University of Maryland Medical Center Baltimore, MD, United States
Brandon Rodgers, MD1, Grace Kim, MD1, Daniel G. Hwang, MD2, Whitney Green, MD3, Lance Uradomo, MD2 1University of Maryland Medical Center, Baltimore, MD; 2University of Maryland School of Medicine, Baltimore, MD; 3University of Maryland Baltimore Washington Medical Center, Baltimore, MD
Introduction: Xanthomas are lipid deposits found most often in the subcutaneous tissue and skin. Xanthomas can also present within the gastrointestinal tract, most commonly in the stomach. Incidence of gastric xanthomas ranges from 0.23% to 7%, and they are associated with Helicobacter pylori infection, chronic gastritis, and hyperlipidemia. Xanthomas are usually asymptomatic diagnosed incidentally via endoscopy. Here we present a unique presentation of a symptomatic xanthoma diagnosed with endoscopic ultrasound guided fine needle biopsy (EUS-FNB).
Case Description/Methods: An 84-year-old man with congestive heart failure and squamous cell carcinoma of the skin presented with one episode of large volume hematemesis. Upper endoscopy revealed a hiatal hernia with a 4-5 centimeter friable mass protruding into the hiatal hernia sac (Figure 1a). Initial pathology of the mass was non diagnostic but concerning for leiomyosarcoma upon review in multidisciplinary tumor board. Patient underwent EUS which showed a 2-centimeter mass in the cardia. Although pathology was negative for malignancy, positron emission tomography/computed tomography (PET/CT) demonstrated mild localization to the gastroesophageal junction. A repeat EUS showed a well-defined, hypoechoic, heterogenous subepithelial mass in the cardia (Figure 1b). FNB confirmed the mass to be a xanthoma (Figure 1c, 1d).
Discussion: Gastric xanthomas can often have similar histologic appearances to gastric malignancies including signet ring cell carcinoma, and xanthoma cell proliferation has also been shown in early gastric cancer. In our case, because of the patient’s age and presentation of hematemesis, malignancy was high on the differential. Our case highlights the importance of EUS guided FNB to provide adequate tissue sample for accurate diagnosis. Furthermore, our case raises the question of how frequently patients with gastric xanthomas should be monitored endoscopically given its association with development of gastric cancer and histopathologic similarities to malignancies. To our knowledge, this is the first case reported in the literature of a gastric xanthoma presenting with hematemesis. Interestingly, initial endoscopy showed the mass to be friable, which was not found on repeat endoscopies. This case shows the possibility for gastric xanthomas to present symptomatically rather than more typically as an incidental finding.
Figure: Figure 1: (a) Friable gastric mass (b) Subepithelial mass visualized on endoscopic ultrasound (c) Gastric mass FNB with clusters of foamy macrophages containing lipid vacuoles admixed with hemosiderin-laden macrophages containing iron (d) CD68 immunochemical stain highlighting the macrophages
Disclosures: Brandon Rodgers indicated no relevant financial relationships. Grace Kim indicated no relevant financial relationships. Daniel Hwang indicated no relevant financial relationships. Whitney Green indicated no relevant financial relationships. Lance Uradomo indicated no relevant financial relationships.
Brandon Rodgers, MD1, Grace Kim, MD1, Daniel G. Hwang, MD2, Whitney Green, MD3, Lance Uradomo, MD2. P3101 - A Case of a Gastric Xanthoma Presenting as Hematemesis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.