Clinical Journal of Gastroenterology

https://doi.org/10.1007/s12328-018-0828-6

CASE REPORT

Vimentin‑positive gastric adenocarcinoma arising in a hyperplastic

polyp
Shogo Kawaguchi1 · Tetsuro Yoshimura1,2 · Hirotake Sakuraba1 · Taka Asari1 · Yohei Sawada1 · Yasumitsu Araki1,2 ·
Koji Kikuchi2 · Toyohito Wada2 · Tomomi Kusumi3 · Shinsaku Fukuda1

Received: 6 November 2017 / Accepted: 30 January 2018

© Japanese Society of Gastroenterology 2018

Abstract
We report a case of vimentin-positive early gastric adenocarcinoma arising in a hyperplastic polyp (HP). A 72-year-old
Japanese man was admitted for the detailed examination of a gastric polyp. He had a subtotal gastrectomy due to acute abdo-
men 12 years ago. Upper endoscopy revealed a pedunculated polyp measuring approximately 2 cm on the greater curvature
of upper body of the remnant stomach. Magnifying endoscopy revealed that the microsurface pattern was irregular and
partially absent accompanied with irregular microvessels at the upper end of the polyp. We speculated that the lesion was
an adenocarcinoma arising in the HP. Endoscopic submucosal dissection (ESD) was performed. Histological examination
of the ESD specimen revealed that the lesion consisted of well- to poorly differentiated adenocarcinoma at the protruding
lesion and foveolar hyperplastic epithelia at the base of the polyp. Immunohistochemically, most of tumor cells that com-
prised poorly-differentiated adenocarcinoma were positive for both cytokeratin and vimentin. Although carcinomas have
occasionally been found in HPs, the histological features of the present case are considered extremely unusual. To the best
of our knowledge, this is the first case of vimentin-positive early gastric carcinoma arising in a HP.

Keywords  Early gastric cancer · Adenocarcinoma · Vimentin · Hyperplastic polyp · ESD

Introduction vimentin-positive poorly differentiated adenocarcinoma aris-

Gastric hyperplastic polyps (HPs) are inflammatory prolif-
erations of the gastric foveolar epithelia and are associated
with chronic atrophic gastritis caused by H. pylori infec-
tion or autoimmune gastritis [1]. Gastric HPs have been
reported to be benign lesions; however, approximately 3%
of the polyps harbor adenocarcinomas [2–4]. Most cases of
adenocarcinoma arising in HPs have been described as well
differentiated; few cases of different histological types of
adenocarcinoma are associated with HPs. We herein report
a rare case of a Japanese man who was diagnosed with
* Shogo Kawaguchi
kawaguchi.s@hirosaki‑u.ac.jp
1
Department of Gastroenterology and Hematology, Hirosaki
University Graduate School of Medicine, 5 Zaifu‑cho,
Hirosaki, Aomori 036‑8562, Japan
2
Department of Gastroenterology, Aomori City Hospital,
Aomori, Japan
3
Department of Pathology, Aomori City Hospital, Aomori,
Japan
ing in gastric HP and treated with endoscopic submucosal
dissection (ESD).
Case report
A 72-year-old Japanese man visited to our hospital for the
detailed examination of a gastric polyp. He had previously
undergone a distal gastrectomy due to acute abdomen at
another hospital 12 years ago. He was positive for serum
anti-H. pylori immunoglobulin G antibody. Upper gastroin-
testinal endoscopy revealed a pedunculated polyp (the sur-
face of which was white-coated) measuring approximately
2 cm on the greater curvature of the upper gastric body of
the remnant stomach (Fig. 1a, b). The color of the polyp
was reddish and partly pale. The upper end of the polyp
was friable and slightly hemorrhagic (Fig. 1c). Magnifying
endoscopy combined with narrow band imaging (ME-NBI)
revealed that the microsurface pattern was regular and the
interfoveolar pattern was swollen at the base of the polyp,
suggesting this area was compatible with hyperplastic lesion

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Fig. 1  Endoscopic findings. A
pedunculated polyp, meas-
uring approximately 2 cm,
was observed on the greater
curvature of upper gastric body
of the remnant stomach (a, b).
The upper end of the polyp was
friable and slightly hemorrhagic
(c)
(Fig. 2a). On the other hand, the surface structure at the
protruding lesion was fine and irregular, suggesting this area
was tumorous (Fig. 2b). Moreover, the microsurface pat-
tern was absent and irregular microvessels were detected
at the upper end of the polyp (Fig. 2c). We speculated that
the lesion was adenocarcinoma arising in HP. ESD was
performed, and the 22-mm lesion was completely resected
with a safe margin both vertically and horizontally (Fig. 3a).
Histologically, hyperplasia of the foveolar epithelia was
detected at the base of the polyp (Fig. 3b), while well- and
poorly differentiated adenocarcinoma was detected at the
protruding lesion (Fig. 3c). The tumor was predominantly
composed of well-differentiated adenocarcinoma, whereas
the poorly differentiated adenocarcinoma cells (the cyto-
plasm of which was broad, clear, and positive for the peri-
odic acid–Schiff (PAS) stain) were medullary proliferated
in the stroma (Fig. 3c, d). A similar finding was observed in
the unstructured area endoscopically detected at the upper
end of the polyp. Immunohistochemical staining revealed
poorly differentiated adenocarcinoma cells that were positive
for both cytokeratin and vimentin (Fig. 4a, b). Some of the
tumor cells similarly expressed human chorionic gonadotro-
pin (hCG) (Fig. 4c). Neither alpha fetoprotein and glypican
3 were not detected. The carcinoma lesion was limited to the
mucosal layer. Neither blood vessel invasion nor lymphatic
vessel invasion were seen. The patient has remained under
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Clinical Journal of Gastroenterology
close observation, and there is no evidence of recurrence
3 years after ESD.
Discussion
Gastric HPs are regarded as benign. However, they occasion-
ally (in 1.8–3.4% of cases) contain malignant lesions [2–4].
The mechanism of carcinogenesis in HPs is speculated to be
dysplasia/carcinoma sequence; namely, as the polyp grows
larger and becomes pedunculated or semipedunculated, a
dysplastic lesion appears, followed by the cancerous lesion
[4]. However, this has not been fully elucidated. The criteria
of Nakamura et al. [5] are commonly used to diagnose the
malignant transformation of HPs. The histological findings
in the present case fulfilled these criteria: (1) the coexist-
ence of benign and malignant parts in the same polyp; (2)
the existence of sufficient evidence that the benign area had
previously been a benign polyp; and (3) the existence of suf-
ficient cellular and structural atypia in the malignant area to
be diagnosed as a cancer.
The histological types of adenocarcinomas arising in HPs
have been described as predominantly well differentiated. A
few cases that showed the other types of differentiation were
reported like poorly differentiated adenocarcinoma or signet
ring cell carcinoma [6–9]. The characteristic histological
Clinical Journal of Gastroenterology
Fig. 2  Magnifying endoscopy
with narrow band imaging (ME-
NBI). The microsurface pattern
was regular and the interfo-
veolar pattern was swollen at
the base of the polyp (a). The
microsurface pattern was fine
and irregular at the protruding
lesion (b). At the upper end of
the polyp, the surface pat-
tern was absent and irregular
microvessels were detected (c)
findings in the present case were that both well- and poorly
differentiated adenocarcinomas were detected in the same
lesion. In this case, the tumor was mainly composed of well-
differentiated adenocarcinoma, while poorly differentiated
adenocarcinoma cells medullary proliferated in the stroma
of the tumor. This distinguishes the histological features of
this case and previously reported adenocarcinomas in HPs.
As mentioned above, dysplastic lesions in HPs are reported
to be associated with the genesis of differentiated adenocar-
cinomas [4]. However, it is not clear whether dysplastic foci
are associated with poorly differentiated adenocarcinomas.
During the immunohistochemical study of the present
case, tumor cells composed of poorly differentiated adeno-
carcinoma expressed both cytokeratin and vimentin, sug-
gesting that they showed rhabdoid features. Vimentin is typi-
cally expressed in mesenchymal tumors, and consequently it
is known as a mesenchymal marker. Although it is unusual
for epithelial tumors to express vimentin, it is known that
vimentin expression may be apparent in carcinomas with
rhabdoid differentiation of the kidney, uterus, and so on [10,
11]. Vimentin-positive gastric adenocarcinomas are reported
to be rare, occurring in approximately 0.4% of all surgically
resected specimens [12, 13]. Poorly differentiated adeno-
carcinoma cells with medullary proliferation sometimes
express vimentin. The tumor cells are round to polygonal
with eosinophilic cytoplasm and eccentric vesicular nuclei
[13]. Of clinical relevance is that vimentin-positive gastric
cancers are very aggressive and related to poor prognosis
due to rapid growth and metastasis [14–16]. Moreover,
adenocarcinomas that co-express cytokeratin (i.e. 53.3%
of vimentin-positive adenocarcinomas) are associated with
worse prognosis [15]. Because of their aggressive behavior,
vimentin-positive early gastric cancers are considered to be
extremely rare [13, 17]. Although vimentin is not expressed
in conventional gastric adenocarcinoma cells, it has been
suggested that tumor cells that dedifferentiate through epi-
thelial mesenchymal transition (EMT) can express vimentin.
Consequently, they can acquire the mesenchymal phenotype
as well as cancer stem cell-like phenotype [18]. Recent evi-
dence has established that the aberrant activation of EMT
plays a crucial role in the tumor progression and metastatic
potential [18]. EMT is reported to be associated with not
only tumor progression, but tumor initiation, therefore it is
possible that molecular mechanisms of EMT are activated
even in instances of early gastric cancers such as the pre-
sent case. Nevertheless, it is not fully understood how the
microenvironment affects the EMT of the tumor cells. Fur-
ther investigations are needed to elucidate the mechanisms
of carcinogenesis in HPs. Additionally, careful histological
investigations are warranted in cases where the characteristic
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 Clinical Journal of Gastroenterology

Fig. 3  Histological findings. a Loupe image of the ESD specimen. b detected at the upper end of the polyp (×1.25). d High magnification
Hyperplastic glands were detected at the base of the polyp on H&E image of the mixture of well- and poorly-differentiated adenocarci-
staining (×1.25). c Well- to poorly-differentiated adenocarcinoma was noma (×20)

Fig. 4  Immunohistochemical
findings. The poorly-differenti-
ated adenocarcinoma cells were
positive for both vimentin (a)
and cytokeratin (b) (×20). A
part of the tumor cells was posi-
tive for hCG (c) (×20)

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Clinical Journal of Gastroenterology
finding of poorly differentiated adenocarcinoma is demon-
strated because vimentin might be expressed even if it is
carcinoma in HPs. To the best of our knowledge, there are
no previous reports on vimentin-positive early gastric adeno-
carcinoma arising in gastric HP. Thus, the present case is
considered quite unique and valuable for the report because
we were able to perform a detailed endoscopic observation
of vimentin-positive cancer prior to progression. Further, we
were able to prove that gastric HPs might contain vimentin-
positive adenocarcinoma.
Furthermore, some of the poorly differentiated adenocar-
cinoma cells expressed hCG. This finding suggests that these
cells might tend to dedifferentiate to choriocarcinoma cells
as well as undifferentiated carcinoma cells with rhabdoid
feature simultaneously, because it is generally accepted that
the dedifferentiation of adenocarcinoma cells may cause the
genesis of gastric choriocarcinoma cells [19]. However, it
is difficult to prove whether EMT involves the acquisition
of an atypical tumor cell phenotype as was observed in this
case. Further studies are needed to elucidate the association
between tumorigenesis of HPs and EMT.
It is sometimes difficult to find cancers coexisting with
HPs using conventional white light endoscopy. It has been
reported that ME-NBI may be useful to diagnose those gas-
tric cancers. Horiuchi et al. reported that abnormal micro-
vasculature and fine mucosal structure were detected at the
area of carcinoma by ME-NBI [20]. According to the report,
combining lesion size (not less than 20 mm) and ME-NBI
findings had a diagnostic accuracy of 100% sensitivity and
58% specificity for detecting the focal cancers coexisting
with gastric HPs [20]. In the present case, the irregular
microsurface pattern and microvessels were detected at the
top of the polyp as described in the report, which assisted in
detecting adenocarcinoma. Although the unstructured area
was detected using ME-NBI at the upper end of the polyp,
it was histologically confirmed that the poorly differentiated
adenocarcinoma did not focally exist at this area, but the
whole tumor was composed of a mixture of well- and poorly
differentiated adenocarcinoma. We speculate that the super-
ficial erosion of the polyp affected the endoscopic finding.
In conclusion, we reported quite a unique case of gastric
adenocarcinoma arising in a HP with unusual features of
differentiations. Careful endoscopic observation is needed
for HPs because not only well-differentiated adenocarci-
noma but also atypical histological types of carcinoma
could coexist.
Compliance with ethical standards  2010;30:5239–43.
Conflict of interest  Shogo Kawaguchi, Tetsuro Yoshimura, Hirotake
Sakuraba, Taka Asari, Yohei Sawada, Yasumitsu Araki, Koji Kikuchi,
Toyohito Wada, Tomomi Kusumi and Shinsaku Fukuda declare that
they have no conflict of interest.
Human/animal rights   All procedures followed have been performed in
accordance with the ethical standards laid down in the 1964 Declara-
tion of Helsinki and its later amendments.
Informed consent  Informed consent was obtained from the patient for
being included in the study.
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