Ectopic Tissue in the Stomach Wall Harbors Stunning Diagnosis

Abstract

Question: A 48-year-old patient was referred for gastroscopy and colonoscopy because of anemia. Personal history was otherwise unremarkable except for Wolf-Parkinson-White syndrome. Gastroscopy showed a submucosal 2 4-cm tumor in the antrum with a central retraction (Figure A, endoscopic finding). On endosonography and MRI, a submucosal tumor was evident, confined to the antral wall, without invasion of the muscularis propria. We performed an endoscopic submucosal dissection (Olympus GIF – H 180). Tumor margins were marked with argon plasma coagulation. For submucosal injection, we used adrenaline (Bichsel, Interlaken, Switzerland), methylene blue (Hanseler, Herisau, Switzerland), and physiogel (gelatine, B. Braun, Melsungen, Germany). In toto resection of the 2 4-cm tumor (Figure B, resection procedure) was done both with dual knife (Olympus, Volketswil, Switzerland) and hook knife (Olympus, Volketswil, Switzerland). Surveillance and 4-day hospitalization were uneventful. Anemia and iron deficiency resolved completely within few days postoperatively after initial iron replacement therapy. Gross pathologic examination showed a well-circumscribed firm submucosal tumor (maximum. 2.5 cm) with a greyish-white cut surface, covered by a normal-appearing gastric mucosa. The histology surprisingly revealed an ectopic lymph node, located in the submucosa, with infiltration of an atypical lymphoid cell population (Figure C, overview). The overlying mucosa was normal, without signs of acute or chronic gastritis. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.