Signet Ring Cell Carcinoma



A small depressed lesion is located on the posterior side of greater curvature of the gastric body.


Gastric Cancer Gastric Mucosa Surface Pattern Signet Ring Cell Carcinoma Indigo Carmine 
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13.1 Let’s Try to Diagnose This Lesion

13.1.1 Let’s Take Notice of the Discoloration of Gastric Mucosa

  • A small depressed lesion is located on the posterior side of greater curvature of the gastric body.

  • Although gastric cancer is strongly suspected because of its clear margin and irregular shape, we have to make more detailed examination to differentiate it from other surrounding discolored lesions (Fig. 13.1a).
    Fig. 13.1

    (a, b) WL endoscopic image (c) Indigo carmine stained image

13.1.2 Let’s Take Notice of the Background Mucosa

  • We can see the atrophic changes of the mucosa, including visible submucosal vessels due to thinning of the gastric mucosa and mixed (red and white) color of the gastric mucosa, on the anal side of the lesion.

  • On the other hand, there is no such finding in the oral side of the lesion.

  • So we can conclude that the lesion is located around the border of the atrophic change (Fig. 13.1a).

13.1.3 Let’s Take a Closer Look on the Lesion

  • We can recognize the lesion by its distinct whitish depressed area compared to the surrounding atrophic mucosa.

  • The surface structure of the depressed area is uniform, and there are no apparent irregularities.

  • Gastric cancer is suspected because of a clearly demarcated irregular depressed lesion. However, we cannot diagnose definitely (Fig. 13.1b).

13.1.4 Let’s Spray Indigo Carmine

  • Although we cannot evaluate the color of the lesion after spraying indigo carmine, we can easily observe the surface structure and difference in height of the lesion against the background mucosa (Fig. 13.1c).

13.1.5 Let’s Pay Attention to the Depressed Area

  • The surface pattern of the surrounding mucosa is regular. However, the surface pattern of the depressed area is unclear.

  • Although the shape of the depressed lesion is irregular, the surface of the lesion is not so irregular. Gastric cancer is strongly suspected. But we cannot make a definite diagnosis (Fig. 13.1c).

13.1.6 Let’s Use NBI

  • With NBI, we can clearly see the margin of the discolored lesion as a whitish irregularly shaped depressed lesion.

  • Although the irregularity of the surface is not so distinct by WL, we can see some island-shaped brownish areas within the depressed lesion by NBI.

  • No further information is available without magnification (Fig. 13.2a).
    Fig. 13.2

    (a) NBI endoscopic image (b) Magnified image of the anal side of the lesion (c) Magnified image of the oral side of the lesion

13.1.7 Let’s Observe with Magnification the Anal Side of the Lesion

  • With NBI magnified endoscopy, a regularly arranged tubelike surface pattern and regular vessels are observed near the anal side of the depressed lesion as indicated by the yellow arrow on the left side. Microvascular pattern and its distribution are also regular. So we diagnosed the area as nonneoplastic.

  • On the other hand, we cannot see glandular surface patterns on the right side indicated by the red arrow. And the surface structure of this area is also irregular.

  • Although we can only see sparse vessels in the area, caliber change and tortuous running are seen in each vessel, and they make up nonnetwork pattern of the vessels. So we diagnosed the lesion as PDA (Fig. 13.2b).

13.1.8 Let’s Observe with Magnification the Oral Side of the Lesion

  • NBI magnified endoscopy of the oral side of the depressed area is shown.

  • The yellow arrow indicates an area with a pitlike surface pattern. As each pit is round and uniformly sized, this area is diagnosed as nonneoplastic.

  • On the other hand, another area indicated by the red arrow shows unclear surface pattern.

  • And the vessels are irregular with caliber changes and tortuous running without forming network patterns, leading to diagnosis of a PDA (Fig. 13.2c).

13.2 Making the Final Diagnosis from the ESD Specimen

13.2.1 Let’s Perform ESD

  • Because the histology of this lesion showed PDA, we confirmed the tumor extent by taking four-point negative biopsies around the lesion with 1 cm margin.

  • We used magnification endoscopy with NBI to identify biopsy scars and placed markings outside these biopsy scars. ESD with en bloc resection was performed without any complications (Fig. 13.3a).
    Fig. 13.3

    (a) Endoscopic image of marking before ESD (b) The freshly resected specimen (c) Fixed specimen (d) The specimen stained with crystal violet

13.2.2 Let’s Observe the Freshly Resected Specimen

  • The lower right side of the figure is the oral side.

  • The surrounding mucosa of the depressed area appears uniform with minimal atrophy consistent with fundic gland gastric mucosa.

  • There is an irregular whitish depressed lesion in the center of the resected specimen, but its border is partially unclear (Fig. 13.3b).

13.2.3 Let’s Observe the Formalin-Fixed Specimen

  • After formalin fixation, we can see the surface structure more clearly.

  • The surface of the depressed area is mostly unclear with some scattered tubular gland-like structures, which are larger than of the surrounding mucosa.

  • The boundary with the surrounding mucosa is mostly clear (Fig. 13.3c).

13.2.4 Let’s Stain with Crystal Violet and Observe with Magnification Using a Stereoscopic Microscope

  • More detailed examination of the surface pattern can be made after crystal violet stain. The surface pattern of the surrounding mucosa appears to have regularly arranged glandular structures.

  • On the other hand, the depressed lesion has larger irregularly shaped villi in part as well as parts which have no clear surface patterns with glandular structures obscured (Fig. 13.3d).

This figure shows the histopathology of the depressed area (HE stained) (Fig. 13.4a). Although there is a layer of regular foveolar epithelium on the surface of the mucosal layer, many mucus-filled eosinophilic cells with peripherally displaced nuclei are noted near the mucous neck region in the lamina propria. The lesion is diagnosed as a signet ring cell carcinoma.
Fig. 13.4

Histology image of the depressed lesion (HE stained)

As there were no findings of submucosal invasion, we diagnosed this lesion as a mucosal signet ring cell carcinoma. The lateral extent of the tumor conformed closely to the depressed area without any submucosal extension. There was no finding of ulcer scar or another lesion within the resected specimen (Fig. 13.4b).

We made a mapping of the tumor extent on a fresh specimen. After that, we matched the mapping image with the endoscopic image by adjusting the oral side of the lesion in the same orientation (Fig. 13.5).
Fig. 13.5

Comparison between the endoscopic image and resected specimen. Mapping on cancer distribution on each image

Conclusive Diagnosis

Gastric adenocarcinoma, signet ring cell carcinoma, T1 (M), ly0, v0, Lateral margin (−), Vertical margin (−), pType 0 -IIc, 14 × 13 mm, M, Gre.


This tumor was a discolored depressed lesion located on the greater curvature of the gastric body. As it was located on the border between atrophic mucosa and normal mucosa, it was difficult to distinguish the tumor margin with WL imaging against the background discolored mucosa. With NBI magnification, we could see the change of surface structure and microvessels, such as loss of clear glandular structures and disappearance of vascular network. Furthermore, we could make a precise diagnosis not only about the lateral extent of the tumor but also about a prediction of its histological type.

(While arguments still remain as to including undifferentiated cancer for indication of ESD, we treated ESD for undifferentiated-type gastric cancer as an expanded indication in this section.)

Copyright information

© Springer Japan 2016

Authors and Affiliations

  1. 1.Division of EndoscopyShizuoka Cancer CenterSunto-gunJapan

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