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Gastric hyperplastic polyps are associated with a risk of neoplastic transformation reaching 10% in a previous study by our team. In this work, retrospectively including 145 gastric hyperplastic polyps, a higher risk of neoplastic changes was associated with a lesion size over 25mm [1]. Nevertheless, the neoplastic component was never predicted by the endoscopic examination before the resection but discovered either on the biopsy samples or on the resected specimen. Here we report the case of a 73-year-old woman followed in our unit for hepatocellular carcinoma developed on a noncirrhotic liver (fibrosis F2) previously treated by hepatectomy. She underwent upper gastrointestinal (GI) endoscopy to detect portal hypertension, and two gastric polyps were diagnosed at the junction of the antrum and gastric body. Helicobacter pylori infection was confirmed. One of the two polyps, measuring less than 2 cm in diameter, presented hyperplastic features on one part of the polyp but also an irregular pit and vascular pattern on a flat area with a demarcation line (▶Fig. 1). An advanced endoscopic diagnosis wasmade with dual focus and acetic acid dye revealing, as previously demonstrated in Barrett’s esophagus [2], a quicker acetowhitening disappearance in the malignant component compared to the hyperplastic component (▶Video 1). This lesion was resected with endoscopic submucosal dissection, and histology revealed a gastric hyperplastic polyp with intramucosal adenocarcinoma resected completely with free margins (R0). This case describes for the first time a clear endoscopic diagnosis of a malignant component within a gastric hyperplastic polyp. In view of the high risk of local recurrence [3] after endoscopic resection, reserving these resections for lesions with neoplastic transformation identified endoscopically could be a better option than a systematic resection of all large gastric hyperplastic polyps.

Malignant gastric hyperplastic polyp: endoscopic features of the demarcated malignant component.