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A Rare Case of Gastric Ulcerative Mass
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI A Rare Case of Gastric Ulcerative Mass Hsuan-Yi Chen,1,2 Chun-Che Lin,1,3 and Tan-Hsia Chen1,3 1 3
Division of Gastroenterology and Hepatology, Chung Shan Medical University Hospital, and 2Institute of Medicine, School of Medicine, Chung Shan Medical University, Taiwan
Question: A 75-yearold woman presented to the emergency department with tarry stool defecation and near syncope. She also experienced body weight loss of 6 kg and poor appetite within the last 3 months. At admission, the heart rate was 109 beats/min, blood pressure was 93/42 mm Hg. The abdomen was flat and supple. Laboratory examination revealed a remarkable decrease in hemoglobin level to 4.7 g/ dL (normal, 12.1-15.1). Esophagogastroduodenoscopy showed a huge protruding oval-shape mass (about 6 cm in size) at the gastric antrum, with an central clean-based ulceration and friable surfaces (Figure A, B). Multiple endoscopic biopsies were performed and revealed epithelial regeneration and hyperemic change of mucosa, with leukocytes and lymphocytes infiltration but no malignancy. Abdominal computed tomography revealed mild thickening of gastric wall without extraluminal outgrowth or invasion. What is the most likely diagnosis? 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. © 2015 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2015.02.023
Gastroenterology 2015;149:e6–e7
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to: Image 3: Inflammatory Fibroid Polyp
A subtotal gastrectomy was performed for concern of significant symptoms. The pathology revealed a light brown to yellow-colored demarcated tumor confined in the submucosal layer with prominent capillaries, proliferation of spindle cells (onion skin appearance) and an inflammatory eosinophil-rich infiltration (Figure C, D). The immunohistochemical stains revealed positive reaction to CD34 (Figure E) and smooth muscle actin and negative reaction to c-kit, DOG-1, and S100. The pathologic diagnosis was inflammatory fibroid polyp (IFP). She recovered gradually after surgery. IFP, first was described by Vanek in 1949, is a rare benign mesenchymal tumor of unknown nature in the gastrointestinal (GI) tract. It can occur at any part of GI tract but only represent <1% of all gastric polyps.1 IFPs arise in the submucosal and manifest as intraluminal lesions, which may mimic the appearance of adenomatous polyps, intraluminal GISTs, carcinoid tumors, or schwannomas.2 The gastric IFPs usually are <2 cm and found incidentally with no symptoms. However, large gastric IFPs can present with varied symptoms. Clinical manifestation of large gastric IFPs can imitate symptoms of gastric malignancy, and differentiation is difficult preoperatively even with correlation with endoscopic, computed tomography, and endoscopic ultrasonography findings. On histologic analysis, IFPs are composed of submucosal proliferation of mononuclear spindle cells, small vessels, and massive inflammatory infiltrate with eosinophils predominate in a perivascular pattern (onion skin appearance).3 Immunohistochemical analysis demonstrates positive for CD34, plateletderived growth factor receptor a, vimentin, and focally positive for smooth muscle actin. C-kit, DOG-1, S100, desmin, and cytokeratin are usually negative.3 Management includes local endoscopic resection or surgical resection in those with relatively large tumor size.
References 1. 2. 3.
Carmack SW, Genta RM, Graham DY, et al. Management of gastric polyps: a pathology-based guide for gastroenterologists. Nat Rev Gastroenterol Hepatol 2009;6:331–341. Kang HC, Menias CO, Gaballah AH, et al. Beyond the GIST: mesenchymal tumors of the stomach. Radiographics 2013; 33:1673–1690. Ozolek JA, Sasatomi E, Swalsky PA, et al. Inflammatory fibroid polyps of the gastrointestinal tract: clinical, pathologic, and molecular characteristics. Appl Immunohistochem Mol Morphol 2004;12:59–66.
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Division of Gastroenterology and Hepatology, Chung Shan Medical University Hospital, and 2Institute of Medicine, School of Medicine, Chung Shan Medical University, Taiwan
Question: A 75-yearold woman presented to the emergency department with tarry stool defecation and near syncope. She also experienced body weight loss of 6 kg and poor appetite within the last 3 months. At admission, the heart rate was 109 beats/min, blood pressure was 93/42 mm Hg. The abdomen was flat and supple. Laboratory examination revealed a remarkable decrease in hemoglobin level to 4.7 g/ dL (normal, 12.1-15.1). Esophagogastroduodenoscopy showed a huge protruding oval-shape mass (about 6 cm in size) at the gastric antrum, with an central clean-based ulceration and friable surfaces (Figure A, B). Multiple endoscopic biopsies were performed and revealed epithelial regeneration and hyperemic change of mucosa, with leukocytes and lymphocytes infiltration but no malignancy. Abdominal computed tomography revealed mild thickening of gastric wall without extraluminal outgrowth or invasion. What is the most likely diagnosis? 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. © 2015 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2015.02.023
Gastroenterology 2015;149:e6–e7
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to: Image 3: Inflammatory Fibroid Polyp
A subtotal gastrectomy was performed for concern of significant symptoms. The pathology revealed a light brown to yellow-colored demarcated tumor confined in the submucosal layer with prominent capillaries, proliferation of spindle cells (onion skin appearance) and an inflammatory eosinophil-rich infiltration (Figure C, D). The immunohistochemical stains revealed positive reaction to CD34 (Figure E) and smooth muscle actin and negative reaction to c-kit, DOG-1, and S100. The pathologic diagnosis was inflammatory fibroid polyp (IFP). She recovered gradually after surgery. IFP, first was described by Vanek in 1949, is a rare benign mesenchymal tumor of unknown nature in the gastrointestinal (GI) tract. It can occur at any part of GI tract but only represent <1% of all gastric polyps.1 IFPs arise in the submucosal and manifest as intraluminal lesions, which may mimic the appearance of adenomatous polyps, intraluminal GISTs, carcinoid tumors, or schwannomas.2 The gastric IFPs usually are <2 cm and found incidentally with no symptoms. However, large gastric IFPs can present with varied symptoms. Clinical manifestation of large gastric IFPs can imitate symptoms of gastric malignancy, and differentiation is difficult preoperatively even with correlation with endoscopic, computed tomography, and endoscopic ultrasonography findings. On histologic analysis, IFPs are composed of submucosal proliferation of mononuclear spindle cells, small vessels, and massive inflammatory infiltrate with eosinophils predominate in a perivascular pattern (onion skin appearance).3 Immunohistochemical analysis demonstrates positive for CD34, plateletderived growth factor receptor a, vimentin, and focally positive for smooth muscle actin. C-kit, DOG-1, S100, desmin, and cytokeratin are usually negative.3 Management includes local endoscopic resection or surgical resection in those with relatively large tumor size.
References 1. 2. 3.
Carmack SW, Genta RM, Graham DY, et al. Management of gastric polyps: a pathology-based guide for gastroenterologists. Nat Rev Gastroenterol Hepatol 2009;6:331–341. Kang HC, Menias CO, Gaballah AH, et al. Beyond the GIST: mesenchymal tumors of the stomach. Radiographics 2013; 33:1673–1690. Ozolek JA, Sasatomi E, Swalsky PA, et al. Inflammatory fibroid polyps of the gastrointestinal tract: clinical, pathologic, and molecular characteristics. Appl Immunohistochem Mol Morphol 2004;12:59–66.
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