Case Report
Poorly Cohesive Carcinoma within Hyperplastic Polyp of the Stomach
Capolupo GT1, Taffon C2, Mascianà G1*, Carannante F1, Crescenzi A2 and Caricato M1
1Department of Geriatric Surgery, University Campus Bio-Medico di Roma, Italy
2Department of Pathology, University Campus Bio-Medico di Roma, Italy
*Corresponding author: Mascianà Gianluca, Department of Geriatric Surgery, University Campus Bio-Medico di Rome, Via Alvaro del Portillo 21 - 00128 Rome, Italy
Published: 26 Jun, 2017
Cite this article as: Capolupo GT, Taffon C, Mascianà G,
Carannante F, Crescenzi A, Caricato
M. Poorly Cohesive Carcinoma within
Hyperplastic Polyp of the Stomach. Ann
Clin Case Rep. 2017; 2: 1386.
Abstract
A 75-year-old woman with a signet-ring cell carcinoma in a gastric hyperplastic polyp is reported. Endoscopic biopsies of the gastric lesion revealed glandular foveolar hyperplasia and ulceration, with focal severe cytological atypical in sparse glands. Total gastrectomy showed the presence of a polyp histologically characterized by hyperplastic glands and the presence of signet-ring cell carcinoma within the stroma. Cancer was limited to the polyp lesion. Extensive sampling of other regions of the stomach was negative for neoplasia. From a review of the literature, only 4 cases of signet ring carcinoma within a gastric hyperplastic polyp were reported. Our case points the focus on the relevance of extensive endoscopic sampling of hyperplastic polyps in order to rule out underlying neoplasia.
Keywords: Gastric polyps; Gastric carcinoma
Introduction
Gastric polyps account for 2% to 3% of gastric examinations, usually as incidental findings [1]. Hyperplastic polyps typically arise in stomach in a background of chronic gastritis and are the second most common gastric polyps [2]. Large polyps can have superficial ulceration or hemorrhage. Hyperplastic polyps usually develop within the body or antrum. It is believed that they represent an exuberant regenerative response of the gastric foveolar cells [3]. Hyperplastic polyps rarely progress to gastric carcinomas; malignant transformation however, although rare is well documented [4].
Case Presentation
A 75-year-old woman with a recent cardiac ischemia was admitted in our hospital for a cardiologic
check-up; clinical and laboratory examination detected a severe normocytic normochromic anemia
(Hb 5.6 g/dl). The patient reported recent hematochezia. A colonoscopy and an upper endoscopy
were performed, the latter showing a bleeding protruding lesion in the gastric fundus, measuring
about 2.5 cm in diameter. The lesion appeared soft, partly ulcerated with fibrin deposition consistent
with bleeding (Figure 1). Biopsies of the lesion were submitted to the department of pathology for
histologic evaluation. Colonoscopy didn’t show relevant alterations.
Histological examination of the gastric biopsies showed hyperplastic polyp mucosae with heavy
inflammatory infiltrate. Foveolar hyperplastic pits showed isolated foci of high grade epithelial
dysplasia characterized by globet cells with depolarized and hyperchromatic nuclei within the basal
membrane.
Although there was no evidence of infiltrative cancer, considering the severe anemia, the
hemodynamic instability, the endoscopic appearance and size of the lesion, the patient was
submitted, prior informed consent, to total gastrectomy. Before the gastrectomy procedure, the
patient was submitted to CT scan resulted negative for other pathologies or distant metastasis. After
surgical procedure the patient was discharged on the 10th post-operative day in good general clinical
condition.
Definitive histology was performed on the surgical specimen. The stomach showed a 2.5 cm
in diameter reddish protruding lesion in the fundus, at 1 cm from the proximal resection margin.
The lesion was totally sampled according to the Japanese rules for gastric cancer [4] embedded in
paraffin. 3 μm thick sections were cut for standard histology and immunohistochemical studies.
Histologically, the polypoid lesion was characterized by a proliferation of the surface foveolar cells lining exaggerated, elongated, and distorted pits that extend from
the surface deep into the lamina propria with mucosal expansion.
The glands developed extensive infoldings, branching in bizarre ways
producing either a serrated appearance or dilated cysts, occasionally
quite prominent. Smooth muscle fibers arborized in the lamina
propria. Mucosa appeared edematous, infiltrated by single atypical
discohesive epithelial elements, and characterized irregular and
pleomorphic nuclei, eccentrically placed, with evident nucleolus, and
ample eosinophilic cytoplasm and sporadically with classical signetring
morphology. Plasma cells, lymphocytes and eosinophils were also
present (Figure 4). Neutrophils were especially prominent in surface
ulcerated areas; vascular proliferations resembling granulation tissue
developed superficially near areas of inflammation. Within the
foveolar hyperplastic lining there were areas of dysplastic changes as
seen in the bioptic samples, with low and high grade intraepithelial
neoplasia with features of signet ring cell (Figure 2-4).
Immunohistochemistry was performed by the streptavidinbiotin
method. The antibodies used were mouse monoclonal antibodies
against Pan-cytokeratins (clone MNF116) and CD68 (clone PGM1)
all from Dakocytomation, Denmark. Sections were treated with
LSAB2 (Dakocytomation) and reaction product was revealed by
3-3-Diaminobenzidine (DAB). Sections were counterstained with
haematoxylin Discohesive atypical epithelial elements resulted positive
for Pan-CK and negative for CD68 at the immunohistochemical analys (Figure 5 and 6).
Diagnosis of gastric carcinoma, poorly cohesive type, arising in
hyperplastic polyp was made. Extensive sampling of other regions
of the stomach showed atrophic, follicular, active and micro-erosive
chronic gastritis of severe grade, associated to extensive type I and II
intestinal metaplasia.
Figure 1
Figure 2,3 amd 4
Figure 5,6
Discussion
Hyperplastic polyps are a quite common form of gastric polyps [5].
They develop around gastric remnants, ulcers, or gastroenterostomy
stomas. It is believed that they represent an exuberant regenerative
response of the gastric foveolar cells. Rare polyps are large and
simulate carcinoma. Most hyperplastic polyps arise on a background
of chronic gastritis. Atypia is either absent or minimal and if present
is of regenerative in nature. Neutrophils are especially prominent in
ulcerated areas. Vascular proliferations resembling granulation tissue
develop superficially near areas of inflammation. These reparative
changes may resemble low-grade dysplasia or adenomas.
Hyperplastic polyps rarely progress to gastric carcinomas with an
incidence of no more than 2% [6]. It is generally acknowledged that
hyperplastic polyps do not transform in carcinoma, although they may
occasionally be associated with gastric cancer [7-9]. The appearing
of adenomatous and dysplastic foci, followed by the cancerous
lesion is considered to be related to the size and macroscopic type
of the hyperplastic polyp [10]. Anyways, an association of poorly
differentiated adenocarcinoma or signet ring carcinoma with
hyperplastic polyp is reported, with particular regard to familiar form
[7,8,10-16]. From a review of the literature, only 4 cases of signet ring
carcinoma arising within a gastric hyperplastic polyp were reported
[12,13,15,16]. One of them describes a case of multifocal signet-ring
carcinoma in an inverted hyperplastic polyp [12].
Our case report a poorly cohesive gastric carcinoma with
combined signet ring cells and pleomorphic eosinophilic cells, raised
in a gastric hyperplastic polyp and associated with foci of foveolar
high grade dysplasia in the surface epithelium. The latter was the
only worrying feature observed at the time of endoscopic sampling
of the lesion. Accuracy in endoscopic sampling and histological
examination are critical points to reveal pre-neoplastic changes and
allow do not miss underling invasive carcinoma.
This case emphasizes the importance for endoscopists to obtain
extensive bioptic sampling from gastric polyps, especially if associated
with chronic gastritis, in order to allow an adequate histological
examination. Reactive hyperplasia need to be accurately screened
to rule out foveolar dysplasia. The microscopic evidence of foveolar
dysplasia (type 2 gastritis associated dysplasia) strongly suggests a
close observation of the patient being the finding a precursor lesion
of invasive neoplasia.
Acknowledgement
Dr. G. Capolupo, Dr. G. Masciana , Dr. F. Carannante: Patient
care and management.
Dr. C. Taffon: Image contribution.
Prof. M. Caricato, Dr. A. Crescenzi: Revision and final approval
of the manuscript.
References
- Dekker W. Clinical relevance of gastric and duodenal polyps. Scand J Gastroenterol Suppl. 1990; 178: 7-12.
- WHO Digestive system 2010.
- Ming SC, Goldman H. Gastric Polyps: a Histogenetic Classification and Its Relation to Carcinoma. Cancer. 1965; 18: 721-726.
- Carneiro F, David L, Seruca R, Castedo S, Nesland JM, Sobrinho-Simões M. Hyperplastic polyposis and diffuse carcinoma of the stomach. A study of a family. Cancer. 1993; 15; 72: 323-9.
- Ming SC. Malignant potential of gastric epithelial polyps. Ming SC, ed. In: Precursors of gastric cancer. New York: Praeger Publishers; 1984:210-230.
- Ahn JY, Da Hye Son, Kee Don Choi, Jin Roh, Hyun Lim, Kwi-Sook Choi et al. Neoplasms arising in large gastric hyperplastic polyps: endoscopic and pathologic features. Gastrointest Endosc. 2014; 80: 1005-1013.
- Daibo M, Itabashi M, Hirota T. Malignant transformation of gastric hyperplastic polyps. The American Journal of Gastroenterology 1987; 82: 1016-1025.
- Yamaguchi K, Shiraishi G, Maeda S, Kitamura K. Adenocarcinoma in hyperplastic polyp of the stomach. The American journal of gastroenterology 1990; 85: 327-328.
- Gotoh Y, Fujimoto K, Sakata Y, Fujisaki J, Nakano S. Poorly differentiated adenocarcinoma in a gastric hyperplastic polyp. Southern Medical Journal. 1996; 89: 453-454.
- Hirasaki S, Suzuki S, Kanzaki H, Fujita K, Matsumura S, Matsumoto E. Minute signet ring cell carcinoma occurring in gastric hyperplastic polyp. World J Gastroenterol. 2007; 13: 5779-5780.
- Shibahara K, Haraguchi Y, Sasaki I. A case of gastric hyperplastic polyp with malignant discussion.
- Fry LC, Lazenby AJ, Lee DH, Monkemuller K. Signet-ring-cell adenocarcinoma arising from a hyperplastic polyp in the stomach. Gastrointest Endosc. 2005; 61: 493-495.