Atypical
Appearances
of Benign
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NORMAN
JOFFE’
AND
DONALD
of gastric
1.-A,
Photomicrograph
benign
adenoma
exhibiting
show a loss of basal orientation. Received
November
viliform
often
growth
There is virtual absence
10, 1977; accepted
contains
to 75%
mas and
after revision March Hospital and Harvard
requests to N. Jofte. tDepartment of Pathology,
Beth
Israel
Hospital
131:147-152, July 1978 Roentgen Ray Society
and Harvard
thin
with
pedunculated.
with
elsewhere
(fig.
1A),
an
inde-
in the stomach
they
are
composed
of
muscle
bundles
originating
from
the
an average
of 41%
The Small
majority
so-called
[5].
than They
are single “flat
Typically,
adeno-
2 cm in diameter) may be sessile or and
situated
adenomas”
in the
which
are
raised only slightly above the surrounding mucosa have been described in Japan [5] but are rarely seen elsewhere. Microscopically (fig. 18), adenomas have a papillary
configuration
tenized
by
and
hyperchromasia,
mal nuclear-cytoplasmic scant or absent; muscular
15, 1978. Medical School, Medical
be associated
are relatively large (greaten have an irregular surface.
antrum.
of mucin production.
Israel
may
carcinoma
musculanis mucosae. The adenoma is a true neoplasm and shows a definite tendency to malignant transformation [2-4]; the reported incidence of such malignant transformation varies from
appearance of hyperplastic gastric polyp. basally-oriented nuclei and copious pattern. Epithelial cells are dysplastic. Nuclei
Beth
Am J Roentgenol © 1978 American
Microscopically
3, 5].
small uniform
of Radiology.
Department
[2,
glandular
characteristics:
polyps
coexisting
6%
showing
these
pendent
hyperplastic glands which are often cystic and lined by a single layer of mature mucus cells with abundant cytoplasm and small basally-oriented nuclei. Nuclear atypia and mitotic activity are not seen except in relation to areas of surface inflammation. The stroma shows varying degrees of inflammation and granulation tissue and
Apart from rare syndromes of diffuse gastrointestinal polyposis, epithelial polyps of the stomach may be separated by histologic means into two basic types: hypenplastic on regenerative polyps and adenomas, including adenomatous polyps and villous adenomas [1-5]. Hyperplastic polyps are not true neoplasms; they are believed to result from excessive regeneration of foveolar cells following inflammatory destruction of the gastric mucosa [5]. These nonneoplastic polyps are often multiple [2, 3, 5]. Typically, they are small (less than 1.5 cm in
completely
Polyps
ANTONIOLI2
although
Introduction
Fig.
A.
Gastric
diameter), smooth or mildly lobulated in contour, and sessile, although larger ones may become pedunculated. Malignant transformation virtually never occurs [4, 5].
The vast majority of epithelial polyps of the stomach can be divided into two groups: (1) hyperplastic or regenerative polyps, and (2) adenomas. Of the two, hyperplastic polyps are much more common; they are nonneoplastic lesions which are typically asymptomatic, small, smooth-surfaced, and often muftiple. Malignant transformation virtually never occurs in this group of polyps. Adenomas are true neoplasms; they are relatively large, have an irregular surface, and show a distinct tendency to undergo malignant transformation. In this paper the radiologic appearances of hyperplastic gastric polyps, with special reference to atypical findings, are discussed and illustrated. It is shown that simple hyperplastic polyps may present any or all of the radiologic criteria suggestive of gastric adenomas or even frank malignancy. Thus, while radiology plays a vital role in the initial detection and followup of gastric polyps, optimum clinical management of the patient is best based on knowledge of the histologic structure of the lesion obtained by endoscopy and biopsy.
having
Hyperplastic
School.
147
show
nuclear
atypia
pleomorphism,
ratios. tissue
Mucus is not
charac-
and
abnor-
production present and
is in-
Glands are formed by surface-foveolar type mucous cells apical mucin production. B, Photomicrograph of portion are enlarged. hyperchromatic, slightly pleomorphic, and
(H and E. x250).
330 Brookline Boston,
Avenue.
Massachusetts
Boston,
Massachusetts
02215.
Address
reprint
02215.
0361 -803X/78/0700
-
01 47 $00.00
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148
JOFFE
Fig. 2.-Case showing multiple in body
1.
Upper
small smooth
of stomach.
carcinoma
flammatory
This
lobulated
finding
was shown
ANTONIOLI
Fig. 3.-case 2. Double contrast examination of stomach showing carcinoma involving lesser curve aspect of body (open arrow). Note two small smooth polyps (arrowheads) proximal to carcinoma. Histologic examination
examination
or mildly
incidental
of pancreas
perplastic
gastrointestinal
AND
polyps
in patient
at autopsy
with
to
be
after subtotal tic polyps.
hy-
polyps.
changes
are
not
a prominent
feature.
gastrectomy
showed
these
to be
hyperplas-
Focal
malignant change with stromal invasion is common [5]. Gastric polyps are relatively uncommon. Autopsy studies suggest an incidence of approximately 0.4#{176}/o[5]. although
the
current
widespread
use
of
endoscopy
is
likely to disclose a higher incidence than previously recognized. Of the two major types, the hyperplastic polyp is much more common. In a study of 90 gastric polyps
from
cases).
49
Ming
hyperplastic
patients
and
(34
surgical
Goldman
(regenerative)
found
polyps
and
In a series of 97 cases ically by Tomasulo [3],
of gastric 76#{176}/o were
to
of gastric
Ming
[5].
75%-90%
and 10%-25% adenomas. The vast majority of asymptomatic
and
4)
and
which
with
radiologic
culties
to
in
above
a variety findings
diagnosis
matic
and of the
present
communication.
and
pathologic
findings
logic,
summarized
Hyperplastic In most are
clinical
and
indiscriminately
gastric
polyp
interchangeably. include Thus.
both despite
gastric The
term
are
(figs.
2. 3.
give
rise
or
to diffisympto-
polyps
are
clinical.
gastric
hyperplastic polyps a vast literature on
tic
illustrative
the
to
distinguish
makes
gastric
cases
dence
was
examInation
anemia showing small smooth was performed:
adenoma and small
between
it virtually
and
the
terms
used
is employed
and true adenomas. gastric polyps. failure
to
the
impossIble
malignant of
of stom large irregsessile polyp microscop-
containing lesion was
determined 138 gastric that
sharply
should the
lesion
different
focus hyperplas-
of
histologic
to extract
potential.
malignant
and adenomatous or malignant
polyps
are frequently polyp
contrast
most published series. The major focus of interest their
Polyps studies.
Double
polyp.
shows tremendous by most authors
adenomatous
adenoma
3
cally. large lesIon malignant transformation
radio-
5-10).
Gastric
4-Case
however.
symptoms
The
radiological termed
aid
polyps
These
in nine
1 (figs.
Fig.
ach in patient with pernicious ular pedunculated polyp and (arrow) Subtotal gastrectomy
morphologic
clinical
gastric
I
‘--.
hyperplastic
Occasionally. may
hyperplastic
in table
gross
management.
topic are
.
which
and
atypical
are
features
of
4
histologAccording
.
gastric
the
autopsy
79% were 21#{176}/a adenomas.
polyps
radiologic
described
present
atypical
exhibit
15
that
polyps studied hyperplastic
hyperplastic
correspond
characteristics
they
and
[2]
reliable
in gastric However.
transformation
variation to differentiate
polyps the in
(00o_500/o) between
defined
polyps as
benign
is larger
than
2 cm
less
than
gastric
smooth
to mci-
polyps
the is
benign largely
In a review [7] concluded 2 cm
adenomatous but
relates
due to the failure the hyperplastic
configuration. and Feldman
be regarded
from
reported
types [5. 6]. Radiologically. nature of a mucosal polyps
by its size and polyps. Marshak
types
data
of
in diameter polyps”
in outline
: if and
BENIGN
HYPERPLASTIC
TABLE Summary ca
Age and Sex
lAY
clinical
65. F
Epigastnic
GASTRIC
1 of Cases Radiological
Features
pain.
Multiple polyps
weight
loss
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stomach
2,TA
73.M
Anorexia,
weight
guaiac-positive
3.EK
80.F
Pernicious
anemia.
positive
guaiac-
stools
61.F
Epigastric distress, microcytic
anemia,
positive Heartburn’ lence
5.BS
67.M
. .
6.YD
81.F
Anorexia,
guaiac-
stools
weight
anemia,
flatu-
and
‘
loss.
guaiac-positive
stools 7,MH
72.F
Anemia,
guaiac-positive
stools
associated
86,F
Severe arteriosclerotic heart disease, anemia. melena
9.ML
59,M
Intermittent epigastric pain. nausea and vomiting
. Entire
polyp
was available
Fig.
5.
showing which
-
Case
for histopathologic
4.
6 cm irregular was
tic polyp.
surgically
Upper
gastrointestinal
polypoid resected
examination
in all cases
examination
lesion in body of stomach and
found
to be
hyperplas-
Material
with
sep-
arate 1 cm smooth sessile polyp (fig. 4) 6 cm irregular polypoid lesion in body of stomach (fig. 5) 2.5 cm polyp-arising from short broad-based stalk (fig. 6) 2.5 cm sessile polyp associated with fixed contour defect in body of stomach (fig. 7) 3.5 cm broad-based polypoid lesion with contour defect on lesser curve of antrum: separate 2.5 cm lobulated polyp near greater
8,SZ
polyps
in body of stomach with coexisting separate carcinoma (fig. 3) Large irregular polypoid lesion in body of stomach
4.EL
Pathologic
Findings
small smooth in body of (fig. 2)
Two small smooth
loss. stools
149
POLYPS
curve
by autopsy
Two small hyperplastic separate stomach Large
adenoma
scopic
polyps;
adenocarcinoma
focus
two separate tic polyps
with
micro-
of carcinoma:
small
Hyperplastic
polyp
Hyperplastic
polyp
Hyperplastic
polyp
Hyperplastic
polyp:
hyperplas-
adenoma-
tous polyp
of antrum
(fig.8) Upper gastrointestinal series showed 1 .5 cm prolapsed polyp in duodenal bulb (fig. 9A); repeat examination 18 months later (fig. 9B) revealed 3.5 cm lobulated prolapsed polyp in duodenal bulb Prolapsing 2.5 cm gastric polyp in duodenal bulb (fig. 10) was provided
Findings
small (1 .0-1 .5 cm) hyperplastic gastric polyps: carcinoma of pancreas
Four
in case
1
and surgically
Hyperplastic
polyp
Hyperplastic
polyp
resected
specimens
in cases
2-9
Fig. 6.-Case 5. Double contrast examination of stomach showing 2.5 cm polyp arising from short broad-based stalk. Local surgical wedge resection was performed. and microscopic
examination
revealed
hyperplastic
polyp.
of
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150
JOFFE
AND
ANTONIOLI
Fig. 7.-Case 6. Upper gastrointestinal examination showing 2.5 cm sessile polyp associated with fixed contour
defect
(arrow)
aspect
of body
scopic
biopsy
perplastic
on
polyp.
including
ing,
was
lesion
tion
curve
Because of clinical chronic bleedremoved by surgical
symptoms, wedge
greater
stomach. Endosuggested simple hyof
resection.
confirmed
Histologic biopsy
nign hyperplastic
examina-
findings
of
be-
polyp.
of cases [2, 5]. In Tomasulo’s polyps less than 2 cm in size Since
malignant
to true malignant
[8] evaluated
studies
of
elevated tric
lumen
type
classification
curve aspect
of antrum.
Because
of signifi-
was adenomatous
polyp.
based
to exclude on
the
it is usually
malignancy. size
and
benign
While
but
these
configuration
of
should
conclugastric
polyps are frequently correct, they do not take into account the histologic structure of the lesion. The reason that small smooth polyps are usually benign is that the majority
tic polyps.
of such
These
lesions
are less than
represent
simple
hyperplas-
1 .5 cm in diameter
in 90%
the
general into
lesions
4
=
essentially and 3 to
correspond to sessile polyps,
In a study
“adenomatous
polyps,”
four
“elevated
no base
2
=
notch; but no In de-
American and type 1 lesions
tumors, types 4 to pedunculated lesions,”
in the benign
submucosal were malignant. of which
type
but
conventional
North that
submucosal and type
jority of malignancies occurred groups. All type 1 lesions were cause they represented four of 65 type 4 cases
gas-
elevations.
more
polyps in the it is apparent
of 217
term the
into
boundary;
pedunculated to
of gastric literature
of
of the elevation and the type 1 = elevations with
a clear
scniptions European
polyps. defect,
=
the the
nature compression
with a boundary at the base elevations with a cleanly notched this
near greater
3
without
of on
and
protrusion
elevated
and
cant gastrointestinal bleeding . antrectomy was performed without prior endoscopic biopsy. Histologic examination showed lesion on lesser curve was simple hyperplastic polyp; that near greater
vast
classified
comparing
be removed
used
any
peduncle;
7. Upper gastrointestinal examination showing lesion with associated contour defect on lesser gastric antrum (arrow). Separate lobulated polyp is
a contour
or malignant
They
type
present
sions
and
of 33
restricted
evaluation depends
contrast
describe
polypoid of the
without
stomach. to
8.-Case
3.5 cm
benign
double
baseline
elevations
curve
the
lesion
a smooth
v
curve
the
one
in nature.
to distinguish between In Japan, Yamada and
groups according to the mode macroscopic profile of its base:
n,’.. Fig.
technique types.
by employing
only
is virtually
[2-5], the ultimate of a gastric polyp
ability ofthe diagnostic the two histopathologic polyps
[3],
adenomatous
transformation
adenomas potential
Ichikawa
series was
the
vast
type 2 and (presumably tumors), There
61 were
2 ma-
type
and were
3 be-
only 130
pedunculated
(type 4) and the remainder equally divided between type 2 and type 3 lesions. Because of the very high incidence of gastric
carcinoma
in Japan,
differences
in histopatho-
BENIGN
HYPERPLASTIC
GASTRIC
151
POLYPS
Fig. 9.-Case
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testinal
8. A, Upper
gastroin-
showing 1 .5 cm pedunculated polyp (open arrows) prolapsed into duodenal bulb. B, Repeat examination 18 months later after acute episode of melena showing marked enlargement of polyp which is again prolapsed into duodenal bulb (open arrows). Note site of origin of pedicle from lesser curve aspect of gastric antrum (arrowhead). Because of significant bleeding and marked increase in size of lesion, it was resected via surgical gastrotomy without prior endoscopy . Histologic examination
examination
revealed
hyperplastic
polyp.
Fig. 10.-Case 9. Upper gastrointestinal examination showing transpyloric
prolapse
of gastric
polyp
respon-
sible for symptoms of intermittent gastric outlet obstruction . Removal via surgical gastrotomy revealed hyperplastic polyp.
logic classifications, and lack of details concerning the precise histologic findings in their cases, it is impossible to compare the findings of Yamada and Ichikawa [8] with published reports in the European and North American literature. We feel that radiology can only provide valid information regarding the malignant potential of gastric polyps
arise
if
short
it can
consistently
distinguish
polyps and true neoplastic this is often not possible employed (i.e., conventional Our illustrative cases show tnic
polyps
may
demonstrate
between
adenomas. regardless or double that simple any
or all
hyperplastic
In our experience of the technique contrast studies). hyperplastic gasof the
radiologic
criteria indicative of adenomas or even frank malignancy. In particular, such polyps may be unusually large (figs. 5, 8, 9B), irregular in contour (figs. 5, 8, 9B), and
from
a short
broad-based
may be associated and 8), a radiologic reliable though
evidence the vast an
scopic
examinations,
[10].
tnic
tally
time
Although
(fig.
serial
have
radiologic
they
occur
the term
and While and
endoscopic, or chronic
(fig.
most are
by
adenoma,
hyperplastic
discovered
gastric
or
reported are
on gross
9).
size
gastric
illustrations
alnot
a relatively
unusual been
7
or endo-
over
exhibit
previously
are asymptomatic acute
rarely,
Moreover, polyps do
occasionally
he used polyps.
6);
9].
growth
which
descriptions
at radiographic,
examinations,
may
polyps
hyperplastic polyps
on
significant
growth
histologic
typical
in size
of
gastric
significant his
increase
period
Benign
stalk
a fixed contour defect (figs. generally believed to represent
of malignancy [7, majority of hyperplastic
exhibit
Kniss
with sign
those
of
gasinciden-
pathologic
hemorrhage
sec-
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152
JOFFE
AND
ondary to surface friability and ulceration (cases 4, 6, 7, and 8), or symptoms of gastric outlet obstruction due to transpylonic prolapse (case 9; fig. 10) may occur. In the latter instance, radiologic differentiation from transpyIonic prolapse of polypoid gastric carcinoma may be difficult or impossible [11]. Another unusual manifestation of hyperplastic gastric polyps relates to their occurrence in the gastric remnant following subtotal gastrectomy. Such polyps develop adjacent to the healed gastroentenic anastomosis and may form large conglomerate masses which tend to recur following polypectomy. The entity of recurring, symptomatic hyperplastic gastric polyps following subtotal gastrectomy is discussed in detail in an earlier communication [12]. We have postulated that reflux bile gastnitis might play an etiologic role in initiating the development of such polyps. The frequency with which hyperplastic gastric polyps present atypical clinical or radiological findings is undetermined. From pathologic studies such as that by Ming and Goldman [2], it is apparent that, based on size alone, approximately 10% will demonstrate atypical radiographic features. From our own experience, we estimate that in clinical practice at least 15% (and perhaps as many as 20% in symptomatic patients) might exhibit one or more of the atypical radiologic features. Since hyperplastic polyps comprise 75%-90% of gastric polyps [51, this represents a significant proportion of cases. It should be emphasized, however, that determination of the precise incidence of atypical clinical and/or radiological findings will have to await further correlative studies of large series in which there is a clear-cut separation of the different histopathologic types of gastric polyps. Although the size, configuration, and growth rate of gastric polyps are valuable indicators of their malignant nature or potential, they are not entirely reliable signs. Multiplicity of polyps is even less reliable, since both hyperplastic polyps and adenomas may be single or multiple, and both types may occur simultaneously in the same stomach (figs. 4 and 8). Thus while radiology plays a vital role in the initial detection and follow-up of gastric polyps, optimum clinical management of the patient is best accomplished by knowledge of the histologic structure of the lesion. Symptomatic polyps, such as those associated with significant bleeding or gastric
ANTONIOLI
outlet obstruction, will require removal irrespective of their histologic nature. Asymptomatic hypenplastic polyps may be followed by serial radiologic and/or endoscopic examinations at appropriate intervals. If biopsy reveals adenomatous epithelium transendoscopic or surgical removal of the entire lesion should be undertaken in order to permit adequate histologic examination. Because carcinoma develops randomly in an adenoma, evidence of malignant change may be missed in small or superficial biopsy samples. In patients with cytologic or biopsy evidence of malignancy, and in selected cases with multiple adenomas, partial gastric resection is the treatment of choice. ,
REFERENCES 1 . Morson BC: Gastric polyps composed hum. BrJ Cancer 9 : 550-557, 1959 2. Ming SC, Goldman H: Gastric polyps: fication and its relation to carcinoma.
of intestinal
epithe-
a histogenetic classiCancer 18 : 721-726,
1965 3. Tomasulo relationship 4.
J: Gastric to gastric
polyps:
histologic
carcinoma.
Cancer
types and their 27 : 1346-1355,
1971 Ming SC: The adenoma-carcinoma sequence in the stomach and colon. II. Malignant potential of gastric polyps.
Gastrointest 5. Ming SC:
polyps, Morson
Radiol 1 : 121-125, The classification in The Gastrointestinal
BC, Abell MR, Baltimore,
1976 and significance of gastric Tract, edited by Yardley JH,
Williams
& Wilkins,
1977,
pp 149-175 6. Bone GE, McClelland RN: Management of gastric polyps. Surg Gynecol Obstet 142 : 933-938, 1976 7. Manshak RH, Feldman F: Gastric polyps. Am J Dig Dis 10 : 909-935, 1965 8. Yamada T, Ichikawa H: X-ray diagnosis of elevated lesions of the stomach. Radiology 1 10 : 79-83, 1974 9. Marshak RH, Lindner AE: Polypoid lesions of the stomach. Semin Roentgenol 6 : 151-167, 1971 10. Kriss N: Some unusual features of gastric adenomas. Am J Dig Dis 15 : 103-110, 1970 1 1 . Joffe N, Goldman H, Antonioli DA: Transpyloric prolapse of polypoid gastric carcinoma. Gastroenterology 72 : 1326-
1330, 1977 12.
Joffe N, Goldman H, Antonioli gastric polyps following subtotal genol 130 : 301-305. 1978
DA: Recurring gastrectomy.
hyperplastic Am J Roent-
Appearances
of Benign
Downloaded from www.ajronline.org by 61.231.15.35 on 10/17/15 from IP address 61.231.15.35. Copyright ARRS. For personal use only; all rights reserved
NORMAN
JOFFE’
AND
DONALD
of gastric
1.-A,
Photomicrograph
benign
adenoma
exhibiting
show a loss of basal orientation. Received
November
viliform
often
growth
There is virtual absence
10, 1977; accepted
contains
to 75%
mas and
after revision March Hospital and Harvard
requests to N. Jofte. tDepartment of Pathology,
Beth
Israel
Hospital
131:147-152, July 1978 Roentgen Ray Society
and Harvard
thin
with
pedunculated.
with
elsewhere
(fig.
1A),
an
inde-
in the stomach
they
are
composed
of
muscle
bundles
originating
from
the
an average
of 41%
The Small
majority
so-called
[5].
than They
are single “flat
Typically,
adeno-
2 cm in diameter) may be sessile or and
situated
adenomas”
in the
which
are
raised only slightly above the surrounding mucosa have been described in Japan [5] but are rarely seen elsewhere. Microscopically (fig. 18), adenomas have a papillary
configuration
tenized
by
and
hyperchromasia,
mal nuclear-cytoplasmic scant or absent; muscular
15, 1978. Medical School, Medical
be associated
are relatively large (greaten have an irregular surface.
antrum.
of mucin production.
Israel
may
carcinoma
musculanis mucosae. The adenoma is a true neoplasm and shows a definite tendency to malignant transformation [2-4]; the reported incidence of such malignant transformation varies from
appearance of hyperplastic gastric polyp. basally-oriented nuclei and copious pattern. Epithelial cells are dysplastic. Nuclei
Beth
Am J Roentgenol © 1978 American
Microscopically
3, 5].
small uniform
of Radiology.
Department
[2,
glandular
characteristics:
polyps
coexisting
6%
showing
these
pendent
hyperplastic glands which are often cystic and lined by a single layer of mature mucus cells with abundant cytoplasm and small basally-oriented nuclei. Nuclear atypia and mitotic activity are not seen except in relation to areas of surface inflammation. The stroma shows varying degrees of inflammation and granulation tissue and
Apart from rare syndromes of diffuse gastrointestinal polyposis, epithelial polyps of the stomach may be separated by histologic means into two basic types: hypenplastic on regenerative polyps and adenomas, including adenomatous polyps and villous adenomas [1-5]. Hyperplastic polyps are not true neoplasms; they are believed to result from excessive regeneration of foveolar cells following inflammatory destruction of the gastric mucosa [5]. These nonneoplastic polyps are often multiple [2, 3, 5]. Typically, they are small (less than 1.5 cm in
completely
Polyps
ANTONIOLI2
although
Introduction
Fig.
A.
Gastric
diameter), smooth or mildly lobulated in contour, and sessile, although larger ones may become pedunculated. Malignant transformation virtually never occurs [4, 5].
The vast majority of epithelial polyps of the stomach can be divided into two groups: (1) hyperplastic or regenerative polyps, and (2) adenomas. Of the two, hyperplastic polyps are much more common; they are nonneoplastic lesions which are typically asymptomatic, small, smooth-surfaced, and often muftiple. Malignant transformation virtually never occurs in this group of polyps. Adenomas are true neoplasms; they are relatively large, have an irregular surface, and show a distinct tendency to undergo malignant transformation. In this paper the radiologic appearances of hyperplastic gastric polyps, with special reference to atypical findings, are discussed and illustrated. It is shown that simple hyperplastic polyps may present any or all of the radiologic criteria suggestive of gastric adenomas or even frank malignancy. Thus, while radiology plays a vital role in the initial detection and followup of gastric polyps, optimum clinical management of the patient is best based on knowledge of the histologic structure of the lesion obtained by endoscopy and biopsy.
having
Hyperplastic
School.
147
show
nuclear
atypia
pleomorphism,
ratios. tissue
Mucus is not
charac-
and
abnor-
production present and
is in-
Glands are formed by surface-foveolar type mucous cells apical mucin production. B, Photomicrograph of portion are enlarged. hyperchromatic, slightly pleomorphic, and
(H and E. x250).
330 Brookline Boston,
Avenue.
Massachusetts
Boston,
Massachusetts
02215.
Address
reprint
02215.
0361 -803X/78/0700
-
01 47 $00.00
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148
JOFFE
Fig. 2.-Case showing multiple in body
1.
Upper
small smooth
of stomach.
carcinoma
flammatory
This
lobulated
finding
was shown
ANTONIOLI
Fig. 3.-case 2. Double contrast examination of stomach showing carcinoma involving lesser curve aspect of body (open arrow). Note two small smooth polyps (arrowheads) proximal to carcinoma. Histologic examination
examination
or mildly
incidental
of pancreas
perplastic
gastrointestinal
AND
polyps
in patient
at autopsy
with
to
be
after subtotal tic polyps.
hy-
polyps.
changes
are
not
a prominent
feature.
gastrectomy
showed
these
to be
hyperplas-
Focal
malignant change with stromal invasion is common [5]. Gastric polyps are relatively uncommon. Autopsy studies suggest an incidence of approximately 0.4#{176}/o[5]. although
the
current
widespread
use
of
endoscopy
is
likely to disclose a higher incidence than previously recognized. Of the two major types, the hyperplastic polyp is much more common. In a study of 90 gastric polyps
from
cases).
49
Ming
hyperplastic
patients
and
(34
surgical
Goldman
(regenerative)
found
polyps
and
In a series of 97 cases ically by Tomasulo [3],
of gastric 76#{176}/o were
to
of gastric
Ming
[5].
75%-90%
and 10%-25% adenomas. The vast majority of asymptomatic
and
4)
and
which
with
radiologic
culties
to
in
above
a variety findings
diagnosis
matic
and of the
present
communication.
and
pathologic
findings
logic,
summarized
Hyperplastic In most are
clinical
and
indiscriminately
gastric
polyp
interchangeably. include Thus.
both despite
gastric The
term
are
(figs.
2. 3.
give
rise
or
to diffisympto-
polyps
are
clinical.
gastric
hyperplastic polyps a vast literature on
tic
illustrative
the
to
distinguish
makes
gastric
cases
dence
was
examInation
anemia showing small smooth was performed:
adenoma and small
between
it virtually
and
the
terms
used
is employed
and true adenomas. gastric polyps. failure
to
the
impossIble
malignant of
of stom large irregsessile polyp microscop-
containing lesion was
determined 138 gastric that
sharply
should the
lesion
different
focus hyperplas-
of
histologic
to extract
potential.
malignant
and adenomatous or malignant
polyps
are frequently polyp
contrast
most published series. The major focus of interest their
Polyps studies.
Double
polyp.
shows tremendous by most authors
adenomatous
adenoma
3
cally. large lesIon malignant transformation
radio-
5-10).
Gastric
4-Case
however.
symptoms
The
radiological termed
aid
polyps
These
in nine
1 (figs.
Fig.
ach in patient with pernicious ular pedunculated polyp and (arrow) Subtotal gastrectomy
morphologic
clinical
gastric
I
‘--.
hyperplastic
Occasionally. may
hyperplastic
in table
gross
management.
topic are
.
which
and
atypical
are
features
of
4
histologAccording
.
gastric
the
autopsy
79% were 21#{176}/a adenomas.
polyps
radiologic
described
present
atypical
exhibit
15
that
polyps studied hyperplastic
hyperplastic
correspond
characteristics
they
and
[2]
reliable
in gastric However.
transformation
variation to differentiate
polyps the in
(00o_500/o) between
defined
polyps as
benign
is larger
than
2 cm
less
than
gastric
smooth
to mci-
polyps
the is
benign largely
In a review [7] concluded 2 cm
adenomatous but
relates
due to the failure the hyperplastic
configuration. and Feldman
be regarded
from
reported
types [5. 6]. Radiologically. nature of a mucosal polyps
by its size and polyps. Marshak
types
data
of
in diameter polyps”
in outline
: if and
BENIGN
HYPERPLASTIC
TABLE Summary ca
Age and Sex
lAY
clinical
65. F
Epigastnic
GASTRIC
1 of Cases Radiological
Features
pain.
Multiple polyps
weight
loss
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stomach
2,TA
73.M
Anorexia,
weight
guaiac-positive
3.EK
80.F
Pernicious
anemia.
positive
guaiac-
stools
61.F
Epigastric distress, microcytic
anemia,
positive Heartburn’ lence
5.BS
67.M
. .
6.YD
81.F
Anorexia,
guaiac-
stools
weight
anemia,
flatu-
and
‘
loss.
guaiac-positive
stools 7,MH
72.F
Anemia,
guaiac-positive
stools
associated
86,F
Severe arteriosclerotic heart disease, anemia. melena
9.ML
59,M
Intermittent epigastric pain. nausea and vomiting
. Entire
polyp
was available
Fig.
5.
showing which
-
Case
for histopathologic
4.
6 cm irregular was
tic polyp.
surgically
Upper
gastrointestinal
polypoid resected
examination
in all cases
examination
lesion in body of stomach and
found
to be
hyperplas-
Material
with
sep-
arate 1 cm smooth sessile polyp (fig. 4) 6 cm irregular polypoid lesion in body of stomach (fig. 5) 2.5 cm polyp-arising from short broad-based stalk (fig. 6) 2.5 cm sessile polyp associated with fixed contour defect in body of stomach (fig. 7) 3.5 cm broad-based polypoid lesion with contour defect on lesser curve of antrum: separate 2.5 cm lobulated polyp near greater
8,SZ
polyps
in body of stomach with coexisting separate carcinoma (fig. 3) Large irregular polypoid lesion in body of stomach
4.EL
Pathologic
Findings
small smooth in body of (fig. 2)
Two small smooth
loss. stools
149
POLYPS
curve
by autopsy
Two small hyperplastic separate stomach Large
adenoma
scopic
polyps;
adenocarcinoma
focus
two separate tic polyps
with
micro-
of carcinoma:
small
Hyperplastic
polyp
Hyperplastic
polyp
Hyperplastic
polyp
Hyperplastic
polyp:
hyperplas-
adenoma-
tous polyp
of antrum
(fig.8) Upper gastrointestinal series showed 1 .5 cm prolapsed polyp in duodenal bulb (fig. 9A); repeat examination 18 months later (fig. 9B) revealed 3.5 cm lobulated prolapsed polyp in duodenal bulb Prolapsing 2.5 cm gastric polyp in duodenal bulb (fig. 10) was provided
Findings
small (1 .0-1 .5 cm) hyperplastic gastric polyps: carcinoma of pancreas
Four
in case
1
and surgically
Hyperplastic
polyp
Hyperplastic
polyp
resected
specimens
in cases
2-9
Fig. 6.-Case 5. Double contrast examination of stomach showing 2.5 cm polyp arising from short broad-based stalk. Local surgical wedge resection was performed. and microscopic
examination
revealed
hyperplastic
polyp.
of
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150
JOFFE
AND
ANTONIOLI
Fig. 7.-Case 6. Upper gastrointestinal examination showing 2.5 cm sessile polyp associated with fixed contour
defect
(arrow)
aspect
of body
scopic
biopsy
perplastic
on
polyp.
including
ing,
was
lesion
tion
curve
Because of clinical chronic bleedremoved by surgical
symptoms, wedge
greater
stomach. Endosuggested simple hyof
resection.
confirmed
Histologic biopsy
nign hyperplastic
examina-
findings
of
be-
polyp.
of cases [2, 5]. In Tomasulo’s polyps less than 2 cm in size Since
malignant
to true malignant
[8] evaluated
studies
of
elevated tric
lumen
type
classification
curve aspect
of antrum.
Because
of signifi-
was adenomatous
polyp.
based
to exclude on
the
it is usually
malignancy. size
and
benign
While
but
these
configuration
of
should
conclugastric
polyps are frequently correct, they do not take into account the histologic structure of the lesion. The reason that small smooth polyps are usually benign is that the majority
tic polyps.
of such
These
lesions
are less than
represent
simple
hyperplas-
1 .5 cm in diameter
in 90%
the
general into
lesions
4
=
essentially and 3 to
correspond to sessile polyps,
In a study
“adenomatous
polyps,”
four
“elevated
no base
2
=
notch; but no In de-
American and type 1 lesions
tumors, types 4 to pedunculated lesions,”
in the benign
submucosal were malignant. of which
type
but
conventional
North that
submucosal and type
jority of malignancies occurred groups. All type 1 lesions were cause they represented four of 65 type 4 cases
gas-
elevations.
more
polyps in the it is apparent
of 217
term the
into
boundary;
pedunculated to
of gastric literature
of
of the elevation and the type 1 = elevations with
a clear
scniptions European
polyps. defect,
=
the the
nature compression
with a boundary at the base elevations with a cleanly notched this
near greater
3
without
of on
and
protrusion
elevated
and
cant gastrointestinal bleeding . antrectomy was performed without prior endoscopic biopsy. Histologic examination showed lesion on lesser curve was simple hyperplastic polyp; that near greater
vast
classified
comparing
be removed
used
any
peduncle;
7. Upper gastrointestinal examination showing lesion with associated contour defect on lesser gastric antrum (arrow). Separate lobulated polyp is
a contour
or malignant
They
type
present
sions
and
of 33
restricted
evaluation depends
contrast
describe
polypoid of the
without
stomach. to
8.-Case
3.5 cm
benign
double
baseline
elevations
curve
the
lesion
a smooth
v
curve
the
one
in nature.
to distinguish between In Japan, Yamada and
groups according to the mode macroscopic profile of its base:
n,’.. Fig.
technique types.
by employing
only
is virtually
[2-5], the ultimate of a gastric polyp
ability ofthe diagnostic the two histopathologic polyps
[3],
adenomatous
transformation
adenomas potential
Ichikawa
series was
the
vast
type 2 and (presumably tumors), There
61 were
2 ma-
type
and were
3 be-
only 130
pedunculated
(type 4) and the remainder equally divided between type 2 and type 3 lesions. Because of the very high incidence of gastric
carcinoma
in Japan,
differences
in histopatho-
BENIGN
HYPERPLASTIC
GASTRIC
151
POLYPS
Fig. 9.-Case
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testinal
8. A, Upper
gastroin-
showing 1 .5 cm pedunculated polyp (open arrows) prolapsed into duodenal bulb. B, Repeat examination 18 months later after acute episode of melena showing marked enlargement of polyp which is again prolapsed into duodenal bulb (open arrows). Note site of origin of pedicle from lesser curve aspect of gastric antrum (arrowhead). Because of significant bleeding and marked increase in size of lesion, it was resected via surgical gastrotomy without prior endoscopy . Histologic examination
examination
revealed
hyperplastic
polyp.
Fig. 10.-Case 9. Upper gastrointestinal examination showing transpyloric
prolapse
of gastric
polyp
respon-
sible for symptoms of intermittent gastric outlet obstruction . Removal via surgical gastrotomy revealed hyperplastic polyp.
logic classifications, and lack of details concerning the precise histologic findings in their cases, it is impossible to compare the findings of Yamada and Ichikawa [8] with published reports in the European and North American literature. We feel that radiology can only provide valid information regarding the malignant potential of gastric polyps
arise
if
short
it can
consistently
distinguish
polyps and true neoplastic this is often not possible employed (i.e., conventional Our illustrative cases show tnic
polyps
may
demonstrate
between
adenomas. regardless or double that simple any
or all
hyperplastic
In our experience of the technique contrast studies). hyperplastic gasof the
radiologic
criteria indicative of adenomas or even frank malignancy. In particular, such polyps may be unusually large (figs. 5, 8, 9B), irregular in contour (figs. 5, 8, 9B), and
from
a short
broad-based
may be associated and 8), a radiologic reliable though
evidence the vast an
scopic
examinations,
[10].
tnic
tally
time
Although
(fig.
serial
have
radiologic
they
occur
the term
and While and
endoscopic, or chronic
(fig.
most are
by
adenoma,
hyperplastic
discovered
gastric
or
reported are
on gross
9).
size
gastric
illustrations
alnot
a relatively
unusual been
7
or endo-
over
exhibit
previously
are asymptomatic acute
rarely,
Moreover, polyps do
occasionally
he used polyps.
6);
9].
growth
which
descriptions
at radiographic,
examinations,
may
polyps
hyperplastic polyps
on
significant
growth
histologic
typical
in size
of
gastric
significant his
increase
period
Benign
stalk
a fixed contour defect (figs. generally believed to represent
of malignancy [7, majority of hyperplastic
exhibit
Kniss
with sign
those
of
gasinciden-
pathologic
hemorrhage
sec-
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152
JOFFE
AND
ondary to surface friability and ulceration (cases 4, 6, 7, and 8), or symptoms of gastric outlet obstruction due to transpylonic prolapse (case 9; fig. 10) may occur. In the latter instance, radiologic differentiation from transpyIonic prolapse of polypoid gastric carcinoma may be difficult or impossible [11]. Another unusual manifestation of hyperplastic gastric polyps relates to their occurrence in the gastric remnant following subtotal gastrectomy. Such polyps develop adjacent to the healed gastroentenic anastomosis and may form large conglomerate masses which tend to recur following polypectomy. The entity of recurring, symptomatic hyperplastic gastric polyps following subtotal gastrectomy is discussed in detail in an earlier communication [12]. We have postulated that reflux bile gastnitis might play an etiologic role in initiating the development of such polyps. The frequency with which hyperplastic gastric polyps present atypical clinical or radiological findings is undetermined. From pathologic studies such as that by Ming and Goldman [2], it is apparent that, based on size alone, approximately 10% will demonstrate atypical radiographic features. From our own experience, we estimate that in clinical practice at least 15% (and perhaps as many as 20% in symptomatic patients) might exhibit one or more of the atypical radiologic features. Since hyperplastic polyps comprise 75%-90% of gastric polyps [51, this represents a significant proportion of cases. It should be emphasized, however, that determination of the precise incidence of atypical clinical and/or radiological findings will have to await further correlative studies of large series in which there is a clear-cut separation of the different histopathologic types of gastric polyps. Although the size, configuration, and growth rate of gastric polyps are valuable indicators of their malignant nature or potential, they are not entirely reliable signs. Multiplicity of polyps is even less reliable, since both hyperplastic polyps and adenomas may be single or multiple, and both types may occur simultaneously in the same stomach (figs. 4 and 8). Thus while radiology plays a vital role in the initial detection and follow-up of gastric polyps, optimum clinical management of the patient is best accomplished by knowledge of the histologic structure of the lesion. Symptomatic polyps, such as those associated with significant bleeding or gastric
ANTONIOLI
outlet obstruction, will require removal irrespective of their histologic nature. Asymptomatic hypenplastic polyps may be followed by serial radiologic and/or endoscopic examinations at appropriate intervals. If biopsy reveals adenomatous epithelium transendoscopic or surgical removal of the entire lesion should be undertaken in order to permit adequate histologic examination. Because carcinoma develops randomly in an adenoma, evidence of malignant change may be missed in small or superficial biopsy samples. In patients with cytologic or biopsy evidence of malignancy, and in selected cases with multiple adenomas, partial gastric resection is the treatment of choice. ,
REFERENCES 1 . Morson BC: Gastric polyps composed hum. BrJ Cancer 9 : 550-557, 1959 2. Ming SC, Goldman H: Gastric polyps: fication and its relation to carcinoma.
of intestinal
epithe-
a histogenetic classiCancer 18 : 721-726,
1965 3. Tomasulo relationship 4.
J: Gastric to gastric
polyps:
histologic
carcinoma.
Cancer
types and their 27 : 1346-1355,
1971 Ming SC: The adenoma-carcinoma sequence in the stomach and colon. II. Malignant potential of gastric polyps.
Gastrointest 5. Ming SC:
polyps, Morson
Radiol 1 : 121-125, The classification in The Gastrointestinal
BC, Abell MR, Baltimore,
1976 and significance of gastric Tract, edited by Yardley JH,
Williams
& Wilkins,
1977,
pp 149-175 6. Bone GE, McClelland RN: Management of gastric polyps. Surg Gynecol Obstet 142 : 933-938, 1976 7. Manshak RH, Feldman F: Gastric polyps. Am J Dig Dis 10 : 909-935, 1965 8. Yamada T, Ichikawa H: X-ray diagnosis of elevated lesions of the stomach. Radiology 1 10 : 79-83, 1974 9. Marshak RH, Lindner AE: Polypoid lesions of the stomach. Semin Roentgenol 6 : 151-167, 1971 10. Kriss N: Some unusual features of gastric adenomas. Am J Dig Dis 15 : 103-110, 1970 1 1 . Joffe N, Goldman H, Antonioli DA: Transpyloric prolapse of polypoid gastric carcinoma. Gastroenterology 72 : 1326-
1330, 1977 12.
Joffe N, Goldman H, Antonioli gastric polyps following subtotal genol 130 : 301-305. 1978
DA: Recurring gastrectomy.
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