A Subepithelial Tumor With Surface Changes Removed by Endoscopic Submucosal Dissection

Dae Gon Ryu; Cheol Woong Choi

doi:10.7704/kjhugr.2025.0071

Question

A 60-year-old man presented with gastric subepithelial tumor with surface changes. A soft subepithelial tumor, measuring approximately 20 mm, was observed on the lesser curvature of the gastric lower body. A whitish color change and depression was seen on its surface (Fig. 1). On endoscopic ultrasonography, the lesion was homogenous, anechoic, and confined to the submucosal layer. Mucosal thickening was observed above it (Fig. 2). What is the most likely diagnosis?

Answer

A forceps biopsy was performed at the whitish color-changed and depressed area on the lesion’s surface, which revealed tubular adenoma with low-grade dysplasia. Endoscopic submucosal dissection (ESD) was performed for complete removal and histologic confirmation of the underlying pathology. After marking the area around the villous change on the tumor surface (Fig. 3A), a 0.9% saline solution with epinephrine and indigo carmine was injected into the submucosal layer (Fig. 3B). After circumferential mucosal incision (Fig. 3C), submucosal dissection was performed with an insulated-tipped knife (Fig. 3D). A cystic lesion with fibrotic tissue was observed below the submucosal injection fluid (Fig. 3E). En-bloc resection of the tumor was safely performed (Figs. 3F and 4). Histopathologic examination revealed a cystically dilated glandular structure extending into the submucosal layer with surrounding fibrotic and inflammatory changes, consistent with gastritis cystica profunda (GCP), and an overlying well-demarcated tubular adenoma with low-grade dysplasia (Fig. 5). The patient was discharged two days after ESD without any complications.

GCP is caused by chronic inflammation, ischemia, and foreign body reaction [1,2]. Because of this long-standing stimulation, GCP often shows surface mucosal changes, and several reports have described the development of adenoma or early gastric cancer on its surface [3,4]. In the present case, ESD was safely performed for a lesion with such surface changes, leading to complete resection and histologic diagnosis.

Although GCP itself is a benign condition, its potential association with epithelial dysplasia or carcinoma highlights the importance of careful endoscopic evaluation. Recognizing subtle mucosal alterations overlying a subepithelial lesion may allow earlier detection and management of neoplastic transformation. Therefore, ESD should be considered both for diagnostic confirmation and therapeutic removal when surface changes suggest neoplastic potential.

Notes

Availability of Data and Material

The datasets generated or analyzed during the study are available from the corresponding author on reasonable request.

Conflicts of Interest

Dae Gon Ryu, a contributing editor of the Korean Journal of Helicobacter and Upper Gastrointestinal Research, was not involved in the editorial evaluation or decision to publish this article. All remaining authors have declared no conflicts of interest.

Funding Statement

This study was supported by a 2025 research grant from Pusan National University Yangsan Hospital.

Acknowledgements

None

Authors’ Contribution

Conceptualization: Dae Gon Ryu. Data curation: Dae Gon Ryu. Formal analysis: Dae Gon Ryu. Funding acquisition: Dae Gon Ryu. Investigation: Dae Gon Ryu. Methodology: Dae Gon Ryu. Project administration: Dae Gon Ryu. Resources: Dae Gon Ryu. Software: Dae Gon Ryu. Supervision: Dae Gon Ryu, Cheol Woong Choi. Validation: Dae Gon Ryu. Visualization: Dae Gon Ryu. Writing—original draft: Dae Gon Ryu. Writing—review & editing: Dae Gon Ryu, Cheol Woong Choi. Approval of final manuscript: Dae Gon Ryu, Cheol Woong Choi.

Ethics Statement

The paper was written with the patient’s consent.

Fig. 1.

A subepithelial tumor with color change and depression on its surface was seen in the lower gastric body.

Fig. 2.

On endoscopic ultrasonography, a homogenous anechoic lesion confined to the submucosal layer (yellow arrow) was found. Above it, mucosal thickening was observed (white arrow).

Fig. 3.

Endoscopic submucosal dissection procedure. A: Marking around the lesion. B: Submucosal injection to lift the lesion. C: Pre-cutting along the marking. D: Submucosal dissection. E: A cystic lesion (yellow arrow), including its fibrotic tissues, was observed below the submucosal injection fluid (blue arrow). F: Artificial ulcer after completion of endoscopic submucosal dissection.

Fig. 4.

En-bloc resection specimen after endoscopic submucosal dissection. A: The gross appearance of the resected lesion. B: The inner surface of the resected specimen.

Fig. 5.

Histopathologically, a cystically dilated glandular structure with fibrotic and inflammatory changes was observed in the submucosal layer (yellow arrow) (hematoxylin and eosin [H&E] stain, ×20), consistent with gastritis cystica profunda. In the overlying mucosa (boxed area), a tubular adenoma with low-grade dysplasia was noted (H&E stain, ×100).

REFERENCES

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