Two cases of adenocarcinoma occurring in sporadic fundic gland polyps observed by magnifying endoscopy with narrow band imaging

Gastric Foveolar-type Adenocarcinoma with Raspberry-like Appearance in a Helicobacter pylori-uninfected Stomach: A Long-term Retrospective Follow-up of 16 Years

Esophagogastroduodenoscopy in a 58-year-old man revealed a protruding lesion measuring 6 mm in diameter in the fornix. An endoscopic biopsy of the lesion indicated well-differentiated adenocarcinoma. The lesion was resected by polypectomy. According to the Japanese histologic diagnostic criteria, we made a final diagnosis of early gastric cancer (U, Gre, 6×6 mm, Type 0-I, tub1, pT1a (M), pUl0, Ly0, V0, pHM0, pVM0). A retrospective review of the endoscopic images showed that this lesion had already been present in the images taken 16 years ago. The size and morphology of the lesion were the same as those of the first detected lesion.

A Noninvasive Risk Stratification Tool Build Using an Artificial Intelligence Approach for Colorectal Polyps Based on Annual Checkup Data

Colorectal cancer is the leading cause of cancer-related deaths worldwide, and early detection has proven to be an effective method for reducing mortality. The machine learning method can be implemented to build a noninvasive stratifying tool that helps identify patients with potential colorectal precancerous lesions (polyps). This study aimed to develop a noninvasive risk-stratified tool for colorectal polyps in asymptomatic, healthy participants. A total of 20,129 consecutive asymptomatic patients who underwent a health checkup between January 2005 and August 2007 were recruited. Positive relationships between noninvasive risk factors, such as age, Helicobacter pylori infection, hypertension, gallbladder polyps/stone, and BMI and colorectal polyps were observed (p < 0.0001), regardless of sex, whereas significant findings were noted in men with tooth disease (p = 0.0053). A risk stratification tool was developed, for colorectal polyps, that considers annual checkup results from noninvasive examinations. For the noninvasive stratified tool, the area under the receiver operating characteristic curve (AUC) of obese females (males) aged <50 years was 91% (83%). In elderly patients (>50 years old), the AUCs of the stratifying tools were >85%. Our results indicate that the risk stratification tool can be built by using random forest and serve as an efficient noninvasive tool to identify patients requiring colonoscopy.

High interobserver variability and frequent overdiagnosis of dysplasia in fundic gland polyps can be improved by detecting atypia on the surface epithelium and an abrupt transition to non-neoplastic cells

AIMS

Fundic gland polyps (FGPs) arise sporadically and in combination with familial adenomatous polyposis (FAP). Criteria for distinguishing low-grade dysplasia (LGD) from regenerative atypia in FGPs are not well established. The aims of study were to determine: (i) interobserver variability in diagnosing LGD in FGPs; (ii) bias in diagnosing LGD in FAP patients; and (iii) stringent criteria for LGD in FGPs.

METHODS AND RESULTS

Five senior pathologists who were blinded to the clinical history reviewed 72 FAP-associated FGPs and 34 sporadic FGPs. Cases were classified as negative (score = 0) or positive (score = 1) for LGD. Each case was assigned a 'combined dysplasia score' (CDS) ranging from 0 to 5 to reflect all five opinions. Fleiss' kappa showed only moderate interobserver agreement (κ = 0.46). Forty-one FGPs were classified as negative for dysplasia by consensus (CDS = 0-1), including 10 (24%) originally diagnosed as LGD. In contrast, all 37 cases classified as LGD by consensus (CDS = 4-5) were originally diagnosed as LGD, indicating that overdiagnosis of dysplasia is more common than underdiagnosis (P = 0.0012). Cytological atypia in the surface epithelium and an abrupt transition between atypical and normal-appearing epithelium were the most sensitive (97% and 100%, respectively) and specific (100% and 98%, respectively) features of dysplasia (P < 0.0001 for both comparisons). Very good agreement was achieved when a diagnosis of dysplasia was based on the presence of both features (κ = 0.85).

CONCLUSIONS

There is high interobserver variability and a tendency to overdiagnose LGD in FGPs. Strict criteria requiring both surface atypia and abrupt transition for LGD in FGPs result in low interobserver variability.

Sporadic fundic gland polyps with dysplasia or carcinoma: Clinical and endoscopic characteristics

Fundic gland polyps (FGPs) are the most common gastric polyps and have been regarded as benign lesions with little malignant potential, except in the setting of familial adenomatous polyposis. However, in recent years, the prevalence of FGPs has been increasing along with the widespread and frequent use of proton pump inhibitors (PPIs). To date, several cases of FGPs with dysplasia or carcinoma (FGPD/CAs) have been reported. In this review, we evaluated the clinical and endoscopic characteristics of sporadic FGPD/CAs. Majority of the patients with sporadic FGPD/CAs were middle-aged women receiving PPI therapy and without Helicobacter pylori (H. pylori) infection. Majority of the sporadic FGPD/ CAs occurred in the body of the stomach and were sessile and small with a mean size of 5.4 mm. The sporadic FGPs with carcinoma showed redness, irregular surface structure, depression, or erosion during white light observation and irregular microvessels on the lesion surface during magnifying narrow-band imaging. In addition, sporadic FGPs, even with dysplasia, are likely to progress to cancer slowly. Therefore, frequent endoscopy is not required for patients with sporadic FGPs. However, histopathological evaluation is necessary if endoscopic findings different from ordinary FGPs are observed, regardless of their size. In the future, the prevalence of FGPs is expected to further increase along with the widespread and frequent use of PPIs and decreasing infection rate of H. pylori. Currently, it is unclear whether FGPD/CAs will also increase in the same way as FGPs. However, the trends of these lesions warrant further attention in the future.

Gastric adenocarcinoma and proximal polyposis of the stomach (GAPPS) - A Helicobacter-opposite point

Gastric adenocarcinoma and proximal polyposis of the stomach (GAPPS) is a rare familial gastric cancer syndrome with an autosomal dominant pattern of inheritance. It is characterised by fundic gland polyposis of the gastric body and is associated with a significant risk of gastric adenocarcinoma. Unlike sporadic gastric cancer, Helicobacter pylori is usually absent in patients with GAPPS. This opposite-point finding has so far not been fully clarified. Prophylactic total gastrectomy is indicated in all cases of GAPPS with fundic gland polyposis and the presence of any dysplasia. If no dysplasia is found at histology, prophylactic gastrectomy is suggested at between 30 and 35 years of age, or at five years earlier than the age at which the youngest family member developed gastric cancer. Different phenotypes of GAPPS demand an individual approach to particular family members.

Clinical features of fundic gland polyps and their correlation with colorectal tumors

Fundic gland polyps (FGPs) are multiple, sessile polypoid bumps formed by the gastric mucosa of the fundus and body, which are the most common type of gastric polyps and generally tend to be benign. Studies have shown that patients with FGPs have a higher risk of developing colorectal tumors (adenoma and cancer) than the general population, but their correlation is still controversial. This article is aimed to review the clinical features of FGPs and their correlation with colorectal tumors.

A case of gastric adenocarcinoma considered to originate from a sporadic fundic gland polyp in a Helicobacter pylori-uninfected stomach

We encountered a rare case of gastric adenocarcinoma considered to arise from a sporadic fundic gland polyp (FGP). A woman in her 70 s, who had been prescribed a proton pump inhibitor for 5 years, was referred to our institution for further investigation and treatment of a gastric lesion. White light endoscopy showed numerous isochromatic FGPs in the greater curvature of the gastric body and a 15-mm reddish polypoid lesion with uneven surface characteristics. Magnifying endoscopy with narrow band imaging revealed an irregular granular microsurface structure with irregular microvessels, which is suggestive of cancer. The absence of atrophic changes in the entire gastric mucosa was confirmed endoscopically and histologically, and multiple Helicobacter pylori (HP) tests were negative. An en bloc resection was performed by polypectomy. The specimen showed adenocarcinoma that was thought to arise from an FGP. The lesion consisted of cystically dilated fundic glands in the basal part and neoplastic cells with nuclear atypia and high nuclear-cytoplasmic ratio in the foveolar part; on the basis of these findings, noninvasive adenocarcinoma was diagnosed. Although both adenocarcinoma in an HP-uninfected stomach and epithelial high-grade dysplasia in a sporadic FGP are extremely rare, this possibility should be considered when performing esophagogastroduodenoscopy.

Gastric foveolar-type adenomas endoscopically showing a raspberry-like appearance in the Helicobacter pylori -uninfected stomach

Background and study aims  Foveolar-type adenoma is described as a very rare tumor that occurs in individuals without Helicobacter pylori (HP) infection and diagnosed as adenocarcinoma in the Japanese Classification of Gastric Carcinoma (JCGC). However, we have frequently encountered patients with foveolar-type adenoma that endoscopically resembles a hyperplastic polyp, suggesting that it has just been overlooked to date. Here, we analyzed clinicopathological characteristics of a special subtype of foveolar-type adenoma showing specific endoscopic findings. Patients and methods  From a total of 212 patients with gastric cancer resected during a 22-month period, we enrolled 14 (6.6 %) diagnosed with foveolar-type adenoma (adenocarcinoma in JCGC). HP infection status was determined by eradication history, HP serum IgG antibody level, urea breath test, and endoscopic and histological findings. All lesions were observed using white-light endoscopy and narrow-band imaging with magnification endoscopy (NBIME). Endoscopically resected lesions were histologically examined. Results  None of 14 patients had a current or past history of HP infection. All lesions were visualized on non-atrophic gastric mucosa as small reddish protrusions with fine granular surface, showing a raspberry-like appearance. NBIME showed papillary or gyrus-like microstructures with irregular capillary. Lesions were histologically diagnosed as foveolar-type adenoma showing MUC5AC-positive gastric mucin phenotype. Ki-67 was overexpressed (median labeling index 69.9 %, range 28.4 - 92.1 %), though all lesions were an intraepithelial tumor without stromal invasion. p53 over-staining was not seen in any. Conclusions  Raspberry-like lesions on non-atrophic gastric mucosa in HP-uninfected individuals should be evaluated for the possibility of a special subtype of foveolar-type adenoma.

Endoscopic and histologic features associated with gastric cancer in familial adenomatous polyposis

BACKGROUND AND AIMS

Gastric cancer (GC) is a newly described cancer risk in Western patients with familial adenomatous polyposis (FAP). Little is known about clinical, endoscopic, and pathologic features associated with FAP-related GC. We compared these features in FAP patients with and without GC.

METHODS

FAP patients were identified through the David G. Jagelman Inherited Colorectal Cancer Registries Cologene database. FAP patients with GC and randomly selected FAP patients without GC who had undergone at least 2 EGDs were analyzed. Demographic, clinical, endoscopic, and pathologic features were compared.

RESULTS

Ten FAP patients with GC were identified, and 40 age-matched FAP control subjects were selected. No demographic differences were noted between patients and control subjects. All GC cases arose in the proximal stomach among gastric polyposis, with only 2 endoscopically visible. The prevalence of gastric polyposis was similar (100% vs 93%). Endoscopic features associated with GC included a carpeting of gastric polyps (100% vs 22.5%), solitary polyps >20 mm (100% vs 0%), and a polypoid mound of polyps (80% vs 0%; all P < .001). GC patients had a higher prevalence of gastric adenomas (30% vs 5%, P = .048) and polyps with high-grade dysplasia, including fundic gland polyps (50% vs 10%, P = .01) and pyloric gland adenomas (20% vs 0%, P = .037).

CONCLUSIONS

We identified endoscopic features and advanced pathology present in the stomachs of Western patients with FAP who developed GC. Upper GI surveillance in FAP should include the stomach and awareness of features associated with GC. Optimal approaches to treatment of gastric polyposis and methods of identification of early GC precursors in FAP are needed.

No transformation of a fundic gland polyp with dysplasia into invasive carcinoma after 14 years of follow-up in a proton pump inhibitor-treated patient: A case report

A fundic gland polyp (FGP) is a common gastric polyp. Intraepithelial neoplasia in FGPs, referred to as FGP with dysplasia, is often seen in patients with familial adenomatous polyposis (FAP). In sporadic FGPs, low-grade dysplasia (LGD) is rare, and high-grade dysplasia (HGD) or carcinoma arising from sporadic FGPs is extremely rare. Because of this rarity, the prognosis and appropriate management of these lesions have not been clarified. In the present case, a sporadic FGP with LGD did not develop into invasive carcinoma, but contained foci of HGD 14 years after diagnosis. The biopsy specimen of the polyp taken at the first esophagogastroduodenoscopy 15 years earlier was diagnosed as FGP without dysplasia. At the second histological examination, LGD was found. Because the polyp increased in size during proton pump inhibitor therapy for 14 years, endoscopic mucosal resection was performed. The pathological diagnosis of the resected specimen was FGP with HGD mixed in LGD, with no invasive carcinoma. Dysplasia in FGPs might have less malignant potential regardless of dysplasia or size.

Gastric adenocarcinoma coexisting with a reddish semipedunculated polyp arising from Helicobacter pylori-negative normal gastric mucosa: a report of two cases

We experienced two cases of adenocarcinoma coexisting with a hyperplastic polyp arising from Helicobacter pylori-negative normal gastric mucosa. The first case was of a 59-year-old man. Esophagogastroduodenoscopy revealed a protruding lesion measuring 4 mm in diameter on the greater curvature of the middle gastric body. The second case was of a 47-year-old man. Esophagogastroduodenoscopy showed a protruding lesion measuring 5 mm located at the greater curvature of the upper gastric body. The absence of atrophic changes in the entire gastric mucosa was confirmed endoscopically in both cases. Multiple H. pylori tests were all negative. Endoscopically, these protruding lesions appeared as reddish, semipedunculated polyps. Hyperplastic polyps were suspected based on white light endoscopic findings. Magnified endoscopy with narrow band imaging could not predict the coexistence of cancer. However, histopathological examination of the resected specimen revealed focal cancer at the surface of the gastric hyperplastic polyps. Considering the possibility that cancer may be coexisting in polyps, when reddish polyps are detected in H. pylori-negative normal gastric mucosa, it is important to perform a biopsy, or a careful follow-up endoscopy.

Comparison of dysplastic fundic gland polyps in patients with and without familial adenomatous polyposis

AIMS

Dysplastic fundic gland polyps (d-FGPs) typically arise in patients with familial adenomatous polyposis (FAP) but may occur in non-syndromic patients. They rarely become malignant, but their significance is unclear, especially in non-syndromic patients. We aimed to compare d-FGPs in patients with and without FAP, using clinicopathologic findings and β-catenin immunohistochemistry (IHC).

METHODS AND RESULTS

We identified 124 fundic gland polyps with low-grade dysplasia (LGD) or high-grade dysplasia (HGD) or indefinite for dysplasia (IFD) from 66 patients (27 with FAP; 39 non-syndromic). We recorded patient sex, age at first d-FGP, time until subsequent d-FGP (if any), history of non-gastric cancer (no patients had gastric cancer), proton-pump inhibitor use, and the presence of Helicobacter pylori. β-Catenin IHC was performed on cases with available blocks. The mean age at d-FGP diagnosis was 31 years for FAP patients and 61 years for non-syndromic patients (P < 0.0001). Sixteen FAP patients (59%) developed at least one subsequent d-FGP, as compared with 10 (27%) non-syndromic patients (P = 0.0099). The median time between d-FGP detection was 11.5 months in FAP patients and 7 months in non-syndromic patients (P = 0.82). Six FAP patients (22%) and 17 non-syndromic patients (44%) had non-gastric malignancies (P = 0.11). β-Catenin IHC showed nuclear positivity in 14 of 112 (13%) d-FGPs: 12 of 94 with LGD, two of three with HGD, and none of 15 with IFD polyps.

CONCLUSIONS

Familial adenomatous polyposis patients develop d-FGPs earlier and more often develop additional ones than non-syndromic patients. d-FGPs in FAP and non-syndromic patients have similar low rates of β-catenin nuclear IHC positivity. FAP and non-syndromic patients developed non-gastric cancers at similar rates, suggesting that d-FGPs may portend a general increased risk of carcinogenesis in non-syndromic patients.