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Pathology of Gastric Epithelial Dysplasia 

Dr Sampurna Roy MD

 

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What is a precancerous condition? Precancerus condition is a clinical state associated with increased risk of cancer.

Example:

1. Atrophic gastritis with intestinal metaplasia,

2. Pernicious anaemia

3. Gastric stump

4. Certain types of gastric polyps

What is a precancerous lesion?

Precancerous lesion is a histopathological abnormality in which cancer is more likely to occur. Example: Gastric dysplasia.  

While diagnosing a case of gastric dysplasia the histopathologist must consider the following:

1. Whether the biopsy origiate from an adenoma or flat gastric mucosa.

2. Whether  the biopsy is from the margin of a carcinoma

3. Whether there is carcinoma elsewhere.

4. Whether the lesion is part of a wider mucosal abnormality.

Gastric dysplasia may present as a raised, circumscribed lesion (adenoma) or as a flat/depressed lesion.

Adenomatous dysplasia :

- Precancerous condition.

- Associated  with atrophic gastritis with intestinal metaplasia.

- Site: Usually antrum

- Size- About 3-4 cm in diameter

- Sessile or pedunculated lesion with a lobular surface.

- Histologically, gastric adenomas are  composed of dysplastic epithelium.

- Malignancy is related to size, dysplasia and villous growth pattern.

- On the basis of architecture, adenomas are divided into tubular, tubulovillous and villous architecture.

- Degree of dysplasia (mild, moderate or severe) is based on nuclear crowding , hyperchromasia, stratification & mitotic activity.

- Adenomas may show:

(i) gastric foveolar or pyloric gland type epithelium;

(ii) gastric and intestinal type features;

(iii) paneth cell type (paneth cell adenoma).

- Treated by endoscopic polypectomy.

- Intramucosal adenocarcinoma in adenoma is characterized by invasion of dysplastic epithelium into lamina propria. 
 

Visit: Early gastric carcinoma Chronic gastritis.

Gastric epithelial dysplasia (flat/ depressed) :

- Site: Usually in gastric antrum (along lesser curvature)

- Gross features: Ill-defined thickened and congested mucosa which may be slightly depressed or raised from the mucosa.

- Microscopic features: 

1) Gastric dysplasia usually arises in the backround of chronic  atrophic gastritis with immature intestinal metaplasia.

Cytological and architectural atypia, irregular nuclear hyperchromatism, irregular nucleoli.

Composed of tall columnar cells with pale cytoplasm.

A few goblet cells are present.
Prominent budding or branching of glands.

Lack of maturation of cells.

Abrupt interphase with adjacent epithelium.

2) Gastric dysplasia of non-metaplastic foveolar epithelium (tubule neck dysplasia) is rare.

These are precursor of diffuse type gastric carcinoma.

Grading of gastric dysplasia:

Two tier system followed : High grade and low grade.

Previously three tier system: Mild, moderate, severe.


Classification of gastrointestinal epithelial neoplasia:

Category I
Negative for neoplasia/dysplasia

Category 2
Indefinite for neoplasia/dysplasia

Category 3
Non-invasive neoplasia low grade (low grade adenoma/dysplasia)

Category 4
Non invasive neoplasia high grade:

(i ) High grade adenoma/dysplasia

(ii) Non-invasive carcinoma (carcinoma in situ)

(iii) Suspicious of invasive carcinoma

Category 5
Invasive neoplasia:

(i)   Intramucosal carcinoma

(ii)  Submucosal carcinoma or beyond

Differential diagnosis of Gastric Dysplasia:

1.Reactive epithelial  hyperplasia(gastritis, erosion or ulceration).

Enlarged pleomorphic nuclei that show homogeneous basophilia and are basally orientated.

Prominent but small and uniform nucleoli.

Surface maturation is present.

Gradual transition with adjacent epithelium.

Atypical glands embedded in granulation tissue,fibrin and ulcer slough (useful clue).

Note : Histopathologist should be very careful while making a diagnosis of high grade dysplasia in the presence of large numbers of intraepithelial neutrophils.

2. Reflux gastritis:  

3. Epithelial atypia associated with irradiation or antineoplastic chemotherapy.

- Present in specialized (deeper part ) mucosa. 
- Stromal cells affected.
- No architectural abnormality.
- No increase in mitotic activity.
 

Further reading:

Combination of Paris and Vienna classifications may optimize follow-up of gastric epithelial neoplasia patients.

Gastric high-grade dysplasia can be associated with submucosal invasion: evaluation of its prevalence in a series of 121 endoscopically resected specimens.

Epithelial dysplasia of the stomach with gastric immunophenotype shows features of biological aggressiveness.

Gastrointestinal dysplasia.

Characteristic gene expression profiles in the progression from normal gastric epithelial cells to moderate gastric epithelial dysplasia and to gastric cancer.

Detection of precancerous gastric lesions and gastric cancer through exhaled breath.

CDX-2 homeobox gene expression in human gastric carcinoma and precursor lesions.

The Vienna classification of gastrointestinal epithelial neoplasia.

The long term outcome of gastric non-invasive neoplasia.

Gastric atrophy, metaplasia, and dysplasia: a clinical perspective.

Immunohistochemical expression of Fhit protein in Helicobacter pylori related chronic gastritis, gastric precancerous lesions and gastric carcinoma: correlation with conventional clinicopathologic.

Gastric epithelial dysplasia.  

Risk of gastric carcinoma in patients with mucosal dysplasia associated with atrophic gastritis: a follow up study.

Precursors of gastric carcinoma.

Gastric epithelial dysplasia in the natural history of gastric cancer: a multicenter prospective follow-up study. Interdisciplinary Group on Gastric Epithelial Dysplasia. 

Depressed tubular adenoma of the stomach : pathological and immuno- histochemical  features.  

High grade dysplasia of the gastric mucosa : a marker for gastric carcinoma.  

Gastric epithelial dysplasia. How clinicopathologic background relates to management.

Long term follow upstudy on gastric adenoma and its relation to gastric adenoma and its relation to gastric protruded carcinoma.

Precancerous conditions and epithelial dysplasia in the stomach.  

Zhang Y-C. Typing and grading of gastric dysplasia. In: Zhang Y-C, Kawai K , eds. Precancerous conditions and lesions of the stomach. Berlin: Springer-Verlag. 1993; 64-84

Histopathology of gastric dysplasia. In : Filipe MI, Jass JR (eds) Gastric carcinoma. Churchill Livingstone, Edinburgh, 1986: 116-131

 

 

Dr Sampurna Roy  MD

Consultant  Histopathologist (Kolkata - India)


 

 

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