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Year : 2011  |  Volume : 54  |  Issue : 3  |  Page : 622-623
Gastric inflammatory fibroid polyp


1 Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina
2 Department of Gastroenterology, University of North Carolina, Chapel Hill, North Carolina

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Date of Web Publication20-Sep-2011
 

How to cite this article:
Woodward K, Gangarosa LM, Hunt HV. Gastric inflammatory fibroid polyp. Indian J Pathol Microbiol 2011;54:622-3

How to cite this URL:
Woodward K, Gangarosa LM, Hunt HV. Gastric inflammatory fibroid polyp. Indian J Pathol Microbiol [serial online] 2011 [cited 2020 Jun 3];54:622-3. Available from: http://www.ijpmonline.org/text.asp?2011/54/3/622/85120


Inflammatory fibroid polyp occurring in the stomach is reported in this report. A 64-year-old female presented with complaints of mild, intermittent chest discomfort for the last two weeks, some of which were attributed clinically to costochondritis. Since she also had a history of gastroesophageal reflux, she underwent an upper endoscopy, which revealed a well circumscribed, round, pedunculated polyp in the antrum of the stomach measuring 15 mm [Figure 1]. The surface of the polyp was smooth without erosions. Sonographically, the lesion was hypoechoic and appeared to arise from the submucosa or deep mucosa without involvement of the muscularis propria. A biopsy of the surrounding gastric antrum showed mild, focally active, chronic gastritis with no evidence of dysplasia or malignancy. A Diff Quik stain was negative for Helicobacter pylori. The polyp was removed in its entirety with a hot snare.
Figure 1: Endoscopic impression: Round subepithelial polypoid lesion in the antrum of the stomach measuring 1.5 cm. Endosonographically, lesion appeared hypoechoic and limited to mucosa or submucosa, with well-defined borders (image not shown)

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On gross examination, the mass appeared as a red-tan polyp measuring 1.1 Χ 1.0 Χ 0.8 cm. Microscopy showed a well-circumscribed, submucosal spindle-cell proliferation with a mixed inflammatory infiltrate consisting predominantly of eosinophils [Figure 2]. The lesion extended superficially into the mucosa. In addition to the prominent eosinophils, there was also a mixture of lymphocytes, plasma cells and mast cells as well as some ill-defined follicles in the stroma. Some concentric (onion-skin) condensation of fibroblast-like spindle cells around vessels and glands was noted. No surface erosion, necrosis, dysplasia or intestinal metaplasia was seen. No mitoses were identified in 20 high-power fields. Immunohistochemical stains were strongly positive for CD34 [Figure 3] and negative for CD117 (c-kit) [Figure 4] in the spindle cell stromal cell population, confirming the diagnosis of a gastric inflammatory fibroid polyp.
Figure 2: Histology (H and E stain): Spindle cell proliferation with prominent inflammatory infiltrate rich in eosinophils. Occasional vessels show peripheral condensation (onion-skin whorls) of the spindle cell proliferation, x200

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Figure 3: CD34 immunohistochemical stain: Strong positivity in stromal spindle cells, x200

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Figure 4: C-kit (CD117) immunohistochemical stain: Positive in scattered mast cells, but negative in stromal spindle cells, x40

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   Discussion Top


Representing less than 1% of all gastric polyps, inflammatory fibroid polyps (IFPs) were first described by Vanek in 1949 as "gastric submucosal granuloma(s) with eosinophilic infiltration." [1] While these types of polyps can be found anywhere along the gastrointestinal tract, approximately 75% occur in the antral portion of the stomach. [2],[3] They are often incidental findings, but have occasionally been associated with abdominal pain or obstruction, especially if they are very large. [4],[5]

On endoscopic examination, IFPs are typically ulcerated and can be sessile or pedunculated. [1],[2],[3],[4],[5] Microscopically, they exhibit a submucosal loose connective tissue of bland spindle cells without necrosis or a significant rate of mitosis. [1],[2],[3],[4],[5] In hypocellular areas, numerous thin-walled blood vessels are present. A characteristic perivascular (onion skin) whorling of the spindle cells may be seen. [4] The associated mixed inflammatory infiltrate consists of lymphocytes, plasma cells and prominent eosinophils. [1],[4] Although the prominence of eosinophils has led to the hypothesis that there may be an allergic or hypersensitivity component to the development of IFPs, no peripheral eosinophilia is typically encountered. [1],[4],[5] An article by Pantanowitz et al. of an in-depth immunohistochemical analysis of 16 IFPs of the gastrointestinal tract provided evidence that these lesions may have a dendritic cell origin. [4] A genetic role has been implicated by a report documenting the increased incidence of these polyps in a family living in Devon, UK, but this could not be corroborated further by other authors thus far. [2] A recent study examining 29 IFPs of the stomach, small bowel and colon showed activating mutations in PDGFRA exons 12 and 18 in 69% of cases, with D842V being the most frequent mutation. [5] These types of mutations have been documented in gastrointestinal stromal tumors (GIST) and suggest that IFPs represent true benign neoplasms. [5] IFPs are negative for CD117 (c-kit), a finding that readily distinguishes these lesions from GIST. [4],[5] They characteristically show strong immunohistochemical positivity for CD34, as did our case. [3],[4] In addition to GIST, the differential diagnosis for IFP includes other benign mesenchymal tumors, such as schwanomma and spindle cell leiomyoma. [2] Schwanommas have a similar age at presentation (average 58 years) and are typically well circumscribed. Small lymphoid aggregates can be seen at the periphery of the lesion, just as in IFP. However, schwanommas will show immunoreactivity for S100 and are typically CD34 negative. Spindle cell leiomyomas are rare lesions and show positive staining for desmin and smooth muscle actin with only a small minority showing positivity for CD34 (10-15%). [2]

Following complete excision, inflammatory fibroid polyps typically do not recur, making any other adjunct therapies and/or surveillance unnecessary. [2],[4]

 
   References Top

1.Vanek J. Gastric submucosal granuloma with eosinophilic infiltration. Am J Pathol 1949;25:397-411.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Carmack SW, Genta RM, Graham DY, Lauwers GY. Management of gastric polyps: A pathology-based guide for gastroenterologists. Nat Rev Gastroenterol Hepatol 2009;6:331-41.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Kim MK, Higgins J, Cho EY, Ko YH, Oh YL. Expression of CD34, bcl-2, and Kit in Inflammatory Fibroid Polyps of the Gastrointestinal Tract. Appl Immunhistochem Mol Morphol 2000;8:147-53.  Back to cited text no. 3
    
4.Pantanowitz L, Antonioli DA, Pinkus GS, Shahsafaei A, Odze RD. Inflammatory fibroid polyps of the gastrointestinal tract-Evidence for a dendritic cell origin. Am J Surg Pathol 2004;28:107-14.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Schildhaus HU, Buttner R, Binot E, Merkelbach-Bruse S, Wardelmann E. Inflammatory fibroid polyps are true neoplasms with PDGFRA mutations. Pathologe 2009;30:117-20.  Back to cited text no. 5
    

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Correspondence Address:
Heike V Hunt
Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, CB #7525, Chapel Hill, North Carolina 27514

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.85120

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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