Gastrointestinal: White Granules in the Stomach Caused by Lymphangitis Carcinomatosis From Signet‐Ring Cell Gastric Carcinoma

An 84-year-old female patient presented to our hospital with abdominal distention. Computed tomography (CT) imaging revealed gastric wall thickening, ascites, nodules suggestive of peritoneal dissemination, and increased fatty tissue density. Positron emission tomography/computed tomography (PET/CT) indicated heterogenous FDG hyperaccumulation in the gastric wall, omentum, and para-aortic lymph nodes. Upper gastrointestinal endoscopy revealed a quarter circumferential raised lesion with indistinct borders and erosions on the anterior wall of the gastric corpus. Small white granules, each measuring 5 mm with well-defined borders, were observed throughout the fornix (Figure 1a–c). Biopsy of the main lesion revealed signet ring cell adenocarcinoma, indicating an advanced cancer. Biopsy of a white granule showed dilated lymphatic vessels within the mucosal lamina propria filled with poorly differentiated adenocarcinoma cells, consistent with a diagnosis of cancerous lymphangiopathy within the gastric mucosa (Figure 1d). Due to the patient's advanced age and worsening overall condition, palliative care was initiated. Two months later, she passed away. Lymphangitis carcinomatosis refers to lymph stasis and obstruction by tumor emboli due to cancer cell proliferation within lymphatic vessels [1]. The endoscopic white granules were attributed to extensive mucosal cancerous lymphangiopathy, with the white coloration representing lymph stasis and necrotic tumor debris. Although gastric cancer-associated cancerous lymphangiopathy often occurs in the lungs, this case describes its manifestation in the gastric mucosa, observed through magnified endoscopic examination with image-enhanced endoscopy.