Inflammatory fibroid polyps harbour mutations in the platelet-derived growth factor receptor alpha (PDGFRA) gene

Inflammatory Fibroid Polyp (Vanek's Tumor): A Retrospective Multicentric Analysis of 67 Cases

OBJECTIVES

Inflammatory fibroid polyps, also known as Vanek's tumors, are rare benign lesions of the gastrointestinal tract. Although the exact cause remains unclear, several theories suggest an association with inflammatory processes and genetic factors. This study aims to present the largest cohort of inflammatory fibroid polyp cases to date, analyzing their clinical presentation, diagnostic methods, and treatment approaches.

MATERIALS AND METHODS

A retrospective multicentric analysis was conducted on 67 patients diagnosed with inflammatory fibroid polyps between 2013 and 2023 across four hospitals. Clinical data regarding tumor location, size, symptoms, and treatment were collected. Non-parametric statistical tests, including the chi-square test, Cramér's V coefficient, and the Mann-Whitney U test, were used to identify association between tumor characteristics, location, and treatment outcomes.

RESULTS

The cohort included 67 patients (58.2% female, median age 60 years). The stomach was the most common tumor site (47.8%), followed by the colon (32.8%), and small intestine (10.4%). The majority of patients (73.1%) were asymptomatic, while 9% experienced intestinal obstruction, all of which were located in the small intestine. Endoscopic resection was successful in 77.6% of cases, but surgical intervention was more frequently required for tumors in the small intestine. A significant association was found between larger tumor size, emergency presentation, intestinal location, and the need for surgery.

CONCLUSIONS

Inflammatory fibroid polyps are commonly managed with endoscopic resection, particularly in gastric and colonic locations. However, small intestinal tumors more often need surgical treatment, especially when presenting with complications like intestinal obstruction.

Invasive inflammatory fibroid polyp of the stomach: A case report and literature review

RATIONALE

Inflammatory fibrous polyp (IFP) is a distinct fibroblastic neoplasm with a predilection for the stomach and ileum. It usually presents prominent inflammatory infiltration, particularly eosinophils, and has been widely considered benign tumors without malignant biological behaviors. However, rare invasive cases have been reported.

PATIENT CONCERNS

A 75-year-old woman presented with unexplained hematemesis, dizziness, and weakness for 3 hours. Physical examination revealed upper abdominal tenderness on palpation.

DIAGNOSES

Contrast-enhanced computed tomography revealed a 6 cm nodule with a high-density shadow and ring enhancement with well-defined borders in the gastric body. Gastroscopy showed multiple gastric polyps as well as a gastric submucosal mass with surface ulceration and mucosal disruption. Emergency laboratory results revealed anemia symptoms with an erythrocyte count of 2.63 × 1012/L and a hemoglobin level of 58.00 g/L. A laparoscopic distal gastrectomy was performed. The pathological results support the diagnosis of invasive IFP, and the tumor cells were infiltrated into gastric's serosa layer.

INTERVENTIONS

The patient underwent laparoscopic distal gastrectomy resection. In addition, the patient received blood transfusion therapy for severe anemia, including Leukocyte privative red blood cell and Fresh frozen plasma.

OUTCOMES

The patient was discharged home 2 weeks after surgery. There was no evidence of recurrence within the 4 years of surgery.

LESSONS

Except the common gastrointestinal stromal tumor and leiomyoma, IFP should also be considered by pathologists in the diagnosis of primary gastric non-epithelial tumor. Our case also emphasizes the invasive nature of IFP, a rare non benign biological feature (only 5 cases have been reported previously). Although it is very rare, it represents the potential development of the tumor, and should be paid attention to by pathologists and physicians. Otherwise, we report this case because of the first case of an IFP presenting with both gastritis cystica polyposa and inverted hyperplastic poly.

A large gastric inflammatory fibroid polyp revealed by an upper gastrointestinal bleeding: a case report

Inflammatory fibroid polyps (IFPs) are rare submucosal lesions that usually arise in the stomach. It represents 0.1% of all gastric polypoid lesions and are frequently asymptomatic. It's usually revealed by an abdominal pain. Gastrointestinal bleeding can occur when the polyp is ulcerated. We report a case of a 72-year-old female with an IFP of the prepyloric region. The head of the polyp was thirty-five millimeters in diameter. It was revealed by an upper gastrointestinal bleeding and epigastric pain. An endoscopic resection was performed.

Inflammatory polyp of the ileum causing small bowel intussusception: A case report

Adult intussusception is rare, and an underlying benign or malignant aetiology is often found. Inflammatory fibroid polyp, a benign neoplastic polyp that can arise anywhere in the gastrointestinal tract is a rare cause of intussusception of the small bowel. Clinical presentation differs depending on the location of the lesion in the gastrointestinal tract. Diagnosis may be confirmed on a computed tomography scan or ultrasound. Definite diagnosis is based on histopathology and immunocytochemistry. We present the case of a 58-year-old lady with an inflammatory fibroid polyp who presented with microcytic anaemia and chronic abdominal pain due to recurrent intussusception.

Non-gastrointestinal stromal tumor, mesenchymal neoplasms of the gastrointestinal tract: a review of tumor genetics, pathology, and cross-sectional imaging findings

There is a diverse group of non-gastrointestinal stromal tumor (GIST), mesenchymal neoplasms of the gastrointestinal (GI) tract that demonstrate characteristic pathology and histogenesis as well as variable imaging findings and biological behavior. Recent advancements in tumor genetics have unveiled specific abnormalities associated with certain tumors, influencing their molecular pathogenesis, biology, response to treatment, and prognosis. Notably, giant fibrovascular polyps of the esophagus, identified through MDM2 gene amplifications, are now classified as liposarcomas. Some tumors exhibit distinctive patterns of disease distribution. Glomus tumors and plexiform fibromyxomas exhibit a pronounced affinity for the gastric antrum. In contrast, smooth muscle tumors within the GI tract are predominantly found in the esophagus and colorectum, surpassing the incidence of GISTs in these locations. Surgical resection suffices for symptomatic benign tumors; multimodality treatment may be necessary for frank sarcomas. This article aims to elucidate the cross-sectional imaging findings associated with a wide spectrum of these tumors, providing insights that align with their histopathological features.

Endoscopic submucosal dissection for the treatment of a large inflammatory fibroid polyp in the gastric antrum prolapsing into the duodenum: A case report

RATIONALE

Inflammatory fibroid polyp (IFP), also known as Vanek tumor, is a rare, benign gastrointestinal lesion characterized by its inflammatory and fibroid histological features. IFP is often discovered incidentally during endoscopic examinations. It is exceedingly rare for an IFP to prolapse into the duodenum and results in incomplete obstruction of the pylorus.

PATIENT CONCERNS

A 64-year-old male patient was admitted to the hospital with recurrent episodes of melena over a 6-month period, along with complaints of dizziness and fatigue in the past 10 days.

DIAGNOSES

Gastroscopy showed a giant polypoid mass on the posterior wall of the gastric antrum, prolapsing into the duodenum. Abdominal computer tomography (CT) confirmed the tumor protruding into the duodenum. Pathologic examination of the resected specimen confirmed the IFP diagnosis.

INTERVENTIONS

The giant tumor was completely and successfully excised using endoscopic submucosal dissection (ESD). After the surgery, the patient underwent acid suppression and fluid replenishment therapy.

OUTCOMES

The patient responded well to ESD and was discharged in stable condition. As of the submission of the case report, there has been no recurrence of the tumor after a 5-month follow-up, and the patient is still under follow-up.

LESSONS

While IFPs have traditionally been managed surgically, ESD demonstrates promising treatment outcomes, avoiding the need for surgical distal gastrectomy, and emerges as a safe and effective treatment option.

Vanek's Tumour as a Rare Cause of Dyspeptic Syndrome in a Patient with Primary Biliary Cholangitis: A Case Report

BACKGROUND

Inflammatory Fibroid Polyp (IFP), also known as Vanek's tumour, is a rare mesenchymal gastrointestinal tumour, potentially causing a wide range of clinical manifestations (even though it can be completely asymptomatic) primarily related to the location of the formation. The available evidence suggests a fundamentally non-neoplastic behaviour of IFP.

CASE PRESENTATION

A 67-year-old female was presented with persistent dyspepsia despite symptomatic therapy. The patient's medical history included primary biliary cholangitis, managed with ursodeoxycholic acid, non-haemorrhagic uterine fibroids, and right knee arthrosis. Clinical examination revealed mild epigastric tenderness, and esophagogastroduodenoscopy identified a sessile mucosal formation. Histological analysis of biopsy samples revealed a gastric hyperplastic polyp, leading to a subsequent esophagogastroduodenoscopy for polypectomy. The excised specimen confirmed the diagnosis of gastric IFP. Post-polypectomy, the patient experienced progressive symptom amelioration, leading to complete resolution within three weeks.

DISCUSSION

This case thus describes a rare cause of dyspeptic syndrome associated with the presence of a gastric IFP, promptly managed and resolved after endoscopic removal of the polyp, with no histological signs of neoplasia within the en bloc resected sample.

CONCLUSION

IFP is a possible and rare cause of dyspeptic syndrome. There remain significant challenges in diagnosing this rare condition, which lacks pathognomonic or specific signs and symptoms of its presence (especially when it causes symptoms). Endoscopy, when feasible, remains a cornerstone in the resective management of such lesions.

A rare case of jejunal Vanek's tumor causing intussusception in an adult: a case report and comprehensive literature overview

Inflammatory fibroid polyp, or Vanek's tumor, is an uncommon benign small bowel tumor and a rare cause of intussusception in adults. This case involves a 62-year-old man with persistent abdominal pain, diagnosed with jejunoileal intussusception. A 4 cm inflammatory fibroid polyp was discovered during surgery, leading to distal jejunal resection. Despite the rarity of adult intussusceptions, they should be considered in abdominal pain diagnoses. The optimal management approach, whether en bloc resection or initial reduction with limited resection, remains debated.

Inflammatory fibroid polyp of the renal pelvis: first report at an extra-gastrointestinal site with molecular confirmation

Inflammatory fibroid polyps (IFP) are rare and benign mesenchymal tumours of the gastrointestinal tract. They are submucosal spindle cell lesions with an eosinophilic-rich inflammatory infiltrate and mutations in the platelet-derived growth factor receptor alpha (PDGFRA) gene. In this report, we present the case of a 74-year-old female with a solid tumour of the kidney, which presented as a bland proliferation of spindle cells with thin-walled blood vessels and an inflammatory infiltrate with eosinophilic granulocytes. Immunohistochemistry revealed a positivity for vimentin and a weak staining for CD99 and CD34 in the spindle cells. Because of the morphological similarity to IFPs of the gastrointestinal tract, a molecular pathology analysis was performed. This identified an oncogenic mutation in exon 18 of the PDGFRA gene, which is characteristic for inflammatory fibroid polyps of the gastrointestinal tract. To the best of our knowledge, this is the first case of an IFP in the urogenital tract.

A Rare PDGFRA Exon 15 Germline Mutation Identified in a Patient With Phenotypic Manifestations Concerning for GIST-Plus Syndrome: A Case Report and Review of Literature

Molecular alterations in PDGFRA are well-described as drivers of sporadic gastrointestinal stromal tumors (GISTs) and inflammatory fibroid polyps (IFPs). However, a small number of families with germline PDGFRA mutations in exons 12, 14, and 18 have been reported, forming the basis of an autosomal dominant inherited disorder with incomplete penetrance and variable expressivity, now referred to as PDGFRA-mutant syndrome or GIST-plus syndrome. Phenotypic manifestations of this rare syndrome include multiple gastrointestinal GISTS, IFPs, fibrous tumors, and other variable features. Herein, we report the case of a 58-year-old female who presented with a gastric GIST and numerous small intestinal IFPs, found to harbor a previously undescribed germline PDGFRA exon 15 p.G680R mutation. Somatic tumor testing was performed on the GIST, a duodenal IFP, and an ileal IFP utilizing a targeted next-generation sequencing panel, revealing additional and distinct secondary PDGFRA exon 12 somatic mutations in each of the 3 tumors. Our findings raise important considerations regarding mechanisms of tumor development in patients with underlying germline PDGFRA alterations and highlight the potential utility of expanding currently available germline and somatic testing panels to include exons outside the typical hotspot regions.

Intussusception in an adult revealing a Vanek's tumor: A case report

INTRODUCTION AND IMPORTANCE

Inflammatory fibroid tumors (IFT) or Vanek's tumors are scarce benign neoplasms. They can affect any part of the digestive tract. They are underdiagnosed conditions that are generally revealed by a life-threatening complication such as intussusception. The final diagnosis is set on the resection specimen after curative surgery.

CASE PRESENTATION

A 35-year-old patient presented with an acute small bowel occlusion related with an ileo-ileal intussusception revealed by an emergency CT-scan. The etiology of the occlusion wasn't clear but we suspected a complicated malignant tumor of the small bowel. Therefore, an emergency surgery was performed and we resected the tumor with margins. The diagnosis of Vanek's tumor was set at the pathology examination.

DISCUSSION

Inflammatory fibroid tumors are mesenchymal tumors with no malignant potential. However, they can be revealed by a dangerous complication leading to an emergency surgery. Complete resection is required and pathology examination set the diagnosis.

CONCLUSION

Surgeons should include IFT among the several differential diagnosis of ileal intussusception of the adults as it mimics other small bowel tumors. Only pathology examination can set the diagnosis.

Nilotinib efficacy and safety as salvage treatment following imatinib intolerance and/or inefficacy in steroid refractory chronic graft-versus-host-disease (SR-cGVHD): a prospective, multicenter, phase II study on behalf of the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC)

Imatinib is used for patients with SR-cGVHD. However, in 50% of cases imatinib is discontinued due to intolerance or inefficacy. In order to investigate nilotinib's role as salvage therapy in those patients, we conducted a prospective, multicenter, phase II study. (NCT02891395). Patients with SR-cGVHD were included to receive imatinib. Patients who stopped imatinib due to intolerance or inefficacy switched to Nilotinib. The primary endpoint was defined as the week-12 response rate to Nilotinib. The response was considered successful if superior to the 30% endpoint. Sixty-two patients started the IM-phase. Fourteen patients (22%) discontinued imatinib before week 12 due to: cGVHD progression (10%) or TKI-class-specific intolerance (12%). At week 12, we observed complete remission in 13 patients (21%) and partial response in 8 patients (13%). Twenty-nine patients switched to Nilotinib. Nilotinib response at week-12 was observed in 6 patients (21%) while 23 patients (79%) discontinued Nilotinib due to intolerance/cGVHD progression. The primary endpoint was not reached. This prospective study confirmed the efficacy of imatinib in patients with steroid refractory cGVHD. It failed to demonstrate the efficacy of nilotinib as a salvage therapy in patients who were intolerant/unresponsive to imatinib.

Jejunal Intussusception Secondary to a Large Inflammatory Fibroid Polyp: A Case Report and Discussion of Differential Diagnosis

Inflammatory fibroid polyp (IFP), initially considered a reactive process, is now recognized as a benign mesenchymal neoplasm of the gastrointestinal tract. We report a case of a 68-year-old woman with medically refractory Crohn disease that presented with intussusception requiring surgical intervention. The resection revealed a jejunal mass consisting of a submucosal proliferation of bland spindle cells in a fibrous stroma infiltrated by numerous eosinophils. By immunohistochemistry, the lesion was positive for vimentin and negative for desmin, smooth muscle actin (SMA), S-100, CD117, DOG1, ALK (D5F3), Melan-A, HMB-45, CD34, and STAT6. Ki-67 proliferative index was low (<1%). The mass was classified as IFP by its characteristic morphology and associated eosinophilia. IFP should be considered in the differential diagnosis of adults with intussusception or bowel obstruction. Definitive treatment typically requires surgical resection of the involved bowel segment.

Inflammatory fibroid polyp of the anus in a 12-month-old girl: Case report and review of the literature

Inflammatory fibroid polyp (IFP) is a rare, usually solitary and intraluminal polypoid benign tumour that can affect any part of the gastrointestinal (GI) tract. Its aetiology is unknown and clinical presentation depends on the site of involvement. We present the case of a 12-month-old girl with IFP and review all reported cases of IFP in children and adolescents <18 years. A 12-month-old girl presented with rectal bleeding. The patient underwent colonoscopy which revealed an anus polyp. Surgical resection was performed and histopathological examination of the specimen showed features of IFP. A literature review of 20 cases (including ours) between 1966 and January 2022 is also presented. To our knowledge, this is the youngest reported patient with IFP and the first in the anal area.

NF1-Associated Inflammatory Polyp of the Colon: First Report of a Sporadic Case

"Juvenile-like (hyperplastic/inflammatory) mucosal polyp" is a term proposed for rare benign mesenchymal lesions of the gastro-intestinal tract so far reported only in patients with type 1 neurofibromatosis (NF1). We report here a first sporadic case of NF1-associated mucosal inflammatory polyp of the colon. The diagnosis was made in a 53-year old female patient with a large polypoid tumor of the cecum. The lesion was predominantly mucosal, made of fibroblast-like cells associated with inflammatory infiltrates rich in eosinophils and containing entrapped, distorted epithelial glands, responsible for the juvenile-like appearance. Whole exome sequencing showed a pathogenic variant of NF1. The patient had no evidence of NF1; no NF1 mutation was detected in normal tissues. Our observation may support the existence of juvenile-like inflammatory polyps associated with NF1 alterations, either germline or somatic. This justifies to test NF1 in difficult-to-classify gastrointestinal mesenchymal tumors.

Combined Ileoileal and Ileocolic Intussusception Secondary to Inflammatory Fibroid Polyp in an Adult: A Case Report

Intestinal intussusception is relatively rare in adults and accounts for approximately 5% of intestinal obstruction. Intussusception is classified into subtypes according to the location, including ileoileal, ileocolic, ileo-ileocolic, colo-colic, jejuno-ileal, or jejuno-jejunal; the ileocolic type being the most common. However, intussusception of a combination of different subtypes has rarely been reported in the available literature. Abdominal computed tomography (CT) is the most accurate tool to evaluate intestinal intussusception. The pathological lead point in the intestine typically results in adult intussusception. Surgical intervention is usually adopted in cases of adult intussusception due to a high incidence of underlying bowel malignancy. An inflammatory fibroid polyp (IFP) is one of the uncommon benign neoplasms of the gastrointestinal (GI) system, which can result in intestinal intussusception. Herein, we present a case of a 50-year-old female with combined ileoileal and ileocolic intussusception, which was initially diagnosed by abdominal CT. Therefore, laparoscopic right hemicolectomy surgery was performed, confirming the final diagnosis as ileoileal and ileocolic intussusception secondary to IFP.

[Mesenchymal tumors and tumor-like lesions of the gastrointestinal tract: an overview]

Mesenchymal tumors and tumor-like lesions of the gastrointestinal (GI) tract are uncommon. They vary from reactive tumefactive lesions and benign neoplasms to highly aggressive sarcomas. Among them, GI stromal tumors (GISTs) are most common, followed, with less frequency, by smooth muscle and neurogenic tumors. The major challenge resides in correctly identifying GISTs and providing a comprehensive report (including risk assessment and genotyping) that represents the basis for an optimized surgical-oncological treatment and/or adjuvant therapy. On the other hand, the challenge of benign lesions is to find a good name (well understandable and reproducible diagnostic term) that helps avoid diagnostic ambiguity and prognostic uncertainty so that overprognostication and overtreatment can be prevented. Moreover, several recently described genetically defined benign and malignant entities need be correctly diagnosed due to their special "targeted" therapeutic options and to further characterize their clinicopathological and biological properties in the future. These recent entities include aggressive epithelioid inflammatory myofibroblastic sarcoma (ALK-RANBP2-driven), malignant gastrointestinal neuroectodermal tumor (EWSR1-ATF1/CREB-related), NTRK-rearranged neoplasms, and, most recently, colorectal NUTM1-rearranged sarcomas. This review highlights the major clinicopathological features of gastrointestinal mesenchymal lesions in light of recent developments.

[Abdominal soft tissue tumors]

Gastrointestinal stromal tumors are the most common mesenchymal tumors in the abdomen and occur in Germany with an incidence of 10 to 15 cases per million inhabitants. Clear identification and characterization are of major importance for the prognosis and therapy of patients. Similarly, they have to be differentiated from other mesenchymal neoplasias such as leiomyomatous, neurogenic, adipocytic, and fibroblastic tumors. Additionally, the number of translocation positive neoplasias is increasing, requiring the use of adequate molecular assays. The aim of this paper is to give practical advice for their identification. Reference pathology is one possibility to support the correct diagnosis.

Inflammatory Fibroid Polyp of the Gastrointestinal Tract: A Systematic Review for a Benign Tumor

BACKGROUND/AIM

Inflammatory fibroid polyp (IFP) is a rare, usually solitary and intraluminal polypoid benign tumor that can affect any part of the gastrointestinal (GI) tract, although in the majority of cases it affects the stomach. This lesion is characterized by proliferation of highly vascular fibrous tissue and infiltration by a variable number of different inflammatory cells. Its etiology is unknown. Our aim was to describe all the reported data concerning IFP.

MATERIALS AND METHODS

An extensive search of the PubMed Index was performed for publications with titles or abstracts containing the terms: "inflammatory fibroid polyp" with/without "Vanek". Results were filtered for publications in English and concerning only humans. One hundred and twenty-four publications were finally included in this review.

RESULTS

IFP has a female predominance. It affects patients in their 5th decade of life, although there are cases of patients from 4 to 84 years of age. IFP usually affects the stomach and more specifically the gastric antrum but can be detected throughout the GI tract. A significant number of cases remain asymptomatic but the most frequent presentations of IFP are abdominal pain, acute abdomen and GI bleeding. Most cases are treated by endoscopic resection of the lesion. No recurrence nor IFP-specific complications have been reported. Histopathology of IFP varies.

CONCLUSION

It is relatively safe to conclude that both the etiology and the timing of diagnosis might change the histopathology, immunohistological staining and tissue structure of IFP. Suggested theories should be taken into consideration with caution as the etiology and pathophysiological mechanisms of IFP are unknown.

Mesenchymal tumours of the gastrointestinal tract

Mesenchymal tumours represent a heterogenous group of neoplasms encopassing benign, intermediate malignancy, and malignant entities. Sarcomas account for approximately 1% of human malignancies. In consideration of their rarity as well as of intrinsic complexity, diagnostic accuracy represents a major challenge. Traditionally, mesenchymal tumours are regarded as lesions the occurrence of which is mostly limited to somatic soft tissues. However, the occurrence of soft tissue tumours at visceral sites represent a well recognized event, and the GI-tract ranks among the most frequently involved visceral location. There exist entities such as gastrointestinal stromal tumours (GIST) and malignant gastointestinal neuroectodermal tumors that exhibit exquisite tropism for the GI-tract. This review will focus also on other relevant clinico-pathologic entities in which occurrence at visceral location is not at all negligible.

Gastric Inflammatory Fibroid Polyp: A Rare Cause of Occult Upper Gastrointestinal Bleeding

Inflammatory fibroid polyps (IFPs) are rare mesenchymal lesions that can arise throughout the gastrointestinal tract. These tumors represent less than 0.1% of all gastric polypoid lesions and are frequently found incidentally on endoscopic evaluation. While presenting symptoms depend on the location of the tumor, gastric polyps commonly present with epigastric pain and early satiety. We hereby delineate the case of a middle-aged female who presented with chronic iron deficiency anemia and a positive fecal occult blood test. She underwent an upper endoscopy, which revealed an actively oozing umbilicated lesion in the gastric antrum. Endoscopic ultrasound divulged the submucosal origin of the lesion. It was subsequently excised using endoscopic mucosal resection. Pathologic examination of the resected specimen confirmed the diagnosis of gastric IFP. Furthermore, we conducted a systematic literature search of the MEDLINE database centered on gastric IFPs from January 2000 till March 2020. The data on patient demographics, clinical features, endoscopic findings, lesion site and size, and treatment approaches were collected and analyzed. This article illustrates the overarching need for clinicians to be vigilant of gastric IFPs presenting with initial clinical symptoms suggestive of occult upper gastrointestinal bleeding. Prompt diagnosis and management of gastric IFPs carry paramount importance to combat chronic unexplained iron deficiency anemia following occult bleeding in such patients. A concoction of endoscopy, biopsy, and immunohistochemical examination can be employed toward their prompt detection. Although gastric IFPs have conventionally been treated with surgery, endoscopic resection is now emerging as a safe and efficient therapeutic modality.

Endoscopic mucosal resection of a large inflammatory fibroid polyp (Vanek's tumor): a case report

Vanek’s Tumor (inflammatory fibroid polyp) is a rare benign mesenchymal lesion occurring throughout the digestive tract. Classical Vanek’s tumor (“gastric”) contains concentric formations of proliferating spindle cells, which are CD34 positive. Atypical-inflammatory pseudotumor-like Vanek’s tumor (“intestinal”) lacks concentric formations and is CD34 negative. A 70-years-old man patient presented during hematochemical routine tests, sideropenic anemia and leukopiastrinosis. The patient performed osteomyelitis biopsy and esophagogastroduodenoscopy (EGD) showing a gastric wall with nodular appearance and, in antrum pre-pyloric, a polypoid pedunculated lesion, measuring approximately 3 cm in diameter, surrounded by hyperemic mucosa. The lesion then was removed by en bloc endoscopic mucosal resection (EMR) and histo-morphological, immune-cytochemical and biomolecular evaluations were performed. The data were compatible with a benign polyp fibroid inflammatory (Vanek’s Tumor). The results of this study suggest that endoscopic mucosal resection is a safe and efficacy solution for the resection of these gastrointestinal polyps and the two morphological patterns of Vanek’s tumor more probably represent only variants of one type of tumor than two different lesions. BRAF mutations were not shown growth PDGFRA wild-type Vanek’s tumor. (www.actabiomedica.it)

Rare case of gastric inflammatory fibroid polyp located at the fornix of the stomach and mimicking gastric cancer: a case report

BACKGROUND

Gastric inflammatory fibroid polyp (IFP) is a rare polypoid lesion of the stomach that is characterized pathologically by the presence of spindle cells, a prominent network of blood vessels, and inflammatory infiltration of eosinophils. IFP is mainly located in the gastric antrum and is usually semi-pedunculated and covered with normal mucosa. There have been several reports of large IFPs with ulceration on the surface, at the apex, but no report of the IFP with ulceration at the fornix of the stomach. We report a case of IFP with ulceration that was suggested to be gastric cancer and was resected for diagnostic treatment.

CASE PRESENTATION

A 79-year-old woman presented to our hospital. During mass screening for cancer, stomach fluoroscopy revealed an abnormal shadow. Endoscopy showed an ulcerated tumor at the fornix of stomach; hence, gastric cancer was suggested because of the polypoid lesion with irregular ridges and ulceration. Pathological diagnosis of gastric biopsy specimens revealed an inflammation of the gastric mucosa, and specific findings for gastric cancer were not obtained. Because we could not exclude gastric malignancies such as cancer or gastrointestinal stromal tumor, we performed a partial resection of the stomach with a 2-cm margin using the laparoscopic-assisted method. Pathological examination of the resected specimen revealed that the tumor was present in the submucosal layer and consisted of collagen fiber containing inflammatory cell infiltration of mainly eosinophils. A prominent network of blood vessels was also found in the specimens. Immunohistochemical staining revealed mild positivity for CD34, and α-SMA and was negative for c-kit, DOG-1, s-100, desmin, ALK, and IgG4. The lesion was thus diagnosed as an IFP. The postoperative course was uneventful. The patient is currently asymptomatic and has shown no recurrence.

CONCLUSION

IFPs have variable locational, morphological, histological, pathological, and immunohistochemical features. We reported that the gastric IFP was located at the fornix of the stomach and was similar in morphology to gastric cancer. This case is clinically significant to avoid over-surgery.

Giant Ileocecal Inflammatory Fibroid Polyp: Unique Clinical Presentation

Inflammatory fibroid polyps (IFPs) are infrequent gastrointestinal tract benign neoplasms. They mostly occur in the stomach especially the antrum. Signs and symptoms depend on their anatomic location and lesion size. Lesion biopsies are very challenging for accurate diagnosis in these lesions. Histopathological examination of resected tissue along with immunohistochemical studies is the perfect way to confirm the final diagnosis. In this paper, the authors present an unusual case of IFP in a 23-year-old female patient presented to the emergency room (ER) with a picture of intestinal obstruction and severe abdominal pain. Her investigations revealed a huge mass located at the ileocecal valve, with overall features mimic gastrointestinal stromal tumor (GIST) clinical presentation. Surgical resection is considered the most commonly used treatment method. The overall prognosis is good with a low risk of recurrence.

Ileal Intussusception in an Adult Caused by a Locally Invasive Inflammatory Fibroid Polyp: A Case Report

Inflammatory fibroid polyps (IFPs) are rare mesenchymal neoplasms affecting the gastrointestinal tract which are considered benign and noninvasive. We present a case of an invasive IFP in a 46-year-old woman who presented with signs of intestinal obstruction due to ileal intussusception. A segment of the small intestine was resected and subsequently intestinal continuity was restored. A polypoid lesion was found obstructing the lumen. Histopathology revealed a mesenchymal proliferation of spindle and stellate cells, without cytological atypia, arranged in a fibromyxoid stroma. The tumor cells were located in the submucosa but also infiltrated the muscularis propria and the subserosa and were CD34 positive. The molecular study by PCR showed mutation in exon 12 of the PDGFRA gene. IFP is considered a true neoplasm and can also be considered as a potentially invasive lesion.

Vanek's tumor causing ileoileal intussusception in a middle-aged man

Intestinal obstruction is a common surgical emergency requiring urgent intervention. Small bowel obstruction secondary to intussusception is rarely encountered especially when inflammatory fibroid polyp (IFP) is the lead point. A 41-year-old gentleman with intestinal intussusception secondary to IFP presented to us with a classic symptom of intestinal obstruction. Computed tomography revealed a target or sausage-shaped soft tissue mass with a layering effect, which was confirmed by intraoperative findings. Histopathology was consistent with IFP and supported by immunoreactivity of CD34 and negative immunostaining for CD117. He recovered without any surgical complication or recurrence. Even intussusception can be managed via non-surgical technique in children; surgery is the mainstay of treatment in adults.

Inflammatory Fibroid Polyp: An Unusual Cause of Abdominal Pain in the Upper Gastrointestinal Tract a Case Report

Inflammatory fibroid polyps (IFPs) tend to occur in the gastrointestinal tract, and they are rare and benign neoplasms. In general, IFPs often come from epithelial tissue. The gastric antrum is the most common location. Endoscopic ultrasound (EUS) often shows a predominantly hypoechoic mass with well-defined borders originating from the submucosal area. Here, we report the case of a 46-year-old woman with abdominal pain who underwent computed tomography (CT), endoscopic ultrasound and endoscopic submucosal dissection (ESD) of resected specimens; the diagnosis was ultimately an inflammatory fibroid polyp. She is currently in clinical remission.

Spindle cell proliferations of the sigmoid colon, rectum and anus: a review with emphasis on perineurioma

A wide range of spindle cell proliferations are found uncommonly in the sigmoid colon, rectum and anus. They usually present as polyps, and include reactive lesions and benign and malignant neoplasms which may be primary or metastatic. They are less frequently described in the literature compared to those in the upper gastrointestinal tract, and may be underdiagnosed. The widespread use of sigmoidoscopy in symptomatic patients and bowel cancer screening programmes means that histopathologists must be aware of, and adopt a logical approach to, diagnosing spindle cell proliferations in biopsy and polypectomy specimens. This is particularly relevant given the strong association of some mesenchymal polyps with hereditary cancer syndromes. This review article will focus on perineurioma and the recent debate in relation to its overlap with fibroblastic polyp. The clinical, endoscopic, histological and immunohistochemical features of spindle cell proliferations which should be considered in the differential diagnosis of perineurioma will be discussed. There is also a brief reference to malignant spindle cell tumours of diagnostic importance.

Laparoscopy Endoscopy Cooperative Surgery for Inflammatory Fibroid Polyp in the Esophagus

Inflammatory fibroid polyp (IFP) appears most often in the stomach. We herein report an extremely rare case of esophageal IFP resected using laparoscopy endoscopy cooperative surgery (LECS). A 73-year-old man with dysphagia underwent esophagogastroduodenoscopy. A 50-mm semi-pedunculated submucosal tumor was observed in the esophagogastric junction. Endoscopic ultrasonography showed a homogeneous, hypoechoic, and well-vascularized tumor in the second and third layers of the stomach, but endoscopic ultrasonography-guided fine-needle aspiration failed to establish a definite diagnosis. Since he was suffering from dysphagia, LECS was performed. The resected specimen proved that the tumor was an IFP originating from the esophagus.

A case of inflammatory fibroid polyp of the stomach with an "erect penis like appearance" successfully removed by endoscopic submucosal dissection

A 37-year-old woman was diagnosed by esophagogastroduodenoscopy (EGD) as having a 15-mm subepithelial lesion (SEL) in the gastric body. For 2 years, she experienced epigastric pain and anemia; she then underwent emergency EGD, which revealed a significant morphological change of the lesion. The SEL had a disintegrated tip and its submucosal portion was substantially exposed out of the mucosa, showing an "erect penis like appearance". Based on the pathological findings of biopsied samples from the exposed portion and the endoscopic features, an inflammatory fibroid polyp (IFP) was suspected. This lesion was considered responsible for the anemia and was removed by endoscopic submucosal dissection (ESD). The pathological findings confirmed the lesion to be IFP. This report presents a case of gastric IFP that showed a marked morphological change and unique endoscopic features and was successfully removed by ESD.

Gastrointestinal juvenile-like (inflammatory/hyperplastic) mucosal polyps in neurofibromatosis type 1 with no concurrent genetic or clinical evidence of other syndromes

Gastrointestinal "juvenile-like (inflammatory/hyperplastic) mucosal polyps" (JLIHMPs) have been proposed as a neurofibromatosis type 1 (NF1)-specific gastrointestinal manifestation. Juvenile polyposis syndrome (JPS) has also been reported in a NF1 patient, harboring concurrent NF1 and SMAD4 germline mutations. Additionally, NF1-like cafe-au-lait spots have been described in biallelic mismatch repair deficiency, another condition featuring gastrointestinal polyps. The SMAD4 and BMPR1A genes that are involved in 50-60% of JPS cases have not been investigated in the ~ 20 published cases of NF1-associated JLIHMPs with the exception of the abovementioned patient with concomitant JPS and NF1. NF1 defects have been found in the only two cases exhaustively tested. Therefore, JLIHMP has been questioned as an independent, NF1-specific entity. Incidental associations between NF1 and gastrointestinal polyposes at risk for gastrointestinal carcinoma should not be overlooked, given their implications in terms of clinical surveillance. We describe two patients featuring JLIHMPs in clinically/genetically proven NF1, in the absence of SMAD4 and BMPR1A mutations. In one case, the intervening mucosa was markedly inflamed, unlike JPS. We suggest that JLIHMP probably represents a gastrointestinal lesion specific to NF1.

Telocytes are the physiological counterpart of inflammatory fibroid polyps and PDGFRA-mutant GISTs

PDGFRA mutations in the gastrointestinal (GI) tract can cause GI stromal tumour (GIST) and inflammatory fibroid polyp (IFP). Hitherto no cell type has been identified as a physiological counterpart of the latter, while interstitial Cajal cells (ICC) are considered the precursor of the former. However, ICC hyperplasia (ICCH), which strongly supports the ICC role in GIST pathogenesis, has been identified in germline KIT-mutant settings but not in PDGFRA-mutant ones, challenging the precursor role of ICC for PDGFRA-driven GISTs. Telocytes are a recently described interstitial cell type, CD34+/PDGFRA+. Formerly considered fibroblasts, they are found in many organs, including the GI tract where they are thought to be involved in neurotransmission. Alongside IFPs and gastric GISTs, GI wall "fibrosis" has been reported in germline PDGFRA-mutants. Taking the opportunity offered by its presence in a germline PDGFRA-mutant individual, we demonstrate that this lesion is sustained by hyperplastic telocytes, constituting the PDGFRA-mutant counterpart of germline KIT mutation-associated ICCH. Moreover, our findings support a pathogenetic relationship between telocyte hyperplasia and both IFPs and PDGFRA-mutant GISTs. We propose the term "telocytoma" for defining IFP, as it conveys both the pathogenetic (neoplastic) and histotypic ("telocytary") essence of this tumour, unlike IFP, which rather evokes an inflammatory-hyperplastic lesion.

Invasive inflammatory fibroid polyp of the stomach: a case report and literature review

Background

Inflammatory fibroid polyps (IFPs) are rare mesenchymal lesions that affect the gastrointestinal tract. IFPs are generally considered benign, noninvasive lesions; however, we report a case of an invasive gastric IFP. To the best of our knowledge, this is only the second case report of an invasive gastric IFP.

Case presentation

A 62-year-old woman presented with complaints of epigastric pain and vomiting. Computed tomography showed a 27-mm, hyper-enhancing tumor in the prepyloric antrum. Upper endoscopy also showed a submucosal tumor causing subtotal obstruction of the gastric outlet. Because a gastrointestinal stromal tumor was suspected, distal gastrectomy was performed. Histopathological examination revealed spindle cell proliferation in the submucosal layer. The spindle cells had invaded the muscularis propria layer and extended to the subserosal layer. The tumor was finally diagnosed as an IFP based on immunohistochemical findings. No mutations were identified in the platelet-derived growth factor receptor alpha (PDGFRA) gene via molecular genetic analysis.

Discussion and conclusions

After the discovery that IFPs often harbor PDGFRA mutations, these growths have been considered neoplastic lesions rather than reactive lesions. Based on the present case, IFPs might be considered not only neoplastic but also potentially invasive lesions.

Differential diagnosis of gastrointestinal stromal tumor by histopathology and immunohistochemistry

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors in the gastrointestinal (GI) tract. GISTs account for approximately 80% of the clinically relevant GI mesenchymal tumors. Although most GISTs show spindle cell morphology, 10-15% of GISTs show pure epithelioid configuration. Therefore, not only spindle cell tumors but also epithelioid cell ones developing in the GI tract are subject to the differential diagnoses of GISTs. GISTs are basically positive for KIT, a receptor tyrosine kinase (RTK) encoded by protooncogene c-kit, by immunohistochemistry, but approximately 5% of GISTs are only weakly or barely positive for KIT. Since almost all spindle cell type GISTs are strongly and diffusely positive for KIT regardless of different genetic subtypes, diagnosis of the spindle cell type GISTs is not difficult. On the other hand, epithelioid cell type GISTs show different staining patterns of KIT in different genetic backgrounds. Approximately half of the epithelioid cell type GISTs with platelet-derived growth factor receptor alpha (PDGFRA) gene mutation might show weak or undetectable staining of KIT. On the other hand, almost all GISTs are negative for desmin, which is a positive marker for mature smooth muscle cells, and S100 protein, which is a Schwann cell marker. Smooth muscle tumors such as leiomyomas and leiomyosarcomas, which usually show the spindle cell morphology, consist of approximately 10% of the clinically relevant GI mesenchymal tumors and are almost positive for desmin and negative for KIT and S100 protein. Schwannomas which nearly always show the spindle cell pattern, comprise up to 5% of the GI mesenchymal tumors, and almost all of them are positive for S100 protein and negative for KIT and desmin. Thus, most GI mesenchymal tumors are differentially diagnosed by immunohistochemistry (IHC) of KIT, desmin and S100 protein. However, mesenchymal tumors such as desmoids, solitary fibrous tumors (SFTs), inflammatory myofibroblastic tumors (IMTs), perivascular epithelioid cell tumors (PEComas), inflammatory fibroid polyps (IFPs), rarely develop in the GI tract, and have to be correctly diagnosed through detection of specific immunohistochemical markers and/or unique genetic aberrations.

Nonsyndromic Intestinal Lipomas are Probably not Associated With Mutations of PDGFRA

The purpose of this study was to test the hypothesis that intestinal lipomas occurring in patients devoid of signs of PDGFRA-mutant syndrome might represent sporadic counterparts of familial lipomatous tumors occurring in the spectrum of tumors associated with PDGFRA mutations. PDGFRA-mutant syndrome may manifest with gastrointestinal stromal tumors, Vanek tumors, fibrous tumors, and lipomatous tumors. Until now there has been no molecular genetic study of PDGFRA mutations in intestinal lipomas published in the world literature. A series of 20 intestinal lipomas were obtained from 17 patients, and mutational analysis of exons 12, 14, and 18 of the PDGFRA gene was performed. None of the 16 analyzable tumors showed mutations in PDGFRA. Thus, PDGFRA mutations probably do not play an important role in the development of sporadic lipomas of the intestines.

Inflammatory Fibroid Polyp: An Unusual Cause of Ileoileal Intussusception

Inflammatory fibroid polyp (IFP), or Vanek's tumor, is a rare benign lesion of the gastrointestinal tract. Clinical manifestations of IFP vary based on size and location within the GI tract. This case describes a patient who presented with hematochezia and abdominal pain. Computed tomography revealed ileoileal intussusception without a clear lead point. The patient underwent resection of the intussuscepted small bowel with primary anastomosis. A large polypoid mass was identified as the pathological lead point. Histopathological and immunohistochemical analysis revealed an IFP. Review of the literature indicates that early surgical intervention is the treatment of choice for intussusception caused by IFP. Lesions are typically reported as solitary, and resection is curative.

Inflammatory fibroid polyp of the gastric antrum presenting as hypovolemic shock: Case report and literature review

Inflammatory fibroid polyps (IFP) are an extremely rare entity that arise within the submucosa of the gastrointestinal tract, and represent less than 0.1% of all gastric polyps. They are most commonly localized to the gastric antrum, small intestines and recto-sigmoid colon. IFPs are most commonly found incidentally upon endoscopic evaluation in the absence of symptoms. Presenting symptoms depend on the location of the tumor, although polyps located in the stomach most commonly present with epigastric pain and early satiety. Classic histologic features include perivascular onion skinning of spindle cells with an abundance of eosinophilic infiltration. The prompt diagnosis and management of IFP is essential due to its underlying risk for intussusception, outlet obstruction and acute hemorrhage. In addition, recent evidence has shown that IFP is driven by an activating mutation in the platelet derived growth factor receptor alpha (PDGFRA) gene, suggesting a neoplastic etiology. Herein, we discuss a case of a 65-year-old woman with an inflammatory fibroid polyp of the gastric antrum who initially presented with early hypovolemic shock and melena. Diagnosis was made by endoscopic visualization, biopsy and immunohistochemical analysis.

PDGFRα controls the balance of stromal and adipogenic cells during adipose tissue organogenesis

Adipose tissue is distributed in depots throughout the body with specialized roles in energy storage and thermogenesis. PDGFRα is a marker of adipocyte precursors, and increased PDGFRα activity causes adipose tissue fibrosis in adult mice. However, the function of PDGFRα during adipose tissue organogenesis is unknown. Here, by analyzing mice with juxtamembrane or kinase domain point mutations that increase PDGFRα activity (V561D or D842V), we found that PDGFRα activation inhibits embryonic white adipose tissue organogenesis in a tissue-autonomous manner. By lineage tracing analysis, we also found that collagen-expressing precursor fibroblasts differentiate into white adipocytes in the embryo. PDGFRα inhibited the formation of adipocytes from these precursors while favoring the formation of stromal fibroblasts. This imbalance between adipocytes and stromal cells was accompanied by overexpression of the cell fate regulator Zfp521. PDGFRα activation also inhibited the formation of juvenile beige adipocytes in the inguinal fat pad. Our data highlight the importance of balancing stromal versus adipogenic cell expansion during white adipose tissue development, with PDGFRα activity coordinating this crucial process in the embryo.

An Unusual Cause of Intestinal Obstruction in a Young Adult Patient: Inflammatory Fibroid Polyp

Inflammatory fibroid polyps are uncommon benign lesions that originate in the submucosa of the gastrointestinal tract. The stomach and the ileum are the most commonly affected sites. Although inflammatory fibroid polyp is one of the rare conditions leading to intestinal obstruction in adults, it should be considered as a possible diagnosis in obstructive tumors of the small bowel causing intussusceptions. We present one case of inflammatory fibroid polyp as a rare cause of intussusception in a young adult patient.

[Gastrointestinal stromal tumors of the stomach and precursor lesions]

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors in the gastrointestinal tract although they are much less frequent than epithelial tumors. In more than 60% of cases they occur in the stomach. Especially small lesions measuring ≤1 cm in diameter, so-called microscopic GIST can occur multifocally, frequently in the proximal stomach wall and sometimes as an incidental finding in a gastrectomy specimen resected for gastric cancer. The multicentricity of GIST alone is not proof of a metastatic behavior or a syndromal or hereditary disease. Multiple sporadic synchronous and metachronous GIST are characterized by different primary mutations mostly in the KIT or PDGFRA genes and are often less aggressive. It is speculative whether a field effect is responsible or whether still unknown GIST-promoting factors may facilitate the development of several independent lesions. If KIT or PDGFRA mutations are lacking, a succinate dehydrogenase (SDH) deficient GIST has to be considered, either hereditary as Carney-Stratakis syndrome or syndromal as part of a Carney triad.

Giant Inflammatory Fibroid Polyp of the Hepatic Flexure of Colon Presenting with an Acute Abdomen

Background. Inflammatory Fibroid Polyp (IFP) of the colon is an exceedingly rare condition. Since 1952 till now only 32 cases have been reported worldwide of which only 5 were giant (>4 cm) polyps mostly found in the caecum (15 cases) with only 3 in the descending colon. Case Presentation. A 36-year-old female with no previous illness presented to the emergency unit with an acute onset pain over the right hypochondrium for 3 days associated with intermittent fever and anorexia. As she had evidence of localized peritonitis she underwent a diagnostic laparoscopy and subsequently an exploratory laparotomy. A mass measuring 8 × 7 × 5 cm arising from the hepatic flexure of colon was noted. Right hemicolectomy with ileotransverse anastomosis was performed. The mass was subsequently reported to be IFP. Conclusion. IFP is a very rare condition with clinical presentation depending upon its size and location. Definitive diagnosis is possible with histopathological examination of tissue aided by immunohistochemical studies. Surgical resection has been the most common method of treatment especially for large and giant colonic IFPs owing to challenges in terms of diagnosis and technical difficulties associated with endoscopic methods.

Syndromic gastrointestinal stromal tumors

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of gastrointestinal tract. They feature heterogeneous triggering mechanisms, implying relevant clinical differences. The vast majority of GISTs are sporadic tumors. Rarely, however, GIST-prone syndromes occur, mostly depending on heritable GIST predisposing molecular defects involving the entire organism. These conditions need to be properly identified in order to plan appropriate diagnostic, prognostic and therapeutic procedures. Clinically, GIST-prone syndromes must be thought of whenever GISTs are multiple and/or associated with accompanying signs peculiar to the background tumorigenic trigger, either in single individuals or in kindreds. Moreover, syndromic GISTs, individually considered, tend to show distinctive features depending on the underlying condition. When applicable, genotyping is usually confirmatory. In GIST-prone conditions, the prognostic features of each GIST, defined according to the criteria routinely applied to sporadic GISTs, combine with the characters proper to the background syndromes, defining peculiar clinical settings which challenge physicians to undertake complex decisions. The latter concern preventive therapy and single tumor therapy, implying possible surgical and molecularly targeted options. In the absence of specific comprehensive guidelines, this review will highlight the traits characteristic of GIST-predisposing syndromes, with particular emphasis on diagnostic, prognostic and therapeutic implications, which can help the clinical management of these rare diseases.

Divergent gastrointestinal stromal tumors in syndromic settings

The vast majority of gastrointestinal stromal tumors (GISTs) occur as sporadic tumors. Rarely, however, these neoplasms can arise in syndromic contexts. Under these circumstances, GISTs are often multiple and associated with accompanying signs peculiar of the hosting syndrome. Moreover, syndromic GISTs themselves tend to show heterogeneous features depending on the underlying condition. Multiple inflammatory fibroid polyps (IFPs) and a jejunal spindle-cell GIST were resected in a germline PDGFRA-mutant individual. Although the association of IFP and GIST is typical of this genetic setting (PDGFRA mutations can in fact trigger both these tumor types), PDGFRA-mutant GISTs are usually epithelioid and gastric. This discrepancy was settled evidencing a somatic KIT mutation in the GIST. The awareness of possible somatic mutations can be critical in the management of high-risk/malignant GISTs arising in syndromic settings. GIST features unusual for a given GIST-predisposing syndrome are a valuable tool in the hands of physicians for suspecting these "extra" triggers, which could not be sought for once a diagnosis of GIST-prone syndrome is well established, in a bona fide cost/benefit perspective.

Locally infiltrative inflammatory fibroid polyp of the ileum: report of a case showing transmural proliferation

Morphologically, an inflammatory fibroid polyp (IFP) is usually centred in the submucosa. Extension of an IFP to the subserosa with destruction of the muscularis propria is exceedingly rare. Herein, we describe a 70-year-old woman who presented with right lower abdominal pain but was finally diagnosed with an IFP. Contrast-enhanced computed tomography revealed a target-like structure with a hypovascular mass at the leading edge, which was consistent with intussusception due to a tumour. Following surgery, the resected specimen displayed a mass measuring 4 × 3 × 3 cm that was protruding into the lumen. Microscopically, the mass was centred in the submucosa, extending up to the mucosal surface and down to the subserosa and serosa. The muscularis mucosae and muscularis propria were destroyed focally. A PDGFRA gene mutation in exon 2 (1837_1851 del) that was found in this case, as well as a highly infiltrative growth pattern, strongly supported the neoplastic nature of IFP.