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Boost Your Learning with Quiz A Rare Cause of Subepithelial Tumor in the Gastric Fundus
Da Mi Kim1orcid, Gwang Ha Kim1,orcid, Kyungbin Kim2orcid
Clinical Endoscopy 2022;55(2):313-314.
DOI: https://doi.org/10.5946/ce.2022.039
Published online: February 25, 2022

1Department of Internal Medicine, Pusan National University College of Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea

2Department of Pathology, Pusan National University Hospital, Busan, Korea

Correspondence: Gwang Ha Kim Department of Internal Medicine, Pusan National University College of Medicine and Biomedical Research Institute, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan 49241, Korea Tel: +82-51-240-7869, Fax: +82-51-244-8180, E-mail: doc0224@pusan.ac.kr
• Received: January 3, 2022   • Revised: January 5, 2022   • Accepted: January 6, 2022

Copyright © 2022 Korean Society of Gastrointestinal Endoscopy

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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A 46-year-old woman presented with a gastric subepithelial tumor. The tumor was incidentally detected during a screening endoscopy. The tumor was located on the posterior wall of the gastric fundus, without any observable erosion or ulceration on its surface (Fig. 1A). When compressed using biopsy forceps, the tumor felt hard and partially fixed. On endoscopic ultrasonography, the tumor measured 0.8 cm in diameter and presented as a heterogeneously hypoechoic lesion in the submucosal layer (Fig. 1B). Examination of the specimen obtained from the endoscopic biopsy revealed only chronic gastritis. The patient underwent a follow-up endoscopy 2 years later, which revealed that the tumor size had increased (Fig. 1C). Therefore, traction-assisted endoscopic submucosal dissection was performed (Fig. 1D-F).
What is the most likely diagnosis?
Histopathological examination of the resected specimen revealed spindle cell proliferation, and infiltration of lymphocytes and plasma cells with fibroedematous stroma, in the submucosal layer (Fig. 2A). The spindle cells were immunopositive for CD34 (Fig. 2B) and immunonegative for c-kit, smooth muscle actin, and S-100 protein. Based on these findings, an inflammatory fibroid polyp (IFP) of the stomach was diagnosed. Because the tumor was completely resected, further treatment was not pursued. No recurrence was observed on follow-up endoscopy one year later.
IFPs are rare, benign, mesenchymal tumors occurring throughout the gastrointestinal tract, and they are most commonly found in the gastric antrum [1]. Although the pathogenesis and etiology of IFPs remain unclear, an association with local inflammatory response caused by injury, infection, or metabolic triggers has been suggested [2]. The typical endoscopic findings are semi-pedunculated, subepithelial tumors covered by normal mucosa, often with ulceration, in the gastric antrum. Although IFPs are generally considered benign lesions, it is challenging to diagnose before resection, similar to other mesenchymal tumors located in the submucosa or muscularis propria [3]. Therefore, endoscopic resection and surgical resection are sometimes performed for therapeutic and diagnostic purposes [4].
In the present case, the tumor was located at the gastric fundus, a rare location for IFPs, and its size had increased during the follow-up. Therefore, a malignant lesion, such as a neuroendocrine tumor or gastrointestinal mesenchymal tumor, was suspected. Traction-assisted endoscopic submucosal dissection was performed to provide adequate visualization, facilitating a complete and safe submucosal dissection.

Conflicts of Interest: Gwnag Ha Kim is currently serving as a deputy editor in Clinical Endoscopy; however, he was not involved in the peer reviewer selection, evaluation, or decision process for this article. The authors have no potential conflicts of interest.

Funding

This work was supported by a clinical research grant from the Pusan National University Hospital in 2021.

Author Contributions

Conceptualization: Gwang Ha Kim

Investigation: Da Mi Kim, Kyungbin Kim

Supervision: GHK

Writing-review & editing: DMK, GHK, KK

Fig. 1.
(A) Initial endoscopy reveals a small subepithelial tumor on the posterior wall of the gastric fundus. (B) On endoscopic ultrasonography, the tumor presents as a heterogeneously hypoechoic lesion in the submucosal layer, measuring 0.8 cm in diameter. (C) On follow-up endoscopy 2 years later, the tumor has increased in size although no erosion or ulceration is noted. (D) Traction-assisted endoscopic submucosal dissection is performed. (E) The tumor is removed completely. (F) The inner surface of the resected specimen.
ce-2022-039f1.jpg
Fig. 2.
(A) Histopathological examination reveals spindle cell proliferation and infiltration of lymphocytes and plasma cells in the submucosal layer (hematoxylin & eosin stain, ×200). (B) The spindle cells are immunopositive for CD34, and immunonegative for c-kit, smooth muscle actin, and S-100 protein (CD34 stain, ×100).
ce-2022-039f2.jpg
  • 1. Albuquerque A, Rios E, Carneiro F, Macedo G. Evaluation of clinico-pathological features and Helicobacter pylori infection in gastric inflammatory fibroid polyps. Virchows Arch 2014;465:643–647.ArticlePubMed
  • 2. Kawai A, Matsumoto H, Haruma K, et al. Rare case of gastric inflammatory fibroid polyp located at the fornix of the stomach and mimicking gastric cancer: a case report. Surg Case Rep 2020;6:292.ArticlePubMedPMC
  • 3. Kim GH, Park DY. A rare cause of gastric subepithelial tumor. Clin Endosc 2020;53:377–378.ArticlePubMedPMC
  • 4. Mavrogenis G, Herin M, Natale MD, Hassaini H. Resection of a gastric fibroid inflammatory polyp by means of endoscopic submucosal dissection: how deep is deep enough? Ann Gastroenterol 2016;29:380.ArticlePubMedPMC

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        A Rare Cause of Subepithelial Tumor in the Gastric Fundus
        Clin Endosc. 2022;55(2):313-314.   Published online February 25, 2022
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      A Rare Cause of Subepithelial Tumor in the Gastric Fundus
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      Fig. 1. (A) Initial endoscopy reveals a small subepithelial tumor on the posterior wall of the gastric fundus. (B) On endoscopic ultrasonography, the tumor presents as a heterogeneously hypoechoic lesion in the submucosal layer, measuring 0.8 cm in diameter. (C) On follow-up endoscopy 2 years later, the tumor has increased in size although no erosion or ulceration is noted. (D) Traction-assisted endoscopic submucosal dissection is performed. (E) The tumor is removed completely. (F) The inner surface of the resected specimen.
      Fig. 2. (A) Histopathological examination reveals spindle cell proliferation and infiltration of lymphocytes and plasma cells in the submucosal layer (hematoxylin & eosin stain, ×200). (B) The spindle cells are immunopositive for CD34, and immunonegative for c-kit, smooth muscle actin, and S-100 protein (CD34 stain, ×100).
      A Rare Cause of Subepithelial Tumor in the Gastric Fundus

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