女性患者，72岁。最近体重减轻4公斤，没有吞咽困难和胃肠道出血。

肉眼检查，距离胃食管交界3cm处、胃近端可见10*9*1.2cm的肿块，表面隆起，呈牛肉红色，无溃疡形成，连续切片显示肿块位于粘膜层。

I've tried to upload the photos several times. Finally 小荷 helps me put them in.

Please be patience with me. I'm still learning and get there.

Many thanks!

Main clinicopathological features: Elder female with a large mass confined within the mucosal layer. Microscopically, the mass arises in a background of chronic atrophic gastritis with intestinal metaplasia (at the bottom portion of Figure 1 and Figure 2, below). The mass consists of closely packed pyloric gland-type tubules or glands lined by a single layer of columnar or cuboidal epithelium. The cytoplasm is eosinophilic or oncocytic, leading to a "ground-glass" appearance.    Intracellular mucin droplets are not identifiable. Low-grade dysplasia is readily seen, and foci of high-grade dysplasia(complex glandular architecture with marked cytological atypia, without desmoplastic stroma) is also seen. Some of the high-grade dysplasia shown in the photos may be called as “intramucosal adenocarcinoma” using Japanese criteria. 

Diagnosis:

Pyloric gland adenoma with foci of high-grade dysplasia, without definite invasive adenocarcinoma.

Differential Diagnosis:

The differential diagnosis of this case includes hyperplastic polyp, Menetrier disease, and other gastric adenomas, namely gastric foveolar type adenoma and intestinal type adenoma. 

There are overlapping features in pyloric gland adenoma and gastric hyperplastic polyp(GHP). For example, GHP also usually arises in a background of atrophic gastritis.  Characteristically, GHP consists of marked elongation, infolding, and branching of the gastric pits leading to a serrated appearance. Mucin-secreting foveolar cells, some resembling goblet cells, line exaggerated, elongated, and distorted pits.In contrast, pyloric gland adenoma characteristically reveals a cytoplasmic "ground-glass" appearance, rather than foveolar-type cells with prominent apical cytoplasmic mucin droplets. 

In Menetrier disease,  the proliferative epithelium also forms hyperplastic gastric folds, while chronic atrophic gastritis and intestinal metaplasia are absent.

It is essential to distinguish foveolar-type gastric adenoma and pyloric gland adenoma because the latter likely has foci of high grade dysplasia and/or invasive adenocarcinoma. In foveolar type gastric adenoma, the epithelial cells resembling foveolar epithelium similar to that of GHP. Moreover, These lesions usually arise in gastric mucosa which does not show evidence of atrophy or intestinal metaplasia.

Like its counterpart in the coloretum, intestinal-type gastric adenoma usually  contain scattered goblet or Paneth cells, though it also often arise in association with chronic atrophic gastritis.

Key Points

**Pyloric gland adenoma is relatively rare gastric epithelial lesion, which is probably under-recognized by pathologists. It can also occurs in non-gastric organs (it has been reported in the gallbladder 

and pancreas).

**Pyloric adenoma is usually large ( about 2.0cm and larger) at the time of diagnosis. 

**Elder female is the usual patient population.

**Usually it arises in a background of chronic atrophic gastritis with intestinal metaplasia.

**High-grade dysplasia is common, and carefully look for invasive adenocarcinoma is warranted, since reported adenocarcinoma(up to 30% of patients) is usually quite small. 

References

Abraham SC, Montgomery EA, Singh VK, et al. Gastric adenomas. Intestinal-type and gastric-type adenomas differ in the risk of adenocarcinoma and presence of background mucosal pathology. Am J Surg Pathol 2002;26:1276-1285.

Vieth M, Kushima R, Borchard F, Stolte M. Pyloric gland adenoma: a clinico-pathological analysis of 90 cases. Virchows Arch 2003;442: 317-321. 

Chen ZM, Scudiere JR, Abraham SC, Montgomery E. Pyloric gland adenoma. An entity distinct from gastric foveolar type adenoma. Am J Surg Pathol, 2008, 

Vieth M, Kushima R, de Jonge JP, et al. Adenoma with gastric differentiation (so-called pyloric gland adenoma) in a heterotopic gastric corpus mucosa in the rectum. Virchows Arch 2005;446:542-545. 

Happy Labor Day (May 1)!

Excellent differential diagnosis.

I would like to hear more from all of you.

The answer will be posted on April 30.

Thanks.

试翻译：

女性患者，72岁。最近体重减轻4公斤，没有吞咽困难和胃肠道出血。

肉眼检查，距离胃食管交界3cm处、胃近端可见10*9*1.2cm的肿块，表面隆起，呈牛肉红色，无溃疡形成，连续切片显示肿块位于粘膜层。

 谢谢谈教授。

快一年了，复习一下

Main clinicopathological features:主要临床病理特征

Elder female with a large mass confined within the mucosal layer.年长女性，肿块较大，局限于黏膜层内。

Microscopically, the mass arises in a background of chronic atrophic gastritis with intestinal metaplasia (at the bottom portion of Figure 1 and Figure 2, below). 镜下，肿瘤位于慢性萎缩性胃炎背景之下，伴肠化（图1和图2下方）。

The mass consists of closely packed pyloric gland-type tubules or glands lined by a single layer of columnar or cuboidal epithelium. 肿瘤由拥挤的、紧密排列的幽门腺型小管或腺体组成，被覆单层柱状或立方形上皮。

The cytoplasm is eosinophilic or oncocytic, leading to a "ground-glass" appearance.   胞质嗜酸性，呈“毛玻璃样”外观。

Intracellular mucin droplets are not identifiable. 未见细胞内黏液小滴。

Low-grade dysplasia is readily seen, and foci of high-grade dysplasia(complex glandular architecture with marked cytological atypia, without desmoplastic stroma) is also seen. 可见低级别异型增生，并有局灶高级别异型增生（腺体结构复杂，显著细胞学异型性，无促纤维性间质）。

Some of the high-grade dysplasia shown in the photos may be called as “intramucosal adenocarcinoma” using Japanese criteria. 如果采用日本标准，图中一部分高级别异型增生可称为“黏膜内腺瘤”。

Diagnosis:诊断

Pyloric gland adenoma with foci of high-grade dysplasia, without definite invasive adenocarcinoma.

幽门腺腺瘤伴局灶高级别异型增生，无明确的浸润性腺癌。

Differential Diagnosis:鉴别诊断

The differential diagnosis of this case includes hyperplastic polyp, Menetrier disease, and other gastric adenomas, namely gastric foveolar type adenoma and intestinal type adenoma. 本例鉴别诊断包括：增生性息肉，Menetrier病，以及其他胃腺瘤，即胃小凹型腺瘤和肠型腺瘤。

1 增生性息肉（GHP）

There are overlapping features in pyloric gland adenoma and gastric hyperplastic polyp(GHP). 幽门腺腺瘤和胃的增生性息肉（GHP）在形态学上存在重叠。

For example, GHP also usually arises in a background of atrophic gastritis.  例如，GHP也常常发生于萎缩性胃炎背景。

Characteristically, GHP consists of marked elongation, infolding, and branching of the gastric pits leading to a serrated appearance. GHP的特征包括：胃小凹显著增长、折叠、分支，形成锯齿状结构。

Mucin-secreting foveolar cells, some resembling goblet cells, line exaggerated, elongated, and distorted pits.胃小凹细胞可分泌黏液，部分似印戒细胞，被覆于增大、拉长、扭曲的胃小凹内。

In contrast, pyloric gland adenoma characteristically reveals a cytoplasmic "ground-glass" appearance, rather than foveolar-type cells with prominent apical cytoplasmic mucin droplets. 相反，幽门腺腺瘤的特征为胞质呈“毛玻璃”样，而不是具有明显胞质顶端突起黏液小滴的胃小凹型细胞。
2 Menetrier 病

In Menetrier disease,  the proliferative epithelium also forms hyperplastic gastric folds, while chronic atrophic gastritis and intestinal metaplasia are absent.

Menetrier病增生性上皮也形成胃皱襞增多，但无慢性萎缩性胃炎和肠化。

3 胃小凹型胃腺瘤

It is essential to distinguish foveolar-type gastric adenoma and pyloric gland adenoma because the latter likely has foci of high grade dysplasia and/or invasive adenocarcinoma.

重要的是区分胃小凹型胃腺瘤，因为幽门腺腺瘤可能有局部高级别异型增生和/或浸润性腺癌。

In foveolar type gastric adenoma, the epithelial cells resembling foveolar epithelium similar to that of GHP.

胃小凹型胃腺瘤的上皮细胞类似GHP中的胃小凹上皮。

Moreover, These lesions usually arise in gastric mucosa which does not show evidence of atrophy or intestinal metaplasia.而且，这些病变的胃黏膜无萎缩或肠化背景。

4 肠型腺瘤

Like its counterpart in the coloretum, intestinal-type gastric adenoma usually  contain scattered goblet or Paneth cells, though it also often arise in association with chronic atrophic gastritis.与结直肠腺瘤相似，肠型胃腺瘤通常含有散在杯状细胞或Paneth细胞，但它也常常也慢性萎缩性胃炎相伴发。

Key Points要点

**Pyloric gland adenoma is relatively rare gastric epithelial lesion, which is probably under-recognized by pathologists. It can also occurs in non-gastric organs (it has been reported in the gallbladder 

and pancreas).

幽门腺腺瘤是相当罕见的胃病变，对此可能认识不足。它也可以发生于胃以外器官（膀胱和胰腺都有报道）。

**Pyloric adenoma is usually large ( about 2.0cm and larger) at the time of diagnosis. 

幽门腺腺瘤诊断时通常较大（约2.0cm或更大）。

**Elder female is the usual patient population.

年长女性常见。

**Usually it arises in a background of chronic atrophic gastritis with intestinal metaplasia.

背景通常为慢性萎缩性胃炎伴肠化。

**High-grade dysplasia is common, and carefully look for invasive adenocarcinoma is warranted, since reported adenocarcinoma(up to 30% of patients) is usually quite small. 

常有高级别异型增生，必须仔细寻找有无浸润性腺癌，因为报道的腺癌（发生率高达患者数量的30%）通常范围很小。

References

Abraham SC, Montgomery EA, Singh VK, et al. Gastric adenomas. Intestinal-type and gastric-type adenomas differ in the risk of adenocarcinoma and presence of background mucosal pathology. Am J Surg Pathol 2002;26:1276-1285.

Vieth M, Kushima R, Borchard F, Stolte M. Pyloric gland adenoma: a clinico-pathological analysis of 90 cases. Virchows Arch 2003;442: 317-321. 

Chen ZM, Scudiere JR, Abraham SC, Montgomery E. Pyloric gland adenoma. An entity distinct from gastric foveolar type adenoma. Am J Surg Pathol, 2008, 

Vieth M, Kushima R, de Jonge JP, et al. Adenoma with gastric differentiation (so-called pyloric gland adenoma) in a heterotopic gastric corpus mucosa in the rectum. Virchows Arch 2005;446:542-545.