Gastrointestinal Stromal Tumour

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December 2009

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An outline of the anatomy and normal histology of the  stomach for pathologists.

Reporting of gastric biopsies (non-neoplastic gastric lesions).

Pathology and pathogenesis of peptic ulcer.

Acute Gastritis 

Chronic Gastritis

Helicobacter pylori  associated(TypeB) Gastritis 

Autoimmune Gastritis (Type A) 

Reactive /Reflux/ Chemical Gastritis (Type C)

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Gastric Xanthoma/Xanthelasma

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Benign tumour and tumour- like lesions

Gastric Lymphoma

Gastric Carcinoid Tumour

Gastrointestinal Stromal Tumour 

Gastric Epithelial Dysplasia

Early Gastric Carcinoma

Gross Examination of the Gastrectomy Specimen 

Drug related lesions of the gastrointestinal tract

- Normal Histology of the Large Intestine

- Interpretation of Large Intestinal Biopsies

- Assessment of abnormalities -1 (lumen, surface epithelium, subepithelial zone)

- Assessment of abnormalities - 2  (crypt density , architecture and epithelium)

- Assessment of abnormalities - 3 (changes in the lamina propria,muscularis mucosae and submucosa) 

Pathology of the Intestinal PolypsGross examination of polypectomey specimens

Hyperplastic polyps and serrated adenomas

Inflammatory polyps/ Inflammatory cap polyps / Polypoid mucosal polyps
                    
Certain general rules must be kept in mind before looking at the biopsy followed by systematic interpretaion of the biopsy-

General rules-

1. A detailed clinical history with clinical impression must be provided by the clinician.This should include age of the patient, sex, clinical findings and their duration,history of previous surgery, history of immunosuppression,drug history, history of systemic or dermatologic disorders.

2. Site of the biopsy (upper, middle or lower third of the esophagus).

3. Endoscopic finding plays a critical role in the diagnosis of esophageal lesions.    Endoscopic images

Interpretation of the biopsy-

1. Is the esophageal biopsy is normal or abnormal? Normal esophageal biopsy

2. Is the abnormality non-neoplastic or neoplastic in nature?
3. In case of non-neoplastic lesion:

       
-
What type of epithelium is included in the biopsy (squamous , glandular or junctional)?
        - What is the type and severity of inflammation?
        - Is it associated with ulceration?
        - Is the inflammation due to fungal or viral organisms?
        - How to differentiate between regenerative changes  and true  epithelial dysplasia in Barrett's esophagus?
         - How to grade the epithelial dysplastic changes?

4. If the lesion is neoplastic in nature:         
         
- What is the tumour type and differentiation?
         - Does the biopsy include normal esophageal mucosa?
         - Is there any overlying squamous dysplasia , glandular dysplasia or Barrett's metaplasia?
         - Is it possible to comment on the submucosal invasion in the biopsy specimen?

 

                       

In the diagnosis of non-neoplastic esophageal lesions the following points should be kept in mind: 

1. Inflammation throughout esophagus suggests infective cause specially in immunocompromised patients.
The histopathologist must carefully search  for organisms and viral inclusions .
- In suspected case of  Cytomegalovirus infection , biopsy should be taken from the ulcer base to sample infected fibroblasts and endothelial cells. Microscopic features include  large cells in the subepithelial layer with intranuclear inclusions, a halo around the nucleus and multiple small cytoplasmic inclusions. 
  IMAGE  
- In Candida oesophagitis PAS and Grocott stains are useful in demonstrating the organisms. IMAGE  
- In Herpes simplex virus esophagitis biopsy should be taken from the squamous epithelium at the margins of the ulcer. Microsocpically there are multinucleated giant cells and intranuclear ground glass inclusions.

(GROSS)IMAGE 1 2   (MICRO) IMAGE 3  ;  4

2. Acid or bile reflux is common in the lower third of the esophagus.   
When
reflux esophagitis is suspected the histopathologist should look for the following features-
    
Basal cell hyperplasia ; vascular prominence ; elongation of lamina propria increased intraepithelial eosinophils and varying degree of chronic inflammation.
    
Reflux esophagitis may progress to superficial ulceration and spread of  inflammation to the wall.

3. In Barrett's esophagus (columnar lined esophagus) the biopsy  may show any of the following features-

    - Fundic type mucosa (with parietal and chief cells)
    - Cardiac or junctional type mucosa (composed of mainly mucous glands).
    - Flat mucosa with specialised (incomplete) intestinal metaplasia   
Mucin histochemistry is useful in  the identification of immature intestinal metaplasia. 

Presence of submucosal glands with ducts beneath distorted glandular mucosa is diagnostic of Barrett's esophagus.   
In many cases the histopathologists report the case as :
" If the biopsy is truely from esophagus , it corroborates with an endoscopic diagnosis of Barrett's esophagus."
Glandular dysplasia in Barrett's esophagus is reported as indefinite, low grade or high grade. 

Low magnification view is very important.

In true dysplasia ,due to consistent presence of nuclear hyperchromasia attention is immediately drawn to the dysplastic area.
To diagnose true dysplasia the full length of the gland must be assessed. In dysplasia,  the cytological changes are present throughout the crypt from the base to the surface epithelium and there is abrupt interphase with adjacent epithelium.  In reactive hyperplasia there is surface maturation and gradual transition with adjacent epithelium.

Often the case is reported as: " Indefinite for dyplasia. A repeat biopsy is advised after the inflammation has subsided." IMAGE LINK(AFIP)

Invasive carcinoma developing in Barrett's esophagus is usually adenocarcinoma in type. Carcinoma is reported only  when there is unequivocal  evidence of  invasion into the lamina propria.  

 An endoscopic biopsy protocol can differentiate high-grade dysplasia from early adenocarcinoma in Barrett's esophagus.Gastroenterology. 1993 Jul;105(1):40-50.

Following treatment in Barrett's esophagus the biopsy shows squamous re-epithelization. The histopathologist plays an important role in identifying  hidden foci of glandular mucosa under surface squamous epithelium (deep biopsy is advised in these cases).

Note:   It is often difficult to make a confident diagnosis: 1) if the esophageal biopsy is crushed 2) if the biopsy is tangentially cut and 3) in the presence of inflammation and regenerative changes.

                         

 

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NORMAL HISTOLOGY OF ESOPHAGUS

AN APPROACH TO THE  REPORTING  OF ESOPHAGEAL BIOPSIES

BARRETT'S   ESOPHAGUS   (INTESTINAL METAPLASIA  DYSPLASIA  &   ADENOCARCINOMA)

BENIGN TUMOURS AND  TUMOUR - LIKE CONDITIONS  OF  ESOPHAGUS

 1. SQUAMOUS PAPILLOMA OF THE ESOPHAGUS

 2. INFLAMMATORY FIBROID POLYP OF THE ESOPHAGUS

 3. LEIOMYOMA OF THE ESOPHAGUS

 4. GRANULAR CELL TUMOUR OF THE ESOPHAGUS

 5. ESOPHAGEAL CYSTS

 6. GLYCOGENIC ACANTHOSIS

 7.FIBROVASCULAR POLYPS

REPORTING  OF  ESOPHAGEAL  RESECTION SPECIMENS

SQUAMOUS  EPITHELIAL  DYSPLASIA INCLUDING SQUAMOUS CELL CARCINOMA IN-SITU OF THE ESOPHAGUS

SMALL CELL CARCINOMA OF THE ESOPHAGUS

DRUG  RELATED  LESIONS  OF  THE GASTROINTESTINAL TRACT

   SQUAMOUS CELL CARCINOMA OF THE ESOPHAGUS

   CARCINOSARCOMA OF THE ESOPHAGUS

   SMALL CELL CARCINOMA OF THE ESOPHAGUS

Juvenile polyp ; Peutz-Jeghers polyp ; Inflammatory fibroid polyp ; Multiple Lymphomatous polyposis ;  Lymphoid polyp

Normal histology of the small intestine for anatomic pathologists

An approach to evaluation of small intestinal biopsy.

Malabsorption syndrome (causes  and clinical investigations)

Tropical Sprue

Coeliac Disease

Enteropathy-associated T-cell lymphoma

Intestinal lymphangiectasia

Pathogens commonly affecting Small Intestine

Ascariasis

Cryptosporidium

Cytomegalovirus infection

Giardiasis

Hookworm Infection

Isosporiasis

Microsporidia

Mycobacterium Avium Intracellulare

Schistosomiasis

Whipple's disease

Lesions causing small bowel obstruction and bleeding - 
Intussusception : Adhesions : Volvulus

Meckel's diverticulum

Ischemic bowel disease 

Brunner's Gland Adenoma

Duodenal  Gangliocytic Paraganglioma

Lymphoma of the small intestine


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