Definition/General
Introduction:
Gastric hemangioma is a benign vascular tumor composed of proliferating endothelial cells
It represents less than 1% of gastric tumors
Most common vascular lesion of the stomach
Can present as solitary or multiple lesions.
Origin:
Arises from vascular endothelium of gastric wall
May originate from submucosal vascular plexus
Can involve multiple layers of gastric wall
Represents hamartomatous proliferation rather than true neoplasm.
Classification:
Capillary hemangioma (most common type)
Cavernous hemangioma (large vascular spaces)
Mixed type hemangioma
Arteriovenous malformation (AVM) variant
Pyogenic granuloma (reactive lesion).
Epidemiology:
Can occur at any age but peak in 4th-5th decades
Equal gender distribution
Rare in children unlike cutaneous hemangiomas
Sporadic occurrence in most cases.
Clinical Features
Presentation:
Gastrointestinal bleeding (60-70% cases)
Iron deficiency anemia from chronic blood loss
Asymptomatic in small lesions
Epigastric pain (20-30%)
Hematemesis and melena in active bleeding.
Symptoms:
Chronic GI bleeding leading to anemia
Acute massive hemorrhage (rare)
Postprandial discomfort
Early satiety in large lesions
Fatigue and weakness from anemia.
Risk Factors:
Vascular malformation syndromes
Hereditary hemorrhagic telangiectasia
Blue rubber bleb nevus syndrome
Klippel-Trenaunay syndrome
Previous gastric trauma or surgery.
Screening:
Upper endoscopy for GI bleeding
CT angiography for vascular assessment
MRI for lesion characterization
Capsule endoscopy for small bowel involvement
Genetic counseling for syndromic cases.
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Gross Description
Appearance:
Red to purple polypoid or sessile lesions
Soft, compressible consistency
Well-demarcated from surrounding mucosa
Multiple lesions possible
Surface ulceration in bleeding cases.
Characteristics:
Spongy texture with blood-filled spaces
Easy bleeding on manipulation
Variable size from few millimeters to several centimeters
Blanching on pressure application.
Size Location:
Size ranges from 0.5-5 cm (most <2 cm)
Antrum most common location (40-50%)
Body and fundus (30-40%)
Multiple locations in syndromic cases.
Multifocality:
Solitary lesions in sporadic cases (80-90%)
Multiple lesions in Blue rubber bleb nevus syndrome
Associated with cutaneous hemangiomas
Small bowel involvement possible.
Microscopic Description
Histological Features:
Proliferating endothelial cells lining vascular spaces
Capillary type: Small, slit-like spaces
Cavernous type: Large, dilated vascular channels
Feeding vessels and draining veins identifiable.
Cellular Characteristics:
Bland endothelial cells without atypia
Single layer lining vascular spaces
Minimal mitotic activity
No cellular pleomorphism
Pericytes around vessels.
Architectural Patterns:
Lobular architecture in capillary type
Large cavernous spaces in cavernous type
Feeding artery and draining vein
Smooth muscle walls in larger vessels.
Grading Criteria:
Benign lesions by definition
No malignant potential
Absence of mitoses and atypia
Well-formed vascular channels
Endothelial cell monolayer.
Immunohistochemistry
Positive Markers:
CD31 (95-100% positive)
CD34 (90-95% positive)
Factor VIII (80-90% positive)
ERG (nuclear, 95% positive)
FLI-1 (nuclear, 90% positive)
Vimentin positive.
Negative Markers:
Cytokeratins negative
S-100 negative
Desmin negative
Smooth muscle actin (negative in endothelium)
KIT negative
GLUT-1 variable.
Diagnostic Utility:
Endothelial markers confirm vascular nature
CD31 and ERG most reliable
Smooth muscle actin highlights vessel walls
Ki-67 shows low proliferation (<5%)
D2-40 may highlight lymphatics.
Molecular Subtypes:
No established molecular subtypes
GLUT-1 expression distinguishes from other vascular lesions
WT1 positivity in some cases
Prox-1 positive in lymphatic components.
Molecular/Genetic
Genetic Mutations:
No consistent genetic alterations
TEK mutations in some familial cases
RASA1 mutations in capillary malformation-AVM
PIK3CA mutations in some vascular malformations
Somatic mosaicism possible.
Molecular Markers:
Low proliferation index (Ki-67 <5%)
VEGF expression variable
Angiopoietin expression
Tie-2 expression
PDGF signaling components.
Prognostic Significance:
Excellent prognosis with appropriate treatment
No malignant potential
Bleeding risk main concern
Recurrence rare after complete excision.
Therapeutic Targets:
Endoscopic therapy (sclerotherapy, band ligation)
Surgical resection for large lesions
Pharmacological: Beta-blockers, corticosteroids
Interventional radiology: Embolization.
Differential Diagnosis
Similar Entities:
Angiosarcoma (malignant vascular tumor)
Kaposi sarcoma
Pyogenic granuloma
Arteriovenous malformation
Glomus tumor
Hemangioendothelioma.
Distinguishing Features:
Hemangioma: Bland endothelium, no atypia
Angiosarcoma: Atypical endothelium, mitoses
Kaposi sarcoma: Spindle cells, HHV-8 positive
Pyogenic granuloma: Reactive, ulcerated surface
AVM: Direct arteriovenous connection.
Diagnostic Challenges:
Distinguishing capillary hemangioma from pyogenic granuloma
Separating from well-differentiated angiosarcoma
Identifying syndromic associations
Sampling artifacts from fragile tissue.
Rare Variants:
Epithelioid hemangioma
Spindle cell hemangioma
Anastomosing hemangioma
Microvenular hemangioma
Targetoid hemosiderotic hemangioma.
Sample Pathology Report
Template Format
Sample Pathology Report
Complete Report: This is an example of how the final pathology report should be structured for this condition.
Specimen
[type], [size] cm
Diagnosis
[Capillary/Cavernous] hemangioma
Features
Benign vascular proliferation with [describe pattern]
IHC
CD31: +, ERG: +, Ki-67: <5%
Final Diagnosis
Gastric [type] hemangioma, [size] cm