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Gastric hyperplastic polyps (hyperplasiogenic polyps): a constant debate!
The manuscript by Forté et al.  reported the clinical outcomes of 145 gastric hyperplastic polyps in 108 patients in the context of a retrospective multicenter study. Studies have reported marked variabilities in the detection of gastric hyperplastic polyps        ; however, the differing frequencies of gastric hyperplastic polyps, between 28 % and 75 %, are due to the authors' definitions of gastric hyperplastic polyps. Unfortunately, gastric hyperplastic polyps are often mixed up with foveolar hyperplasia, but it has been proven that foveolar hyperplasia shows a different morphology and is not a precursor of a gastric hyperplastic polyp  . Forté et al.  reinforced this idea of the origin of gastric hyperplastic polyps by citing references that promoted the concept that “hyperplastic wound healing” may play a role in the etiology of gastric hyperplastic polyps. It should be underlined that gastric hyperplastic polyps are not the most frequent gastric polyp. Indeed, the most frequent gastric polyps are Elster's cysts , an observation that notably was published in Endoscopy more than 25 years ago.
Additionally, we would like to comment on the risk of malignant transformation of gastric hyperplastic polyps. In the stomach, about 80 % of all polyps are non-neoplastic. The taking of a biopsy at endoscopy, instead of performing prophylactic polypectomy, may therefore be justified; however, as gastric hyperplastic polyps harbor a risk of malignant transformation, primary polypectomy is advised. Various rates of neoplastic transformation in gastric hyperplastic polyps have been reported in the literature. The rate of 10.4 % reported in this manuscript, however, sets a new record. Interestingly, the reported percentage of transformation appears directly related to the cohort size. Therefore, it is no surprise that the percentages given in the literature of between 0 and 8 % show a mean value of only 2.1 % . The 149 patients included in the present study will not markedly affect the reported mean value of 2.1 % and it should be highlighted that this value is also probably too high. It may be speculated that the estimated real frequency would be around 0.5 % if all studies with systematic diagnostic and methodological flaws were excluded.
We were disappointed to see that the authors did not comment on the reasons why they found such a high frequency of neoplasia. It is also known that the status of the gastric mucosa plays a huge role in this regard . Therefore, it is surprising in our opinion that Forté et al.  aggregated cases with autoimmune gastritis into a group of 33 patients labelled as “gastric atrophy,” while cases with corpus-dominant Helicobacter gastritis were included in a large group entitled “H. pylori infection.” It is also known from the literature that the majority of patients develop a relapse of gastric hyperplastic polyps after polypectomy. Indeed, this could serve indirectly as a sign that the histological diagnosis was correct.
In summary, the above problems underline the clinical relevance of proper histopathological definitions and the need to use appropriate terminology that may help to compare recent studies with studies from the past and the future.
17 December 2020 (online)
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