Clinicopathological features of pyloric gland adenomas of the duodenum: a multicentre study of 57 cases

Endoscopic features of the duodenal pyloric gland adenoma: A case series of 14 patients

Background

Pyloric gland adenoma (PGA) is a distinct subtype of duodenal adenoma. PGA has been increasingly recognized as a histologically and molecularly distinct entity; however, its endoscopic features have not been precisely described. This study aims to investigate the endoscopic characteristics of duodenal PGA, including the association of their putative precursors, Brunner's gland hyperplasia (BGH), and gastric epithelial heterotopia/metaplasia (GEM/H).

Methods

This study was a single-center, retrospective case series. Fourteen consecutive patients with duodenal PGA were retrieved from the pathological database. PGA was diagnosed according to the World Health Organization classification.

Results

The median tumor size was 22.5 mm (range: 12-40 mm), and 79% of cases were located in the first part of the duodenum. Six PGAs demonstrated high-grade dysplasia. PGA could be classified into two subtypes based on their appearance: villous lobulated type and smoothly protruding type. BGH and GEM/H were identified in the background mucosa in 28% and 7% of the cases, respectively. BGH was more abundant in the background mucosa of the PGA group than in the control group (p < 0.05). Six PGAs (43%) exhibited high-grade dysplasia, and no significant difference was observed in the endoscopic findings between low- and high-grade dysplasia.

Conclusions

The 14 patients with PGA demonstrated characteristic endoscopic findings. BGH and GEM/H might be precursors of PGA.

High frequency electrocoagulation resection effect analysis and prognosis observation in the treatment of patients with gastric polyps under painless gastroscopy

To explore high frequency electrocoagulation resection effect in treatment of patients with gastric polyps under painless gastroscopy. Sixty-four patients with gastric polyps were randomly divided into experimental group (32 cases) and control group (32 cases). Experimental group received basic treatment drugs for 8 weeks, and then treated with painless gastroscope high-frequency electrocoagulation resection. Control group was also given basic treatment drugs for 8 weeks, and then received high-frequency electrocoagulation resection under ordinary gastroscope. The patients in both groups were given rabeprazole sodium enteric coated capsules for 4 weeks. The improvement of symptom score, postoperative gastric mucosal healing and comprehensive curative effect of the 2 groups were observed after treatment. The patients with polyps cured under gastroscopy were subjected to a 6-month follow-up period during which gastroscopy was performed to assess the recurrence of polyps. Symptom scores comparison after treatment showed that experimental group had obvious advantages in improving epigastric fullness, fatigue and loose stool in patients with gastric polyps (P < .01 or P < .05). Gastric mucosa healing in experimental group was better at 2 weeks after operation (P < .05), showing no difference 4 weeks after operation (P > .05). Comprehensive curative effect comparison showed that the experimental group was better (P < .01), showing no difference in long-term efficacy (P > .05). In treating patients with gastric polyps, painless endoscopic high-frequency electrocoagulation resection effect is better, which not only promotes postoperative rehabilitation in patients but also reduces complications incidence, demonstrating a high level of safety. Therefore, it is highly recommended for widespread adoption and application.

[Pyloric gland adenoma - a rare tumor of the upper gastrointestinal tract with a high risk of malignancy]

BACKGROUND

Pyloric gland adenomas (PGA) are rare neoplasms of the gastrointestinal tract. According to the literature, these lesions may be underdiagnosed, and their true frequency of occurrence is underestimated.

OBJECTIVE

Clinical and morphological analysis of eight PGA cases of the upper gastrointestinal tract.

MATERIAL AND METHODS

The study included 8 cases of detection of PGA. In 7 out of 8 cases, the tumor was diagnosed by examining endoscopic biopsies, in 1 case, PGA was an accidental finding in the surgical material after proximal gastric resection.

RESULTS

6 out of 8 patients were female, the median age was 65 years (minimum 36 years and maximum 78 years). In 6 cases, PDA was localized in the stomach, in 1 - in the esophagus and in 1 - in the duodenum The size of the tumors ranged from 0.6 cm to 7.5 cm. 4 out of 6 stomach tumors appeared on the background of confirmed autoimmune gastritis, 1 - on the background of lymphocytic gastritis. 4 tumors were found in the body of the stomach, 1 - in the cardia, 1 - in the bottom of the stomach. In 2 out of 8 cases, there were signs of malignancy of the tumor with the transition to a highly differentiated adenocarcinoma. According to the results of the IHC study, the absence of a p53 mutation was noted in these cases.

CONCLUSION

PGA should be considered as neoplasms with a high risk of transformation into invasive adenocarcinoma. Increasing the recognition of PGA among pathologists and further understanding of the molecular mechanisms involved in their neoplastic transformation will improve the diagnosis and treatment of this pathology.

Pyloric Gastric Adenoma: Endoscopic Detection, Removal, and Echoendosonographic Characterization

Pyloric gland adenomas (PGAs) are rare neoplasms found not only in the gastrointestinal tract but also in other extragastrointestinal organs. They have potential for malignant conversion, and early detection and removal is imperative to prevent invasive disease. PGAs prove difficult in management and surveillance given their rarity. However, increasing familiarity with histological appearance and use of advanced tools such as echoendosonography can bring greater understanding of their clinical history. We describe a unique case of a PGA detected within a hiatal hernia sac characterized with echoendosonography and highlight the need to develop surveillance protocols for these types of lesions.

Multifocal Pyloric Gland Adenoma of the Esophagus Treated by Circumferential Endoscopic Submucosal Dissection

Pyloric gland adenoma is a rare neoplasm of the gastrointestinal tract typically observed in the stomach with a substantial malignant potential warranting its resection. While isolated esophageal pyloric gland adenoma has been reported, there is no literature on the encounter of diffuse, multifocal esophageal pyloric gland adenoma or its management. We present a unique case of multifocal pyloric gland adenoma of the esophagus treated by circumferential endoscopic submucosal dissection. We demonstrate endoscopic submucosal dissection to be a feasible management option.

A case of pyloric gland adenoma with high-grade dysplasia in the duodenum arising from heterotopic gastric mucosa observed over 5 years

Pyloric gland adenoma (PGA) in the duodenum is a rare gastric phenotype duodenal neoplasm. Although heterotopic gastric mucosa in the duodenum has been recognized as a benign lesion, it is a potential precursor of PGA and gastric phenotype adenocarcinoma. Herein, we present a case follow-up of endoscopic and histological changes in the PGA in the duodenum from low-grade to high-grade dysplasia. PGA was considered to arise from the heterotopic gastric mucosa, because the heterotopic gastric mucosa was observed in the initial examination. It is difficult to distinguish heterotopic gastric mucosa from PGAs, both endoscopically and histologically. This increase in size may be useful for their differentiation. Therefore, endoscopists should not underestimate the growth of the heterotopic gastric mucosa compared to that in the previous examination.

Histologic heterogeneity and syndromic associations of non-ampullary duodenal polyps and superficial mucosal lesions

BACKGROUND

Duodenal polyps and superficial mucosal lesions (DP/SMLs) are poorly characterised.

AIMS

To describe a series of endoscopically-diagnosed extra-ampullary DPs/SMLs.

METHODS

This is a retrospective study conducted in a tertiary referral Endoscopy Unit, including patients who had DPs or SMLs that were biopsied or removed in 2010-2019. Age, gender, history of familial polyposis syndromes, DP/SML characteristics were recorded. Histopathological, immunohistochemical and molecular analyses were performed.

RESULTS

399 non-ampullary DP/SMLs from 345 patients (60.6% males; median age 67 years) were identified. Gastric foveolar metaplasia represented the most frequent histotype (193 cases, 48.4%), followed by duodenal adenomas (DAs; 77 cases, 19.3%). Most DAs (median size 6 mm) were sessile (Paris Is; 48%), intestinal-type (96.1%) with low-grade dysplasia (93.5%). Among syndromic DAs (23%), 15 lesions occurred in familial adenomatous polyposis 1, two were in MUTYH-associated polyposis and one was in Peutz-Jeghers syndrome (foveolar-type, p53-positive, low-grade dysplasia). Only one (3.3%) tubular, low-grade DA showed mismatch repair deficiency (combined loss of MLH1 and PMS2, heterogeneous MSH6 expression), and it was associated with a MLH1 gene germline mutation (Lynch syndrome).

CONCLUSION

DPs/SMLs are heterogeneous lesions, most of which showing foveolar metaplasia, followed by low-grade, intestinal-type, non-syndromic DAs. MMR-d testing may identify cases associated with Lynch syndrome.

Multi-slice spiral CT findings of tubulovillous adenoma of the duodenum

OBJECTIVES

To analyze the appearance of duodenal tubulovillous adenoma on multi-slice spiral CT images to facilitate early diagnosis and treatment to potentially improve prognosis.

METHODS

We retrospectively analyzed clinical data and CT imaging findings of 11 cases of duodenal tubulovillous adenomas, all confirmed by pathology. The location, size, shape, CT density, relationship with surrounding structures, accompanying bile duct obstruction, and enhancement pattern of each lesion were documented.

RESULTS

All 11 lesions occurred in the descending part of the duodenum. Ten cases occurred in the duodenal papilla area. Nine cases had a low-density ring sign or semicircle sign between the lesion and the adjacent normal intestinal wall on axial images. Eight cases had differing degrees of bile duct dilatation, five of which had concomitant pancreatic duct dilatation. Noncontrast images revealed uniform soft tissue density; contrast enhanced images showed moderate, mostly uniform enhancement, with the most enhancement in the venous phase. In the arterial phase, two lesions showed linear enhancing vessels.

CONCLUSIONS

On multi-slice spiral CT imaging, duodenal tubulovillous adenomas have certain characteristics that could be used for clinical diagnosis and treatment.

PRECIS

On multi-slice spiral CT imaging of duodenal tubulovillous adenoma, findings of nodular or cauliflower-like shape, uniform density, uniform moderate enhancement, and a peripheral low-density ring sign could improve diagnostic accuracy.

APC mutations are common in adenomas but infrequent in adenocarcinomas of the non-ampullary duodenum

BACKGROUND

Recent studies highlighted the clinicopathological heterogeneity of non-ampullary duodenal adenomas and adenocarcinomas, but the detailed process of the malignant transformation remains unclear.

METHODS

We analyzed 144 adenomas and 54 adenocarcinomas of the non-ampullary duodenum for immunohistochemical phenotypes, genetic alterations, and mismatch repair (MMR) status to probe their histogenetic relationship.

RESULTS

The median ages of patients with adenoma and adenocarcinoma were the same (66 years). Adenomas were histologically classified as intestinal-type adenoma (n = 124), pyloric gland adenoma (PGA, n = 10), gastric-type adenoma, not otherwise specified (n = 9), and foveolar-type adenoma (n = 1). Protein-truncating APC mutations were highly frequent in adenomas (85%), with the highest prevalence in intestinal-type adenomas (89%), but rare in adenocarcinomas (9%; P = 2.1 × 10^-23). Close associations between phenotypic marker expression and genetic alterations were observed in adenomas, but not in adenocarcinomas, excluding the common association between GNAS mutations and MUC5AC expression. MMR deficiency was more frequent in adenocarcinomas (20%) than in adenomas (1%; P = 2.6 × 10^-6). One MMR-deficient adenoma and three MMR-deficient adenocarcinomas occurred in patients with Lynch syndrome. Additionally, three other patients with an MMR-deficient adenocarcinoma fulfilled the revised Bethesda criteria.

CONCLUSION

The discrepant APC mutation frequency between adenomas and adenocarcinomas suggests that APC-mutated adenomas, which constitute the large majority of non-ampullary duodenal adenomas, are less prone to malignant transformation. Non-ampullary duodenal adenocarcinomas frequently exhibit MMR deficiency and should be subject to MMR testing to determine appropriate clinical management, including the identification of patients with Lynch syndrome.

Small Bowel Epithelial Precursor Lesions: A Focus on Molecular Alterations

The wider use of gastrointestinal endoscopic procedures has led to an increased detection of small intestinal preneoplastic and neoplastic epithelial lesions, most of which are identified in the duodenum and ampullary region. Like their malignant counterparts, small intestinal glandular precursor lesions, which include adenomas and hamartomas, may arise sporadically or be associated with hereditary tumor syndromes, such as familial adenomatous polyposis, MUTYH-associated polyposis, Lynch syndrome, Peutz-Jeghers syndrome, juvenile polyposis syndrome, and Cowden syndrome. In addition, dysplastic, preinvasive lesions have been observed adjacent to small bowel adenocarcinomas complicating immune-related disorders, such as celiac or Crohn's disease. Adenomatous lesions may exhibit an intestinal-type, gastric-type, or, very rarely, serrated differentiation, related to different molecular pathogenetic mechanisms. Finally, in the background of multiple endocrine neoplasia 1 syndrome, precursor neuroendocrine growths have been described. In this review we offer a comprehensive description on the histo-molecular features of the main histotypes of small bowel epithelial precursors lesions, including: (i) sporadic adenomas (intestinal-type and gastric-type; non-ampullary and ampullary); (ii) syndromic adenomas; (iii) small bowel dysplasia in celiac and Crohn's disease; (iv) serrated lesions; (v) hamartomatous lesions; and (vi) neuroendocrine precursor lesions.

Large duodenal pyloric gland adenoma successfully resected by endoscopic submucosal dissection

A 71-year-old woman was given a barium meal examination as part of a workup for recurring melena and iron deficiency anemia (IDA), and it revealed a large duodenal polyp measuring 60 mm in diameter. Subsequent upper gastrointestinal endoscopy showed a large pedunculated polyp in the duodenal bulb. Magnifying endoscopy with narrow-band imaging (NBI) showed that the lesion consisted of a regular enlarged intervening part between crypts of the epithelium that resembled gastric mucosa. Although the lesion was suspected of being benign, it was resected by endoscopic submucosal dissection (ESD) to prevent the progression of the IDA. The pathology examination revealed the proliferation of mildly irregular-shaped or dilated glands lined by cuboidal cells and low columnar cells in the submucosa. The gastric glands were immunohistochemically positive for MUC6, suggesting pyloric gland differentiation. The lesion was covered by a foveolar-type epithelium, and we made a diagnosis of pyloric gland adenoma (PGA). PGAs are most common in the stomach, and they are rare in the duodenum, where endoscopic treatment is technically challenging. Here we report a case of large duodenal PGA successfully resected by ESD. Since part of PGAs has been reported to be associated with adenocarcinoma, minimally invasive treatment strategies are desirable to reduce the risk of progression to carcinoma.

Non-conventional dysplasias of the tubular gut: a review and illustration of their histomorphological spectrum

The increasing use of gastrointestinal endoscopic procedures has led to the recognition by histopathologists of non-conventional (or special-type) dysplasias of the gastrointestinal tract. These lesions can be recognised in association with prevalent underlying gastrointestinal conditions, such as Barrett oesophagus, chronic atrophic gastritis, and inflammatory bowel disease. The diagnosis of these special types can be challenging, and their biological behaviours are not fully characterised. The aim of this review is to provide a global view of non-conventional dysplastic lesions observed in the various segments of the tubular gastrointestinal tract and describe their salient features. Furthermore, as the clinical implications of these various subtypes have not been broadly tested in practice and are not represented in most management guidelines, we offer guidance on the best management practices for these lesions.

The pathology of gastric and duodenal polyps: current concepts

The liberal use of upper endoscopy has led to an increased detection of gastric and duodenal polyps, which are identified in as many as 6 and 4.6% of patient examinations, respectively. Gastroduodenal polyps are a heterogeneous group of lesions that can be neoplastic or non-neoplastic (e.g. hyperplastic or heterotopical). Most polyps present characteristic topographical features, as well as endoscopic appearance and size. Evaluation of the surrounding mucosa is essential in assessing the underlying pathology (e.g. Helicobacter pylori, autoimmune gastritis or inherited polyposis syndromes). Phylogenetically, gastric and duodenal polyps can be classified according to the epithelial compartment from which they derive. Polyps that arise from the surface epithelium can either be of foveolar or intestinal type, and they can develop from either the native mucosa or the metaplastic epithelium (gastric intestinal metaplasia or duodenal foveolar metaplasia). Other polyps develop from the deeper glandular component, such as pyloric/oxyntic gland derived subtypes. In this review we focus upon epithelial polyps, with an emphasis on the most common and clinically relevant lesions, and present recently described entities.

Gastric pyloric gland adenoma resembling a submucosal tumor: A case report

BACKGROUND

Pyloric gland adenoma (PGA) is a recently described and rare tumor. Submucosal tumor (SMT)-like PGA is more difficult to diagnose and differentiate from other submucosal lesions.

CASE SUMMARY

We present the case of a 69-year-old man with a 10 mm SMT-like elevated lesion with an opening in the upper part of the gastric body, referred to our hospital for further endoscopic treatment. Magnifying endoscopy with narrow-band imaging, endoscopic ultrasonography, and complete endoscopic submucosal dissection were performed on the patient. Histopathological findings revealed tightly packed tubular glands lined with cuboidal or columnar cells that had round-to-oval nuclei containing occasional prominent nucleoli and an eosinophilic cytoplasm similar to that in non-neoplastic gastric pyloric glands. Additionally, immunohistochemical analysis showed positive staining for both mucin 5AC and mucin 6. Therefore, we arrived at the final diagnosis of gastric PGA. Although there was no apparent malignant component in this tumor, PGA has been considered a precancerous disease with a high risk of transformation into adenocarcinoma.

CONCLUSION

PGA should be considered when detecting gastric SMT-like lesions. Physicians and pathologists should focus on PGA due to its malignant potential.