Git j club gastric polyps.

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Management of Gastric Polyps: An Endoscopy-Based Approach

Supervisor:Dr.Mohamed Al-

Shekhani

CLINICAL GASTROENTEROLOGY& HEPATOLOGY 2013;11:1374–1384

Kurdistan Board gastroenterology weekly Journal club.

Gastric polyps: the 3 main types.

1FGPs 2HPPs

An abnormal growth of tissue projectingfrom the gastric mucosal membrane.

Definition

Fundal gland polyps:Now the most frequent in West BZ of wide PPIs UseHyperplastic polyps: the 2nd most common polyps notable for their association with gastritis& their low but important potential for harboring dysplastic or neoplastic fociAdenomas: now raised intraepithelial neoplasia ,decreasing in parallel with HP; important as harbingers of GC, sp in E Asia. GIST have low incidence, no known associations, malignant potentialis high; early diagnosis&proper management are crucial.

Overview

Inflammatory fibroid polyps:Should be recognized, particularly by pathologists, to avoid misdiagnosis.Gastric neuroendocrine tumors (carcinoids) important because of their association with either atrophic gastritis or MEN syndromes; those do not arise in these backgrounds have high malignant Potential & require aggressive management.

2Overview

Polyps that reveal a malignancy upon histopathologic exam lose their polyp status, irrespective of their initial endoscopic appearance.Lesions (eg, lipomas, heterotopias, leiomyomas) are unlikely to cause clinical dilemmas.

Excluded:

Fundic gland polyps: The most common type of polyps detected at EGD in West. 6% of EGDs 74% of all gastric polyps submitted for HP. Endoscopically, usually multiple,small (1 cm), smooth, glassy, sessile. By NBI a honeycomb appearance withdense vasculature(nonspecific also seen in hyperplastic polyps).

Fundic gland polyps:Histology consist of one or more dilated oxyntic glands, lined by flattened parietal&mucous cells .Among the most characteristic lesions of the stomach. Regenerative appearance may be misinterpreted as dysplasia. True dysplasia, particularly high grade, isexceedingly rare and is virtually limited to fundic gland polyps found in patients with polyposis syndromes.

Fundic gland polyps: clinical approach1 or more should undergo biopsy.Large polyps (1 cm) ,ulcerated, > 20, unusual location as antrum should prompt a more aggressive approach.Biopsy is not adequate because may not include dysplasia or neoplasia.When found in a young , espif numerous (eg, 20),possibility of polyposis should be considered. Individuals with FAP typically are <40, occasionally have polyps in the antrum.When gastric polyps are associatedwith duodenal adenomas a familial polyposis syndrome strongly should be considered &colonoscopy recommended.

Fundic gland polyps: clinical approachIf FGPs > 20 or > 1 cm & on PPI. Withdraw PPI & see if number or size reduced.If so & still need for PP,give I MINIMAL effective dose or change to another PPI or H2RBs.Measure serum gastrin.Exclude gastrinoma.

Hyperplastic PolypsInflammatory proliferations of gastric foveolar cells (mucin-producing epithelial cells lining gastric surface& pits). inflammatory polyps or foveolar.Occur in patients with post-Billroth I & II gastric stumps exposed to bile.The classic association with mucosal atrophy, whether H pylorior autoimmune-induced.Now more with normal mucosa without HP.

Hyperplastic PolypsEqually common in men & womentypically occur in the sixth&seventh decades ( 66 y). Endoscopically, most frequently in antrum,often multiple. Usually smooth, dome-shaped, 0.5-1.5 cm, may be larger. Large hyperplastic polyps often become lobulated,Pedunculated, surface typically is erodedresult in chronic blood loss & IDA, Rarely, if large GOO.The overall prevalence of carcinoma in hyperplasticpolyps is <2%, > ]in polyps >2 cm.

Hyperplastic Polyps>1 cm should be excised completely. If dysplasia or intramucosal carcinoma is found, but the stalk is not affected, the lesion considered completely cured.Excision accompanied by additional sampling of the unaffected mucosa from the antrum&corpusto to obtain reliable information about the topography/severity of the background gastritis & atrophy.When hyperplastic polyps arise in a background of chronicatrophic gastritis (a precursor lesion for gastric adenocarcinoma) the severity and extent of the atrophic gastritis should be evaluated, using the Operative Link for Gastritis Assessment (OLGA) or the Operative Link on Gastritis/Intestinal Metaplasia Assessment staging systems.Preferably 7-biopsy , 3 specimens from the antrum(which can be submitted in a single formalin container), 2 from the lesser curvature, 2 from the greatercurvature, with each set in a separate container.

Hyperplastic PolypsIf present, H pylori should be eradicated &endoscopicfollow-up evaluation should be scheduled between 3 & 6months after therapy to confirm successful eradication. Alternatively, noninvasive test as the urea breath test used.Patients with OLGA stages III and IV (moderate diffuse atrophy or severe atrophy in either the corpus or antrum, usually accompanied by extensive intestinal metaplasia) should be considered for longterm endoscopic surveillance.

Hyperplastic PolypsIf present, H pylori should be eradicated &endoscopicfollow-up evaluation should be scheduled between 3 and 6months after therapy to confirm successful eradication. Alternatively, noninvasive test as the urea breath test used.Patients with OLGA stages III and IV (moderate diffuse atrophy or severe atrophy in either the corpus or antrum, usually accompanied by extensive intestinal metaplasia) should be considered for longterm endoscopic surveillance.

The most common gastric neoplastic polyp is an epithelial(raised intraepithelial neoplasia) by the World Health Organization.H pylori–related sporadic gastric adenomas have become rare, accounting for <1% of all gastric polyps. This contrasts markedly with some East Asian regions, where the incidence of gastric cancer remains high &gastric adenomas still constitute approximately a quarter of all gastric polyps.similar frequency in men &women Most commonly velvety lobulated appearance ,usually solitaryCan be found anywhere in the stomach, located more often in the antrum.

Gastric Adenomas (Raised Intraepithelial Neoplasia)

Often arise in a background of atrophy & intestinal metaplasiatypically associated with H pylori infection. As in the colon,gastric adenomas can be viewed as part of a sequence leading from dysplasia to carcinoma. The larger an adenomatous polyp, the greater the probability it contains foci of adenocarcinoma.Synchronous adenocarcinomas, reported in up to 30% of patients with adenomas ontaining foci of adenocarcinoma.

Completely excisice all adenomasSeverity/ extent of the atrophic gastritis should be evaluated. The same biopsy protocols&use of the OLGA or Operative Link on Gastritis/Intestinal Metaplasiaall patients with a diagnosis of gastric adenoma need to be placed in a surveillance program irrespective of their atrophy stage. Eradication of H pylori followed by confirmation of the cure by biopsy examination or urea breath test is necessary.Gastric adenomas are neoplastic with malignantpotential, so multiple sections from each lesion must beexamined to exclude invasion. Outside the research arena, neither special stains nor molecular studies are necessary.

(A) Flat gastric adenoma with a velvety appearance in the distal body of the stomach. (B) Gastric adenomas consist of dysplastic columnar epithelium indistinguishable from colonic adenoma. In resected specimens, the only clue to their gastric origin is often a small remnant of gastric tissue from which they originate (arrow).

Neoplastic proliferations of the interstitial cells of Cajal (or their precursors)Arise in any segment of GIT rarely, abd/ pelvic cavity.4000 new cases/year in US40-60% in stomach, 2% of all gastric tums.>in men >in the gastric fundus.Can be found in other regions of the stomach.No predisposing factors the gastric mucosa overlying these tumors may be

Gastrointestinal Stromal Tumors

Endoscopically, GISTs are well-circumscribed submucosallesions; the overlying gastric mucosa is usually normal, but itmay have an eroded or ulcerated centerBiopsy often normal so the best way is to perform an EUS -FNA or a tru-cut needle biopsy.Composed by dense aggregates offusiform cells (spindle cells) Two main types in the stomach (spindled & epithelioid) with subtypes.(presence of perinuclear vacuoles, numbers of mitoses, necrosis&tissue invasion) help predict their behavior.

Gastrointestinal Stromal Tumors

The vast majority: <1 cmAsymptomatic detected incidentally during an endoscopicExam for other indications. As they grow, they cause erosions or ulcerations or compress adjacent structures; The 2 more common manifestations are bleeding (occult or overt)& pain.

GIST:Clinical approach

All must be considered as having malignant potential:Up to 50% larger GISTs (2 cm) have metastatic disease at presentation, usually to the liver. A good correlation between size, mitotic activity&clinical behavior. Surgical resection recommended if >2cm; ? Endoscopic enucleation followed by surveillance is an option for smaller. TKIs in cases of metastasis&surgically unresectable or neoadjuvant after surgery.

IHC:The antibody CD117, stains 95% the remaining 5% ( typically more epithelioid) stain with antibodies to DOG-1 or platelet-derived growth factor .If none of these 3 stains, tumors of smooth muscle (leiomyomas)or neural (neuromas, schwannomas) origin should beConsidered &immunostaining for actin& S-100 should beperformed.

What’s Your Message?

Inflammatory fibroid polyps: Vanek tumors

Extremely rare < 0.1% of all gastric polyps.Endoscopy: firm, solitary, sessile or pedunculated,often ulcerated.The histology distinctive: submucosal proliferations of spindle cells, small vessels& conspicuous inflam infiltrate with a predominance of eosinophils. IHC staining suggests these polyps have a dendritic cell origin.A recent study:70% of inflam fibroid polyps containgain-of-function mutations in the platelet-derived growth factorReceptor polypeptide gene, similar to those found inCD117-negative GISTs, suggesting a neoplastic Process.

Clin approach:Most are asymptomatic.Larger polyps cause abd pain, early satiety, anemia, GOO,The EUS appearance may be helpful in establishing the diagnosis, characterized by an indistinct margin, a hypoechoic homogeneous lesion, within 2nd or 3rd layer with an intact 4th layer.Extremely rare, once familiar with their unique morphology they can be diagnosed instantly.IHC: stain for CD31.

Gastric NETs (carcinoid):< 2% of gastric polyps.Of 3 types:Type I , 70- 80% of all gastric NETs. They are associated with hypergastrinemia resultingfrom autoimmune (corpus-restricted) atrophic gastritisfound more commonly in elderly, sp women, with atrophic gastritis and often are associated with pernicious anemia. These tumors are small (1 cm), confined to the oxyntic mucosa, tend to be multiple, usually co-exist with multifocal ECL cell hyperplasia.Gastric NET tend to be found incidentally, often in patients undergoing EGD as part of an evaluation for anemia.

Gastric NETs (carcinoid):Type II gastric NET are associated with hypergastrinemia resulting from a gastrin-secreting tumor.They frequently are detected as part of the work-up for MEN-1syndrome or for Zollinger–Ellison syndrome.Are usually small (1 cm).This type is the most uncommon only 5-8% of gastric NET.

Gastric NETs (carcinoid):Clin approachType I and II tumors often can be removed endoscopically.In select patient with numerous&recurrent type I NETs, antral resection could be a reasonable option. Newer treatments; gastrin receptor antagonist netazepidebeing investigated.Sporadic carcinoids (type III) may present with anemia, epigastricpain, or signs and symptoms caused by metastases, includingthe rare carcinoid syndrome (characterized by cutaneousflushing, diarrhea, bronchospasm, and cardiac valvular lesions).Surgery followed with chemotherapy is the treatment of choice.

Gastric NETs (carcinoid):IHCNeuroendocrine tumors are best diagnosed withIHC stain (synaptophysin, chromogranin A, or CD56). These 3 stains are essentially equivalent to highlight neuroendocrine markers: In addition, a Ki-67 stain should be performed to count thepercentage of proliferating cells &the grade of the tumor.

Overall approach:After the histopathologic diagnosis is received, a decisionwhether polypectomy is needed ;endoscopic or surgical. Several factors should be considered when making that decision: 1. Risk of missing more serious pathology in the large polyps.2. The presence of symptoms3. The patient’s overall health status preferences4. local expertise. Biopsy-first approach is reasonable because it allows definitivetreatment to be planned according to pathology results&after consultation with the patient. If resection is planned, the endoscopist should be prepared to deal with potential complications as many are highly vascular & bleed; some (inflammatory fibroid polyps, carcinoids,GISTs) have submucosal components that increase the risk of perforation.

Overall approach:After removed or sampled, the non-affected gastric mucosashould be inspected& a minimum of 3 biopsy specimensfrom the antrum (including one from the incisura angularis)&2 - 4 from the corpus, both the greater & lessercurvature, should be submitted for pathologic exam, ideally in separate containers, to see if there is H pylori infection,atrophic gastritis, possibly with diffuse neuroendocrinehyperplasia, or a normal mucosa. Each of these findings would point to different management.

Follow-up evaluation:No evidence-based guidelines exist.A surveillance endoscopy on non-fundic gland polyps within 1 year is a reasonable approach to evaluate the site for recurrence & assess for new polyps.Follow-up evaluation after resection of polyps with high-gradedysplasia or early cancer should be individualized, but (at leastfor the first 2–3 years) short intervals (eg, 6 mo) would seemDesirable. Gastric carcinoids managed endoscopically (usuallytype 1) should be followed up with endoscopy every 1 to 2 years.

SCQ1:The most common gastric polyp in the west is:A.Fundic gland polyps.B.Hperplastic polyps.C.Raised intraepithelial neoplasia.D.Inflammatory fibroid polyps.E.NET.

SCQ2:The gastric polyp that respond to a therapeutic trial is:A.Fundic gland polyps.B.Hperplastic polyps.C.Raised intraepithelial neoplasia.D.Inflammatory fibroid polyps.E.NET.

SCQ3:Fundic gland polyps in the west is the most common type BZ of:A. Decreased incidence of HP infections.B. Decreased incidence of hyperplastic polyps.C. Increased survival of FAP patients.D.Widespread use of antibiotics use.E. Widespread use of PPI use.

SCQ4:The rarest type of gastric polyps is:A. FGPs.B. HPPs.C. RIN.D.IFPs.E. NET.

SCQ5:IFP is usually diagnosed on:A. OGD.B. Barium meal study.C. Histopathology.D.EUS.E. PET scan.

SCQ6:IFP has a characteristic appearance on:A. OGD.B. EUS.C. Barium.D.CT.E. PET scan.

SCQ7:The finding of FGPs & ampullary polyp should indicate:A. OGD.B. EUS.C. Barium.D.CT.E. Colonoscopy.

SCQ8:The finding of numerous, large or irregular shaped FGPs should raise the possibility of:A. FAP.B. HNPCC.C. PJS.D.JPS.E. NETs.

SCQ9:The following gastric polyps are associated with gastric atrophy except:A. FGP.B. HPP.C. RIN.D.IFP.E. NETs.

SCQ10:The MOST common gastric NET is:A. Type 1.B. Type 2.C. Type 3.D. All Equal.E. None .

SCQ11:The NET with worst prognosis is:A. Type 1.B. Type 2.C. Type 3 sporadic .D. All Equal.E. None.

SCQ12:The NET with worst prognosis is:A. Type 1.B. Type 2.C. Type 3 sporadic .D. All Equal.E. None.

SCQ13:The NET type that can respond to netazepide include:A. Type 1.B. Type 2.C. Type 3 sporadic .D. A&B.E. None.

SCQ14:The gastric GIST that doesn't’t stain with the usual GIST –specific stains should raise the possibility of all except:A. Leimymoma.B. Neuroma.C. Shwanoma.D. Epiotheloid type.E. EGC.

SCQ14:The gastric GIST that doesn't’t stain with the usual GIST–specific stains should raise the possibility of all except:A. Leimymoma.B. Neuroma.C. Shwanoma.D. Epitheloid type.E.None.

SCQ15:The best diagnostic approach to gastric GIST is:A. EUS-FNA.B.EUS- Truecut needle biopsy.C. OGD biopsy.D. None.E.All.

Git j club gastric polyps.

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