Roger
K. Harned,
MD
James
#{149}
L. Buck,
Comdr,
MC,
Inflammatory Fibroid ofthe Gastrointestinal Radiologic Evaluation’ Inflammatory
fibroid
polyps
(IFPs)
I
ogy
literature.
The
authors
reviewed
the cases of 33 patients (20 women and 13 men; average age, 45 years) determine if these polyps had any distinctive tures. The
stomach (n = 13), sions
and
diagnostic IFPs were
were
in the
composed
inflammatory
blood often
radiologic fealocated in the
(n = 16), small and colon (n
originated
cells,
vessels. located
usually
=
bowel 4). The
be-
submucosa
of fibrobbasts, and
a network
Gastric IFPs in the antrum
ulcerated.
to
Most
of
were most and were
of the
pa-
tients presented with clinical evidence of gastrointestinal blood boss. Small bowel polyps were usually bocated in the ileum, and patients were typically older women with intestinal obstruction due to intussusception. Most of the lesions appeared as large, intramural masses at radiobogic examination. Some of the lesions were pedunculated, and all were solitary. There were no distinctive features to differentiate IFPs from other mural or intraluminab intestinal
lesions
of the
gastro-
tract.
Index terms: Colon, neoplasms, 75.311 #{149} Intestines, neoplasms, 74.31 1 #{149}Stomach, neoplasms, 72.311
Kris
#{149}
M. Shekitka,
are
fibroid
histologically
polyps distinctive
(IFPs) le-
sions peculiar to the gastrointestinal (CI) tract. IFPs are nonneoplastic celbular proliferations originating primanily in the submucosa and composed of fibrobbasts, blood vessels, and inflammatory cells within an edematous and coblagenous stroma. They are usually large and nonencapsulated, and may infiltrate through the muscubans propna. Erosions and ulcerations of the polyps are common (1-6). Historically, IFPs have been reported in the literature under a vanety of names, including eosinophilic granuboma, hemangiopericytoma, fibroma, submucosal fibroma, inflammatory pseudotumor, and myxoma (1-3,7-9). The term inflammatory fibroid polyp was first proposed by Hebwig and Ranier in 1953 and is now widely accepted as the most appropriate name for these lesions (4). Only a few case reports of 1FF have appeared in the radiology literature (10,11). Therefore, the purpose of this study was to review a larger series of cases to further familiarize radiologists with these unusual lesions and to determine if the lesions were characterized by any unique, diagnostic radiobogic features.
MATERIALS
AND
METHODS
Two CI radiologists CI pathologist (K.M.S.) Radiology
1992; 182:863-866
From
(R.K.H., J.L.B.) and a reviewed data on 33 cases of lFPs obtained from the files of the radiobogic pathology department at
the Departments of Radiologic Pathology (R.K.H., J.L.B.) and Gastrointestinal Pathology Forces Institute of Pathology, Washington, DC. From the 1989 RSNA scientific assembly. Received June 28, 1991; revision requested July 24; revision received October 2; accepted October 3. Address reprint requests to R.K.H., Department of Radiology, University of Nebraska Medical Center, 600 S 42nd St. Omaha, NE 68198-1045. The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Navy, Department of the Air Force, or Department of Defense. 2 Current address: Department of Anatomic Pathology, Malcolm Grow USAF Medical Center, Andrews Air Force Base, Md. ‘ RSNA, 1992 I
(K.M.S.),
Armed
Lt Col,
MC,
USAF2
Polyps Tract:
jNFLAMMATORY
are uncommon lesions of the gastrointestinal tract. Only scattered case reports have appeared in the radiol-
USNR
the Armed Forces Institute of Pathology. For all patients (20 women and 13 men; mean age, 45 years), medical histories, appropriate CI radiobogic contrast material-enhanced studies, and histologic verification were available. There were descriptions of the gross specimens in 32 cases and photographs of the specimens in 17.
RESULTS All of the IFPs originated in the submucosa and most appeared as large, solitary, sessile masses. The stomach was involved in 16 cases (48%), the small bowel in 13 (39%), and the colon in four (12%). No esophageal cases were documented.
Stomach Ten (62%) of 16 patients (nine men and seven women, aged 23-71 years; mean age, 45 years) presented with clinical evidence of blood loss from the GI tract in the form of anemia with guaiac-positive stools or mebena. The rest (38%) presented with abdominal pain. Upper CI contrast-enhanced radiographic studies showed that the lesions were most commonly located in the antrum (n = 10 [62% 1)’ followed by the gastric body (n = 5 [31%]) and the hindus (,i = 1 [6% 1). Eight (50%) of the IFPs had the classic radiobogic appearance of an intramural mass with smooth, sharply defined margins forming obtuse angles with the adjacent bowel wall. Seven (44%) appeared as intraluminal polyps, of which five (71%) were pedunculated and two (29%) were sessile. The morphobogy of one lesion could not be determined because of poor film quality and the absence of a description of the gross specimen. The lesions were large: 1.5-6.5 cm long. Eight (50%) of the 16 gross specimens were ulcer-
Abbreviations: inflammatory
GI fibroid
=
gastrointestinal, polyp.
IFP
=
863
b.
a.
C.
Figure
1. IFP in a 38-year-old woman presenting with abdominal pain. ing the lesser curvature of the gastric antrum (arrows). (b) Gross specimen the smooth, sharply marginated mural mass seen in a. The intact mucosa ceration is well demonstrated. (c) Histologic section oriented to correspond central ulceration (short arrow) are clearly shown. The remaining mucosa toxylin-eosin stain; original magnification, x2.)
ated, and six ulcerations volving five intramural and one pedunculated were evident on upper enhanced images.
Small
(38%), inlesions (83%) polyp (17%), CI contrast-
Bowel
Six (46%) of 13 patients (10 women and three men, aged 21-84 years; mean age, 58 years) presented with nausea and vomiting accompanied by severe, cramping abdominal pain. Five patients (38%) presented with mild abdominal pain, and two (15%) with only vague abdominal discomfont. Nine lesions (69%) appeared as intussuscepting masses on CI contnast-enhanced radiographic or ultrasound (US) images. Eight (89%) of these intussusceptions involved the ileum and one (11%), the jejunum. It could not be radiologically determined whether the masses were intraluminal or intramural in location. Three other lesions (23%) appeared as nonintussuscepting lesions; two (67%) of these were intramural duodenal masses and one (33%) was an intraluminab sessile polyp of the ileum. In one case, the lesion was too large to permit determination of morphobogy. Examination of the gross specimens, which varied in length from 1.5 to 12.5 cm, showed that 12 (92%) (8%)
noted were
were
sessile
masses
and
one
peduncubated. Ulcers were in two of the specimens but not evident on contrast images.
was
Colon Two (50%) men and one
864
#{149} Radiology
of four woman,
patients aged
(three 24-74
(a) Upper GI radiograph shows an ulcerated intramural mass involvof the IFP. Note the submucosal location (arrows), corresponding to overlies the periphery of the lesion (arrowheads), and the central ulto the gross specimen. The submucosal location (long arrow) and is seen overlying the periphery of the lesion (arrowheads). (Hema-
presented with bloody diarrhea and cramping abdominal pain. One patient had left bower abdominal pain with maroon stools; no medical history was available for the other patient. Colon contrast examinations showed that two (50%) of the lesions were peduncubated: One was sessile and the other appeared as a plaquelike mass. The polyps were 3.6-5.0 cm in length. One polyp (25%) was bocated in the cecum and three (75%), in the transverse colon. One gross specimen showed evidence of ulceration.
years)
Histologic
Findings
The histopathologic features of the IFPs in this study were similar to those previously reported in the literatune (2-4,6,9,12). The basic component cell was the fibroblast in spindle, steblate, or oval form. Inflammatory cells were numerous, with lymphocytes, plasma cells, and eosinophils typically present; mast cells were occasionably found. Blood vessels were prominent and varied from slits to gaping vessels surrounded by concentric rims of collagen. The stroma varied from densely collagenous to loosely textured.
DISCUSSION The exact pathogenesis of an IFP is unknown. It has been postulated that IFPs may represent an exuberant host response to a local injury (3). Some authors suggest that the presence of eosinophilic infiltration indicates an allergic origin and that IFPs are localized variants of eosinophilic gastroen-
Figure 2. IFP in a 53-year-old man who had had anorexia and epigastric distress for the previous 3 months. Contrast-enhanced CT scan of the stomach shows an intraluminal mass with soft-tissue area of low attenuation (arrow) representing an IFP.
tenitis (2,3). Eosinophilic infiltration, however, is not a distinctive histologic feature of IFPs and is common in a vaniety of other CI lesions (2,4,6). In addition, blood eosinophilia and a history of allergy, present in most patients with eosinophibic gastroentenitis, have not been noted in patients with IFPs (2,3,6,13). Therefore, IFPs and eosinophilic gastroentenitis are now accepted as separate entities by most investigators (2-4). Despite the large size and infiltrative growth of many IFPs, the lesions are benign, and malignant change has not been reported (2-5,11,14). Recurrence after operative removal has been documented only once in the literature (15).
March
1992
Figure
3.
IFP in a 78-year-old
woman
presenting
with
diarrhea,
susception of the distal ileum (arrow). (b) Gross specimen of the (c) Histologic section of the pedunculated IFP shows submucosal ation of the mucosa (short arrows) and the residual, nonulcerated magnification, x 2.)
i4
Figure
4.
vomiting,
and
IFP in a 56-year-old
senting with Contrast-enhanced 12.5-cm-long
IFP involving
abdominal
pain.
large, pedunculated ileal location and prominent mucosa at the periphery
increasing smooth
(arrows).
(Reprinted,
14.)
pre-
epigastric pain. radiograph shows a polyp representing
the transverse
reference
man
with
an
duodenum permission,
from
mon location, and most gastric lesions were located in the antrum along the lesser and greater curvatures (Fig 1). Fifty percent of these gastric lesions had radiologic features of mural masses similar to those of other benign and malignant lesions such as duplication cysts, lipomas, leiomyomas, leiomyosarcomas, metastases, and bymphoma. The remainder of the gastric IFPs appeared as either pedunculated or sessile intraluminal masses. This appearance most closely resembles that of lesions of mucosal origin such as adenomas and hyperplastic polyps. The other mural besions mentioned above, however, may have a similar appearance. Ulcers were present in 50% of the gross specimens; 75% of these ulcers were diagnosed at upper GI examination. Computed performed not furnish information
Figure 5. IFP ing with bloody image of colon
in a 28-year-old man presentdiarrhea. Single-contrast shows a barge, smooth mass
(IFP) in the cecum.
We
did
not
diobogic
find
features
polyps
appeared
nation
as solitary,
sions.
Volume
The
182
any for
distinctive an
IFP.
at radiobogic
stomach
#{149} Number
usually was
examilarge
the
3
ra-
All of the
most
becom-
(a) Radiograph
of small
IFP that was the leading edge vascularity (long arrow). Note (arrowhead). (Hematoxylin-eosin
tomography (CT) was in only one case and did any unique diagnostic for IFPs (Fig 2). CT, how-
ever, should be helpful in differentiating IFPs from lesions such as lipomas or duplication cysts. The small bowel was the second most common site for IFPs. Seventyfive percent of small bowel IFPs were located in the ileum (Figs 3, 4), and patients with this type of lesion were generally older and more likely to be female than were patients with gastric lesions. Most patients presented with clinical evidence of small bowel obstruction, which in most cases was due to intussuscepting lesions. As one might expect, intussusception was the
bowel
shows
an intus-
of the intussusception. the extensive ulcerstain; original
most common radiobogic finding at contrast-enhanced examination (Fig 2). It was often difficult to determine from these studies the morphology of the leading mass. Examination of the nesected gross specimens confirmed that almost all the lesions were large polypoid masses. Only one polyp, located in the ileum, had a definite pedicle. Colonic IFPs are very rare. In one reported series of 15 inflammatory fibroid polyps, none were located in the colon (6), and in our study, only four cases involved colonic IFPs. Thus, it is difficult to establish characteristic clinical or radiobogic presentations. The cobonic lesions in our study, however, resembled IFPs involving other segments of the GI tract (Fig 5). Although IFPs have no distinctive radiobogic features, radiologists should not discount them when making a differential diagnosis of large, single, mural on intraluminab lesions of the stomach, small bowel, and cobon. Histologic confirmation will be necessary in almost all cases. Due to the submucosal origin of IFPs, endoscopic biopsy may not always yield adequate tissue for diagnosis. Therefore, surgical resection of the lesion for both diagnosis and treatment will be required in most cases. U
References 1.
2.
3.
4.
Vanek J. Gastric submucosal granuloma with eosinophilic infiltration. Am J Pathol 1949; 25:397-407. Johnstone JM, Morson BC. Inflammatory fibroid polyp of the gastrointestinal tract. Histopathology 1978; 2:349-361. Shimer GR, Helwig EG. Inflammatory fibroid polyps of the intestine. Am J Clin Pathol 1984; 81:708-714. Helwig EB, Ranier A. Inflammatory fibroid polyps of the stomach. Surg Gynecol Obstet 1953; 96:355-367.
Radiology
#{149} 865
5.
6.
7.
Allman RM, Cavanaugh RC, Helwig EB, Lichtenstein JE. Inflammatory fibroid polyp: RPC from the AFIP. Radiology 1978; 127:69-73. Kim Yl, Kim WH. Inflammatory fibroid polyps of gastrointestinal tract: evolution of histologic patterns. Am J Clin Pathol 1988; 89:721-727. Booher RJ, Grant RN. Eosinophilic granu-
loma of the stomach 8.
866
10.
LiVolsi VA, Perzin 1(1-I. Inflammatory pseudotumor (inflammatory fibrous po1yps) of the small intestine: a clinicopathologic study. Am J Dig Dis 1975; 20:325-336. Koch W, Stockmeyer E, Apablaza H. Eosinophilic
11.
and small intestine.
Surgery 1951; 30:388-397. Cohen N, Yesner R, Spiro HM. Inflammatory fibroid polyp (“hemangiopericytoma”) of the stomach. Am J Dig Dis 1959; 4:549555.
#{149} Radiology
9.
12.
granuloma
of the stomach:
M, Tamura
S, Enjoji
M, Sugumachi
K.
Johnstone JM, Morson BC. gastroenteritis. Histopathology 348.
Eosinophilic
1978; 2:335-
14.
Ott DJ, Wu WC, Shiflett DW. Inflammatory fibroid polyp of the duodenum. AmJ Gastroenterol 1980; 73:62-64.
15.
McGreevy
re-
port of a case. AJR 1958; 80:51-56. Schroeder BA, Wells RG, StyJR. Inflammatory fibroid polyp of the stomach in a child. Pediatr Radiol 1987; 17:71-72. Mori
13.
P, Doberneck
RC, McLeay
JM, et
ab. Recurrent eosinophilic infiltrate (granuloma) of the ileum causing intussusception in a two-year-old child. Pediatr Surg 1967; 61:280-284.
Concomitant presence of inflammatory fibroid polyps and carcinoma or adenoma of the stomach. Arch Pathol Lab Med 1988; 112:829-832.
March
1992
K. Harned,
MD
James
#{149}
L. Buck,
Comdr,
MC,
Inflammatory Fibroid ofthe Gastrointestinal Radiologic Evaluation’ Inflammatory
fibroid
polyps
(IFPs)
I
ogy
literature.
The
authors
reviewed
the cases of 33 patients (20 women and 13 men; average age, 45 years) determine if these polyps had any distinctive tures. The
stomach (n = 13), sions
and
diagnostic IFPs were
were
in the
composed
inflammatory
blood often
radiologic fealocated in the
(n = 16), small and colon (n
originated
cells,
vessels. located
usually
=
bowel 4). The
be-
submucosa
of fibrobbasts, and
a network
Gastric IFPs in the antrum
ulcerated.
to
Most
of
were most and were
of the
pa-
tients presented with clinical evidence of gastrointestinal blood boss. Small bowel polyps were usually bocated in the ileum, and patients were typically older women with intestinal obstruction due to intussusception. Most of the lesions appeared as large, intramural masses at radiobogic examination. Some of the lesions were pedunculated, and all were solitary. There were no distinctive features to differentiate IFPs from other mural or intraluminab intestinal
lesions
of the
gastro-
tract.
Index terms: Colon, neoplasms, 75.311 #{149} Intestines, neoplasms, 74.31 1 #{149}Stomach, neoplasms, 72.311
Kris
#{149}
M. Shekitka,
are
fibroid
histologically
polyps distinctive
(IFPs) le-
sions peculiar to the gastrointestinal (CI) tract. IFPs are nonneoplastic celbular proliferations originating primanily in the submucosa and composed of fibrobbasts, blood vessels, and inflammatory cells within an edematous and coblagenous stroma. They are usually large and nonencapsulated, and may infiltrate through the muscubans propna. Erosions and ulcerations of the polyps are common (1-6). Historically, IFPs have been reported in the literature under a vanety of names, including eosinophilic granuboma, hemangiopericytoma, fibroma, submucosal fibroma, inflammatory pseudotumor, and myxoma (1-3,7-9). The term inflammatory fibroid polyp was first proposed by Hebwig and Ranier in 1953 and is now widely accepted as the most appropriate name for these lesions (4). Only a few case reports of 1FF have appeared in the radiology literature (10,11). Therefore, the purpose of this study was to review a larger series of cases to further familiarize radiologists with these unusual lesions and to determine if the lesions were characterized by any unique, diagnostic radiobogic features.
MATERIALS
AND
METHODS
Two CI radiologists CI pathologist (K.M.S.) Radiology
1992; 182:863-866
From
(R.K.H., J.L.B.) and a reviewed data on 33 cases of lFPs obtained from the files of the radiobogic pathology department at
the Departments of Radiologic Pathology (R.K.H., J.L.B.) and Gastrointestinal Pathology Forces Institute of Pathology, Washington, DC. From the 1989 RSNA scientific assembly. Received June 28, 1991; revision requested July 24; revision received October 2; accepted October 3. Address reprint requests to R.K.H., Department of Radiology, University of Nebraska Medical Center, 600 S 42nd St. Omaha, NE 68198-1045. The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Navy, Department of the Air Force, or Department of Defense. 2 Current address: Department of Anatomic Pathology, Malcolm Grow USAF Medical Center, Andrews Air Force Base, Md. ‘ RSNA, 1992 I
(K.M.S.),
Armed
Lt Col,
MC,
USAF2
Polyps Tract:
jNFLAMMATORY
are uncommon lesions of the gastrointestinal tract. Only scattered case reports have appeared in the radiol-
USNR
the Armed Forces Institute of Pathology. For all patients (20 women and 13 men; mean age, 45 years), medical histories, appropriate CI radiobogic contrast material-enhanced studies, and histologic verification were available. There were descriptions of the gross specimens in 32 cases and photographs of the specimens in 17.
RESULTS All of the IFPs originated in the submucosa and most appeared as large, solitary, sessile masses. The stomach was involved in 16 cases (48%), the small bowel in 13 (39%), and the colon in four (12%). No esophageal cases were documented.
Stomach Ten (62%) of 16 patients (nine men and seven women, aged 23-71 years; mean age, 45 years) presented with clinical evidence of blood loss from the GI tract in the form of anemia with guaiac-positive stools or mebena. The rest (38%) presented with abdominal pain. Upper CI contrast-enhanced radiographic studies showed that the lesions were most commonly located in the antrum (n = 10 [62% 1)’ followed by the gastric body (n = 5 [31%]) and the hindus (,i = 1 [6% 1). Eight (50%) of the IFPs had the classic radiobogic appearance of an intramural mass with smooth, sharply defined margins forming obtuse angles with the adjacent bowel wall. Seven (44%) appeared as intraluminal polyps, of which five (71%) were pedunculated and two (29%) were sessile. The morphobogy of one lesion could not be determined because of poor film quality and the absence of a description of the gross specimen. The lesions were large: 1.5-6.5 cm long. Eight (50%) of the 16 gross specimens were ulcer-
Abbreviations: inflammatory
GI fibroid
=
gastrointestinal, polyp.
IFP
=
863
b.
a.
C.
Figure
1. IFP in a 38-year-old woman presenting with abdominal pain. ing the lesser curvature of the gastric antrum (arrows). (b) Gross specimen the smooth, sharply marginated mural mass seen in a. The intact mucosa ceration is well demonstrated. (c) Histologic section oriented to correspond central ulceration (short arrow) are clearly shown. The remaining mucosa toxylin-eosin stain; original magnification, x2.)
ated, and six ulcerations volving five intramural and one pedunculated were evident on upper enhanced images.
Small
(38%), inlesions (83%) polyp (17%), CI contrast-
Bowel
Six (46%) of 13 patients (10 women and three men, aged 21-84 years; mean age, 58 years) presented with nausea and vomiting accompanied by severe, cramping abdominal pain. Five patients (38%) presented with mild abdominal pain, and two (15%) with only vague abdominal discomfont. Nine lesions (69%) appeared as intussuscepting masses on CI contnast-enhanced radiographic or ultrasound (US) images. Eight (89%) of these intussusceptions involved the ileum and one (11%), the jejunum. It could not be radiologically determined whether the masses were intraluminal or intramural in location. Three other lesions (23%) appeared as nonintussuscepting lesions; two (67%) of these were intramural duodenal masses and one (33%) was an intraluminab sessile polyp of the ileum. In one case, the lesion was too large to permit determination of morphobogy. Examination of the gross specimens, which varied in length from 1.5 to 12.5 cm, showed that 12 (92%) (8%)
noted were
were
sessile
masses
and
one
peduncubated. Ulcers were in two of the specimens but not evident on contrast images.
was
Colon Two (50%) men and one
864
#{149} Radiology
of four woman,
patients aged
(three 24-74
(a) Upper GI radiograph shows an ulcerated intramural mass involvof the IFP. Note the submucosal location (arrows), corresponding to overlies the periphery of the lesion (arrowheads), and the central ulto the gross specimen. The submucosal location (long arrow) and is seen overlying the periphery of the lesion (arrowheads). (Hema-
presented with bloody diarrhea and cramping abdominal pain. One patient had left bower abdominal pain with maroon stools; no medical history was available for the other patient. Colon contrast examinations showed that two (50%) of the lesions were peduncubated: One was sessile and the other appeared as a plaquelike mass. The polyps were 3.6-5.0 cm in length. One polyp (25%) was bocated in the cecum and three (75%), in the transverse colon. One gross specimen showed evidence of ulceration.
years)
Histologic
Findings
The histopathologic features of the IFPs in this study were similar to those previously reported in the literatune (2-4,6,9,12). The basic component cell was the fibroblast in spindle, steblate, or oval form. Inflammatory cells were numerous, with lymphocytes, plasma cells, and eosinophils typically present; mast cells were occasionably found. Blood vessels were prominent and varied from slits to gaping vessels surrounded by concentric rims of collagen. The stroma varied from densely collagenous to loosely textured.
DISCUSSION The exact pathogenesis of an IFP is unknown. It has been postulated that IFPs may represent an exuberant host response to a local injury (3). Some authors suggest that the presence of eosinophilic infiltration indicates an allergic origin and that IFPs are localized variants of eosinophilic gastroen-
Figure 2. IFP in a 53-year-old man who had had anorexia and epigastric distress for the previous 3 months. Contrast-enhanced CT scan of the stomach shows an intraluminal mass with soft-tissue area of low attenuation (arrow) representing an IFP.
tenitis (2,3). Eosinophilic infiltration, however, is not a distinctive histologic feature of IFPs and is common in a vaniety of other CI lesions (2,4,6). In addition, blood eosinophilia and a history of allergy, present in most patients with eosinophibic gastroentenitis, have not been noted in patients with IFPs (2,3,6,13). Therefore, IFPs and eosinophilic gastroentenitis are now accepted as separate entities by most investigators (2-4). Despite the large size and infiltrative growth of many IFPs, the lesions are benign, and malignant change has not been reported (2-5,11,14). Recurrence after operative removal has been documented only once in the literature (15).
March
1992
Figure
3.
IFP in a 78-year-old
woman
presenting
with
diarrhea,
susception of the distal ileum (arrow). (b) Gross specimen of the (c) Histologic section of the pedunculated IFP shows submucosal ation of the mucosa (short arrows) and the residual, nonulcerated magnification, x 2.)
i4
Figure
4.
vomiting,
and
IFP in a 56-year-old
senting with Contrast-enhanced 12.5-cm-long
IFP involving
abdominal
pain.
large, pedunculated ileal location and prominent mucosa at the periphery
increasing smooth
(arrows).
(Reprinted,
14.)
pre-
epigastric pain. radiograph shows a polyp representing
the transverse
reference
man
with
an
duodenum permission,
from
mon location, and most gastric lesions were located in the antrum along the lesser and greater curvatures (Fig 1). Fifty percent of these gastric lesions had radiologic features of mural masses similar to those of other benign and malignant lesions such as duplication cysts, lipomas, leiomyomas, leiomyosarcomas, metastases, and bymphoma. The remainder of the gastric IFPs appeared as either pedunculated or sessile intraluminal masses. This appearance most closely resembles that of lesions of mucosal origin such as adenomas and hyperplastic polyps. The other mural besions mentioned above, however, may have a similar appearance. Ulcers were present in 50% of the gross specimens; 75% of these ulcers were diagnosed at upper GI examination. Computed performed not furnish information
Figure 5. IFP ing with bloody image of colon
in a 28-year-old man presentdiarrhea. Single-contrast shows a barge, smooth mass
(IFP) in the cecum.
We
did
not
diobogic
find
features
polyps
appeared
nation
as solitary,
sions.
Volume
The
182
any for
distinctive an
IFP.
at radiobogic
stomach
#{149} Number
usually was
examilarge
the
3
ra-
All of the
most
becom-
(a) Radiograph
of small
IFP that was the leading edge vascularity (long arrow). Note (arrowhead). (Hematoxylin-eosin
tomography (CT) was in only one case and did any unique diagnostic for IFPs (Fig 2). CT, how-
ever, should be helpful in differentiating IFPs from lesions such as lipomas or duplication cysts. The small bowel was the second most common site for IFPs. Seventyfive percent of small bowel IFPs were located in the ileum (Figs 3, 4), and patients with this type of lesion were generally older and more likely to be female than were patients with gastric lesions. Most patients presented with clinical evidence of small bowel obstruction, which in most cases was due to intussuscepting lesions. As one might expect, intussusception was the
bowel
shows
an intus-
of the intussusception. the extensive ulcerstain; original
most common radiobogic finding at contrast-enhanced examination (Fig 2). It was often difficult to determine from these studies the morphology of the leading mass. Examination of the nesected gross specimens confirmed that almost all the lesions were large polypoid masses. Only one polyp, located in the ileum, had a definite pedicle. Colonic IFPs are very rare. In one reported series of 15 inflammatory fibroid polyps, none were located in the colon (6), and in our study, only four cases involved colonic IFPs. Thus, it is difficult to establish characteristic clinical or radiobogic presentations. The cobonic lesions in our study, however, resembled IFPs involving other segments of the GI tract (Fig 5). Although IFPs have no distinctive radiobogic features, radiologists should not discount them when making a differential diagnosis of large, single, mural on intraluminab lesions of the stomach, small bowel, and cobon. Histologic confirmation will be necessary in almost all cases. Due to the submucosal origin of IFPs, endoscopic biopsy may not always yield adequate tissue for diagnosis. Therefore, surgical resection of the lesion for both diagnosis and treatment will be required in most cases. U
References 1.
2.
3.
4.
Vanek J. Gastric submucosal granuloma with eosinophilic infiltration. Am J Pathol 1949; 25:397-407. Johnstone JM, Morson BC. Inflammatory fibroid polyp of the gastrointestinal tract. Histopathology 1978; 2:349-361. Shimer GR, Helwig EG. Inflammatory fibroid polyps of the intestine. Am J Clin Pathol 1984; 81:708-714. Helwig EB, Ranier A. Inflammatory fibroid polyps of the stomach. Surg Gynecol Obstet 1953; 96:355-367.
Radiology
#{149} 865
5.
6.
7.
Allman RM, Cavanaugh RC, Helwig EB, Lichtenstein JE. Inflammatory fibroid polyp: RPC from the AFIP. Radiology 1978; 127:69-73. Kim Yl, Kim WH. Inflammatory fibroid polyps of gastrointestinal tract: evolution of histologic patterns. Am J Clin Pathol 1988; 89:721-727. Booher RJ, Grant RN. Eosinophilic granu-
loma of the stomach 8.
866
10.
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