Gastritis Cystica Profunda Versus Invasive Adenocarcinoma To the Editor: We read with interest the case report by Greywoode et al 1 titled “Iatrogenic Deep Epithelial Misplace- ment (Gastritis Cystica Profunda) in a Gastric Foveolar-Type Adenoma After Endoscopic Manipulation: A Diag- nostic Pitfall.” The authors describe a 62-year-old man who presented with a sessile, somewhat irregular, nodular mass lesion (gross figure 1A) that could not be removed endoscopically and, thus, ultimately led to a sleeve resection of the stomach. The authors provide 3 microscopic photographs of the lesion, 2 of which (figure 1C and 1D) show low-power and medium-power views of the wall of the stomach and the mus- cularis propria, respectively. Although, admittingly, it is difficult to establish diagnoses on the basis of 2 microscopic photographs in a published journal, it is our opinion, based on an evaluation of these photographs, that the wall of the stomach and the muscularis propria reveal an invasive well-differentiated adenocarcinoma. On the basis of the photographs, the lesion is seen to reveal an infiltrative and dissecting pattern of irregularly shaped glands that vary in size, shape, and contour, some with irregular outpouchings and sharp edges and focally containing intraluminal inflammation and necrotic debris, all features characteristic of an invasive well-differentiated adenocarcinoma. In contrast, gastritis cystica profunda, otherwise known as benign misplaced glands, typically shows glands in the submucosa and/or muscularis propria/ serosa that contain a well-circumscribed lobular arrangement containing a dis- crete rim of lamina propria and often with evidence of tissue reaction such as hemorrhage, hemosiderin, and/or stro- mal reactive changes indicative of prior tissue injury. 2,3 These features are not present in the photographs. The au- thors describe the glands in this case as “noninfiltrative,” with “smooth con- tour,” and “do not invade the muscu- laris propria.” We believe that the figures show, in contrast, quite the op- posite. In addition, the authors do not describe the features of the background stomach, as to whether the patient has an underlying chronic gastritis with or without intestinal metaplasia that may have represented the precursor inflam- matory disorder for an invasive cancer or whether the patient was H. pylori posi- tive. Furthermore, the authors do not describe immunohistochemical findings with regard to Ki67, which we believe would show that the mural glands are proliferative. Other oncogenetic mark- ers, such as p53 or SMAD4, may be helpful as well. The authors indicate that a plausible explanation for the occur- rence of glands within the muscularis propria is related to 3 previous endo- scopic manipulations. However, in order for benign glands to proliferate in the deep portion of the muscularis propria, abutting the serosa, it is likely that endoscopic manipulation with electro- cautery would have caused a defect in the wall of the stomach and, thus, a perforation. The photographs do not reveal any evidence of postendoscopic tissue reaction in the deep portion of the wall. Perhaps the authors can provide more high-power photomicrographs and/or immunohistochemical stains, which can support their theory that this case represents misplacement of benign glands rather than adenocarcinoma. Robert Daniel Odze, MD, FRCPC* Joel Greenson, MDw Gregory Lauwers, MDz John Goldblum, MDy *Brigham and Women’s Hospital Boston, MA wUniversity of Michigan Health System Ann Arbor, MI zMasachusett General Hospital Boston, MA yCleveland Clinic, Cleveland, OH Conflicts of Interest and Source of Funding: The authors have disclosed that they have no significant relationships with, or financial in- terest in, any commercial companies pertaining to this article. REFERENCES 1. Greywoode G, Szut A, Wang LM, et al. Iatrogenic deep epithelial misplacement (gastritis cystica profunda) in a gastric foveolar-type adenoma after endoscopic manipulation: a diagnostic pitfall. Am J Surg Pathol. 2011;35:1419–1421. 2. Franzin G, Novelli P. Gastritis cystica profunda. Histopathology. 1981;5:535–547. 3. Turner JR, Odze RD. Polyps of the stom- ach. In: Odze RD, Goldblum JR, eds. Surgical Pathology of the GI Tract, Liver, Biliary Tract, and Pancreas. Philadelphia, PA: Saunders Elsevier; 2009:415–445. Gastritis Cystic Profunda Versus Adenocarcinoma In Response: 1. There, indeed, was a defect in the wall passing through the muscu- laris propria and extending close to the serosal fat in a clearly defined area that contained the misplaced and deep-lying glandular struc- tures (as seen in figs. 1A, B of the original paper). The prolapsed/ misplaced glands extended into the muscularis propria and beyond in only one area: this was directly related to the area of repeated ele- ctrocautery. Outside this localized area, the gastritis cystica profunda was restricted to the submucosa, and there were no other areas of extension into the muscularis pro- pria. The presence of diathermied, nonviable, infarct-like tissue within the defect is evidence of postendo- scopic reaction in the deep aspect of the wall (Fig. 1). Occasional glands that are entrapped within this area show focal rupture, acute in- flammation, and surrounding gran- ulation tissue (Fig. 1, inset top left). The defect in the wall did not cause an overt clinical perforation, but, as can be seen in figs. 1C, D from the original manuscript, the defect with the lesion has pushed through the muscularis propria and is close (within a millimeter) to the serosal fat. 2. The background gastric mucosa did not show intestinal metaplasia. There was no evidence of chronic gastritis, and Helicobacter pylori were not identified. There was no LETTERS TO THE EDITOR 316 | www.ajsp.com Am J Surg Pathol  Volume 36, Number 2, February 2012