treatment are important, and postoperative monitoring cannot be ignored for patients with “crawling-type” GC.

CONCLUSION

“Crawling-type” gastric adenocarcinoma represents a diagnostic and therapeutic challenge, necessitating the use of advanced endoscopic techniques and vigilant postoperative follow-up. The case discussed by Xu et al[2] underscores the potential for successful treatment with ESD, and highlights the need for continuous monitoring to prevent recurrence. As we refine our diagnostic criteria and treatment strategies, individualized approaches tailored to this rare GC subtype will be essential for improving patient outcomes.