Gastric polyps - classification and diagnostic

Transcription

1 Gastric polyps - classification and diagnostic Poster No.: C-0684 Congress: ECR 2017 Type: Educational Exhibit Authors: A. I. Georgescu, A.-M. Bratu, C. Zaharia; Bucharest/RO Keywords: Gastrointestinal tract, CT, Fluoroscopy, Barium meal, Cancer DOI: /ecr2017/C-0684 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 15

2 Learning objectives A short recap of the types of gastric polyps. Clinical and radiological findings of gastric polyps. Background Gastric polyps are lesions projected above the mucosal surface, which arise from the mucosa, so, in duble contrast studies may be seen as filling defects, with a smooth or lobulated surface and form acute angles with adjacent gastric wall in profile view. In contrast, submucosal lesions have a very smooth surface and form right or obtuse angles with adjacent gastric wall in profile view. They can be unique or multiple, have different shapes (usually round, net shaped), different size (usually small), pedunculated or sessile, with preserved or loss of mucosal detail. There are a lot of types of gastric polyps, but the most frecquent are hyperplastic polyps, reported into various studies in about 75 % of total polyp cases, followed by fundic gland and adenomatous polyps. In fact, literature reports that hyperplastic and adenomatous etiologies represents % of benign gastric tumors and 3,1 % of all gastric tumors. These two types of polyps rarely coexist, and if a patient have multiple lesions is more likely that all are hyperplastic polyps. Despite gastric polyps have no tendency to occur more at male or female, there is a tendency to occur more at patients over 60 years old. There are many classifications in the literature, but the most important are: 1. Related to the number of gastric lesions, they are divided in: Single polyp (like adenomatous polyp); Multiple polyps ( Fig. 1 on page 3 ) - polyposis (example: hyperplastic or hamartromatous polyps) 2. Ralated to their macroscopic appearance, can be: Page 2 of 15

3 sessile ( Fig. 2 on page 4 ) (flat, arising directly from the mucosal layer) pedunculated ( Fig. 3 on page 6 ) (extending from the mucosa through a fibrovascular stalk) 3. Related to their neoplastic potential, gastric polyps can be: nonneoplastic, such as hyperplastic, inflammatory fibrinoid or hamartromatous polyps neoplastic, such as adenoma or fundic gland polyps. The predilect location of all gastric polyps is the gastric antrum, followed by body and fundus. There are also reported some cases of anastomosis site polyps. The most frequent nonneoplastic polyps, hyperplastic polyps are typically smooth or finely lobulated pedunculated or sessile lesions less than 1 cm in size, with regular outline and preserved mucosal detail. Fundic gland polyps, the most frequent neoplastic polyps are smooth-surfaced, sesile protrusions usually located in the fundus and upper body of the stomach. A malignant polyp may infiltrate gastric wall, produce anfractuos wall thickening and loss of mucosal detail. Images for this section: Page 3 of 15

4 Fig. 1: Multiple gastric body polyps - Bucharest/RO Page 4 of 15

5 Page 5 of 15

6 Fig. 2: Sessile gastric polyp - Bucharest/RO Fig. 3: Single pedunculated gastric polyp - Bucharest/RO Page 6 of 15

7 Findings and procedure details 1. Clinical findings Gastric polyps are relatively common tumors, often asymptomatic, occasionally discovered. Depending on location they produce symptoms such as epigastralgia, nausea or vomiting, stomach fullness, bleeding and anemia, or if they have malignant potential, can produce carcinoid syndrome or hypersecretory syndromes. Epigastralgia or abdominal pain appears when a large stomach polyp is inflammated. The patients feel the pain especially when the abdominal region is pressed. Nausea or vomiting can arise intermittently, after eating, or can be continuously. The sensation of satiety, immediately after eating small amount of food, can be caused by a large polyp, or if the polyp`s location is nearby cardiac orifice. 2. Radiological findings Despite upper tract endoscopy is the most common type of investigation which diagnose and treat gastric polyps, barium meal study is still an important examination for patients which refuse or have any contraindication in performing endoscopy. CT is also a very common and useful method of diagnostic. 2.1 Nonneoplastic polyps A benign gastric polyp in classically described at barium meal as unique or multiple filling defect, with variable size, round or oval, net shaped and mucosal folds have normal size or orientation, but they can be pushed away. It can be sessile or pedunculated, the pedicle is a net shaped radiolucent band between the filling defect and the normal mucosal folds ( Fig. 4 on page 9 ) Hyperplastic polyps are the most frequent, representing over 75 % of all gastric polyps. They may appear at any age, but more often at older patients, between 65 and 75 years old. They typically appear on duble contrast barium studies as small lesions, usually under 1 cm, and rarely larger than 2 cm, usually multiple, slightly lobulated, round or ovoid sessile lesion randomly distributed into stomach, more frequent into the fundus or body of the stomach. At CT, most hyperplastic gastric polyps are smooth, sessile, Page 7 of 15

8 round, or oval lesions, ranging from 5 to 10 mm in diameter. In rare cases they may be larger, lobulated, or sometimes pedunculated Inflamatory fibrinoid polyps are characterized by the proliferation of spindle cells, small blood vessels and inflammatory cells, often dominated by eosinophils. They are most frequent located in antropyloric region. Inflammatory fibroid polyps are wellcircumscribed, solitary, small sessile, or pedunculated lesions and more than 50 % are larger than 2 cm Gastric hamartromatous polyps represent almost 10 % of all gastric polyps, they always measure under 1 cm, and constantly under 5 mm. They are located in the gastric fundus, may be single or multiple, when they form one of the hamartromatous syndromes. This group of syndromes includes Peutz-Jeghers, multiple hamartoma, juvenile polyposis, Cronkhite-Canada, and Bannayan-Riley-Ruvalcaba. They have a very small risk of gastric cancer, although there is a small preponderance for small bowel carcinoma. 2.2 Neoplastic polyps Classically in barium meal study, a malignant polyp ( Fig. 5 on page 10 ) is seen as a usually unique filling defect, irregular shape, variable form and size, interrupted or thickened (infiltrated) mucosal folds. Ulcer can be present, but it is not extended beyond the gastric wall and it`s deep is smaller than the surface. In case of large gastric ulcer, the Carman meniscus sign (the inner margin of the barium that fill the ulcer is convex toward the lumen) can be present Gastric adenomas ( Fig. 6 on page 11 ) are defined by the World Health Organization as circumscribed, polypoid lesions composed of either tubular and/or villous structures lined by dysplastic epithelium (neoplastic epithelial alteration representing both a precursor lesion of adenocarcinoma and also a marker of high risk). They are usually single, but multiple, polypoid syndromes should be considered. Gastric adenomas can be sessile or pedunculated, often irregular, lobulated surfaces, cauliflower-like, usually larger than 2 cm. The most common localization of a gastric adenoma is the gastric antrum, so larger lesions may prolapse into the pyloric canal and cause gastric outlet obstruction. Their malignant potential is recognized, and tends to increase with the size of the adenoma Fundic gland polyps are small sessile lesions that occur uniquely in the fundus and upper body of the stomach. FGP may occur sporadically or as a familial condition. Their morphology is characteristic with cystic transformation of the gland lined by parietal cell and chief cells. Despite their association with prolonged proton pump inhibitor therapy Page 8 of 15

9 is debated, the genetic alteration (APC-#- catenin pathway have been reported) is demonstrated in both sporadically and familial adenomatous polyposis. Sporadic fundic gland polyps and those associated with PPI use have virtually no malignant potential, but may rarely show dysplasia. Fundic gland polyps are usually small, under 5 mm, sessile and have a smooth contour. 2.3 Other gastric tumors All polyps arise from the mucosal layer of the stomach. In contrast, some submucosal pathologies may cause mucosal protrusion into the lumen and resemble mucosal polyps. This includes a variety of lesions such as gastric adenocarcinoma, lymphoma, gastrointestinal stromal tumors (GISTs), neural tumors, lipoma/liposarcoma, hemangioma or gastric carcinoid. Carcinoid ( Fig. 7 on page 12 ) is a rare gastric mass, usually is a small lesion, smooth, rounded and hypervascular in case of iv contrast administration. Their growth is usually slow, but can produce metastases when enlarge. Images for this section: Page 9 of 15

10 Fig. 4: Benign pedunculated gastric polyp - Bucharest/RO Page 10 of 15

11 Fig. 5: Malignant antral polyp - Bucharest/RO Page 11 of 15

12 Fig. 6: Adenomatous polyp in the gastric antrum (arrow). Ahmed Ba-Ssalamah, MD, Mathias Prokop, MD, Martin Uffmann, MD, Peter Pokieser, MD, Bela Teleky, MD, and Gerhard Lechner, MD. Dedicated Multidetector CT of the Stomach: Spectrum of Diseases Page 12 of 15

13 Fig. 7: Coronal reformatted image shows a gastric carcinoid tumor as an ulcerated mass. Note the thickened rim of the ulcer (arrows) Ahmed Ba-Ssalamah, MD, Mathias Prokop, MD, Martin Uffmann, MD, Peter Pokieser, MD, Bela Teleky, MD, and Gerhard Lechner, MD. Dedicated Multidetector CT of the Stomach: Spectrum of Diseases Page 13 of 15

14 Conclusion Gastric polyp may pose a threat to patient health not only by the risk of malignancy, but for the risk of pyloric obstruction if are localized nearby pyloric canal. Upper tract endoscopy, barium meal and CT are the most used diagnostic methods. The most important classification is related to oncologic potential. Personal information References 1. Jean-Noel Bruneton. Imaging of gastrointestinal tract tumors 2. Watanabe H, Jass JR, Sobin LH. Histological typing of oesophageal and gastric tumors. In: Watanabe H, Jass JR, Sobin LH, eds. Histological Typing of Oesophageal and Gastric Tumors. Berlin: Springer-Verlag; 1990: Varocha Mahachai, MD, David Y Graham, MD, Robert D Odze, MD, FRCPC. Gastric polyps. 4. Capella C, Solcia E, Sobin LH, Arnold R. Endocrine tumors of the stomach. In: Hamilton SR, Aaltonen LA, eds. Pathology and Genetics of Tumours of the Digestive System. Lyon, France: IARC Press; 2000: World Health Organization. Classification of Tumours. 5. Dedicated Multidetector CT of the Stomach: Spectrum of Diseases Ahmed Ba-Ssalamah, MD, Mathias Prokop, MD, Martin Uffmann, MD, Peter Pokieser, MD, Bela Teleky, MD, and Gerhard Lechner, MD From the Departments of Radiology (A.B.S., M.P., M.U., P.P., G.L.) and Surgery (B.T.), University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria 6. Lewin KJ, Ranchod M, Dorfman RF. Lymphomas of the gastrointestinal tract: a study of 117 cases presenting with gastrointestinal disease. Cancer 1978; 42: Fischback W, Kestel W, Kirchner T, Mossner H, Wilms K. Malignant lymphomas of the upper gastrointestinal tract: results of a prospective study in 103 patients. Cancer 1992; 70: Miettinen M, Lasota J. Gastrointestinal stromal tumors: definition, clinical, histological, immunohistochemical, and molecular genetic features and differential diagnosis. Virchows Arch 2001; 438:1-12. Page 14 of 15

15 9. Giles W. L. Boland, MD, FACR. Gastrointestinal imaging: the requisites, fourth edition. ISBN: Lee Alexander Grant BA (Oxon) FRCR, Nyree Griffin MD FRCR. Grainger & Allison`s Diagnostic Radiology Essentials. ISBN: Serban Aleaxndru Georgescu. Radiologie si imaginstica medicala. ISBN: Marc S. Levine, Parvati Ramchandani, Stephen E. Rubesin. Practical Fluoroscopy of the GI and GU tracts. ISBN: Page 15 of 15