Clin Endosc.  2016 Jul;49(4):336-345. 10.5946/ce.2016.057.

Borrmann Type 4 Advanced Gastric Cancer: Focus on the Development of Scirrhous Gastric Cancer

• Jung K
• Park MI
• Kim SE
• Park SJ

• KMID: 2348251
• DOI: http://doi.org/10.5946/ce.2016.057

Abstract

Early diagnosis of Borrmann type 4 advanced gastric cancer (AGC) is very important for improving the prognosis of AGC patients. Because there is no definite mass in most cases of Borrmann type 4 AGC, its accurate diagnosis via endoscopy requires an understanding of its pathogenesis and developmental process. Moreover, many people confuse linitis plastica (LP) type gastric cancer (GC), scirrhous GC, and Borrmann type 4 AGC. To distinguish each of these cancers, knowledge of their endoscopic and pathological differences is necessary, especially for LP type GCs in the developmental stage. In conclusion, diagnosis of pre-stage or latent LP type GC before progression to typical LP type GC requires the detection of IIc-like lesions in the fundic gland area. It is also crucial to identify any abnormalities such as sclerosis of the gastric wall and hypertrophy of the mucosal folds during endoscopy.

Keyword

Borrmann type 4; Advanced gastric cancer; Linitis plastica; Scirrhous gastric cancer

MeSH Terms

Diagnosis
Early Diagnosis
Endoscopy
Humans
Hypertrophy
Linitis Plastica
Prognosis
Sclerosis
Stomach Neoplasms*

Figure

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  Fig. 1. Relationship between diffuse gastric cancers (scirrhous gastric cancer, Borrmann type 4 advanced gastric cancer [AGC], and linitis plastica).

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  Fig. 2. Typical case of Borrmann type 4 advanced gastric cancer. These images show similar findings with each diagnostic modality (A, B: endoscopy; C: positron emission tomography-computed tomography [CT]; D, E: abdominal CT). After total gastrectomy, the gross pathologic finding (F) also shows diffuse wall thickening, similar to that observed on CT.

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  Fig. 3. Examples of scirrhous gastric cancer. (A, B) Diffusely infiltrating masses with local areas of ulceration were present from the body to the distal antrum. (C, D) At the distal antrum, there were wide areas of extensive fibrous hyperplasia and significant luminal narrowing.

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  Fig. 4. Examples of Borrmann type 4 advanced gastric cancer. (A, B) At the lesser curvature side of the proximal antrum to the lower body, diffuse, irregular, focal ulceration was observed. (C, D) Diffuse wall thickening and hypertrophy of the mucosal folds were present from the upper body to the antrum, with good distensibility.

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  Fig. 5. Examples of linitis plastica gastric cancer. (A, B) There was an ulcerative lesion on the greater curvature side of the upper body with sparing of the antrum. (C, D) Fold thickening with distensibility was observed on the upper to lower body.

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  Fig. 6. Morphologic changes in linitis plastic gastric cancer. Adapted from Nakamura, with permission from Igaku-Shoin Ltd [16].

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  Fig. 7. This picture shows an example of a IIc-like lesion (circle on image A). (A) A 50-year-old man was diagnosed with IIc-type gastric cancer on endoscopic biopsy. (B) Cutting shape of fold convergence was seen on endoscopy. (C, D) After chromoendoscopy with indigo carmine dye, the lesion could be observed more clearly. After gastrectomy, the main lesion was confirmed to be signet ring cell carcinoma without submucosal invasion.

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  Fig. 8. Summary of endoscopic findings and proposed diagnostic steps for scirrhous gastric cancer (GC). UGI, upper gastrointestinal; EUS, endoscopic ultrasound; CT, computed tomography; PET-CT, positron emission tomography-computed tomography; EMR, endoscopic mucosal resection.

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