A massive gastric xanthomatosis

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Xanthelasmas, also known as xanthomas, are incidental lesions rarely encountered during upper gastrointestinal endoscopy. We report a case of gastric xanthomatosis in a 49-year-old asymptomatic woman affected by pulmonary B-cell lymphoma. She underwent esophagogastroduodenoscopy to stage her lymphoproliferative disease. The previous medical history was unremarkable, blood chemistry was normal, and she was not receiving any medication. The upper endoscopy showed soft, white/yellowish, isolated, and confluent multiple nodules, 3 – 8 mm in diameter, mainly distributed in the gastric corpus, primarily along the greater curvature ([Fig. 1]). The histopathologic diagnosis was established by the observation of foamy histiocytes in the mucosal layer with hematoxylin and eosin (H&E) staining ([Fig. 2]). The absence of nuclear atypia and cytokeratins ([Fig. 3]) excluded any gastric malignancies. No follow-up was suggested.

Fig. 1 a, b Soft white/yellowish isolated and confluent multiple nodules 3 – 8 mm in diameter mainly distributed in the gastric corpus primarily along the greater curvature.

Fig. 2 Gastric glands with interposed foamy histiocytes with pale or clear cytoplasm and small nuclei, in the lamina propria (hematoxylin and eosin stain [H&E], original magnification × 40).

Fig. 3 Immunohistochemical staining was negative for cytokeratins in the foamy histiocytes (cytokeratin stain, original magnification × 40).

Xanthelasma is usually observed in elderly women and the most frequent gastrointestinal site is the stomach. Gastric xanthomas frequently occur in a mucosa where pathological changes such as chronic gastritis, intestinal metaplasia, atrophic gastritis, or gastric ulcer are observed [1]. Although the pathogenesis of xanthelasma is still unclear, it has been suggested that its development might be a response to mucosal damage by a mechanism in which lipids derived from broken-down cell membranes are captured by intestinal histiocytes [2]. The typical endoscopic appearance of xanthelasma is of yellow-white, well-demarcated, single or multiple nodules or plaques, ranging in size from 1 to 10 mm in diameter [3]. On histopathologic evaluation, they are characterized by the presence of numerous foamy histiocytes in the lamina propria. This microscopic appearance is reminiscent of that observed in signet ring-cell carcinoma, which is histologically the main differential diagnosis associated with xanthelasma [4].

No treatment or follow-up is necessary but histologic assessment is mandatory because some gastric malignancies may also macroscopically resemble these benign lesions [5].

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References

• 1 Vimala R, Ananthalakshmi V, Murthy M. et al . Xanthelasma of esophagus and stomach.  Indian J Gastroenterol. 2000;  19 135
• 2 Gencosmanoglu R, Sen-Oran E, Kurtkaya-Yapicier O, Tozun N. Xanthelasmas of the upper gastrointestinal tract.  J Gastroenterol. 2004;  39 215-219
• 3 Jeong Y S, Park H, Lee D Y. et al . Gastric xanthomatosis.  Gastrointest Endosc. 2004;  59 399-400
• 4 Oviedo J, Swan N, Farraye F A. Gastric xanthomas.  Am J Gastroenterol. 2001;  96 3216-3218
• 5 Luk I SC, Bhuta S, Lewin K J. Clear cell carcinoid tumor of stomach: a variant mimicking gastric xanthelasma.  Arch Pathol Lab Med. 1997;  121 1100-1103