Retrospective Study Open Access
Copyright ©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Feb 21, 2024; 30(7): 673-684
Published online Feb 21, 2024. doi: 10.3748/wjg.v30.i7.673
Endoscopic features and treatments of gastric cystica profunda
Zi-Han Geng, Yan Zhu, Pei-Yao Fu, Yi-Fan Qu, Wei-Feng Chen, Xia Yang, Ping-Hong Zhou, Quan-Lin Li, Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, China
ORCID number: Pei-Yao Fu (0000-0002-8816-651X); Wei-Feng Chen (0000-0002-4485-9461); Ping-Hong Zhou (0000-0002-5434-0540); Quan-Lin Li (0000-0002-9108-8786).
Co-first authors: Zi-Han Geng and Yan Zhu.
Co-corresponding authors: Ping-Hong Zhou and Quan-Lin Li.
Author contributions: Geng ZH contributed equally to conceptualization, data curation, formal analysis, investigation, methodology, software, validation, and visualization, with a lead role in writing the original draft and leading the writing, review, and editing process; Zhu Y contributed equally to conceptualization and software, with equal roles in writing the original draft and writing, review, and editing; Fu PY contributed equally to conceptualization, software, and writing the original draft, with a lead role in writing, review, and editing; Qu YF contributed equally to conceptualization, software, and writing the original draft, with a lead role in writing, review, and editing; Chen WF contributed equally to conceptualization and data curation; Yang X contributed equally to conceptualization and supervision; Zhou PH contributed equally to conceptualization and supervision; Li QL contributed equally to conceptualization and supervision.
Supported by the 74th General Support of China Postdoctoral Science Foundation, No. 2023M740675; the National Natural Science Foundation of China, No. 82170555; Shanghai Academic/Technology Research Leader, No. 22XD1422400; Shuguang Program of Shanghai Education Development Foundation and Shanghai Municipal Education Commission, No. 2022SG06; and Shanghai "Rising Stars of Medical Talent" Youth Development Program, No. 20224Z0005.
Institutional review board statement: This study was approved by the Ethics Committee of Zhongshan Hospital in accordance with the Declaration of Helsinki (B2021-029), and written consent was obtained from all participating patients.
Informed consent statement: The written consent was obtained from all participating patients.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (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: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Ping-Hong Zhou, FASGE, MD, Chief Physician, Doctor, Surgeon, Teacher, Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai 200032, China. zhou.pinghong@zs-hospital.sh.cn
Received: December 11, 2023
Peer-review started: December 11, 2023
First decision: December 19, 2023
Revised: December 25, 2023
Accepted: January 22, 2024
Article in press: January 22, 2024
Published online: February 21, 2024

Abstract
BACKGROUND

Gastric cystica profunda (GCP) represents a rare condition characterized by cystic dilation of gastric glands within the mucosal and/or submucosal layers. GCP is often linked to, or may progress into, early gastric cancer (EGC).

AIM

To provide a comprehensive evaluation of the endoscopic features of GCP while assessing the efficacy of endoscopic treatment, thereby offering guidance for diagnosis and treatment.

METHODS

This retrospective study involved 104 patients with GCP who underwent endoscopic resection. Alongside demographic and clinical data, regular patient follow-ups were conducted to assess local recurrence.

RESULTS

Among the 104 patients diagnosed with GCP who underwent endoscopic resection, 12.5% had a history of previous gastric procedures. The primary site predominantly affected was the cardia (38.5%, n = 40). GCP commonly exhibited intraluminal growth (99%), regular presentation (74.0%), and ulcerative mucosa (61.5%). The leading endoscopic feature was the mucosal lesion type (59.6%, n = 62). The average maximum diameter was 20.9 ± 15.3 mm, with mucosal involvement in 60.6% (n = 63). Procedures lasted 73.9 ± 57.5 min, achieving complete resection in 91.3% (n = 95). Recurrence (4.8%) was managed via either surgical intervention (n = 1) or through endoscopic resection (n = 4). Final pathology confirmed that 59.6% of GCP cases were associated with EGC. Univariate analysis indicated that elderly males were more susceptible to GCP associated with EGC. Conversely, multivariate analysis identified lesion morphology and endoscopic features as significant risk factors. Survival analysis demonstrated no statistically significant difference in recurrence between GCP with and without EGC (P = 0.72).

CONCLUSION

The findings suggested that endoscopic resection might serve as an effective and minimally invasive treatment for GCP with or without EGC.

Key Words: Gastric cystica profunda, Early gastric cancer, Endoscopic features, Endoscopic resection, Endoscopy

Core Tip: Gastric cystica profunda (GCP) associated early gastric cancer (EGC) was found to be relatively common. Irregular morphology and mucosal lesion type might be the risk factors for development of EGC in GCP. Endoscopic resection can be recommended as an effective and minimally invasive treatment for GCP with or without EGC.



INTRODUCTION

Gastric cystica profunda (GCP) represents a rare gastric lesion characterized by hyperplasia of connective tissues within the interstitium of the glands, involving the submucosal layer and occasionally extending to the muscularis propria of the stomach[1]. Initially, GCP was believed to be an inflammatory pseudotumor associated with ischemia, chronic inflammation, and mucosal defects that may arise from surgical procedures, biopsies, or polypectomies[2]. Widespread chronic active or atrophic gastritis is considered a significant contributing factor to the development of GCP[3]. Over recent years, the emergence of advanced endoscopic techniques such as endoscopic ultrasonography (EUS) and endoscopic resection has led to a gradual increase in the detection of non-surgically resected GCP cases.

Patients with GCP may either remain asymptomatic or present with non-specific digestive symptoms, including abdominal pain and belching[4]. Owing to the unremarkable clinical characteristics and nonspecific endoscopic manifestations, most clinicians possess limited understanding of GCP. Furthermore, GCP has been regarded as a potential premalignant lesion[5]; hence, the endoscopic diagnosis and early excision of GCP are deemed crucial[6,7]. In this study, we conducted a retrospective analysis of 104 cases of GCP treated by endoscopic resection at our center from October 2011 to December 2022. Our analysis was based on their clinical manifestations, endoscopic findings, pathological results, and treatments. The primary objectives were to delineate the endoscopic features of GCP associated with early gastric cancer (EGC) and to assess the impact of endoscopic resection on the diagnosis and treatment of GCP with EGC.

MATERIALS AND METHODS
Patients

We conducted a single-center retrospective study involving 104 consecutive patients diagnosed with GCP who underwent endoscopic resection at Zhongshan Hospital, Fudan University (Shanghai, China) between October 2011 and December 2022. Only patients with complete demographic and clinical information, along with available follow-up data, were included in the study. Patients were assessed based on findings from endoscopy, computed tomography (CT) scans, or EUS during the preoperative phase. All patients with suspected GCP following endoscopic examination underwent biopsy for pathological confirmation. Lesion characteristics, endoscopic methods, complications, en-bloc resection rate, complete resection rate, and the occurrence of local recurrence were evaluated for all patients. This study was approved by the Ethics Committee of Zhongshan Hospital in accordance with the Declaration of Helsinki (B2021-029), and written consent was obtained from all participating patients.

Lesion classification and pathological examination

In this study, lesions were categorized into four types: Mucosal lesion type, polypoid type, submucosal lesion type, and thickened mucosa with rough wrinkles type (Figure 1A-D). According to the pathological diagnostic criteria for GCP, the presence of cystic structure expansion within the mucosal muscle layer and submucosal layer could confirm the diagnosis[8]. Building upon this criterion, the presence of cancerous changes in the gastric mucosal glands, with the lesion tissue confined to the mucosal and submucosal layers, led to a diagnosis of GCP with EGC (Figure 2). Each case was independently reevaluated by two experienced pathologists in a blinded manner, without access to clinical or endoscopic information.

Figure 1
Figure 1 Classification of gastric cystica profunda lesions. A: Mucosal lesion type; B: Submucosal lesion type; C: Polypoid type; D: Thickened mucosa with rough wrinkles type; E and F: Irregular mucosal lesion type in gastric cystica profunda.
Figure 2
Figure 2 Pathological images of gastric cystica profunda and gastric cystica profunda with early gastric cancer. A: Gastric cystica profunda; B: Gastric cystica profunda with early gastric cancer.

Moreover, irregular shapes of GCP primarily encompassed three types: Mucosal lesion type, polypoid type, and submucosal lesion type. The irregular mucosal lesion type manifested as uneven surfaces with raised and depressed areas, often accompanied by surface erosion or ulcers. Irregular polypoid type GCP referred to type Ⅲ and Ⅳ polyps in the Yamada classification[9]. As for the irregularity of the submucosal lesion type, it mainly denoted an irregular shape, presenting as lobulated or branching[10].

Endoscopic resection method and outcome assessments

The choice of endoscopic resection for GCP depended on the appearance during endoscopy. If it appeared as a mucosal lesion, submucosal tumor, or thickened and folded mucosa, then endoscopic submucosal dissection (ESD) would be employed. During ESD, operators cut the mucosa, dissected the submucosal layer, and subsequently removed the tumor after locating the lesions. If it appeared to be polyp-like and raised, then endoscopic mucosal resection (EMR) or electric cutting would be performed.

Following endoscopic resection, a nasogastric tube was inserted to both decompress and monitor potential delayed bleeding from the wound. Additionally, we monitored postoperative symptoms. In cases where patients experienced persistent fever, hematemesis, melena, or pain, emergency endoscopy and CT scans were conducted. Moreover, proton pump inhibitors, antibiotics, and hemocoagulase injections were administered.

Endoscopic outcome assessments included: (1) The duration of procedure and hospital stay; (2) en-bloc resection (the excision of the tumor was performed in one piece without fragmentation) and complete resection (based on en-bloc resection, the excision was performed in a manner that ensures the absence of discernible residual tumors upon macroscopic evaluation at the resection site, coupled with negative margins upon pathologic examination); and (3) complications and local recurrence.

Follow-up

Patients underwent regular follow-up for the assessment of wound healing and the detection of local recurrence through endoscopy at 6 months post-resection. In cases where patients experienced relapses, EUS and CT scans were conducted to check for recurrent lesions.

Statistical analysis

Continuous variables were presented as means and SD, while categorical variables were displayed as numbers and percentages. Statistical analysis was performed using SPSS 26.0 and R 4.0.2.

RESULTS
Clinical characteristics of the patients

A total of 104 consecutive patients, including 27 women and 77 men, with a mean age of 63.4 ± 11.0 years, were diagnosed with GCP and underwent endoscopic resection at Zhongshan Hospital, Fudan University in Shanghai, China. Among these patients, 12.5% had a history of prior gastric endoscopic or surgical treatment. The majority of patients were asymptomatic (n = 66, 63.5%), while 28 (26.9%) reported experiencing epigastric discomfort. Additionally, other symptoms such as regurgitation and melena were also observed (Table 1).

Table 1 Demographic information, lesion characteristics, and procedural outcomes of early gastric cancer, n (%).
        
GCP (n = 104)
Demographic information
        Male77 (74.0)
        Age (yr), mean ± SD63.4 ± 11.0
        History of gastric endoscopic or surgical treatment13 (12.5)
Symptom
        Asymptomatic66 (63.5)
        Epigastric discomfort28 (26.9)
        Regurgitation8 (7.7)
        Melena2 (1.9)
Lesion characteristics
Growth pattern
        Intraluminal growth103 (99.0)
        Extraluminal growth1 (1.0)
Morphology
        Regular77 (74.0)
        Irregular27 (26.0)
Mucosa
        Smooth40 (38.5)
        Ulcerative64 (61.5)
        Max diameter (mm), mean ± SD20.9 ± 15.3
Location
        Cardia40 (38.5)
        Gastric fundus8 (7.7)
        Gastric body35 (33.7)
        Gastric antrum21 (20.2)
Endoscopic features
        Mucosal lesion type62 (59.6)
            IIa29 (46.8)
            IIa + IIc4 (6.5)
            IIc29 (46.8)
        Polypoid type23 (22.1)
        Submucosal lesion type17 (16.3)
        Thickened mucosa with rough wrinkles type2 (1.9)
Infiltration depth
        Mucosa63 (60.6)
        Submucosa40 (38.5)
        Muscularis propria1 (1.0)
        GCP with EGC62 (59.6)
Procedural outcomes
Endoscopic methods
        Electric cutting7 (6.7)
        EMR11 (10.6)
        ESD80 (76.9)
        ESE6 (5.8)
        En-bloc resection95 (91.3)
        Complete resection95 (91.3)
Suture method
        Unstitched62 (59.6)
        Metal clip40 (38.5)
        Nylon rope1 (1.0)
        Metal clip and nylon rope1 (1.0)
        Surgery time (min), mean ± SD73.9 ± 57.5
        Complications1 (1.0)
        Hospital stay (d), mean ± SD3.4 ± 2.3
        Additional surgery1 (1.0)
        Recurrence5 (4.8)
Characteristics of lesions

The most commonly involved sites were the cardia (n = 40, 38.5%), followed by the gastric body (n = 35, 33.7%), gastric antrum (n = 21, 20.2%), and gastric fundus (n = 8, 7.7%). Furthermore, 13 patients (12.5%) with GCP had a history of gastric endoscopic or surgical treatment. Among them, three patients had a history of gastrectomy, where GCP occurred specifically at the cardia, particularly at the anastomotic site. Additionally, ten patients with GCP had undergone previous gastric endoscopic procedures, and seven of these GCP cases (70%) were located at the sites of prior gastric endoscopic interventions.

It was observed that 99% of GCP cases manifested an intraluminal growth pattern. In terms of morphology, 74.0% of GCP presented as regular, while 61.5% exhibited an ulcerative mucosa. The most common endoscopic feature was the mucosal lesion type (n = 62, 59.6%), including Ⅱa (n = 29), Ⅱa+Ⅱc (n = 4), and Ⅱc (n = 29), followed by polypoid type (n = 23, 22.1%), submucosal lesion type (n = 17, 16.3%), and thickened mucosa with rough wrinkles type (n = 1, 1.0%). The maximum diameter ranged from 20.9 ± 15.3 mm. The mucosa was the most commonly involved layer (n = 63, 60.6%), followed by the submucosa (n = 40, 38.5%), and muscularis propria (n = 1, 1.0%; Table 1).

We conducted further comparisons of the endoscopic features between the regular (n = 77) and irregular (n = 27) lesions. We found that the irregular lesion group predominantly consisted of mucosal lesion type (n = 17, 63.0%), polypoid type (n = 4, 14.8%), and submucosal lesion type (n = 6, 22.2%; Supplementary Table 1).

Endoscopic methods and outcomes

Endoscopic resection stands as the primary treatment for GCP. In this study, all 104 patients underwent endoscopic resection, including electric cutting (n = 7, 6.7%), EMR (n = 11, 10.6%), ESD (n = 80, 76.9%), and endoscopic submucosal excavation (n = 6, 5.8%). The suture methods employed included a metal clip (n = 40, 38.5%), nylon rope (n = 1, 1.0%), and a combination of a metal clip and nylon rope (n = 1, 1.0%). The average duration ranged from 73.9 ± 57.5 min. Overall, en-bloc resection was performed for 95 GCP cases (91.3%), and complete resection was achieved in 95 cases (91.3%; Table 1). Further analysis revealed no statistical difference in the rates of en-bloc and complete resection between irregular and regular GCP groups (Supplementary Table 1).

The average duration of hospital stay was 3.4 ± 2.3 d. One patient (1.0%) experienced delayed wound bleeding and required the use of a nylon rope to stop the bleeding. Another patient (1.0%) underwent additional surgery subsequent to endoscopic resection due to pathologic findings indicating invasion of gastric cancer into the submucosa. Recurrence was observed in five patients (4.8%). Among these cases, only one patient had undergone incomplete resection. Ultimately, one patient received treatment through surgery, while the remaining four underwent endoscopic resection (Table 1). Patients undergoing surgery received a pathological diagnosis of gastric cancer, whereas those undergoing endoscopic resection were all diagnosed with GCP without concomitant EGC.

Comparisons between GCP with EGC and GCP without EGC groups

According to the pathologic examination, 59.6% of patients were found to have concomitant EGC. Moreover, we observed significant differences in six variables (sex, age, morphology, mucosa, location, and endoscopic features) between the groups with GCP and those with GCP accompanied by EGC (Table 2). As mucosa and endoscopic features exhibited a significant correlation, the multivariate logistic regression considered five explanatory variables (sex, age, morphology, location, and endoscopic features). The analysis demonstrated that irregular morphology and mucosal lesion type were significant risk factors for GCP accompanied by EGC (P < 0.05; Table 3, Figure 1E and F). The sensitivity analysis depicted the variable importance of risk factors for GCP accompanied by EGC (as shown in Figure 3). Furthermore, survival analysis indicated no statistical difference in recurrence between the groups with GCP accompanied by EGC and those without EGC (P = 0.72; Figure 4).

Figure 3
Figure 3 Significance of variable risk factors for gastric cystica profunda with early gastric cancer.
Figure 4
Figure 4 Survival analysis suggested that there was no statistical difference in recurrence between gastric cystica profunda groups with and without early gastric cancer (P = 0.72). GCP: Gastric cystica profunda; EGC: Early gastric cancer.
Table 2 Demographic information, lesion characteristics, and procedural outcomes of the early gastric cancer without early gastric cancer s and early gastric cancer with early gastric cancer s groups, n (%).
        
GCP without EGCs (n = 42)
GCP with EGCs (n = 62)
P value
Demographic information
        Male23 (54.8)54 (87.1)< 0.001
        Age (yr), mean ± SD58.5 ± 11.966.7 ± 9.1< 0.001
        History of gastric endoscopic or surgical treatment4 (9.5)9 (14.5)0.450
Symptom0.158
        Asymptomatic23 (54.8)43 (69.4)
        Epigastric discomfort15 (35.7)13 (21.0)
        Regurgitation4 (9.5)4 (6.5)
        Melena0 (0)2 (3.2)
Lesion characteristics
Growth pattern1.000
        Intraluminal growth42 (100)61 (98.4)
        Extraluminal growth0 (0)1 (1.6)
Morphology0.007
        Regular37 (88.1)40 (64.5)
        Irregular5 (11.9)22 (35.5)
Mucosa< 0.001
        Smooth27 (64.3)13 (21.0)
        Ulcerative15 (35.7)49 (79.0)
        Max diameter (mm), mean ± SD18.0 ± 14.422.9 ± 15.70.110
Location0.003
        Cardia9 (21.4)31 (50.0)
        Gastric fundus7 (16.7)1 (1.6)
        Gastric body16 (38.1)19 (30.6)
        Gastric antrum10 (23.8)11 (17.7)
Endoscopic features< 0.001
        Mucosal lesion type8 (19.0)54 (87.1)
            IIa6 (75.0)23 (42.6)
            IIa + IIc0 (0)4 (7.4)
            IIc2 (25.0)27 (50.0)
        Polypoid type19 (45.2)4 (6.5)
        Submucosal lesion type13 (31.0)4 (6.5)
        Thickened mucosa with rough wrinkles type2 (4.8)0 (0)
Infiltration depth0.363
        Mucosa24 (57.1)39 (62.9)
        Submucosa17 (40.5)23 (37.1)
        Muscularis propria1 (2.4)0 (0)
Procedural outcomes
Endoscopic methods< 0.001
        Electric cutting7 (16.7)0 (0)
        EMR11 (26.2)0 (0)
        ESD18 (42.9)62 (100)
        ESE6 (14.3)0 (0)
        En-bloc resection38 (90.5)57 (91.9)1.000
        Complete resection38 (90.5)57 (91.9)1.000
Suture method0.011
        Unstitched18 (42.9)44 (71)
        Metal clip23 (54.8)17 (27.4)
        Nylon rope1 (2.4)0 (0)
        Metal clip and nylon rope0 (0)1 (1.6)
        Surgery time (min), mean ± SD38.5 ± 38.696.6 ± 56.3< 0.001
        Complications1 (2.4)0 (0)0.404
        Hospital stay (d), mean ± SD2.6 ± 1.83.9 ± 2.50.006
        Additional surgery0 (0)1 (1.6)1.000
        Recurrence2 (4.8)3 (4.8)1.000
Table 3 Multivariate logistic regression analysis for gastric cystica profunda with early gastric cancers.
FactorsMultivariate analysis
OR [95%CI]
β coefficient
P value
Location
        Cardia1
        Non-cardia0.881 [0.226-3.424]-0.1260.853
Sex
        Male3.323 [0.771-14.764]1.2010.104
        Female1
Morphology
        Regular1
        Irregular15.278 [2.965-111.712]2.7260.003
Endoscopic features
        Mucosal lesion type1
        Non-mucosal lesion type0.029 [0.006-0.108]-3.531< 0.001
        Age1.026 [0.968-1.090]0.0250.392
DISCUSSION

Given the limited literature and reports on GCP, our research might hold significance in raising awareness of GCP as a high-risk factor for EGC. Clinical differentiation from conditions such as hypertrophic gastritis, mesenchymal tumors, gastric cancer, and ectopic pancreas is crucial. Due to GCP's malignant potential, prompt removal through endoscopy or surgery is essential, coupled with regular postoperative follow-up[11]. In this study, we delineated the endoscopic features of GCP and evaluated the impact of endoscopic resection on the diagnosis and treatment of GCP.

Out of the five patients with GCP who experienced recurrence, only one had a recurrence at the original resection site. The remaining four recurrences occurred at sites distinct from the original resection site. Additionally, the patient who experienced a recurrence at the original site had multiple lesions and was unable to undergo en-bloc resection at that time. Hence, it can be inferred that ESD is effective for lesions necessitating en-bloc resection.

GCP is typically regarded as a benign lesion, yet it can serve as a precancerous gastric condition. Given that GCP is commonly associated with gastric adenocarcinoma or EGC, its malignant potential should be underscored. In our study, we noted that 59.6% of GCP cases were linked with EGC. Through multivariate and sensitivity analyses, irregular morphology and mucosal lesion type emerged as significant risk factors for GCP accompanied by EGC. The mucosal lesion type encompassed Ⅱa (mucosal flat elevation), Ⅱa+Ⅱc (mucosal flat elevation with mild depression), and Ⅱc (mild depression). Considering that EGC typically presents as mucosal lesions, it is evident that GCP featuring mucosal lesion types pose a heightened risk for EGC. An asymmetric expansion of glands in the mucosa and submucosa can lead to irregularities, resulting in the appearance of raised and depressed areas, often accompanied by erosion or ulcers. Consequently, the irregular morphology of GCP is deemed a high-risk factor for EGC. Whenever feasible, we recommend endoscopic resection for GCP, particularly when irregular morphology or mucosal lesion type is apparent, as this signifies a heightened risk of concurrent EGC.

The en-bloc resection and complete resection showed no difference between GCP with EGC and GCP without EGC groups. Additionally, there were no differences in complications, additional surgery, or recurrence between these two groups. These findings suggest that there is no disparity in the efficacy of endoscopic resection for GCP, regardless of the presence or absence of EGC. Therefore, similar to ESD for EGC with infiltration depth ≤ 500 μm, ESD emerges as a safe and effective minimally invasive treatment for GCP, irrespective of the presence of concurrent EGC.

To determine whether the irregular shape of GCP impacted en-bloc and complete resection rates, we compared the rates between groups with regular and irregular shapes. Our analysis revealed no statistically significant difference, suggesting that endoscopy can achieve en-bloc or complete resection even for GCPs with irregular shapes.

Despite the promising results, this study had certain limitations, including a small sample size and potential bias inherent in the retrospective design. Further research is imperative to gain a more comprehensive understanding of the natural progression of GCP and its malignant potential.

In summary, irregular shapes and mucosal lesion types observed during endoscopy might serve as high-risk factors for GCP with EGC. Future studies should aim to clarify the disease's natural progression and its malignant potential. Notably, ESD might be a secure and efficacious minimally invasive treatment, regardless of the presence of EGC.

CONCLUSION

The findings suggested that endoscopic resection might serve as an effective and minimally invasive treatment for GCP with or without EGC.

ARTICLE HIGHLIGHTS
Research background

Gastric cystica profunda (GCP) is an uncommon gastric lesion characterized by hyperplasia of connective tissues within the interstitium of the glands, involving the submucosal layer or even the muscularis propria of the stomach. Widespread chronic active or atrophic gastritis is considered a significant factor contributing to GCP. Patients with GCP may either be asymptomatic or present with non-specific digestive symptoms such as abdominal pain and belching. Due to the indistinct clinical characteristics and non-specific endoscopic manifestations, most clinicians have limited understanding of GCP. Additionally, GCP has been regarded as a potential premalignant lesion. Endoscopic identification of irregular shapes and mucosal lesion types may serve as high-risk factors for GCP associated with early gastric cancer (EGC). Irrespective of EGC presence, endoscopic submucosal dissection emerges as a secure and effective minimally invasive treatment.

Research motivation

Patients with GCP may either remain asymptomatic or present with non-specific digestive symptoms, including abdominal pain and belching. Owing to the unremarkable clinical characteristics and nonspecific endoscopic manifestations, most clinicians possess limited understanding of GCP. Furthermore, GCP has been regarded as a potential premalignant lesion; hence, the endoscopic diagnosis and early excision of GCP are deemed crucial. In this study, we conducted a retrospective analysis of 104 cases of GCP treated by endoscopic resection at our center from October 2011 to December 2022. Our analysis was based on their clinical manifestations, endoscopic findings, pathological results, and treatments. The primary objectives were to delineate the endoscopic features of GCP associated with EGC and to assess the impact of endoscopic resection on the diagnosis and treatment of GCP with EGC.

Research objectives

Given the limited literature and reports on GCP, our research might hold significance in raising awareness of GCP as a high-risk factor for EGC. Clinical differentiation from conditions such as hypertrophic gastritis, mesenchymal tumors, gastric cancer, and ectopic pancreas is crucial. Due to GCP's malignant potential, prompt removal through endoscopy or surgery is essential, coupled with regular postoperative follow-up. In this study, we delineated the endoscopic features of GCP and evaluated the impact of endoscopic resection on the diagnosis and treatment of GCP.

Research methods

This retrospective study involved 104 patients with GCP who underwent endoscopic resection. Alongside demographic and clinical data, regular patient follow-ups were conducted to assess local recurrence.

Research results

Among the 104 patients diagnosed with GCP who underwent endoscopic resection, 12.5% had a history of previous gastric procedures. The primary site predominantly affected was the cardia (38.5%, n = 40). GCP commonly exhibited intraluminal growth (99%), regular presentation (74.0%), and ulcerative mucosa (61.5%). The leading endoscopic feature was the mucosal lesion type (59.6%, n = 62). The average maximum diameter was 20.9 ± 15.3 mm, with mucosal involvement in 60.6% (n = 63). Procedures lasted 73.9 ± 57.5 min, achieving complete resection in 91.3% (n = 95). Recurrence (4.8%) was managed via either surgical intervention (n = 1) or through endoscopic resection (n = 4). Final pathology confirmed that 59.6% of GCP cases were associated with EGC. Univariate analysis indicated that elderly males were more susceptible to GCP associated with EGC. Conversely, multivariate analysis identified lesion morphology and endoscopic features as significant risk factors. Survival analysis demonstrated no statistically significant difference in recurrence between GCP with and without EGC (P = 0.72).

Research conclusions

The findings suggested that endoscopic resection might serve as an effective and minimally invasive treatment for GCP with or without EGC.

Research perspectives

Further research is imperative to gain a more comprehensive understanding of the natural progression of GCP and its malignant potential.

Footnotes

Provenance and peer review: Unsolicited article; Externally peer reviewed.

Peer-review model: Single blind

Specialty type: Gastroenterology and hepatology

Country/Territory of origin: China

Peer-review report’s scientific quality classification

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Grade B (Very good): 0

Grade C (Good): C

Grade D (Fair): 0

Grade E (Poor): 0

P-Reviewer: Shahidi N, Canada S-Editor: Li L L-Editor: A P-Editor: Li L

References
1.  Littler ER, Gleibermann E. Gastritis cystica polyposa. (Gastric mucosal prolapse at gastroenterostomy site, with cystic and infiltrative epithelial hyperplasia). Cancer. 1972;29:205-209.  [PubMed]  [DOI]  [Cited in This Article: ]
2.  Lee TH, Lee JS, Jin SY. Gastritis cystica profunda with a long stalk. Gastrointest Endosc. 2013;77:821-2; discussion 822.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 6]  [Cited by in F6Publishing: 9]  [Article Influence: 0.8]  [Reference Citation Analysis (0)]
3.  Xu G, Peng C, Li X, Zhang W, Lv Y, Ling T, Zhou Z, Zhuge Y, Wang L, Zou X, Zhang X, Huang Q. Endoscopic resection of gastritis cystica profunda: preliminary experience with 34 patients from a single center in China. Gastrointest Endosc. 2015;81:1493-1498.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 13]  [Cited by in F6Publishing: 14]  [Article Influence: 1.8]  [Reference Citation Analysis (0)]
4.  Wang R, Lu H, Yu J, Huang W, Li J, Cheng M, Liang P, Li L, Zhao H, Gao J. Computed tomography features and clinical characteristics of gastritis cystica profunda. Insights Imaging. 2022;13:14.  [PubMed]  [DOI]  [Cited in This Article: ]  [Reference Citation Analysis (0)]
5.  Wu JJ, Cheng YQ, Yang HJ, Lin M. Correlation between gastritis cystica profunda and the risk of lymph node metastasis in early gastric cancer. Neoplasma. 2022;69:1459-1465.  [PubMed]  [DOI]  [Cited in This Article: ]  [Reference Citation Analysis (0)]
6.  Park CH, Park JM, Jung CK, Kim DB, Kang SH, Lee SW, Cho YK, Kim SW, Choi MG, Chung IS. Early gastric cancer associated with gastritis cystica polyposa in the unoperated stomach treated by endoscopic submucosal dissection. Gastrointest Endosc. 2009;69:e47-e50.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 20]  [Cited by in F6Publishing: 21]  [Article Influence: 1.4]  [Reference Citation Analysis (0)]
7.  Wahi JE, Pagacz M, Ben-David K. Gastric Adenocarcinoma Arising in a Background of Gastritis Cystica Profunda. J Gastrointest Surg. 2020;24:2387-2388.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 1]  [Cited by in F6Publishing: 1]  [Article Influence: 0.3]  [Reference Citation Analysis (0)]
8.  Park JS, Myung SJ, Jung HY, Yang SK, Hong WS, Kim JH, Kang GH, Ha HK, Min YI. Endoscopic treatment of gastritis cystica polyposa found in an unoperated stomach. Gastrointest Endosc. 2001;54:101-103.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 24]  [Cited by in F6Publishing: 26]  [Article Influence: 1.1]  [Reference Citation Analysis (0)]
9.  Fong TV, Chuah SK, Chiou SS, Chiu KW, Hsu CC, Chiu YC, Wu KL, Chou YP, Ong GY, Changchien CS. Correlation of the morphology and size of colonic polyps with their histology. Chang Gung Med J. 2003;26:339-343.  [PubMed]  [DOI]  [Cited in This Article: ]
10.  Wang L, Yan H, Cao DC, Huo L, Huo HZ, Wang B, Chen Y, Liu HL. Gastritis cystica profunda recurrence after surgical resection: 2-year follow-up. World J Surg Oncol. 2014;12:133.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 4]  [Cited by in F6Publishing: 5]  [Article Influence: 0.5]  [Reference Citation Analysis (0)]
11.  Yu YN, Wang XW, Chen YQ, Cui Z, Tian ZB, Zhao QX, Mao T, Xie M, Yin XY. A retrospective analysis of 13 cases of gastritis cystica profunda treated by endoscopic resection and surgery. J Dig Dis. 2022;23:186-190.  [PubMed]  [DOI]  [Cited in This Article: ]  [Reference Citation Analysis (0)]