Diagnosis of an unusual tumor in the duodenum

A 65-year-old patient was admitted with repeated vomiting and suspected upper gastrointestinal bleeding. He had a known history of acute bleeding of an ulcer of the ileocoecal region, which had to be treated surgically. An esophagogastroduodenoscopy demonstrated a gastric ulcer (Forrest III; Helicobacter pylori negative), and Mallory-Weiss lesions covered with fibrin, with hemorrhagic reaction of the surrounding tissue; there was no sign of acute bleeding. Furthermore, a polyp in the duodenal bulb was seen (Figure [1]), which was considered to be of inflammatory origin. Multiple biopsies were taken.

Figure 1 Endoscopic view of the glomus tumor.

The histological examination of the duodenal polyp (Figure [2]) revealed duodenal mucosa with foveolar gastric metaplasia and regional angiomatous proliferation. There were monomorphic cell clusters, with monomorphic nuclei and eosinophilic cytoplasm. The immunohistochemical staining showed no definite reaction for antibodies against CD34 or smooth muscle actin. The marker for proliferation MIB1 did not demonstrate any significant proliferation. Furthermore, the cells were negative for SMA, CD117, and CD56. There was no sign of malignancy. In summary, these cells represent a duodenal glomus tumor (GT). An endoscopic mucosal resection was then carried out, and confirmed the diagnosis.

Figure 2 Histological sample of the glomus tumor. Glomangioma cell nests (arrows) in a vessel-wall. Basal part of the duodenal mucosa (arrow head). Asterisk, Brunner's glands.

Although the small intestine accounts for about 90 % of the surface of the small bowel intestine tumors are rare [1]. Most frequently, these tumors are adenomatous or hyperplastic polyps, lipomas, or arteriovenous malformations [2]. GTs are mesenchymal tumors consisting of modified smooth muscle cells, representing a neoplastic counterpart of the perivascular glomus bodies [3]. Most commonly, these tumors occur in the distal parts of the extremities but have also been described in the stomach, and small and large intestine [4]. Therefore, GT represents a rare differential diagnosis that has to be considered [5]. Usually, they are benign; however, long-term follow-up data are not described, and there is no standardized management [4]. The patient was advised to undergo at least yearly gastroscopies; the 1-year follow-up was unremarkable.

Endoscopy_UCTN_Code_CCL_1AB_2AZ_3AB

References

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• 4 Miettinen M, Paal E, Lasota J. et al . Gastrointestinal glomus tumors.  Am J Surg Pathol. 2002;  26 301-311
• 5 Jundi M, Lack E E, Brun E A. et al . Glomus tumor of the duodenum: a case report.  Int J Surg Path. 2004;  12 411-414