Causes

The etiology of benign tumors varies depending on the type of tumor and associated pathology and will be discussed in detail in subsequent sections. Previous

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. Previous

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.

Differentials
Achlorhydria Arteriovenous Malformations Gastric Ulcers 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. Note the image below.

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.

Histologic Findings
Hyperplastic polyps
There is marked elongation of the pits with branching, resulting in a corkscrew appearance or in cystic dilatation of foveolae. Also, there is an excess of lamina propria with plasma cells, lymphocytes, eosinophils, mast cells, macrophages, and neutrophils. The gastric glands do not normally participate in the formation of the polyps. The surface may be ulcerated and inflamed with regenerative atypia. There may also be invagination of the surface mucosa with budding.[2]

Inflammatory fibroid polyps

These polyps are centered on the submucosa. Small, thin walled vessels surrounded by spindle cells are arranged in an "onion-skin" pattern. CD 34 positive and c-kit negative.[2]

Hamartomatous polyps of the Peutz-Jeghers type

Gastric mucosa is less frequently involved than the small bowel and the colon. They are composed by hyperplastic glands separated by branching cores of smooth muscle with atrophy of deep glandular components. Dysplasia is very uncommon.[2]

Juvenile polyps
These polyps are very rare and are usually associated with juvenile polyposis. They are composed of edematous and inflamed mucosa with tortuosity of the foveolar zones and are easily confused with hyperplastic polyps. There is an association with an increased risk of cancer.[2]

Gastric polyps in Cowden Disease

The foveolar glands are enlarged and elongated. Smooth muscle fibers are intermingled within the mucosal components and the cystic structures extend into the submucosa.[2]

Gastric polyps in Cronkhite-Canada syndrome

These polyps are usually associated with lesions in other parts of the GI tract. They are indistinguishable from juvenile polyps and hyperplastic polyps, and they are diagnosed if in the presence of alopecia, nail atrophy, or hyperpigmentation.[2]

Fundic gland polyps

These are dilated glands lined by fundic epithelium mixed with normal glands. There is usually no inflammation or atypia, but some disordered muscle fibers may be seen.[2]

Adenomatous polyps
They are composed of tubules or villi of dysplastic epithelium with some degree of intestinal-type differentiation. They can be low grade or high grade, based on the degree of dysplasia. The risk of malignancy is related to the size, the degree of dysplasia, and the villosity of the growth pattern. Forty percent to 50% of lesions greater than 2 cm contain carcinomatous transformation.[2]

Gastric carcinoids
Gastric carcinoids are very rare, representing less than 0.5% of gastric neoplasms, and are seen in 3 different settings: autoimmune atrophic gastritis, Zollinger Ellison syndrome, and MEN-1 syndrome, or they may be seen sporadically. They are usually broad-based, yellowish polypoid lesions overlined by normal mucosa. Chromogranin A is positive, but chromogranin B is usually negative. Synaptophysin is positive in 50% of cases.[2] urgical Care

Gastric polyps
Gastric polyps include hyperplastic polyps, adenomatous polyps, fundic gland polyps, and inflammatory fibroid polyps. Endoscopic excision of gastric polyps provides a minimally invasive approach to diagnosis and treatment. Polyps less 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 Mntrier 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 complete 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
Sometimes 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 can be found throughout the GI tract from the esophagus to the rectum; however, the stomach is the most common site. Most of the patients with GISTs are asymptomatic, but anemia and acute GI bleeding from tumor ulceration can occur. There is a spectrum from benign to malignant. Histologic characteristics, such as the number of mitotic figures, tumor necrosis, and cellularity, are 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 the liver and the 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. As defined by the GIST Consensus Conference, the goal of treatment should be complete resection of visible as well as microscopic disease, while avoiding tumor rupture and obtaining negative margins. Because of the adequacy of a narrow margin of resection, there has been significant interest in developing operative techniques that accomplish effective tumor resection but minimize morbidity, preserving stomach parenchyma, and reduce medical costs. Minimally invasive surgery has been proven to be effective for GIST resection with shorter hospital stays and comparable operating room time and blood loss when compared to open techniques.[4] The GIST Consensus Conference recommended laparoscopic resection for tumors less than 2 cm, and recent studies found laparoscopic treatment to be safe and effective in tumors averaging 4.4 cm. [5, 6] The pathological phenotype and especially the tumor mitosis correlate significantly with patient survival even if the resected tumor size was relatively small.[7]

For GISTs located in the fundus, along the greater curvature, a laparoscopic gastric wedge resection may be beneficial. Tumors in the lesser curvature are less likely to be effectively resected via laparoscopy because of the limited mobility of the stomach in this area. For GE junction tumors, the laparoscopic transgastric procedure can be used successfully.[5] Lipomas are rare submucosal tumors that are sometimes indistinguishable from GISTs. They represent deposits of adipose tissue in the wall of the stomach, usually in the submucosa. They may cause symptoms when exceeding 2 cm in size. The standard treatment is surgical resection, but endoscopic treatment has been proposed for lesions less than 2 cm.[8] 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 mucous-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.

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