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Presented by Peter Illei, M.D. and prepared by Zarir E. Karanjawala, M.D., Ph.D.
Case 4: This 56-year-old female had a strong family history of gastric cancer, which prompted a surveillance endoscopy.
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1. Question
Week 318: Case 4
This 56-year-old female had a strong family history of gastric cancer, which prompted a surveillance endoscopy. On endoscopy, the patient was noted to have multiple polyps throughout the stomach, two of which were very large and demonstrated high-grade dysplasia. A total gastrectomy was performed.images/illei071607_4A.jpg
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images/illei071607_4d.jpgCorrect
Answer: Invasive adenocarcinoma arising in a pyloric gland polyp
Histology: The bulk of this 16.0 cm polypoid mass is composed of an adenoma that shows antral-type glandular differentiation with variable degrees of dysplasia. Foci of high grade dysplasia are seen throughout the mass. On gross exam, a firm area was noted in the center of the mass and sections of that area show an invasive adenocarcinoma that is moderately to poorly differentiated and infiltrates into muscularis propria. In addition, metastatic carcinoma was identified in three of the sampled lymph nodes.
Discussion: Pyloric gland adenomas are rare neoplasms that may arise anywhere in the stomach with a predilection for the antrum. A third of the sporadic cases are seen in a background of autoimmune gastritis and helicobacter or chemical gastritis. High grade dysplastic areas usually have the same histologic features as the rest of the polyp and can be seen in almost half of the patients with familial disease, in contrast to sporadic cases where they are less common. Associated adenocarcinoma can be seen in approximately 30% of the cases and be very difficult to diagnose on biopsies since the cancers are usually bland and well differentiated. There seems to be no correlation between the size of the polyp and the presence of invasion.
Incorrect
Answer: Invasive adenocarcinoma arising in a pyloric gland polyp
Histology: The bulk of this 16.0 cm polypoid mass is composed of an adenoma that shows antral-type glandular differentiation with variable degrees of dysplasia. Foci of high grade dysplasia are seen throughout the mass. On gross exam, a firm area was noted in the center of the mass and sections of that area show an invasive adenocarcinoma that is moderately to poorly differentiated and infiltrates into muscularis propria. In addition, metastatic carcinoma was identified in three of the sampled lymph nodes.
Discussion: Pyloric gland adenomas are rare neoplasms that may arise anywhere in the stomach with a predilection for the antrum. A third of the sporadic cases are seen in a background of autoimmune gastritis and helicobacter or chemical gastritis. High grade dysplastic areas usually have the same histologic features as the rest of the polyp and can be seen in almost half of the patients with familial disease, in contrast to sporadic cases where they are less common. Associated adenocarcinoma can be seen in approximately 30% of the cases and be very difficult to diagnose on biopsies since the cancers are usually bland and well differentiated. There seems to be no correlation between the size of the polyp and the presence of invasion.
