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A gastric submucosal tumor showing unique morphological changes
  1. Daisuke Murakami,
  2. Hideaki Harada,
  3. Yuji Amano
  1. Department of Gastroenterology, New Tokyo Hospital, Matsudo-shi, Japan
  1. Correspondence to Dr Daisuke Murakami, Department of Gastroenterology, New Tokyo Hospital, Matsudo-shi 270-2232, Japan; daisuke.murakami{at}

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An asymptomatic 38-year-old man was endoscopically followed because of a gastric submucosal tumor (SMT) showing a positive cushion sign in the greater curvature of the gastric antrum. The mucosal surface of SMT dramatically changed from normal to red color, whereas with a normal micro-surface pattern (figures 1 and 2). The lesion was harder with poorer mobility. The biopsy samples revealed hyperplastic and hyperemic changes without malignant findings. He had no subjective symptoms or abnormal blood test. Contrast-enhanced computed tomography revealed the SMT with a cystic degenerative lesion with marginal enhancement. The endoscopic ultrasonography showed that it was 27×20 mm in size, multilocular, hypoechoic mass derived from the gastric submucosal layer, suggested gastrointestinal stromal tumor (GIST). Laparoscopic and endoscopic cooperative surgery was performed and histopathological examination revealed pancreatic tissue under the hyperplastic gastric mucosa (figure 3), including islets of Langerhans (figure 3arrows), acinar cells (figure 3asterisks), inflamed ducts and smooth muscle fibers in the submucosa, indicating Heinrich type I of ectopic pancreas (EP).

Figure 1

Endoscopic view of the SMT in the greater curvature of the gastric antrum.

Figure 2

Magnified endoscopic view with narrow-band imaging of the hyperplastic mucosal surface.

Figure 3

HE staining of the SMT revealed ectopic pancreatic tissue under the hyperplastic gastric mucosa, including islets of Langerhans and acinar cells.

Heinrich’s classification is generally used for EP. Type I is similar structure as normal pancreatic tissue. Type II without Langerhans’ island is the most frequent. Cases with only duct and smooth muscle fiber proliferation are classified into type III. Diagnosis of an EP by ultrasonography-guided fine-needle aspiration biopsy is feasible, and the sensitivity, specificity, and accuracy of this method were 61%, 79%, and 67%, respectively.1 The enlargement of an EP originating from pancreatitis, bleeding and/or malignant transformation is an indication for surgical intervention. In this case, the aperture on the top of SMT could not recognized and insufficient drainage of pancreatic juice might induce local inflammatory and enlargement, resulting in the unique mucosal surface changes. These morphological changes are infrequent in EP, albeit frequent in GIST, malignant transformation of hyperplastic polyp,2 inflammatory fibroid polyp or polypoid lesion after curative endoscopic submucosal dissection.3


The authors are grateful to Dr Hideo Yamada (Department of Endoscopic Surgery, New Tokyo Hospital, Chiba, Japan) for technical assistance of laparoscopic and endoscopic cooperative surgery (LECS).


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  • Contributors DM wrote the manuscript and analysed the patient’s data. HH collected the patient’s data. YA gave final approval of the manuscript.

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Ethics approval This study was reviewed and approved by the New Tokyo Hospital Institutional Review Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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