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General Surgery > Abdomen
Benign Gastric Tumors
Article Last Updated: Aug 3, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 9  
Author: Carol E H Scott-Conner, MD, PhD, Professor, Department of Surgery, University of Iowa College of Medicine
Carol E H Scott-Conner is a member of the following medical societies: American Association for Cancer Research, American Association for the Surgery of Trauma, American Burn Association, American Cancer Society, American College of Gastroenterology, American College of Surgeons, American Medical Association, American Society for Gastrointestinal Endoscopy, Association for Academic Surgery, Association for Surgical Education, Association of VA Surgeons, Iowa Medical Society, Sigma Xi, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Critical Care Medicine, Society of Surgical Oncology, Society of University Surgeons, and Southeastern Surgical Congress
Coauthor(s):
Michel M Murr, MD, Associate Professor, Department of Surgery, Director, Department of Bariatric Surgery, University of South Florida
Editors: Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; David L Morris, MD, PhD, Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia; Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy; John Geibel, MD, DSc, MA, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
Author and Editor Disclosure
Synonyms and related keywords:
benign stomach tumors, stomach polyps, gastric wall lesions, hyperplastic polyps, adenomatous polyps, fundic gland polyps, inflammatory fibroid polyps, juvenile polyps, familial polyposis, syndromes, Peutz-Jeghers syndrome, nonmucosal intramural tumors, leiomyoma, fibroma and fibromyoma, lipoma, ectopic pancreas, neurogenic and vascular tumors, cystic tumors, duplication cyst, mucocele
Background
The widespread use of endoscopy has increased the frequency of detection of gastric wall lesions in symptomatic and asymptomatic patients.
Pathophysiology
All layers of the stomach wall have the potential to produce tumorous growths. In 40% of patients with benign gastric tumors, the lesions are mucosa based. Another 40% are muscularis based. Tumors of vascular, endocrine, neurogenic, or mixed cellular origin are exceedingly rare. Types of polyps include the following:
- Hyperplastic polyps
- Adenomatous polyps
- Fundic gland polyps
- Inflammatory fibroid polyps
- Juvenile polyps
- Familial polyposis syndromes
- Peutz-Jeghers syndrome
- Nonmucosal intramural tumors
- Leiomyoma
- Fibroma and fibromyoma
- Lipoma
- Ectopic pancreas
- Neurogenic and vascular tumors
- Cystic tumors
- Duplication cyst
- Mucocele
Frequency
United States
Benign tumors of the stomach are found in 1% of patients undergoing gastroscopy.
History
- Many tumors are found incidentally on gastroscopy.
- Small tumors are usually asymptomatic, but larger tumors can ulcerate and cause occult bleeding and anemia.
- Large antral tumors cause intermittent gastric outlet obstruction as manifested by nausea, vomiting, and early satiety. If ulcerated, these tumors may cause epigastric pain similar to a peptic ulcer.
Physical
- Physical findings are not specific except for underlying conditions such as Peutz-Jeghers syndrome, in which patients may have abnormal pigmentation of the oral mucosa, lips, and digits.
- An abdominal mass may be palpable.
- Palpation may elicit abdominal tenderness.
Achlorhydria
Arteriovenous Malformations
Gastric Ulcers
Other Problems to be Considered
Gastric adenocarcinoma
Gastric lymphoma
Gastric varices
Gastric sarcoma
Lab Studies
- Findings on laboratory serum tests are nonspecific.
Imaging Studies
- Air-contrast studies of the stomach are sensitive in delineating mucosal details and lesions.
- Lesions are often found incidentally by computerized tomography scan or other radiological evaluations of the upper gastrointestinal tract.
Procedures
- Endoscopy has become more common for both diagnostic and therapeutic purposes. Endoscopic findings that suggest malignancy include red coloring, the presence of surface erosions, and the absence of a pedicle. If small superficial lesions are removed endoscopically, follow-up should include a regular annual endoscopy.
- Endoscopic biopsies are difficult to interpret and may be misleading because deep layers of the stomach wall or the tumor are not sampled. Snare biopsies that retrieve the whole specimen are preferred whenever technically possible.
- Endoscopic ultrasound (EUS) is helpful in broad-based lesions, where the relationship of the tumor to the layers of the stomach is important. Disruption of the normal sonographic appearance of 5 layers on EUS may signify invasion.
Medical Care
Gastric polyps
Gastric polyps include hyperplastic polyps, adenomatous polyps, fundic gland polyps, and inflammatory fibroid polyps. Unlike polyps of the colon, gastric polyps are rare and have an incidence of less than 1%.
Endoscopic excision of gastric polyps provides a minimally invasive approach to diagnosis and treatment. Polyps smaller than 2 cm are easily snared. Larger polyps or sessile polyps are best removed operatively to obtain a clear margin and complete removal. Occasionally, staged piecemeal endoscopic removal can be performed in patients with severe comorbidities. Wide, local, or segmental resection of the stomach may be performed for multiple polyps, depending on their histology and location. Gastrectomy is justified in patients with diffuse involvement of the stomach by polyps, which can make detection of a synchronous focus of cancer difficult.
Hyperplastic polyps are by far the most common histologic type, and they can vary in location, number, and size. Most are less than 2 cm. Although these polyps harbor no malignancy, they may be accompanied by atrophic gastritis, which predisposes the nonpolypoid mucosa to malignant transformation. Multiple hyperplastic polyps are found in Ménétrier disease. The histology of these polyps is different from that of colorectal polyps in that it shows submucosal edema and faveolar hyperplasia.
Adenomatous polyps (tubular and villous) are usually solitary lesions in the antrum. They have atypical cells and are associated with adenocarcinoma of the stomach. This association is strongest in polyps greater than 2 cm in diameter. The overall incidence of malignant transformation in adenomatous polyps is about 3.4%.
Fundic gland polyps contain microcysts that are lined by fundic-type parietal and chief cells, and they are located in the fundus and body of the stomach. They are common in familial polyposis syndromes and have no malignant potential.
Inflammatory fibroid polyps are benign spindle cell tumors that are infiltrated by eosinophils, but they are not associated with a systemic allergic reaction or eosinophilia. Excision of inflammatory fibroid polyps is indicated because of their propensity to enlarge and cause obstruction.
Polyposis syndromes
When polyps in the stomach are associated with polyposis syndromes, these syndromes include juvenile polyposis, Gardner, Peutz-Jeghers, and Cronkhite-Canada syndromes.
Juvenile polyposis and Cronkhite-Canada syndrome rarely result in gastric cancer.
Peutz-Jeghers syndrome involves gastric hamartomatous polyps. The gastric involvement is generally less than that observed in the small intestine. These polyps can bleed or obstruct the antrum and should be treated accordingly. Although patients with Peutz-Jeghers syndrome may occasionally develop gastric cancer, other nongastrointestinal cancers are more common.
Adenomatous polyps of the stomach and duodenum develop in 50% of cases of familial polyposis and Gardner syndrome. Polyps are usually multiple, and they are best treated endoscopically. Multiple treatments every 3-4 months may be necessary for complete eradication. Routine surveillance endoscopy should be instituted as a life-long program. Patients with Gardner syndrome develop adenomatous polyps in the duodenum as well as in the stomach and should undergo routine esophagogastroduodenoscopy.
Nonmucosal intramural tumors
Leiomyomas formerly comprised the most common submucosal tumors of the stomach. Many tumors formally designated as leiomyomas (and leiomyosarcomas) are now classified as gastrointestinal stromal tumors (GISTs) and are believed to arise from interstitial cells of Cajal rather than from smooth muscle per se. The overall incidence of GISTs is approximately 4 per 1 million in the general population, and the stomach is the most common site.
There is a spectrum from benign to malignant. Histologic characteristics, such as the number of mitotic figures, tumor necrosis, and cellularity, are unreliable indicators of malignancy. The only reliable indicator of malignancy in these and other GISTs is evidence of extragastric spread. Lymphatic spread is rare, but hematogenous spread to liver and lungs is more common. These tumors can cause symptoms by obstruction, ulceration, and blood loss or by compressing adjacent organs. They appear as large submucosal lesions on endoscopy, and endoscopic biopsies are invariably not deep enough to be of any diagnostic value.
Small tumors can be treated with wide local excision of the surrounding stomach wall. Because these tumors lack a capsule, enucleation is inadequate and leaves tumor cells behind. Intraoperative frozen section examination should guide further treatment. Malignancy is a rare finding on frozen section in such a setting, but, if malignancy is diagnosed, additional resection may be warranted. Larger tumors may require a segmental gastric resection for complete removal.
It is extremely important to avoid penetrating the tumor capsule, as spillage of tumor cells dramatically increases the risk of local recurrence and ultimate treatment failure. In many cases, segmental resection may be accomplished laparoscopically. Transgastric endoscopic surgery is an alternative that is ideally suited for removal of benign lesions too large to remove by conventional endoscopic means.
Lipomas are rare submucosal tumors that are sometimes indistinguishable from GIST. Removal for symptomatic relief and diagnosis is recommended.
Fibroma and fibromyoma are most commonly observed as small intramural or subserosal lesions during the course of an unrelated surgery. Removal is warranted to confirm their benign nature.
Ectopic pancreas can occasionally cause symptoms by obstructing the pylorus or bleeding. Characteristic findings on endoscopy include a nipplelike appearance and a central ductal orifice. Histologic evaluation can reveal acute and chronic pancreatitis and cystic dilatation of the duct. Asymptomatic lesions require no further treatment. Local full-thickness excision of the gastric wall is adequate for complete removal.
Cystic tumors can be mucocele or intramucosal, and they are the most common benign cystic lesion of the stomach. They develop as a result of obstruction of mucus-secreting glands. Duplication cysts are congenital lesions that share a common wall with the stomach but do not communicate with the lumen. They enlarge because of trapped secretions, resulting in symptoms of obstruction. Treatment of duplication cysts is operative excision.
Further Outpatient Care
- In familial polyposis and Gardner syndrome, routine surveillance endoscopy should be instituted as a life-long program.
Prognosis
| Media file 1:
Benign gastric tumors. CT scan of the abdomen showing a large GIST in the wall of the lesser curvature of the stomach. |
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Media type: CT
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Benign Gastric Tumors excerpt Article Last Updated: Aug 3, 2006
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