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A Rapidly Enlarging Gastric Subepithelial Lesion
CLINICAL CHALLENGES AND IMAGES IN GI A Rapidly Enlarging Gastric Subepithelial Lesion Manoop S. Bhutani, Srinivas Ramireddy, and Rei Suzuki UT MD Anderson Cancer Center, Houston, Texas
Question: A 56year-old woman presented to our hospital for a follow-up of a 16mm subepithelial lesion in the stomach seen on esophagogastroduodenoscopy (EGD) a year ago. She had complained of persistent epigastric pain, nausea, and vomiting for a year. Physical examination revealed no abnormalities, including abdominal tenderness or mass. Her past medical history was unremarkable. Laboratory testing showed the following: hemoglobin, 14.2 g/dL; alanine aminotransferase, 32 U/L; aspartate aminotransferase, 21 U/L; amylase, 68 U/L; lipase, 140 U/L; and total bilirubin, 0.5 mg/dL. Repeat EGD showed a 30-mm, smooth subepithelial lesion (Figure A) in the gastric antrum, which doubled in size within 1 year. Endoscopic ultrasonography (EUS) revealed a hypoechoic lesion with irregular border and heterogeneous echotexture involving the submucosa and muscularis propria (Figure B). What is the diagnosis and what should be the management? Look on page 1613 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.02.047
Gastroenterology 2014;146:1612–1613
CLINICAL CHALLENGES AND IMAGES IN GI Answer to the Clinical Challenges and Images in GI: Image 4 (page 1612): Ectopic Pancreas
Initial findings of EGD noted a protruding smooth-surfaced mass in the antrum with an umbilication (Figures C and D). Endoscopic biopsy of the lesion showed antral mucosa with pancreatic acinar cell metaplasia, which was consistent with ectopic pancreas. The doubling in size within 1 year as well as her symptoms were concerning for malignant transformation. EUS-fine-needle aspiration (FNA) biopsy was negative for malignancy, but considering the possibility of a falsenegative FNA, marked and rapid increase in size and symptoms which were possibly caused by the lesion, concern for a malignant transformation was high. Therefore, a gastric wedge resection was performed. Surgical histopathology revealed pancreatic acini without duct structure consistent with ectopic pancreas. No malignancy was observed in the resected specimen. Ectopic pancreas is usually detected incidentally. The prevalence is reported with various ranges (0.55%–13.7%) in autopsy cases.1 The majority of them show no change in size and have a benign clinical course. American Gastroenterological Association Guideline recommends observation for cases without any symptoms or suspicion of malignancy.2 On the other hand, there are some cases of malignancy arising from ectopic pancreas. Typical presentation of malignant ectopic pancreas is symptomatic or increase in size.3 Additionally, preoperative definite diagnosis of malignant subepithelial lesion is sometimes challenging because of its heterogeneous components. To our knowledge, the present case is the first of ectopic pancreas which has rapidly doubled in size without any features of malignancy but masqueraded as a malignant process.
References 1. 2. 3.
Fukumori D, Matuhisa T, Taguchi K, et al. Ectopic gastric pancreatic cancer: report of a case. Hepatogastroenterology 2011;58:740–744. American Gastroenterological Association Institute. American Gastroenterological Association Institute medical position statement on the management of gastric subepithelial masses. Gastroenterology 2006;130:2215–2216. Song DE, Kwon Y, Kim KR, et al. Adenocarcinoma arising in gastric heterotopic pancreas: a case report. J Korean Med Sci 2004;19:145–148.
For submission instructions, please see the Gastroenterology web site (www.gastrojournal.org)
1613
Question: A 56year-old woman presented to our hospital for a follow-up of a 16mm subepithelial lesion in the stomach seen on esophagogastroduodenoscopy (EGD) a year ago. She had complained of persistent epigastric pain, nausea, and vomiting for a year. Physical examination revealed no abnormalities, including abdominal tenderness or mass. Her past medical history was unremarkable. Laboratory testing showed the following: hemoglobin, 14.2 g/dL; alanine aminotransferase, 32 U/L; aspartate aminotransferase, 21 U/L; amylase, 68 U/L; lipase, 140 U/L; and total bilirubin, 0.5 mg/dL. Repeat EGD showed a 30-mm, smooth subepithelial lesion (Figure A) in the gastric antrum, which doubled in size within 1 year. Endoscopic ultrasonography (EUS) revealed a hypoechoic lesion with irregular border and heterogeneous echotexture involving the submucosa and muscularis propria (Figure B). What is the diagnosis and what should be the management? Look on page 1613 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.02.047
Gastroenterology 2014;146:1612–1613
CLINICAL CHALLENGES AND IMAGES IN GI Answer to the Clinical Challenges and Images in GI: Image 4 (page 1612): Ectopic Pancreas
Initial findings of EGD noted a protruding smooth-surfaced mass in the antrum with an umbilication (Figures C and D). Endoscopic biopsy of the lesion showed antral mucosa with pancreatic acinar cell metaplasia, which was consistent with ectopic pancreas. The doubling in size within 1 year as well as her symptoms were concerning for malignant transformation. EUS-fine-needle aspiration (FNA) biopsy was negative for malignancy, but considering the possibility of a falsenegative FNA, marked and rapid increase in size and symptoms which were possibly caused by the lesion, concern for a malignant transformation was high. Therefore, a gastric wedge resection was performed. Surgical histopathology revealed pancreatic acini without duct structure consistent with ectopic pancreas. No malignancy was observed in the resected specimen. Ectopic pancreas is usually detected incidentally. The prevalence is reported with various ranges (0.55%–13.7%) in autopsy cases.1 The majority of them show no change in size and have a benign clinical course. American Gastroenterological Association Guideline recommends observation for cases without any symptoms or suspicion of malignancy.2 On the other hand, there are some cases of malignancy arising from ectopic pancreas. Typical presentation of malignant ectopic pancreas is symptomatic or increase in size.3 Additionally, preoperative definite diagnosis of malignant subepithelial lesion is sometimes challenging because of its heterogeneous components. To our knowledge, the present case is the first of ectopic pancreas which has rapidly doubled in size without any features of malignancy but masqueraded as a malignant process.
References 1. 2. 3.
Fukumori D, Matuhisa T, Taguchi K, et al. Ectopic gastric pancreatic cancer: report of a case. Hepatogastroenterology 2011;58:740–744. American Gastroenterological Association Institute. American Gastroenterological Association Institute medical position statement on the management of gastric subepithelial masses. Gastroenterology 2006;130:2215–2216. Song DE, Kwon Y, Kim KR, et al. Adenocarcinoma arising in gastric heterotopic pancreas: a case report. J Korean Med Sci 2004;19:145–148.
For submission instructions, please see the Gastroenterology web site (www.gastrojournal.org)
1613