| Abstract|| |
Gastric hyperplastic polyps (GHP) account for a majority of benign gastric polyps. Most of the GHPs are <2 cm, asymptomatic, and incidentally detected on endoscopy or radiologically. With increasing size, these polyps manifest as upper gastrointestinal bleeding, iron deficiency anemia, and gastric outlet obstruction (GOO). We report an unusual case of giant GHP simulating gastric carcinoma and posing as a diagnostic challenge for the surgeons emphasizing the diagnostic role of histopathology. A 46-year-old female presented with clinical features of progressive GOO for 1 year. Endoscopy revealed an eccentric proliferative lesion in the antrum. Computed tomography showed a polypoidal, enhancing mural thickening involving distal body and antro-pyloric region measuring 8.4 cm × 6.6 cm × 1.8 cm. Subtotal gastrectomy was done in view of clinical features of GOO and having a clinical suspicion of malignancy. Gross examination showed a giant sessile hyperplastic polyp with lobulated surface. Microscopy revealed features of a large, sessile hyperplastic polyp without any evidence of dysplasia. The patient was symptomatically relieved and is on follow-up. To conclude, giant GHPs can mimic gastric carcinoma on endoscopy and radiology. The possibility of giant GHP should be kept in mind in the presence of an intensely contrast-enhancing polypoidal lesion in the gastric antrum. Long-term endoscopic follow-up is recommended.
Keywords: Dysplasia, gastric polyp, hyperplastic polyp
|How to cite this article:|
Jain A, Chaudhary D, Goyal S, Agarwal AK, Sakhuja P. Giant hyperplastic gastric polyp: A diagnostic dilemma!!. Indian J Pathol Microbiol 2022;65:914-7
|How to cite this URL:|
Jain A, Chaudhary D, Goyal S, Agarwal AK, Sakhuja P. Giant hyperplastic gastric polyp: A diagnostic dilemma!!. Indian J Pathol Microbiol [serial online] 2022 [cited 2022 Nov 30];65:914-7. Available from: https://www.ijpmonline.org/text.asp?2022/65/4/914/359308
| Introduction|| |
Gastric hyperplastic polyps (GHP) are the most common polyps accounting for 75–90% of all gastric polyps. Most of these polyps arise in the antrum and are detected incidentally during radiological examination or endoscopy. With advancing size, the probability of malignant transformation and symptomatic presentation in the form of upper gastrointestinal bleeding, iron deficiency anemia, and gastric outlet obstruction (GOO) increases. We present an unusual case of a giant sessile GHP of 8 cm causing GOO mimicking gastric carcinoma clinico-radiologically.
| Case History|| |
A 46 years old female presented to the Gastrointestinal surgery OPD with chief complaints of recurrent episodes of intermittent, non-bilious, and projectile vomiting for 1 year. It was associated with significant weight loss and anorexia. There was no history of hematemesis, malena, abdominal pain, fever, and alcohol intake. Upper gastrointestinal endoscopy showed an eccentric proliferative lesion in the antrum with normal overlying mucosa which was seen to extend proximally along the lesser curvature. A diagnosis of the gastric antral proliferative lesion with a suspicion of malignancy was suggested on endoscopy. Computed tomography scan showed polypoidal, enhancing mural thickening involving distal body, and antro-pyloric region of size 8.4 cm × 6.6 cm with maximum single wall thickness of 1.8 cm causing significant luminal narrowing [Figure 1]. No lymphadenopathy and no adjacent organ infiltration were seen. On endoscopic-guided biopsy, the diagnosis of hyperplastic polyp was suggested without any evidence of dysplasia. Subtotal gastrectomy with Roux-en-Y gastrojejunostomy was done in view of the giant gastric polyp with clinical suspicion of malignancy and features of GOO. Grossly, a giant sessile hyperplastic polyp with lobulated surface was present in the antrum and distal body measuring 8 cm × 6.4 cm × 1.5 cm [Figure 2]. Microscopy showed an ill-defined sessile polyp comprising of multiple frond-like projections lined by elongated and tortuous foveolar epithelium [Figure 3]a, [Figure 3]b. The foveolar epithelium was markedly hyperplastic with corkscrewing of foveolae and in-folding of lining epithelium in the form of serrations and occasional cystic dilation [Figure 3]c. Arborizing thin bundles of smooth muscle pulled up from muscularis propria were seen invaginating into the cores [Figure 3]b. Abundant apical mucin in the foveolar cells with uniform basal nuclei were seen. The focal area of regenerative atypia in the form of mild nuclear enlargement, hyperchromasia, and loss of cytoplasmic mucin was noted [Figure 3]e. Lamina propria within the polyps showed mild-to-moderate mixed inflammatory infiltrate. Uninvolved gastric mucosae showed a feature of mixed inflammatory infiltrate in lamina with foci of pititis and pit abscess [Figure 3]d. However, no evidence of ulceration, dysplasia, Helicobacter pylori, and glandular atrophy was seen. On immunohistochemistry, P53 was negative and Ki67 labeling index showed expression in the basal crypts only, thereby ruling out any dysplasia [Figure 3]f. The final diagnosis of a giant GHP was rendered. The patient was symptomatically relieved and is on follow-up.
|Figure 1: Axial (a) non-contrast and coronal (b) contrast-enhanced CT images show lobulated homogeneously enhancing nodular wall thickening in the posterior wall of distal body and antrum of stomach|
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|Figure 2: Gross photograph shows (a) a gray-white giant sessile polyp measuring 8 cm in maximum dimension in gastric antrum. (b) closer view shows a distinctly lobulated surface|
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|Figure 3: Photomicrographs show (a) junction of GHP with normal gastric mucosa demonstrating hyperplastic sessile polyp (H&EX0.5) (b) a polyp composed of multiple frond-like projections lined by tortuous and elongated foveolar epithelium with focal crypt dilatation and pulled-up smooth muscle fibers (H&E X0.4) (c) marked foveolar hyperplasia with corkscrewing and focal serration in the lining epithelium (H&EX40) (d) pit abscess (H&E X100) (e) focal regenerative atypia in the form of mild nuclear enlargement and hyperchromasia (H&E X100) (f) Ki-67 IHC showed expression in basal crypts only (IHC X20)|
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| Discussion|| |
GHPs are usually <2 cm, solitary, asymptomatic, and incidentally detected on endoscopy or radiologically. Nevertheless, GHP >2 cm in size can lead to iron deficiency anemia, acute pancreatitis, gastroduodenal intussusception, and GOO in view of the antral location.,
We report a case of giant gastric polyp of size 8 cm in a 46-year-old woman causing GOO. On the basis of endoscopy and imaging findings of a giant sessile polyp of 8 cm in the antrum causing GOO and clinical suspicion of malignancy, the patient was taken up for subtotal gastrectomy. However, on histopathologic examination, no evidence of dysplasia or malignancy was found despite extensive sampling. In literature, there are a very limited number of cases of giant GHPs more than 6 cm presenting with GOO in elderly adults [Table 1].,,,
|Table 1: Details of the previous reported cases of giant GHP measuring more than 6 cm|
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In most of the reported cases of giant GHP, polypectomy was done surgically through gastrostomy.,, Endoscopic submucosal dissection is successful only in pediatric cases.
The hyperplastic polyps develop due to exaggerated regenerative response of gastric foveolar cells to chronic mucosal damage in chronic gastritis as in autoimmune or Helicobacter pylori gastritis. Other proposed risk factors include cirrhosis, partial gastric surgery, long-standing gastroesophageal reflux, and Menetrier disease.
Whether GHP has any malignant potential remains controversial. Previously they were thought to be benign, but recently, a few authors have proposed that dysplasia can arise within these polyps as well as at sites remote from the GHP., For instance, Daibo et al. found focal evidence of malignancy in 2.1% of their GHPs. The prevalence of dysplasia in GHP ranges from 1.5 to 4.4% while that of adenocarcinoma varies between 1.1 and 2.1%.,, Han et al. found a higher incidence of malignant transformation in cases of GHP of size >1 cm when compared to less than 1 cm (8.4% vs 1.6%). The risk factors associated with malignant transformation in GHPs are age >65 years, gastric intestinal metaplasia, and size >2.5 cm. Dysplasia, if present, is evident on the surface as well as in the deeper pits and often shows nuclear overexpression of p53 protein and high Ki-67 index. In view of their controversial malignant potential, a few authors have recommended surgical resection in GHP if it is sessile, symptomatic, and has size >2 cm, and in case of failure of endoscopic management. Forte et al. have recommended resection in all GHP harboring dysplasia irrespective of size, and long-term follow-up by endoscopic biopsies in GHPs >2.5 cm particularly in patients with cirrhosis.
The recurrence rate of GHP varied between 50 and 55% after endoscopic removal as reported in the previous studies., The risk factors associated with high recurrence are age <65 years, cirrhosis, and antral location.
To summarize, giant GHPs can mimic malignancy on endoscopy and radiology and pose a diagnostic dilemma for surgeons. Radiologists must be aware of the fact that in the presence of an intensely contrast-enhancing polypoidal lesion in the gastric antrum, apart from malignancy, the possibility of GHPs should also be kept in the differentials. The GHPs particularly larger than 2.5 cm which are symptomatic should be completely resected in view of the risk of their malignant transformation. It is important for the pathologists to do extensive sampling of the polyp as well as adjacent areas so as not to miss any concomitant focus of malignancy. Because of high recurrence rates at the polypectomy site as documented in the literature, long-term endoscopic follow-up is strongly recommended.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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Department of Pathology, Room No. 323, Academic Block, GIPMER, New Delhi - 110 002
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]