Reply to Matsushita et al.

I would like to thank Dr. Matsushita and colleagues for their interest in my article [1]. Apart from stromal tumors, submucosal lesions of the stomach are uncommon. Ectopic pancreas and, more rarely, adenomyoma are occasionally reported. The histological features of adenomyoma were first described in 1903 by Magnus-Alsleben after incidental identification of five cases at autopsy [2]. While only fewer than 40 cases of gastric adenomyoma had been described up to 1993 [3], ectopic pancreas is relatively more common, with a reported incidence of about 0.25 % during abdominal operations [4].

Gastric adenomyoma has been consistently reported in the pyloric or antral region [3] [5] [6]. Macroscopically, a cystic center is frequently found inside the lesion [6] [7]. Histologically, there is a mixture of glandular elements and smooth muscle. The glandular elements consist of mainly tall columnar epithelium lining areas of cystic spaces. In between the glandular elements are smooth muscles, which are mostly hypertrophic [6].

There has been continuing controversy as to whether gastric adenomyoma is a variant of ectopic pancreas. Whereas a number of authors have expressed doubt that adenomyoma is a separate entity [8], others have taken a different view [3] [6] [7]. Although I do not think that the controversy can be resolved here, I agree with Dr. Matsushita that the EUS features that we described were quite similar. If, in fact, the lesions described by Dr. Matsushita and colleagues were ”adenomyoma”, my claim to have presented the first report would not stand. It was based on a literature search for gastric adenomyoma. I also agree with Dr. Matsushita that endoscopic resection can be performed for selected patients with submucosal lesion. However, when there is doubt about the exact nature of a lesion, laparoscopic resection allows the whole thickness of the stomach wall to be examined. Laparoscopic resection for gastric submucosal tumors, including ectopic pancreas, has also been reported [9] [10].

References

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• 8 Cimmino C V. Gastric adenomyosis vs. aberrant pancreas.  Radiology. 1955;  65 73-77
• 9 Hackett T R, Memon M A, Fitzgibbons R J, Mixter C G. Laparoscopic resection of heterotopic gastric pancreatic tissue.  J Laparoendosc Adv Surg Tech A. 1997;  7 307-312
• 10 Shimizu S, Noshiro H, Nagai E. et al . Laparoscopic wedge resection of gastric submucosal tumors.  Dig Surg. 2002;  19 169-173