Preinvasive Neoplasia in the Stomach: Diagnosis and Treatment Amy Noffsinger, Irving Waxman  Clinical Gastroenterology and Hepatology  Volume 5, Issue 9, Pages 1018-1023 (September 2007) DOI: 10.1016/j.cgh.2007.07.004 Copyright © 2007 AGA Institute Terms and Conditions

Figure 1 Intramucosal adenocarcinoma in an EMR specimen. (A) Low-magnification view of the midportion of the EMR specimen showing glands arranged in a nearly back-to-back architectural pattern. Two glands in the center of the photograph show intestinal metaplasia without dysplasia (arrows). (B) Higher magnification view of the dysplastic gastric glands. The glands in the right half of the photograph contain cells with large, irregular nuclei and prominent nucleoli. The normal basal polarization of the epithelium is lost. A small cluster of cells is present invading the lamina propria, a feature diagnostic for intramucosal carcinoma (arrow). Clinical Gastroenterology and Hepatology 2007 5, 1018-1023DOI: (10.1016/j.cgh.2007.07.004) Copyright © 2007 AGA Institute Terms and Conditions

Figure 2 Gastric dysplasia. (A) Low-grade dysplasia is characterized by cells with crowded, enlarged nuclei that still maintain their basal polarity. (B) In high-grade dysplasia the nuclear abnormalities are more pronounced and normal polarity is lost so that the cells appear disorganized and overlapping. Clinical Gastroenterology and Hepatology 2007 5, 1018-1023DOI: (10.1016/j.cgh.2007.07.004) Copyright © 2007 AGA Institute Terms and Conditions

Figure 3 Intramucosal signet-ring cell carcinoma. (A) In this overstained H&E-stained section it is difficult to appreciate whether or not there are infiltrating neoplastic cells present. (B) The individual signet-ring–type cells appear dark brown and easily are seen infiltrating the lamina propria in this cytokeratin-immunostained section. (C) Immunohistochemical staining for E-cadherin shows loss of expression of this protein in the neoplastic signet-ring cells. The adjacent nonneoplastic gastric glands retain expression of E-cadherin. Clinical Gastroenterology and Hepatology 2007 5, 1018-1023DOI: (10.1016/j.cgh.2007.07.004) Copyright © 2007 AGA Institute Terms and Conditions

Figure 4 Treatment algorithm for dysplasia and intramucosal carcinoma. EMRs optimally should be performed so as to remove the lesion completely en bloc. In this way, the margins of resection can be assessed accurately. If the lesion cannot be removed in one piece, then more intensive surveillance may be necessary after the EMR procedure because the adequacy of resection cannot be determined by the pathologist. Clinical Gastroenterology and Hepatology 2007 5, 1018-1023DOI: (10.1016/j.cgh.2007.07.004) Copyright © 2007 AGA Institute Terms and Conditions