A new differential diagnosis in granulomatous gastritis

Gastric Adenocarcinoma Associated with Granulomatous Gastritis. Case Report and Review of the Literature

Aims

We describe the fourth reported case of granulomatous gastritis associated with gastric adenocarcinoma, with a review of the literature and considerations about the prognostic implications of this association.

Results

A 48-year-old woman who had been suffering from gastritis for ten years was admitted to our institute for increasing left epigastric pain associated with vomiting. After an endoscopic biopsy had revealed an ulcerated signet ring cell carcinoma, the patient was submitted to subtotal gastrectomy with regional lymph node dissection. Pathological examination of the resected specimen revealed a superficial signet ring cell carcinoma (early cancer) associated with multiple granulomas. The granulomas, which were observed within the mucosa and the submucosa at the periphery of the carcinoma, were composed of CD68-positive, CD15-negative epithelioid and giant cells of the Langhans type, confirming their true histiocytic nature, and were also extensively found within the dissected lymph nodes. Since no ocular, skin, pulmonary or other gastrointestinal lesions were found and the granulomas were negative for acid-fast and fungal stain, a diagnosis of granulomatous gastritis was made.

Conclusions

To the best of our knowledge this is the fourth example of gastric adenocarcinoma and granulomatous gastritis. These cases suggest an association between granulomatous gastritis and early gastric cancer.

Gastric carcinoma with osteoclast-like giant cells. Lymphoepithelioma-like carcinoma with Epstein-Barr virus infection is the predominant type

Osteoclast-like giant cells (OGC) are rare in gastric carcinomas. Histopathological study of seven gastric carcinomas with OGC demonstrated three distinct types: lymphoepithelioma-like carcinoma (LELC), non-LELC, and giant cell tumor (GCT) types. LELC is a poorly differentiated adenocarcinoma with prominent lymphoid stroma. The LELC type (n = 4) showed similar histology to LELC of the stomach, except that they were accompanied by OGC and granulomatous reaction. Epstein-Barr virus (EBV) infection was demonstrated by EBV-encoded RNA (EBER) in situ hybridization (ISH) in all the neoplastic cells. The non-LELC type (n = 2) consisted of EBV-negative carcinoma cells with inflammatory infiltrates. OGC and granulomas were frequently observed in the glandular lumens with accumulated mucus. The GCT type (n = 1) was a neuroendocrine carcinoma, containing many OGC with metaplastic bone formation, which showed typical morphological features of OGC in GCT of the bone. In all three types, OGC expressed CD68, but not cytokeratin, indicating that OGC had a reactive histiocytic lineage. Both LELC and non-LELC types are included in the differential diagnosis of isolated granulomatous gastritis, and EBER-ISH was useful for the identification of LELC type. Both LELC and no-LELC types were also suggested to have better prognoses, but the behavior of the GCT type needs to be further characterized.

Gastric adenocarcinoma associated with isolated granulomatous gastritis

BACKGROUND

Granulomatous gastritis is a rarely observed pathological diagnosis. This condition often mimics gastric adenocarcinoma clinically, resulting in gastric resection. However, granulomatous gastritis has long been viewed as a benign process not observed in association with adenocarcinoma of the stomach. This article describes a patient with granulomatous gastritis occurring in close proximity to an area of superficially invading gastric adenocarcinoma.

METHODS

Acid-fast stains, fungal stains, standard cultures, tuberculosis cultures, and a VDRL serum test were all obtained. Both upper endoscopy and colonoscopy were performed. Chest radiographs were taken and pulmonary consultation was obtained.

RESULTS

The gastric samples obtained from resection showed no evidence of foreign body reaction. The acid-fast stains, fungal stains, cultures, and VDRL were all negative. Endoscopic exams did not show granulomatous inflammation in any other part of the gastrointestinal tract. No pulmonary disease was evident on radiographic or pulmonary exam.

CONCLUSION

Isolated granulomatous gastritis is a diagnosis of exclusion. The findings in this patient do not support a diagnosis of Crohn's disease, tuberculosis, sarcoidosis, syphilis, histoplasmosis, berylliosis, or foreign-body reaction. This is a unique case suggesting an association between isolated granulomatous gastritis and metaplastic mucosal changes.

A clinicopathologic study of 42 patients with granulomatous gastritis. Is there really an "idiopathic" granulomatous gastritis?

Idiopathic granulomatous gastritis (IGG) is a diagnosis made only by excluding other causes of granulomatous gastritis, such as infection, foreign bodies, and systemic granulomatous diseases. Recently, several investigators have questioned the existence of IGG. We reviewed the slides and clinical data of all cases of granulomatous gastritis seen at the Cleveland Clinic between 1975 and 1994. In addition to routine hematoxylin and eosin stains, slides from all cases were stained with Ziehl-Neelsen, Gomori's methenamine silver, and Giemsa stains. Clinical information and follow-up were available for 42 patients. The clinicopathologic diagnoses of the 42 patients with granulomatous gastritis were as follows: Crohn's disease (n = 23), three of whom had concomitant chronic active gastritis with Helicobacter pylori infection; sarcoidosis (n = 9), four of whom had concomitant chronic active gastritis with H. pylori infection; chronic active gastritis with H. pylori infection and no other systemic illness (n = 2); distal esophageal adenocarcinoma and chronic active gastritis (n = 2); mucosa-associated lymphoid tissue (MALT) lymphoma with chronic active gastritis and presumed H. pylori infection (n = 2); peptic ulcer complications (n = 2); hypertrophic gastropathy with chronic active gastritis (n = 1); and possible Crohn's disease (n = 1). We conclude that (a) in most cases of granulomatous gastritis, a diagnosis of Crohn's disease or sarcoidosis could be established; (b) the background inflammatory pattern was helpful in suggesting a diagnostic category for granulomatous gastritis; (c) granulomatous gastritis is not associated with H. pylori per se; however, if known cases of Crohn's disease and sarcoidosis are excluded, an association between H. pylori and granulomatous gastritis cannot be ruled out; and (d) IGG, if it exists, is extremely rare.