LAUSR

We are indebted to Helena Popiel, Instructor of the Center for International Education and Research of Tokyo Medical University, for her editorial review of the manuscript. The MAPS II guidelines state that patients with chronic atrophic gastritis or intestinal metaplasia (IM) are at risk of developing gastric adenocarcinoma, and therefore should undergo surveillance endoscopy [1]. In fact, it is well established that IM is associated with intestinal-type gastric adenocarcinoma [2, 3]. Recently, map-like redness, which is specifically observed after Helicobacter pylori eradication, has been shown to indicate IM histologically and to be an independent risk factor for post-eradication gastric adenocarcinoma [4, 5]. We report the case of a 64-year-old man who underwent successful H. pylori eradication therapy 10 years previously. Esophagogastroduodenoscopy (EGD) prior to H. pylori eradication showed atrophic mucosa with a visible vascular pattern in the lesser curvature of the gastric body (▶Fig. 1 a). An EGD 5 years after eradication therapy again displayed atrophic mucosa in the lesser curvature of the gastric body; however, the vascular pattern was less prominent than before H. pylori eradication (▶Fig. 1b). A further EGD 10 years after eradication therapy displayed a 10-mm depressed lesion in the lesser curvature of the lower gastric body, which was histologically diagnosed as a tubular adenocarcinoma (▶Fig. 1 c). Although map-like redness was observed around the gastric adenocarcinoma, the mucosal atrophy and vascular patterns were unclear. The gastric adenocarcinoma was successfully resected en bloc by endoscopic submucosal dissection (ESD) (▶Video 1). The tumor was histologically diagnosed as a well-differentiated adenocarcinoma limited to the mucosal layer, and curative resection was achieved. IM and almost normal gastric fundic glands were observed in patches of the background mucosa of the tumor (▶Fig. 2 and ▶Fig. 3). This case suggested that the histological difference between improvement in gastric mucosal atrophy upon H. pylori eradication and IM represents endoscopic map-like redness. Therefore, map-like redness may not be observed in the early period after H. pylori eradication, so care should be taken not to underestimate the risk of gastric adenocarcinoma when performing surveillance EGDs.