Endoscopy 2012; 44(S 02): E21-E22
DOI: 10.1055/s-0031-1291502
Unusual cases and technical notes
© Georg Thieme Verlag KG Stuttgart · New York

A pseudosarcomatous lesion resembling a malignant tumor of the esophagocardiac junction, diagnosed by a total biopsy with endoscopic surgery

K. Ando
1   Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
,
M. Fujiya
1   Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
,
T. Ito
1   Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
,
R. Sugiyama
1   Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
,
T. Nata
1   Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
,
Y. Nomura
1   Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
,
N. Ueno
1   Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
,
S. Kashima
1   Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
,
C. Ishikawa
1   Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
,
Y. Inaba
1   Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
,
K. Moriichi
1   Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
,
K. Okamoto
1   Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
,
K. Ikuta
1   Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
,
H. Tanabe
1   Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
,
Y. Tokusashi
2   Department of Surgical Pathology, Asahikawa Medical University Hospital, Asahikawa, Japan
,
N. Miyokawa
2   Department of Surgical Pathology, Asahikawa Medical University Hospital, Asahikawa, Japan
,
J. Watari
3   Division of Upper Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
,
Y. Mizukami
1   Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
,
Y. Kohgo
1   Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
› Author Affiliations
Further Information

Corresponding author

M. Fujiya, MD, PhD
Division of Gastroenterology and Hematology/Oncology
Department of Medicine
Asahikawa Medical University
2-1 Midorigaoka-higashi
Asahikawa
Hokkaido 078-8510
Japan   
Fax: +81-166-682469   

Publication History

Publication Date:
06 March 2012 (online)

 

A pseudosarcomatous lesion is a benign lesion resembling sarcoma either clinically or histologically, which often leads to unnecessary or excessive treatments, including esophagectomy [1] [2] [3]. This report presents a case of a pseudosarcomatous lesion which was correctly diagnosed by a total biopsy with endoscopic submucosal dissection (ESD) [4].

A 60-year-old man was examined by esophagogastroscopy to screen the upper gastrointestinal tract. A 5-mm elevation with a thick white coating was detected in the lower esophagus ([Fig. 1 a]). Narrow band imaging (NBI) [5] revealed petal-like clusters of regularly dilated capillaries through a crack in the white coating ([Fig.1 b]).

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Fig. 1 Endoscopic image of the lesion using: a conventional colonoscopy; b narrow band imaging (NBI).

Histological examination of biopsy specimens showed dysplastic spindle cells with no immunoreactivity for epithelial or mesenchymal markers other than vimentin ([Fig. 2 a]), thus suggesting spindle cell sarcoma. The lesion was not clinically consistent with a typical sarcoma, therefore ESD was performed to make a definitive diagnosis. Histological examination of the specimen showed granulation tissue with augmentations of vessels and spindle-shaped cells. Atypical-grade tissue tended to become less atypical in the deeper areas of the lesion ([Fig. 2 b, c]), thus resulting in a final diagnosis of reactive inflammatory granuloma with no tumorous component.

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Fig. 2 Histological findings of: a biopsy specimen; b, c removed specimens (hematoxylin and eosin; × 40 and × 200 respectively).

This case suggests that a total biopsy by ESD, which can accurately control the depth of submucosal exfoliation under endoscopic view [4], is helpful for the diagnosis of sarcoma-like lesions, thereby avoiding excessive treatments including esophagectomy. From the 18 reported cases of esophageal pseudosarcomatous lesions ([Table 1]) [1] [2] [3] [6] [7] [8] [9], a polypoid lesion with ulcers and reflux esophagitis is a typical endoscopic finding. The present case shows the characteristic NBI findings for a pseudosarcomatous lesion, which may be key for discrimination of pseudosarcomatous tissue from malignant lesions.

Table 1

Reported cases of pseudosarcomatous lesion in the esophagocardiac junction or esophagus.

Age

Gender

Location

Symptom

Endoscopic
findings

Complication

Diagnosis at biopsy

Treatment

Reference

64

F

Esophagus

Dysphagia

Ulcer with stricture

ND

Carcinoma

Esophagectomy

Isaacson, 1982

52

F

Esophagus

Dyspepsia

Ulcer

ND

Suspicious for malignancy

Improved on treatment

Isaacson, 1982

75

F

ECJ

Epigastric pain

Necrotic lesion

Gastrectomy

Suspicious for malignancy

Polypectomy

Dirschmid, 1983

52

F

ECJ

Epigastricpain

ND

None

Suspicious for malignancy

Polypectomy

Dirschmid, 1983

57

M

ECJ

Epigastric pain

ND

Gastrectomy

Suspicious for malignancy

Polypectomy

Dirschmid, 1983

43

M

ECJ

Epigastric pain

ND

Gastrectomy

Suspicious for malignancy

Observation (repeated biopsies)

Dirschmid, 1983

59

M

ECJ

Melena

Polypoid mass with ulceration

None

Suspicious for squamous cell carcinoma

Segmental resection

Wolf, 1988

21

F

ECJ

Dysphagia

Stricturing mass

None

ND

Esophagogastrectomy

Wolf, 1988

ND

ND

ECJ

ND

Polyp

ND

ND

Polypectomy or biopsy

Shekitka, 1990

ND

ND

ECJ

ND

Ulcer

ND

ND

Polypectomy or biopsy

Shekitka, 1990

ND

ND

ECJ

Epigastric pain

Polyp

ND

ND

Polypectomy or biopsy

Shekitka, 1990

ND

ND

ECJ

Epigastric pain

Polyp

ND

ND

Polypectomy or biopsy

Shekitka, 1990

ND

ND

ECJ

Epigastric pain

Polyp

ND

ND

Polypectomy or biopsy

Shekitka, 1990

ND

ND

ECJ

Epigastric pain

Polyp

ND

ND

segmental resection

Shekitka, 1990

73

F

Dysphagia

Small polypoid lesion with stalk

Reflux esophagitis

Suspicious for malignancy

Polypectomy

Ajiki, 1996

53

M

None

Polyp with patchy mucous exudate on surface and linear erosion at base

Reflux esophagitis

Bizarre cells

Polypectomy

Moriyama, 2003

70

M

Melena, anemia

Small polypoid lesion with ulceration and erosion

Reflux esophagitis

Stromal atypia

Endoscopic mucosal resection

Honda, 2005

60

M

None

Small polyp with erosion and linear erosion at oral side

Reflux esophagitis

Suspicious for spindle cell sarcoma

Endoscopic submucosal dissection

Present case

F, female; M, male; ND, not described; ECJ, esophagocardiac junction.

Endoscopy_UCTN_Code_CCL_1AB_2AC_3AB


#

Competing interests: None

  • References

  • 1 Isaacson P. Biopsy appearances easily mistaken for malignancy in gastrointestinal endoscopy. Histopathology 1982; 6: 377-389
  • 2 Dirschmid K, Walser J, Hugel H. Pseudomalignant erosion in hyperplastic gastric polyps. Cancer 1984; 54: 2290-2293
  • 3 Shekitka KM, Helwig EB. Deceptive bizarre stromal cells in polyps and ulcers of the gastrointestinal tract. Cancer 1991; 67: 2111-2117
  • 4 Gotoda T, Kondo H, Ono H et al. A new endoscopic mucosal resection (EMR) procedure using an insulation-tipped diathermic (IT) knife for rectal flat lesions. Gastrointest Endosc 1999; 50: 560-563
  • 5 Machida H, Sano Y, Hamamoto Y et al. Narrow-band imaging in the diagnosis of colorectal mucosal lesions: a pilot study. Endoscopy 2004; 36: 1094-1098
  • 6 Wolf BC, Khettry U, Leonardi HK et al. Benign lesions mimicking malignant tumors of the esophagus. Hum Pathol 1988; 19: 148-154
  • 7 Ajiki T, Fujimori T, Hamabe Y et al. Inflammatory esophageal polyp with pseudosarcomatous lesion. Endoscopy 1996; 28: 524-524
  • 8 Moriyama T, Matsumoto T, Jo Y et al. Pseudomalignant erosion in an inflammatory polyp at esophagocardial junction. Gastrointest Endosc 2003; 57: 987-989
  • 9 Honda H, Kume K, Murakami H et al. Pseudomalignant erosion in hyperplastic polyp at esophago-gastric junction. J Gastroenterol Hepatol 2005; 20: 800-803

Corresponding author

M. Fujiya, MD, PhD
Division of Gastroenterology and Hematology/Oncology
Department of Medicine
Asahikawa Medical University
2-1 Midorigaoka-higashi
Asahikawa
Hokkaido 078-8510
Japan   
Fax: +81-166-682469   

  • References

  • 1 Isaacson P. Biopsy appearances easily mistaken for malignancy in gastrointestinal endoscopy. Histopathology 1982; 6: 377-389
  • 2 Dirschmid K, Walser J, Hugel H. Pseudomalignant erosion in hyperplastic gastric polyps. Cancer 1984; 54: 2290-2293
  • 3 Shekitka KM, Helwig EB. Deceptive bizarre stromal cells in polyps and ulcers of the gastrointestinal tract. Cancer 1991; 67: 2111-2117
  • 4 Gotoda T, Kondo H, Ono H et al. A new endoscopic mucosal resection (EMR) procedure using an insulation-tipped diathermic (IT) knife for rectal flat lesions. Gastrointest Endosc 1999; 50: 560-563
  • 5 Machida H, Sano Y, Hamamoto Y et al. Narrow-band imaging in the diagnosis of colorectal mucosal lesions: a pilot study. Endoscopy 2004; 36: 1094-1098
  • 6 Wolf BC, Khettry U, Leonardi HK et al. Benign lesions mimicking malignant tumors of the esophagus. Hum Pathol 1988; 19: 148-154
  • 7 Ajiki T, Fujimori T, Hamabe Y et al. Inflammatory esophageal polyp with pseudosarcomatous lesion. Endoscopy 1996; 28: 524-524
  • 8 Moriyama T, Matsumoto T, Jo Y et al. Pseudomalignant erosion in an inflammatory polyp at esophagocardial junction. Gastrointest Endosc 2003; 57: 987-989
  • 9 Honda H, Kume K, Murakami H et al. Pseudomalignant erosion in hyperplastic polyp at esophago-gastric junction. J Gastroenterol Hepatol 2005; 20: 800-803

Zoom Image
Zoom Image
Fig. 1 Endoscopic image of the lesion using: a conventional colonoscopy; b narrow band imaging (NBI).
Zoom Image
Zoom Image
Zoom Image
Fig. 2 Histological findings of: a biopsy specimen; b, c removed specimens (hematoxylin and eosin; × 40 and × 200 respectively).