Correspondence Address:
Teresa Pusiol
MD, Institute of Anatomic Pathology, S. Maria del Carmine Hospital, Piazzale S. Maria 6, 38068 Rovereto (TN)
Italy

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Sir,

Metaplasia is the replacement of a mature cell type into another type. Five major types of metaplasias affect the gastric mucosa: Intestinal, pyloric, pancreatic, ciliated, and squamous. In June 2011, an 83-year-old woman presented with episodic epigastric pain. Endoscopic gastric visualization showed a round, sharply punched-out lesion in the antrum. The surrounding mucosa was flattened. Areas endoscopically suspicious for neoplastic lesion were not found. Biopsies of ulcer and adjacent antral mucosa were performed. The six biopsies taken from ulcer showed polymorphonuclear leukocytes, coagulation necrosis, and granulation tissue. In the eight biopsies of the antral adjacent mucosa, the typical antral gastric glands cells were replaced by cells with subnuclear empty vacuoles [Figure 1]. Features suspicious for dysplasia or neoplasia were not found in the mucosa. Inflammation and Helicobacter pylori infection were not present. Special histochemical studies (PAS, Alcian blue pH 0.5 and pH 2, colloidal iron, and Grimelius stain) were performed. All were negative. Congenital heterotopias differ from metaplastic (acquired) lesions in that they usually retain a normal organizational structure, whereas metaplastic processes tend to consist of a single cell type lacking normal tissue patterns. Consequently, heterotopic lesions (intestinal, pyloric, pancreatic, ciliated, squamous, and Brunner gland) were excluded.{Figure 1}

The typical findings of artifacts, including improper fixation, the type of fixative, poor dehydration, improper reagents, or poor microtome sectioning, were not found.

Cytoplasmic vacuolization in epithelial cells is considered a pathological event when found in the gastric mucosa. [1] Surgical procedure was not performed. In October 2011, a second endoscopic examination was performed. Five biopsies of the same areas of the antral mucosa showed a similar pattern of metaplasia. Neoplastic and dysplastic lesions were not present. Groups of pyloric glands composed of cells with apparently empty vacuoles were first described by Rubio and Kato [1] in the gastric mucosa adjacent to ulcerated, moderately differentiated adenocarcinoma, found in the minor curvature from the angulus to the pylorus. [1] These authors believe that this cellular type is usually seen in one single gland or in groups of pyloric glands. The vacuoles contain fat. [2] Rubio and Kato [1] described four other different types of vacuolated cells occurring in the gastric mucosa. One type was characterized by supranuclear clear vacuoles, the other by supranuclear dark vacuoles, another by usually supranuclear vacuoles and cilia, and a fourth type by supranuclear clear vacuoles centered by a lymphocyte. [3] In our experience of 158.020 gastric biopsies, the present case is the first finding of "subnuclear empty vacuolated cell" metaplasia of the gastric mucosa. According to our knowledge, this type of metaplasia has not been reported till now.

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