Unrecognizable intramucosal spread of diffuse-type mucosal gastric carcinomas of less than 20 mm in size

Diffuse-type intramucosal gastric carcinomas sometimes spread within the mucosa beyond their macroscopic margins, often causing positive resection margins upon local resections such as endoscopic mucosal resection.

A consecutive series of 34 patients with solitary, small (less than 20 mm in diameter macroscopically), and macroscopically well demarcated diffuse-type mucosal carcinomas, who were treated with gastrectomy followed by detailed pathological examination, were included in the present study. Unrecognizable intramucosal spread is defined as an area of cancer which is indistinguishable macroscopically from its peripheral noncancerous area, and covered by normal epithelium with neither morphologic nor color changes. We examined the extent of unrecognizable intramucosal spread, measuring the maximum distances between macroscopic and microscopic margins on the sections, and investigated its relationship with four factors: location of the lesion, macroscopic size, histologic ulcer formation, and degree of atrophy of the background mucosa.

The maximum distance between macroscopic and microscopic margins was significantly larger (maximum 10 mm) in the background mucosas with marked atrophy than in those with little or no atrophy. No other factors, including location, macroscopic size and ulcer formation, correlated with it.

We should pay particular attention to unrecognizable intramucosal spread, especially in markedly atrophied mucosa, when treating small diffuse-type mucosal gastric cancer by local resections such as endoscopic mucosal resection. In addition, because of unrecognizable intramucosal spread, a surgical incision margin of at least 10 mm from the macroscopic margin is indicated.