ИСТИНА

The speaker is Buntseva Olga. It is our experience in CLE for the diagnosis of EGC in a patient with a hyperplastic polyp. A 60 years old man was admitted to our hospital for endoscopic polypectomy of 30 mm pedunculated hyperplastic gastric polyp. At gastroscopy just near the polyp we also revealed a superficial elevated lesion type 0-IIa+Is, 25 mm in size, with unclear margins. The lesion was flat, smooth, little whitish with small reddish protrusion in the distal part. Surrounding mucosa between the polyp and the lesion was inflamed and with infiltrative changes – so we can’t exclude infiltrative type of cancer. That is why we started from polypectomy of the pedunculated polyp and detailed biopsy from the lesion and the surrounding mucosa. The results of histological examination were: the polyp was hyperplastic, in the surrounding mucosa were severe inflammation, incomplete intestinal metaplasia and moderate epithelial dysplasia and Helicobacter pylori ++, in the flat part of the lesion - incomplete intestinal metaplasia and high grade epithelial dysplasia, and in the protruding part of the lesion histology showed moderate differentiated adenocarcinoma. After two weeks of eradication therapy control EGD showed more clear lesion margins, less swelling and infiltrative changes in the surrounding mucosa. We performed precise endoscopic diagnostics: chromoendoscopy with indigo carmine, NBI and magnifying endoscopy. We found clear demarcation line at the border between the lesion and the surrounding mucosa. In the surrounding mucosa we found quite regular stick-like pit-pattern but irregular wavy microvascular pattern. In the lesion we found irregular superficial and microvascular pattern, especially in it’s protruding part. In the flat part of the lesion the pits were elongated and branching, different in shape and size, and vessels were wavy and unevenly dilated. And in the protruding part of the lesion we saw irregular unclear small-pits microsurface pattern and fine network vascular pattern, what was specified for differentiated adenocarcinoma. Then we performed the probe-based confocal laser endomicroscopy. It showed clear differences in the structure between the lesion and surrounding mucosa. In the surrounding mucosa glands had oval shape and symmetrical arrangement, distances between glands were the same, the cylindrical epithelium of the glands was even, with normal cell’s polarity. Also we saw the Goblet- cells, which indicated an intestinal metaplasia. In the lesion we found diffusely strongly deformed and dark glands, distances between glands were different. Epithelial cells in glands had different shapes and height, the cell’s polarity was broken. In the protruding part of the lesion the glands sometimes were partly destroyed and vessels were unevenly dilated. So pCLE proved the difference between non-neoplastic changes in surrounding mucosa and high grade neoplasia in the lesion. EUS showed intramucosal spreading of the tumour. And lymph nodes were not visualized. So we considered to perform ESD. We performed ESD: the lesion was en-block removed without any complications. And the specimen was almost 4 cm in diameter. Histology showed that resection margins were free from the tumor, there were no tumor embols in blood and lymphatic vessels. The lesion was a high grade dysplasia with multiple sites of intramucosal well-differentiated adenocarcinoma. So this endoscopic operation was curative. Control EGD after 3, 6 and 12 months showed no disease recurrence and no other lesions. In conclusion I would like to say: The most accurate diagnosis contributes the maximum benefit for the patient. CLE allows to perform precise characterization of gastric lesion and choose appropriate treatment. Презентация доклада на сайте: http://www.cellvizio.net/sites/default/files/issu_presentation/Early%20gastric%20cancer%20in%20a%20patient%20with%20hyper%20plastic%20polyp%20crucial%20contribution%20of%20confocal%20laser%20endomicroscopy%20in%20establishing%20correct%20diagnosis.pdf