Endoscopic resection of granular cell tumors in the gastrointestinal tract: a single center experience

Gastric granular cell tumor: A case report and literature review

Granular cell tumors (GCTs) are neoplasms of uncertain histopathological etiology and therefore there are no universally accepted treatment strategies. GCTs are characterized by abundant eosinophilic granules. Since they are predominantly located in the skin and subcutaneous tissues, gastric GCTs are exceedingly rare. The present study documents the case of a 52-year-old man who visited the Gastroenterology Clinic of the People's Hospital of Putuo District (Zhoushan, China) due to upper abdominal fullness. Endoscopic ultrasonography revealed a well-defined hypoechoic nodule in the submucosal layer of the stomach body. The lesion was completely excised using endoscopic submucosal dissection and the patient made a full postoperative recovery. Immunohistochemistry showed positivity for S100 and CD68, with CD34 expression surrounding the tumor cells. At telephone follow-up until May 2024, the patient's fullness and discomfort were noted to be relieved. The characteristics of the CD34 expression pattern may serve as a novel basis for the pathological diagnosis of gastric GCTs. Endoscopic resection is a feasible option for gastric GCTs smaller than 2 cm.

The Diagnosis of Small Gastrointestinal Subepithelial Lesions by Endoscopic Ultrasound-Guided Fine Needle Aspiration and Biopsy

Endoscopic ultrasonography (EUS) has been widely accepted in the diagnosis of all types of tumors, especially pancreatic tumors, lymph nodes, and subepithelial lesions (SELs). One reason is that the examination can provide a detailed observation, with tissue samples being immediately obtained by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). Many SELs are detected incidentally during endoscopic examinations without symptoms. Most SELs are mesenchymal tumors originating from the fourth layer, such as gastrointestinal stromal tumors (GISTs), leiomyomas, and schwannomas. GISTs are potentially malignant. Surgical treatment is recommended for localized GISTs of ≥20 mm. However, the indications for the diagnosis and follow-up of GISTs of <20 mm in size are controversial. There are several reports on the rapid progression or metastasis of small GISTs. Therefore, it is important to determine whether a SEL is a GIST or not. The main diagnostic method is EUS-FNA. Recently, endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) using a new biopsy needle has been reported to obtain larger tissue samples. Additionally, various biopsy methods have been reported to have a high diagnostic rate for small GISTs. In local gastric SELs, regardless of the tumor size, EUS can be performed first; then, EUS-FNA/B or various biopsy methods can be used to obtain tissue samples for decision-making in relation to therapy and the follow-up period.

Systematic Endoscopic Approach for Diagnosing Gastric Subepithelial Tumors

Subepithelial tumors (SETs) are commonly encountered during upper gastrointestinal endoscopy, especially during national gastric cancer screening programs in Korea. Although the majority of SETs are benign, endoscopists harbor concerns regarding whether a SET is benign or malignant because the diagnosis cannot be established on the basis of routine endoscopic biopsy findings. The differential diagnosis of SETs is important, beginning with meticulous endoscopic examination, including the evaluation of the location, macroscopic shape, color, surface characteristics, mobility, consistency, and size of the tumors. The yield of endoscopic biopsy increases with the use of the bite-on-bite technique for SETs without the rolling or tenting sign, with large openings, and with erosion or ulceration. In this review, a systematic approach for the diagnosis of gastric SETs during conventional endoscopy is introduced.

Rare case of granular cell tumor of perianal region: a case report and literature review

Granular cell tumors (GCTs) are rare submucosal neoplasms, with tumors in the oral mucosa accounting for about a third of all cases. In contrast, GCT is a rare anal neoplasm, with fewer than 30 cases of perianal GCT reported in the literature. We report the case of a 36-year-old woman with a perianal lump with no obvious local lesion as the main clinical complaint. The tumor was completely resected and histologically confirmed as a GCT. The patient remained under continuous follow-up. GCT is difficult for surgeons and pathologists to diagnose, and biopsy and immunohistochemical analysis are prerequisites for an accurate diagnosis. An integrated understanding of GCT in terms of its differential diagnosis will contribute to better identification and more appropriate treatment of this disease.

Gastrointestinal and biliary granular cell tumor: diagnosis and management

Granular cell tumors (GCTs) are generally thought to be of Schwann cell origin and are typically S-100 positive. Up to 11% of these tumors affect the gastrointestinal tract, most commonly the esophagus, colon, and stomach. While GCTs are mostly benign, malignant and metastatic GCTs have been reported. GCTs are usually found incidentally during esophagogastroduodenoscopy, colonoscopy, imaging studies or during the evaluation of non-specific symptoms. Endoscopically, they are typically yellow in appearance with intact mucosa. On endoscopic ultrasound, they usually are hypoechoic, homogenous, smooth-edged lesions that appear to originate from the submucosal layer, although other endoscopic and ultrasound appearances have been described. There is no consensus on how to treat GCT. Surgical and conservative approaches have been described in the literature. GCTs can also affect the biliary tract, where patients may be misdiagnosed with cholangiocarcinoma. We explore the epidemiology, histology, clinical presentation, diagnosis and treatment of these tumors in the gastrointestinal tract, including the pharynx, esophagus, stomach, small intestine, large intestine and the perianal region. In addition, GCTs in the biliary tract are reviewed.

Early gastric cancer with diffuse heterotopic gastric glands and granular cell tumors mimicking advanced gastric cancer

INTRODUCTION

Heterotopic gastric grands (HGGs) are gastric grands that are observed in the submucosa and are considered to be paracancerous lesions or precursors of gastric cancer (GC). Granular cell tumors (GCTs) are benign neural origin tumors. Gastrointestinal GCTs are rare and gastric GCTs are seldom seen. We report the case of a patient who was diagnosed with early GC with diffuse HGGs affecting the whole stomach and two GCTs mimicking advanced GC.

PRESENTATION OF CASE

The patient is a 71-year-old male with epigastric discomfort. Gastrointestinal endoscopy revealed an ulcerated lesion at the mid-gastric body. A biopsy specimen indicated adenocarcinoma. Moreover, gastrointestinal endoscopy revealed a submucosal tumor at the posterior wall and multiple transparent protuberances across the entire stomach. Computed tomography demonstrated diffuse gastric wall thickening with lymphadenopathies. Total gastrectomy was performed under the preoperative diagnosis of advanced GC with lymph node metastases. The pathological diagnosis was adenocarcinoma invading submucosal stroma without lymph node metastasis, two GCTs, and diffuse HGGs affecting whole stomach.

DISCUSSION

Preoperative diagnosis of GC depth or range associated with HGGs is often difficult. Although diffuse HGGs are sometimes observed, there is no previous report of a case of HGGs with whole gastric wall thickening observed by computed tomography. As a result, this case was overdiagnosed as advanced GC. Although the relationship between GCTs and HGGs or GC is unclear, there is no case report of GCTs accompanied by HGGs or GC.

CONCLUSION

This case report suggested that cautious preoperative assessment for GC co-occurring with HGGs is required.

Endoscopic resection for small esophageal submucosa tumor: Band ligation versus conventional endoscopic mucosal resection

Because an esophageal submucosa tumor (SMT) may be malignant despite its small size, a safe endoscopic resection method is needed in some small SMTs. Conventional endoscopic mucosal resection (EMR) may be simple, but incomplete pathologic resection margin status is common. We aimed to investigate the clinical outcomes of 2 kinds of EMR techniques (conventional EMR and EMR with band ligation device) and to evaluate the factors associated with incomplete pathologic resection.We evaluated the medical records of 36 patients. All lesions were esophageal SMTs located in the submucosa or muscularis mucosa less than 10 mm in size by endoscopic ultrasound (EUS). The clinical outcomes based on the endoscopic procedures and factors associated with incomplete pathologic resection were evaluated.The mean tumor size was 6.6 ± 4.1 mm. The overall en bloc and complete resection rates were 100% and 80.6%, respectively. No procedure-related complications, such as perforation and bleeding, were found. Univariate analysis showed that complete resection rates were higher in granular cell tumors than in leiomyomas (82.8% vs 17.2%, P = .029), tumors located in the submucosa layer than in the muscularis mucosa (96.6% vs 3.4%, P = .003), and in EMR with band ligation device than in conventional EMR (82.8% vs 17.2%, P < .001). Multivariate analysis showed that conventional EMR was the only significant factor associated with incomplete resection (OR, 35.594; 95% CI, 2.042-520.329; P = .014)EMR with a band ligation device is an effective and safe treatment method for small esophageal SMT.

Progress in research of esophageal granular cell tumors

Esophageal granular cell tumor is a rare benign soft tissue tumor with malignant potential, and its histogenesis remains unclear. Since clinical manifestations lack specificity, the diagnosis depends on endoscopy, endoscopic ultrasonography, pathology and immunohistochemistry. Esophageal granular cell tumors have the potential of malignant transformation and are easily confused with leiomyoma and interstitialoma. At present, the treatment of this disease has not yet reached a consensus. This review aims to elucidate the histogenesis, clinical manifestations, diagnosis, treatment and prognosis of esophageal granular cell tumors.

Endoscopic resection of colorectal granular cell tumors

AIM: To determine the feasibility and effectiveness of endoscopic resection for the treatment of colorectal granular cell tumors (GCTs).

METHODS: This was a retrospective study performed at a single institution. From January 2008 to April 2015, we examined a total of 11 lesions in 11 patients who were treated by an endoscopic procedure for colorectal GCTs in the Endoscopy Center, Zhongshan Hospital of Fudan University, Shanghai, China. Either endoscopic mucosal resection or endoscopic submucosal dissection (ESD) was performed by three surgeons with expertise in endoscopic treatment. The pre- and post-operative condition and follow-up of these patients were evaluated by colonoscopy and endoscopic ultrasonography (EUS).

RESULTS: Of these 11 lesions, 2 were located in the cecum, 3 were in the ileocecal junction, 5 were in the ascending colon, and 1 was in the rectum. The median maximum diameter of the tumors was 0.81 cm (range 0.4-1.2 cm). The en bloc rate was 100%, and the complete resection rate was 90.9% (10/11). Post-operative pathology in one patient showed a tumor at the cauterization margin. However, during ESD, this lesion was removed en bloc, and no tumor tissue was seen in the wound. No perforations or delayed perforations were observed and emergency surgery was not required for complications. All patients were followed up to May 2015, and none had recurrence, metastasis, or complaints of discomfort.

CONCLUSION: Endoscopic treatment performed by endoscopists with sufficient experience appears to be feasible and effective for colorectal GCTs.

Benign esophageal tumors

Benign esophageal and paraesophageal masses and cysts are a rare but important group of pathologies. Although often asymptomatic, these lesions can cause a variety of symptoms and, in some cases, demonstrate variable biological behavior. Contemporary categorization relies heavily on endoscopic ultrasound and other imaging modalities and immunohistochemical analysis when appropriate. Minimally invasive options including endoscopic, laparoscopic, and thoracoscopic methods are increasingly used for symptomatic or indeterminate lesions.

Endoscopic resection using band ligation for esophageal SMT in less than 10 mm

AIM: To evaluate the safety and feasibility of endoscopic resection using band ligation (EMR-B) for the diagnostic and therapeutic removal of tumors located in the esophageal subepithelial region having originated from the submucosa.

METHODS: From May 2009 to September 2014, after medical chart and endoscopic ultrasonography report review, a total of 15 esophageal tumors located in the submucosal layer were resected by EMR-B. Previous symptom, location, pathology, complete resection rate, incidence of complications, incidence of minor complication, size, length of procedures time and follow up months were evaluated. To evaluate local recurrence at the resection site, periodic follow-up endoscopic examination was undertaken in all of the patients. The first endoscopic examination was performed about 6 mo after the endoscopic resection. Thereafter, the endoscopic follow up were scheduled annually.

RESULTS: The mean age was 50.3 ± 9.67 years. The mean tumor size was 6.93 ± 3.15 mm and most of the lesions size was between 5-10 mm in diameter (10/15, 66.6%). In all patients, endoscopic en bloc resection was achieved. In one patient, the vertical margin was involved. The mean procedural time was 8.86 ± 3.66 min. In all patients, no evidence of severe complications such as perforation or bleeding occurred. Minor complications such as chest pain (2/15, 13.3%) and heartburn (3/15, 13.3%) were reported but they symptoms were controlled by proton pump inhibitors, ulcermin and/or analgesics. Histologic assessments of the removed specimens revealed 10 granular cell tumors (66.6%), 4 leiomyomas (16.6%) and one lipoma (6.6%). No recurrence was observed during the mean follow up period of 45 ± 3.5 mo (range: 5-64 mo).

CONCLUSION: EMR-B might be considered safe and effective for the diagnosis and treatment of lesions measuring less than 10 mm in diameter.

Granular cell tumor of the gastrointestinal tract: histologic and immunohistochemical analysis of 98 cases

Granular cell tumors (GCTs) are uncommon benign neoplasms in the gastrointestinal (GI) tract, and our current understanding of GCT in GI tract is limited. A total of 98 GCTs were retrieved from 95 patients, and the clinicopathological and immunohistochemical features were compared. The male-to-female ratio was 2.2:1 and with a mean age of 49 years. The mean tumor size was 0.37 cm. Seventy-three esophageal (75%), 21 colorectal (21%), and 4 gastric (4%) GCTs were included. Gastric (mean, 0.75 cm) and colorectal (0.6 cm) GCTs were significantly larger than esophageal tumors (0.27 cm; P<.001). Colonic and gastric GCTs showed a more infiltrative growth pattern (P<.001) and peritumoral lymphoid cuffs (P<.001) than esophageal tumors. Involvement of mucosa, submucosa, and both were noted in 58 cases (59%), 11 cases (11%), and 28 cases (29%), respectively. One GCT from the sigmoid colon (1%) had infiltration to pericolic soft tissue and with lymph node metastasis. High frequency of immunolabeling for S-100 protein (81/81, 100%), CD56 (55/58, 95%), CD68 (58/61, 95%), SOX-10 (54/58, 93%), and inhibin-α (30/58, 52%) were observed. In summary, GCTs in the GI tract were observed with the following frequency: esophagus, colorectum, and stomach. Colorectal and gastric GCTs were larger and had infiltrative growth and more lymphoid cuffs than esophageal GCTs. Although invasive GCT was rare, it could be observed in the GI tract. Inhibin-α expression were more common in colonic GCTs than esophageal tumors. High S-100 protein, CD56, CD68, and SOX-10 expression rates were observed in GCTs from GI tracts.