Verrucous gastritis-like lesion in intramucosal Helicobacter pylori-uninfected signet ring cell carcinoma with poorly differentiated adenocarcinoma

Sep 21, 2026

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Japan’s availability of Helicobacter pylori (Hp) eradication therapy has been linked to a rising prevalence of gastric cancers in Hp-uninfected stomachs, where signet ring cell carcinoma (SRCC) is predominant. Intramucosal SRCC with poorly differentiated adenocarcinoma arising in Hp-uninfected mucosa is rare, especially when presenting as an elevated, verrucous gastritis-like lesion. A 57-year-old man underwent curative endoscopic submucosal dissection, with histopathology revealing dense tumor growth and fibromuscular obliteration with smooth muscle bundles extending into the lamina propria. The case highlights characteristics of advanced Hp-uninfected gastric cancers.

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Clinical Journal of Gastroenterology (2024) 17:412–418 [https://doi.org/10.1007/s12328-024-01952-9](https://doi.org/10.1007/s12328-024-01952-9) Verrucous gastritis‑like lesion in intramucosal Helicobacter pylori‑uninfected signet ring cell carcinoma with poorly differentiatedadenocarcinoma Hiroki Takemoto1 · Takahiro Kotachi1 · Hajime Teshima1 · Hirosato Tamari1 · Akiyoshi Tsuboi1 · Hidenori Tanaka1 · Ken Yamashita1 · Yuji Urabe2 · Akira Ishikawa3 · Shiro Oka1 Received: 27 December 2023 / Accepted: 10 March 2024 / Published online: 23 March 2024 © The Author(s) 2024 Abstract In Japan, accessible Helicobacter pylori (Hp) eradication therapy is associated with an increase in the prevalence of gastric cancers (GCs) in Hp uninfected stomachs. Signet ring cell carcinoma (SRCC) is the most common of these GCs. Intramucosal SRCC with poorly differentiated adenocarcinoma (PDA) occurring in Hp uninfected gastric mucosa is rare; furthermore, many Hp uninfected pure SRCCs exhibit discoloration and flat or slightly depressed lesions, and morphological elevation is relatively rare. We report a case of intramucosal SRCC with PDA with an elevated, verrucous gastritis-like lesion in a 57-year-old male patient. In the present case, the PDA area showed dense tumor cell growth and coexisting desmoplastic and fibrotic reactions. Histopathology and immunohistochemical staining identified extensive fibromuscular obliteration with smooth muscle bundles extending from the muscularis mucosa into the lamina propria. The patient underwent curative endoscopic submucosal dissection. The reporting and analysis of such rare cases may lead to a better understanding of the characteristics of advanced Hp uninfected GCs. Keywords Helicobacter pylori uninfected gastric cancer · Signet ring cell carcinoma · Poorly differentiatedadenocarcinoma · Fibromuscular obliteration · Intramucosal SRCC with PDA Introduction The World Health Organization’s International Agency for Research on Cancer has classified Helicobacter pylori (Hp) as a carcinogen that causes gastric cancer (GC) [1] . National health insurance coverage for Hp eradication therapy for the treatment of Hp associated chronic gastritis has become available in Japan. As a result, the number of patients with reduced Hp infected status and the relative number of cases of Hp uninfected GC has increased. The frequency of Hp * Takahiro Kotachi [ooi0926yuyu@gmail.com](ooi0926yuyu@gmail.com) 1 Department of Gastroenterology, Hiroshima University Hospital, 1-2-3 Kasumi, Minamiku, Hiroshima 734-8553, Japan 2 Department of Gastrointestinal Endoscopy and Medicine, Hiroshima University Hospital, Hiroshima, Japan 3 Department of Molecular Pathology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan uninfected GC ranges from 0.4 to 5.0%[2–7]. Among these cases, signet ring cell carcinoma (SRCC), characterized by a discolored and flat or slightly depressed lesion, accounts for over 90% of cases [8] . SRCC in Hp uninfected gastric mucosa shows lower proliferative activity, lesser extensive spread, and slower progression than SRCC in Hp infected gastric mucosa [4]. However, although extremely rare, cases of advanced Hp uninfected GC have also been reported [9, 10] . The invasive potential of SRCC increases after TP53 mutation, and the cancer progresses to poorly differentiatedadenocarcinoma (PDA) [11] . We report a case involving a small, flat-elevated, depressed SRCC lesion with PDA occurring in Hp uninfected gastric mucosa that was curatively resected by endoscopic submucosal dissection (ESD) . Case report The patient was a 57-year-old male. He had no symptoms and was diagnosed with early GC. A depressed lesion of 10 mm in diameter located at the greater curvature of the gastric antrum was found during a routine upper gastrointestinal endoscopy procedure. He was referred to Hiroshima University Hospital, Hiroshima, Japan, after a biopsy indicating SR

FAQs

Why are Hp-uninfected gastric cancers increasing in Japan?

Accessible Hp eradication therapy has reduced Hp-infected status, and the relative number of Hp-uninfected gastric cancer cases has increased.

What makes intramucosal SRCC with PDA in Hp-uninfected mucosa rare?

The occurrence in Hp-uninfected gastric mucosa is uncommon, and many pure SRCCs show mostly discoloration and flat or slightly depressed lesions, while elevated verrucous gastritis-like morphology is relatively rare.

What treatment was used and what did pathology show?

The patient underwent curative endoscopic submucosal dissection. Histopathology and immunohistochemical staining identified extensive fibromuscular obliteration with smooth muscle bundles extending from the muscularis mucosa into the lamina propria.

Sep 21, 2026

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