A 28-year-old woman visited our clinic with a chief complaint of epigastralgia. She had received successful Helicobacter pylori (H. pylori ) eradication therapy 5 years before. We repeated esophagogastroduodenoscopy, and a discolored depressed area with reddish spots and converging folds, 20 mm in size, was detected. No atrophic change including intestinal metaplasia or nodular gastritis was seen endoscopically. Two endoscopic biopsies revealed undifferentiated adenocarcinoma.No H. pylori was found, and the 13 C-urea breath test was also negative. Abdominal computed tomography demonstrated no nodal involvement, distant metastasis or fluid collection. She underwent a laparoscopyassisted distal gastrectomy. Histologically, the resected specimen revealed an early undifferentiated gastric cancer that had invaded deeply into the submucosal layer. Nodal involvement was histologically confirmed.No atrophic change or H. pylori infection was evident histologically. This is the youngest patient ever reported to have developed a node-positive early gastric cancer after eradication of H. pylori .

A 64-year-old woman without Helicobacter pylori infection underwent an esophagogastroduodenoscopy during a health examination. A 2-mm flat lesion (0-IIb) with faded color and harboring a regular arrangement of collecting venules was detected at the greater curvature of the gastric fundus. Narrow-band imaging (NBI) showed a distinct whitish lesion. Magnifying endoscopy with NBI revealed a regular microsurface and microvascular pattern without a demarcation line, and a noncancer diagnosis was made [1]. However, as the endoscopic features on white-light imaging still strongly suggested neoplastic lesion in the background of mucosa not infected by H. pylori, a biopsy was taken. Histologically, a gastric adenocarcinoma resembling fundic gland cells with submucosal invasion was seen ( ¶ Fig. 1). A pathological diagnosis of gastric adenocarcinoma of the fundic-gland type [2, 3] was further confirmed by immunohistochemical staining. Endoscopic submucosal dissection was performed. No residual tumor was detected in the resected specimen, indicating that the tumor had been completely removed by endoscopic biopsy ( ¶ Video 1). Despite the lesion being the smallest ever reported, submucosal invasion was seen histologically. Adenocarcinoma rather than adenoma is appropriate naming for this kind of lesion. As gastric cancer without H. pylori infection is expected to become more prevalent, we believe that the endoscopic features of this case can help endoscopists to detect more gastric adenocarcinomas of the fundic-gland type at an earlier phase to ensure effective treatment. Endoscopy_UCTN_Code_TTT_1AO_2AG Competing interestsThe authors declare that they have no conflict of interest.Video 1 Minute gastric adenocarcinoma of the fundic-gland type with submucosal invasion. ¶Fig.1 A 2-mm flat lesion (0-IIb) with faded color and harboring a regular arrangement of collecting venules was detected at the greater curvature of the gastric fundus (yellow arrow): a distant view; b closer view. c Narrow-band imaging showed a distinct whitish lesion (yellow arrow). d A biopsy specimen showed a gastric adenocarcinoma of the fundic-gland type with submucosal invasion (red arrow).

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