Gastrointestinal Stromal Tumour

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 August 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)

Lymphocytic Gastritis

Collagenous Gastritis

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Eosinophilic Gastritis

Gastric Xanthoma/Xanthelasma

Other Non-Neoplastic Gastric Lesions

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 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

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Schistosomiasis

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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

- 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 Polyps

Gross examination of polypectomey specimens

Hyperplastic polyps and serrated adenomas

Inflammatory polyps/ Inflammatory cap polyps / Polypoid mucosal polyps

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

               

                                

Histopathology report of a gastric polyp should comment on the following:
- Biopsy or excision specimen
- Histological features of the polyp:
    -  Presence of cystic dilatation
    - Lining epithelium of the cyst
    - Presence of muscle fibres in the lamina propria.
    - Inflammatory inflltrate ( Eg. presence of eosinophils. )  
- Mention the type of polyp- (Neoplastic or non-neoplastic)
- Presence or absence of dysplasia or malignancy.
- Finally comment on whether the excision is complete. ( Not possible in a small biopsy )
A polyp is applied to any nodule or mass that projects above the level of the surrounding mucosa.
Gastric polyps are rare and are found   in 0.4% of adult autopsies and 3-5% of Japanese adults.
Classification:   
1.Regenerative (hyperplastic)
2.Hamartomatous (eg. Peutz- Jeghers, juvenile polyp )
3.Neoplastic (adenomatous polyp)

Note: Some neoplastic lesions present as gastric polyps.

-Gastric epithelial polyps (first part).Rev Gastroenterol Peru. 2003 ;23(4):277-92.
-Gastric epithelial polyps (part two).Rev Gastroenterol Peru. 2004;24(1):50-74. 

-Carcinoid -Lymphoma-Stromal tumour

Non-neoplastic  lesion presenting as as a gastric polyp - Inflammatory fibroid polyp.

Inflammatory fibroid polyps:    Path Case49

Site:  Antrum

Gross: Well circumscribed small sessile or peduculated lesion.
Microscopy :   

Blood vessels surrounded by spindle cells(CD34 positive) and chronic  inflammatory cells (mainly eosinophils). Multinucleated giant cells may be  present.
D/D: Eosinophilic gastritis (diffusely thickened ,deformed antrum, eosinophils in peripheral blood).
Eosinophilic granuloma (parasitic infection).

 Visit: Inflammatory Fibroid Polyp of the Esophagus:

Abstracts:  -Inflammatory fibroid polyp of the stomach: a special reference to an immunohistochemical profile of 42 cases. Am J Surg Pathol.1993 ; 17: 1159-1168

-CD34 expression by inflammatory fibroid polyps of the stomach. Mod Pathol 1997; 10:451-456

                         

Gastritis cystica polyposa:

Site: At the site of gastroenterostomy stoma.
Gross: Multiple sessile polyp around the stoma.
Microscopy:

Resemble hyperplastic polyp.Cystically dilated glands extend through the muscularis mucosae into the submucosa. Intestinal metaplasia may be present. No evidence of any atypia.
May be associated with development of gastric stump carcinoma.

Abstracts:  -Gastritis cystica polyposa: report of 7 cases and literature review.Tunis Med. 2005 Sep;83(9):562-7.

-Pathologic features and mucin histochemistry of primary gastric stump carcinoma associated with gastritis cystica polyposa: a study of six cases. Am J Surg Pathol.1985; 9(6): 401-410

Fundic gland polyps:   

Common in patients treated with proton pump inhibitors. May also occur in patients with  familial adenomatous polyposis.
These are not premalignant lesions.
Site:  Body and fundus.
Gross:  Multiple transparent, sessile polyps usually less than 1cm in diameter.
Microscopy:   

Cystically dilated glands lined by gastric body type mucosa.
Irregular shortened foveolae, smooth muscle fibres around the dilated glands. Hypertrophy and hyperplasia of parietal cells in patients treated with proton pump inhibitors.

Abstracts:  -Chief cell hyperplasia with structural and nuclear atypia: a variant of fundic gland polyp.Pathol Res Pract. 2005;200(11-12):817-21.

-Gastric fundic polyps: a morphology study using mucin histochemistry, stereometry and MIB1 histochemistry using. Hum Pathol 1996 ;27: 896-903           

-Sporadic fundic gland polyps: an immunohistochemical study of their antigenic profile.Pathol Res Pract. 1996 Aug;192(8):808-15.

-The histopathology of fundic gland polyps of the stomach.  Am J Clin Pathol.1986 ;86(4): 498-503.

Hyperplastic polyps:  

Most common type of gastric polyp. (Type I and II).
Polyp formation related to:
-Helicobacter - associated  gastritis.
-Pernicious anaemia
-Adjacent to ulcers and erosions.
-Gastroenterostomy stoma.
Gross:   Sessile or pedunculated.
Less than 2 cm in diameter.
Type I : Solitary . In the antrum.
Type II : Multiple. In distal fundic mucosa (junction of body and antrum). Central dimple noted in some cases.
Microscopy:

Elongated, tortuous glands,irregular branching. Glands lined by hyperplastic foveolar-type epithelium. Cystic changes may be present.

Other features:  -Smooth muscle fibres present in lamina propria. ;  -Stroma edematous and inflamed. ;  -Pseudo-invasion may be present.

In Type II hyperplastic  polyp, superficial glands show  onion-skin like arrangement.

Abstracts: Why is the hyperplastic polyp a marker for the precancerous condition of the gastric mucosa? Virchows Arch. 2006 Jan;448(1):80-4. Epub 2005

Cardiac glands hyperplastic polyp of the stomach.J Gastroenterol Hepatol. 2005 Sep;20(9):1461-3.

A case of gastric hyperplastic polyp with malignant transformation. Hepatogastroenterology.  2005 Jan-Feb;52(61):319-21.

Hamartomatous polyps:

Rare in stomach.

Peutz Jeghers polyp: Hyperplastic glands lined by foveolar epithelium. Broad bands of smooth  muscle fibres branch out. Path Case48

Juvenile polyp:  Antrum. May be associated with juvenile polyposis. Histologically, the glands are tortuous, elongated, and cystically dilated . Backround mucosa is  edematous and inflamed. Path Case 47

Polyps in Cronkhite Canada syndrome: (associated  with nail atrophy, alopecia or hyperpigmentation)

Polyps in Cowden's disease: Elongated cystically dilated glands with papillary infoldings. Connective tissue component - neural or muscular.

Pancreatic heterotopia:

May occur as a mass in the pylorus or antrum. Central depression noted on the mucosal surface.
Histologically normal pancreatic acini and ducts are noted.

Abstract: -Pancreatic (acinar)  metaplasia of the gastric mucosa. Histology, ultrastructure, immunocytochemistry, and clinicopathologic correlations of 101 cases. Am J Surg Pathol. 1993;17:1134-1143.

                            

Soft Tissue Pathology;

Myxoid Tumours of Soft Tissue Classification of Soft Tissue Tumour;  Gross examination of soft tissue specimen ;  A practical approach to histopathological reporting of soft tissue tumours Grading of soft tissue tumours ; Lipomatous tumours ;Neural tumours ; Myogenic tumours ;Vascular tumours ; Fibroblastic/ Myofibroblastic tumours ; Myofibroblastic tumours ;  Fibrohistiocytic tumours ; ChondroOsseous tumours ; Soft TissueTumours of Uncertain Differentiation ; Notochordal Tumour -Chordoma ;Extra-adrenal Paraganglioma ; Gastrointestinal Stromal Tumour ;

 

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