[Histopathological diagnosis and differential diagnosis of colorectal serrated polys: findings of a consensus conference of the working group "gastroenterological pathology of the German Society of Pathology"]. / Histopathologische Diagnostik und Differenzialdiagnostik serratierter Polypen im Kolorektum : Ergebnisse einer Konsensuskonferenz der AG "Gastroenterologische Pathologie der DGP"

Until recently, two major types of colorectal epithelial polyps were distinguished: the adenoma and the hyperplastic polyp. While adenomas - because of their cytological atypia - were recognized as precursor lesions for colorectal carcinoma, hyperplastic polyps were perceived as harmless lesions without any potential for malignant progression, mainly because hyperplastic polyps lack cytological atypia. Meanwhile, it is evident that the lesions formerly classified as hyperplastic represent a heterogeneous group of polyps, some of which exhibit a significant risk of neoplastic progression. These lesions show characteristic epigenetic alterations not commonly seen in colorectal adenomas and progress to colorectal carcinoma via the so-called serrated pathway (CIMP pathway). This group of polyps is comprised not only of hyperplastic polyps, but also of sessile serrated adenomas (SSA), traditional serrated adenomas (TSA) and mixed polyps, showing serrated and "classical" adenomatous features. In a consensus conference of the working group of gastroenterological pathology of the German Society of Pathology, standardization of nomenclature and diagnostic criteria as well as recommendations for clinical management of these serrated polyps were formulated and are presented herein.

Scanning electron microscopic (SEM) studies on the effect of x-ray contrast media on aortic endothelium in the rat.

A study comparing the effects of diatrizoate, ioxitalamate, metrizamide, ioxaglate, and a 22% sorbitol on aortic endothelia of the rat was performed. In each case 1 ml of the respective solution was injected in a single dose into the aorta. Endothelial damage was seen after injection of metrizamide, diatrizoate, and ioxitalamate. After injection of ioxaglate or sorbitol, only minor endothelial changes were observed.

Malignant pleural mesothelioma: some aspects of epidemiology, differential diagnosis and prognosis. Histological and immunohistochemical evaluation and follow-up of mesotheliomas diagnosed from 1964 to January 1985.

64 diffuse pleural mesotheliomas diagnosed between 1964 and January 1985 at the Institute of Pathology of the University of Freiburg were analyzed. Since 1980 an increase from one case to 10 cases per year has been observed. The tumor was 3 to 4 times more frequent in men than in women. The age distribution showed a peak between the age of 50 and 60. In 26 cases evidence of exposure to asbestos was detected. In one patient radiotherapy of Hodgkin's disease may have been of etiological significance. The median survival time was 13 months. The five-year survival rate was only 4%. Histologic reevaluation was only possible in cases diagnosed after 1975. Of 43 cases thus evaluated 26 were pure mesothelial, 15 biphasic and 2 of the spindle-cell subtype. A median survival time of 23 months for pure mesothelial mesothelioma in comparison to 13 months for the biphasic mesothelioma indicated a better prognosis for pure mesothelial mesothelioma. Although no other primary tumors were detected, in 10 cases the differential diagnosis of adenocarcinoma had to be considered, and in 3 cases tumors of non-epithelial origin had to be excluded. 35 of 43 mesothelioma were CEA-negative, 38 out of 43 cytokeratin-positive, and 33 out of 43 were EMA-positive. Factor-VIII-related antigen was not demonstrated. 12 of 43 mesotheliomas showed PAS-positive staining, 29 of 43 were stained with Alcian blue. 7 of these 29 showed a positive digestion with hyaluronidase. Although CEA may not be negative in every mesothelioma, this marker seems to be a valid tool for the differential diagnosis of adenocarcinoma. In order to safeguard against a mistaken diagnosis of pleural mesothelioma, the exclusion of other tumors is always indispensable.

An evaluation of gastric dysplasia in the years 1986 and 1987.

Since the fate and significance of gastric mucosal dysplasia is still largely unknown we have started a follow-up study for patients with dysplasia in the years 1986 and 1987. In this paper the short term results are reported. Dysplasia grade II was found in 2% of all patients and dysplasia grade III in 0.5%. The following results suggest a close-possibly sequential relationship of dysplasia and gastric cancer: dysplasia and gastric cancer are preferentially located in distal parts of the stomach; sex distribution of dysplasia and gastric cancer (especially intestinal type) are similar; considering the mean age of patients with dysplasia or gastric cancer we have observed that patients with dysplasia II were younger than patients with dysplasia III and both were younger than patients with gastric cancer of the intestinal type; during the short term follow-up (12-24 months) 4-8% of patients with dysplasia II and 18-20% of patients with dysplasia III showed a progression; of 26 carcinomas detected by follow-up of patients with dysplasia III 10 were early gastric cancer, 11 resectable with curative intent, 2 were metastatic and 3 without sufficient information for staging. We conclude therefore that gastric dysplasia is probably a true precancerous lesion that helps to identify high risk patients and thus contributes to the objective of an early diagnosis of gastric cancer.

Drug-induced liver injury in liver biopsies of the years 1981 and 1983, their prevalence and type of presentation.

Based on the histological picture of liver biopsies examined in the years 1981 and 1983, drug-induced liver injury has been suspected in 131 and 170 cases. In relation to the total number of the examined liver biopsies this accounted for 6 and 9.6%, respectively. In only 20 (i.e. 15%), respectively 17 (i.e. 10%) of the cases, a drug-induced injury could be clinically excluded. However, a drug-induced injury was doubtlessly secured in 21 (16%) and 28 (16.5%) of the cases. The histological phenotype seen in association with the incriminated drug is presented. In 90 (68.7%) and 125 (73.5%) of the cases it was neither possible to secure nor to exclude the drug as cause of this damage, either because in 32/72 cases the clinical work-up was incomplete or because the drug-induced damage was clinically suspected, but not sufficiently documented by follow-up examinations after drug-withdrawal.

Prevalence of Campylobacter pylori as demonstrated by histology or CLO-test in different types of gastritis. A study in 5 clinically predefined groups of patients.

The prevalence of Campylobacter pylori infection as detected by histology was studied in 5 predefined groups of patients. The associated histologic and endoscopic findings were registered. Validity of CLO-test was tested against the histologic detection. The following groups of patients were studied: A) Non-ulcer dyspepsia (defined by one or all of three symptoms: heartburn, nausea/inappetence, halitosis/belching) B) control group (no specific symptoms, no ulcer, no history of gastric surgery) C) Duodenal ulcer D) Gastric ulcer E) Billroth I or II resection of the stomach. 200 patients were recruited for group A-C, in group D 134 patients and in group E 113 patients were studied. A mean prevalence of 60% was observed. Prevalence was highest in patients with duodenal ulcer (86%). In group D a prevalence of 65%, in A and E a prevalence of 54%, and in B of 40% were seen. The overall test sensitivity of the CLO-test compared against the histologic detection rate was 75%, the specificity 81%. Sensitivity was reduced in group A (69%) and E (53%) and in patients with inactive chronic gastritis (67%). In all groups patients with active forms of gastritis showed the highest prevalence of C. pylori infection. The specificity of the CLO-test was reduced in patients with duodenal ulcer (46%) and gastric ulcer (48%). Decreased specificity observed after therapy with histamin receptor (H2) blockers may explain this finding. The relationship of C. pylori infection with active types of gastritis or gastro-duodenal ulcer hints at a causal relation but is no definite proof of its etiologic role. The validity of the CLO-test seems questionable in patients with gastroduodenal ulcer or operated stomach.

[The effect of diatrizoate (Angiografin) on the aortic endothelium of the rat in shock]. / Uber die Wirkung von Diatrizoat (Angiografin) auf das Aortenendothel der Ratte im Schock.

Investigations have been carried out on the endothelial damage produced by diatrizoate (Angiografin) during the course of endotoxin shock. A single injection was given directly into the aorta of 1 ml of the contrast medium, with an iodine content of 300 mg/ml. The increased proliferation of the aortic endothelium could be shown to be due to the endotoxin shock, but was not further increased by administration of the contrast medium.

Follow-up of treated adult celiac disease: clinical and morphological studies.

A follow-up study of 18 patients with celiac disease is reported. Adherence to the diet, blood chemistry and serum amino acid concentration were investigated in all patients. In addition, HLA blood group typing was performed. Ten patients agreed to undergo jejunal biopsy, xylose test and X-ray of the small intestine. The jejunal mucosa showed no complete restitution even in patients on a strict diet and function tests were abnormal, too. In this study HLA typing demonstrated an association with HLA-B8, HLA-DR3, and HLA-DR7. The results of the follow-up study are discussed with special reference to therapeutic aim and definition of therapeutic success of the gluten-free diet. In addition, a case of jejunal adenocarcinoma complicating celiac disease is presented.

[Retrospective analysis of colorectal carcinomas reveals potential for improvement of diagnostic quality]. / [Indentifikation von Verbessurngspotenzial in der Diagnostik kolorecktaler karzinome mittels retrospektiver Analyse]

INTRODUCTION: The histopathological work-up of colorectal cancer is of critical importance for prognosis and therapy. Therefore we retrospectively analyzed all colorectal carcinomas diagnosed at our institution from January 2002 through March 2003. METHODS: 735 of a total of 777 carcinomas could be followed up. These tumors comprised 74 polypectomy specimens, 32 transanal microscopic surgery specimens, 322 surgical resection specimens analyzed at our own institution (subgroup A) and 263 surgical resection specimens that had been worked up at other pathological institutions (subgroup B) after the diagnosis of carcinoma had been established in our own institution in biopsies. 44 tumors were not treated locally until the end of the study. Quantitative quality parameters were analyzed statistically using Fisher's exact test. RESULTS: Between subgroups A and B significant differences were found within 1. the proportion of specimens with less than 12 lymph nodes examined (11 vs. 25 %), 2. for the detection of an R1 situation despite macroscopic R0 resection (9 vs. 1 %), 3. the proportion of early colonic cancers (9 vs. 4 %), 4. of mucinous adenocarcinomas (19 vs. 4 %), 5. of lymphatic (48 vs. 23 %) and venous invasion (25 vs. 8 %), 6. the frequency of a macroscopic description of mesorectum quality (85 vs. 14 %). In 7 of 32 surgically treated patients with a high-risk carcinoma originally found within a polypectomy specimen, residual tumor was detected in the surgical resection specimen (at the polypectomy site and/or in regional lymph nodes). CONCLUSION: Due to retrospective analysis of colorectal cancer specimens we were able to identify potential for improvement of diagnostic quality. Furthermore our data underline the importance of an oncological resection, if a high risk carcinoma has been detected within a polypectomy specimen.

The use of proliferating cell nuclear antigen (PCNA) expression and intraepithelial lymphocyte count in the differential diagnosis of inflammatory bowel disease.

Colonic biopsies of 283 patients with Crohn's disease (CD), ulcerative colitis (UC), infectious colitis (IC) lymphocytic colitis (LC) and controls for patients with either CD or UC, matched for age and sex, were evaluated with respect to the number of intraepithelial lymphocytes (IEL) and PCNA (cyclin) positive crypt epithelia. The IEL count of patients with LC differed significantly from all other patient groups, indicating that this condition bears no relation to the other diseases. Our patients with histologic diagnosis of LC had no uniform clinical presentation and the significance of this characteristic increase in IEL is unclear. The mean value of PCNA positive crypt epithelia in the lower crypt half was significantly higher in UC patients than in CD patients. PCNA counts in patients with IC or LC were not different from values in UC patients. PCNA counts in CD patients overlapped frequently with those in UC patients. This parameter thus fails to distinguish between CD and UC in individual patients and, though not investigated by us, is unlikely to be effective in the differential diagnosis in patients with a provisional diagnosis of indeterminate colitis.

The bilateral subcutaneous rupture of the achilles tendon--a rare injury.

A very rare case of simultaneous bilateral rupture of the achilles tendon is reported. The histology revealed severe degenerative lesions on both achilles-tendons in a healthy patient. This severe degeneration obviously caused the ruptures following an extreme initial stress.

[Gluten-sensitive enteropathy--in the light of new clinical and pathogenetic aspects]. / Glutensensitive Enteropathie - im Lichte neuer klinischer und pathogenetischer Aspekte.

The corn protein gluten causes the gluten-sensitive enteropathy in susceptible persons (HLA-antigens). The diagnosis is made on the basis of the morphological criteria of villous atrophy of the jejunal mucosa and the clinical observation that the malabsorption can be healed by a gluten-free diet. The disease, which occurs in children and adults, is a distinct entity. Life-long adherence to a gluten-free diet is difficult. Intentional or unintentional reintroduction of gluten often causes masked disease states. These are best classified on the basis of electron-microscopy study of the jejunal biopsy. We propose a new classification of the phases of remission. A group of diseases exist which are closely related to gluten-sensitive enteropathy. Frequently villous atrophy is detectable. However, the disease does not respond to a gluten-free diet. The pathophysiology of these diseases is at present unclear. Diseases involving autoimmune processes also appear to be associated with gluten-sensitive enteropathy. The common factor is probably an immuno-genetic defect. This is supported by the existence of common HLA-antigen constellations. Gluten has been characterised in vitro as a lectin with oligomannose specificity. This provides a new pathomechanism for the gluten induced enterocytic destruction.

Electron microscopic studies on the small intestine of rats after mechanical intestinal obstruction.

The morphologic changes of the small intestine after the mechanical obstruction were studied by light and electron microscopy. After the ligation of the upper small intestine, segments of jejunum, both proximal and distal to the site of obstruction, were removed at intervals varying from 45 min to 24 h. The essential changes were found in the epithelial cells of the tips of villi, and few morphologic differences were recognized between samples proximal and distal to the site of obstruction. The most remarkable changes in the mucosa were the pseudopodlike extension of the cytoplasm, vacuolar alteration of the villus epithelial cells, desquamation of these degenerated cells, and the dilatation of the epithelial intercellular spaces. A few epithelial cells showed hypertrophy of the smooth endoplasmic reticulum. In the submucosa, vascular stasis and edema were observed throughout the course. The mechanism of fluid loss into the intestinal lumen was discussed briefly.

[Non-tropical sprue discrepancy between clinical and biopsy findings. Five years' observation of a case (author's transl)]. / Einheimische Sprue-Diskrepanz von klinischem und bioptischem Befund. Eine Verlaufsbeobachtung über fünf Jahre.

After doagnosis and establishment of an appropriate diet a 51-year-old female patient with coeliac disease, who was critically ill in the beginning, became symptomless; nevertheless, a five year follow-up study with mucosa biopsies reveals a persisting villous atrophy with hyperplastic crypts ("flat mucosa"). This discrepancy between clinical and histological findings is discussed and it is emphasized that for coeliac patients a strict adherence to a gluten-free diet and bioptic supervision of therapy are essential. Treatment aimed solely at abolishing the clinical symptoms obviously bears the risk of a persisting symptomless illness and the danger of late complications.

[Lymphangioleiomyomatosis. Problems in differential diagnosis, etiology and prognosis (author's transl)]. / Die Lymphangioleiomyomatose. Differentialdiagnostische Probleme und Fragen zur Atiologie und Prognose.

Four different cases (diffuse interstitial lung fibrosis with leiomyomatosis, Lymphangioleiomyomatosis of the lung, fibroleiomyoma of the lung and adenomyofibroma of the lung) are presented and the differential diagnostic criteria are discussed. On survey of the literature on Lymphangioleiomyomatosis it is concluded that so far this diagnosis seems ill defined. As it cannot be excluded that the cases described so far represent an assortment of various diseases with different etiology, the authors believe that it is impossible to give a reliable statement on prognosis either for the condition in general or for an individual case.

Electron microscopic studies on the small intestinal mucosa of rats after mechanical intestinal obstruction and ischemia.

Ultrastructural changes in the small intestine during the early phase following mechanical obstruction were compared with those after vascular ligation. In both experiments (the early phase of mechanical ileus and ischemia) intestinal epithelial cells at the tips of villi showed common features. One of the most significant changes was an alteration in microvilli, with fragmentation into vesicles, narrowing of apical microvilli and decrease in number. The other change was fatty degeneration of the epithelial cells, which was accompanied by vesiculation of smooth endoplasmic reticulum beneath the terminal webs, fat deposition and dilated Golgi complex containing fat. These observations suggest that in the early phase of mechanical ileus, ischemic damage plays an important role.