| Abstract|| |
Introduction: Incidence of gastric carcinoma and gastric polyps is on rise all over the world. Chronic atrophic gastritis to intestinal metaplasia progressing to adenocarcinoma has been documented pathway for gastric carcinogenesis. Another pathway for gastric carcinoma is adenoma carcinoma sequence similar to colon cancer. Aim: To study prevalence, endoscopic, and histomorphological features of gastric polyps. Methods and Material: This was retrospective analysis of gastric polyps from 2012 to 2019 in consecutive 10,800 upper gastrointestinal endoscopies. Demographic, endoscopic, and histopathological data were obtained from hospital records. All gastric polyps were classified as per standard histologic criteria. Additional histological features noted were presence of dysplasia, focus of adenoma, or malignancy. Results: The prevalence of gastric polyps was 434 (4%) of 10,800 upper gastrointestinal endoscopies. Majority of polyps were found in the last 4 years (277: 63.8%). Mean age was 55.4 years with male to female ratio 1:1.2. Most of the polyps (94.9%) were less than 1 cm, located in gastric antrum. Multiple polyps were seen in 20.9% cases. On histopathology, fundic gland polyps were most common (147: 33.8%), followed by hyperplastic (128: 29.4%) polyps. Adenomatous polyps were nine (2%); of these, two cases of hyperplastic polyps and one each of fundic gland polyp and benign epithelial polyp showed adenomatous foci. Conclusion: Fundic gland polyps were the most common polyps. With rising incidence of gastric carcinoma, identification of gastric polyps on endoscopy with biopsy can prevent progression to carcinogenesis.
Keywords: Adenoma, fundic gland polyp, gastric carcinoma, gastric preneoplastic lesion, hyperplastic polyp, portal hypertensive polyps
|How to cite this article:|
Amarapurkar AD, Kale KM, Naik LP, Shukla AP. Histomorphological analysis of gastric polyps. Indian J Pathol Microbiol 2021;64:69-72
| Introduction|| |
Gastrointestinal polyps are abnormal mucosal protrusions projecting above the epithelial surfaces. Majority of the gastrointestinal polyps are seen in the colorectal region. Adenomatous colorectal polyps have been known to have a definite association with colorectal cancer., Adenoma carcinoma sequence for colorectal cancer is well established.,
Epigenetic and genetic mutations are known in the multistep process of carcinogenesis. Chronic atrophic gastritis to intestinal metaplasia progressing to gastric intestinal type of adenocarcinoma on the background of H pylori infection has been documented to be one of the pathways for gastric carcinogenesis. Another pathway for gastric carcinoma is adenoma carcinoma sequence. Since gastric and colon tumors share common genetic pathways, the pathogenesis for some of the gastric carcinoma may be on the lines similar to colonic adenoma-carcinoma sequence., Kim HS et al. have shown that gastric carcinoma arising from gastric adenoma is frequently associated with mismatch repair gene.
Gastric cancer is the fifth most common cancer worldwide. The incidence (Age Standardized Rate) of gastric cancer as reported by GLOBOCAN series 2018 is 11.1 per 100,000 population worldwide. Geographical variation has been observed in incidence of gastric cancer. The incidence of gastric cancer is very high in southeast Asia such as China, Japan, and south Korea. Overall incidence of gastric cancer in India is less as compared to western countries. The age-adjusted rate (AAR) of gastric cancer among urban registries in India is (3.0–13.2) compared to the worldwide AAR (4.1–95.5). Within India, regional variation has been observed for incidence of gastric cancer which may be due to different socioeconomical conditions and dietary habits. North eastern and southern part of the India has high incidence of gastric cancer as compared to the rest of the country. In Mizoram, north east state of India, incidence of gastric cancer is exceptionally high, among men (Age Adjusted incidence Rate = 64.2) and women (Age Adjusted incidence Rate = 31.2).
With an increasing incidence of gastric neoplasia, encountering a polyp in the stomach during endoscopy is concerned regarding its malignant potential. In view of paucity of published data on gastric polyps from India, we aim to study the prevalence, endoscopic features, and histological characteristics of gastric polyps from western India.
| Materials and Methods|| |
This was retrospective analysis of gastric polyps from January 2012 to June 2019 in consecutive 10,800 upper gastrointestinal endoscopies from tertiary referral center. Ethics permission was obtained from hospital ethics committee. All polypectomy and biopsy specimens from gastric polyps received in the Department of Pathology were included in this study. Biopsy from gastric polyp was processed routinely like endoscopic mucosal biopsy. For larger polyp more than 1 cm, the size and the type of polyp were noted (pedunculated or sessile). After fixation, larger sessile polyp was given serial sections and embedded entirely. For pedunculated polyps, initially base of the stalk was identified and inked. Then, the sections were taken such that head and the stalk were embedded together in continuity. The samples were processed routinely and stained with Haematoxylin Eosin stain.
Demographic data such as age, gender, presentation of patient, intake of proton pump inhibitors, family history of polyps or gastric cancer, and evidence of cirrhosis were noted. Endoscopic findings were obtained from hospital records. These were number and size of polyps, site, and appearance of adjacent gastric mucosa.
On histology, polyps were classified as epithelial and nonepithelial (mesenchymal)., Epithelial polyps were further classified into non-neoplastic and neoplastic. Non-neoplastic epithelial polyps were hyperplastic, fundic gland polyp, portal hypertensive polyp (PHP), inflammatory polyp, and miscellaneous polyps. Neoplastic epithelial polyps included adenomas, carcinoma, and neuroendocrine tumor. Additional histological features were noted such as presence of dysplasia, focus of adenoma or malignancy. Prevalence of gastric polyps from year 2012 to 2015 was compared with polyps seen during 2016–2019. The data were expressed quantitatively in percentage and Chi-square test.
| Results|| |
Of total 10,800 upper gastrointestinal endoscopies, gastric polyps were found in 434 (4%) cases from January 2012 to June 2019. Prevalence of polyps was more 277 (63.8%) in the last 4 years (2015–2019). Most of the polyps 210 (48.3%) were found between 51 and 70 years of age with mean age of 55.4 years. There were 240 (55.2%) females and 194 (44.8%) males. Majority of the patients underwent upper gastrointestinal endoscopy for symptoms of prolonged dyspepsia. In total, 428 (98.5%) of gastric polyps were incidental findings during endoscopy. History of ingestion of proton pump inhibitor for dyspepsia was given in 98 (22.5%) cases. Location of gastric polyp on endoscopy was antrum (65%) followed by gastric body. Size of the polyp was less than 1 cm in 412 (94.9%) cases. Multiple polyps (more than two) were seen in 91 (20.9%) cases. Adjacent gastric mucosa on endoscopy showed evidence of chronic gastritis in 87 (20%) and atrophy in 25 (5.7%) cases.
On histopathology, the most common polyps were fundic gland polyps 147 (33.8%) followed by hyperplastic polyps 128 (29.4%) [[Figure 1]a and [Figure 1]b, respectively]. There were 81 (18.6%) cases that were presumed to be tiny polyps on endoscopy and on biopsy showed only normal gastric mucosa without inflammation, hyperplasia, or dysplasia. Inflammatory polyps were 22 (5%) and PHPs in 8 (1.8%) [Figure 1]c. In addition to polypoidal hyperplastic gastric mucosa, PHPs showed extensive proliferation of capillaries within lamina propria that reflects increased portal pressure. Adenomatous polyps were nine (2%) [Figure 1]d, which included tubular adenoma (five cases), hyperplastic polyp with focus of adenoma (two cases). Other two cases were fundic gland polyp and benign epithelial polyp with tiny focus of adenoma each. All nine cases of adenomatous polyps showed low-grade dysplasia. Other nonepithelial polyps were hamartomatous (Peutz Jegher's) polyp three cases (0.6%) and a single case each of lipomatous polyp, ectopic pancreas, and gastritis cystica profunda. Neoplastic polyps were neuroendocrine tumor in 15 (3.4%), gastrointestinal stromal tumor in 2 (0.4%), and gastric carcinoma presenting as polyp in 16 (3.6%) cases [Table 1]. Histopathological findings in multiple polyps were hyperplastic polyps, portal hypertensive, and benign epithelial polyps.
|Figure 1: (a) Fundic gland polyp 100X HE. (b) Hyperplastic polyp 100X HE. (c) Portal hypertensive polyp 100X HE. (d) Tubular adenomatous polyp 100X HE|
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While analyzing trend of gastric polyps over the last 8 years, it was observed that number of gastric polyps have significantly increased (277 verses 157, P < 0.05) in the last 4 years as compared to polyps seen between years 2012 and 2015. It was also noted that the prevalence of fundic gland polyps, PHPs, and adenomatous polyps was more during the period 2016–2019.
| Discussion|| |
Gastrointestinal malignancy is a global oncologic problem. With rising incidence of gastric carcinoma, identification of gastric polyps on endoscopy with biopsy can prevent progression of carcinogenesis. In this study, prevalence of gastric polyps was found to be 434 (4%), which is consistent with study from Brazil. Highest prevalence (29.8%) of gastric polyps has been reported by Wang et al. from Taiwan. They have also shown that majority of gastric polyps are asymptomatic, which is consistent with this study. A large national histopathology database from the USA consisting of 74,351 patients has shown prevalence of 9.66% during 2008–2013 years. Carmack et al. from Caris Diagnostics USA studied the spectrum of gastric polyps over 1 year from 2007 to 2008 with prevalence of 6.35%. Great variation has been observed in prevalence of gastric polyps with some of the studies showing low prevalence ranging from 0.5% to 2%.,,,
There is paucity of data on gastric polyps from India, and most of it is limited to case reports. From our earlier study in 2013 on PHPs, the overall prevalence of gastric polyps was found to be 121 (3.2%), which is similar to present results. Mohapatra et al. in 2017 from north India have also shown similar prevalence (4%) of gastric polyps, while analyzing 31,000 upper gastrointestinal endoscopy procedures over a period of 4 years. Shanthi Velusamy and Geetha Devadas in 2018 from south India analyzed histomorphological polyps of gastrointestinal tract from 2008 to 2012. Of 60,671 endoscopic procedures, gastric polyps and polypoidal lesions were identified in 120 (26.5%) cases. From these, gastric polyps were 66 and majority 46 (69.6%) were hyperplastic polyps, 2 fundic gland polyps, 7 inflammatory, and 1 inflammatory fibroid polyp. In the present study, while analyzing the trend of gastric polyps from 2012 to 2019, it was observed that there was rising prevalence of gastric polyps between years 2016 and 2019. Similar change in trend of gastric polyps was observed in a recent study from Mexico.
On demographic profile gastric polyps have been reported more frequently in females as compared to males.,, Similar observation is obtained from present study with a male to female ratio of 1:1.2. Around 65% of polyps were present in gastric antrum and 412 (94.9%) were less than 1 cm in size. These findings were in concordance with other studies in literature.,,,
On histomorphology, earlier literature has described hyperplastic polyps as most common. However, recently fundic gland polyps have emerged as the most frequent histological type of gastric polyps.,, This is due to the increased use of proton pump inhibitors in general population. We have observed that the fundic gland polyps were the most common gastric polyps 147 (33.8%) and were frequently seen over the last 4 years as compared to year 2012–2015. This is in agreement with recent studies in the literature., Hyperplastic polyps have been closely associated with H. Pylori infection. High prevalence of hyperplastic polyps (46%) was reported from Turkey in 2003 and Brazil in 2007., However, few reports have shown reduction in the prevalence of hyperplastic polyps probably due to eradication of H pylori infection., In this study, hyperplastic polyps represented 128 (29.4%) of all polyps and none of the sections studied showed presence of H. Pylori. PHPs are unique seen in patients of liver cirrhosis with portal hypertension. Majority of them are multiple, located in antrum without risk of malignant transformation. The prevalence of PHP reported in literature is 0.9%–1.3% of patients with portal hypertension, which is in agreement with present study., A major chunk 81 (18.6%) of our cases showed normal gastric mucosa on histopathological examination but were presumed to be polyps on endoscopy. This correlated with 16.1% of polyps in a study by Carmack et al. in 2009, which had polypoidal configuration on endoscopy but revealed only normal gastric mucosa. Although this is a common finding on endoscopy, no further significance is associated with this category of lesions. The presence of polypoidal nature of mucosa can attributed to mucosal folds on endoscopy with a normal gastric mucosa on histology, rarely to lamina propria edema or underlying lymphoid hyperplasia. No histological features other than normal mucosa were identified in these cases.
Gastric adenomas are a preneoplastic condition. In this study, there were nine (2%) adenomatous polyps. All of them were less than 1 cm in size having low-grade dysplasia. This finding is similar to the study done by Wang FW et al. during 2015–2016 from Taiwan. Of total nine adenomas, five were tubular adenomas, two hyperplastic polyps, and one each of fundic gland and benign epithelial polyp which showed foci of adenomatous change. These adenomatous foci in non-neoplastic polyp have been described in the literature. We should be aware of adenomatous foci in benign polyps, which may progress to gastric carcinoma.,
In conclusion, this retrospective study revealed increase in prevalence of gastric polyps over the last 4 years. Fundic gland polyps being commonest followed by hyperplastic polyps. With rising incidence of gastric carcinoma, identification of gastric polyps on endoscopy with biopsy can prevent progression to carcinogenesis.
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Anjali D Amarapurkar
D 401, Ameya Society, New Prabhadevi Road, Mumbai, Maharashtra - 400 025
Source of Support: None, Conflict of Interest: None