Reproducibility of the villous component and high-grade dysplasia in colorectal adenomas <1 cm: implications for endoscopic surveillance.

The presence of high-grade dysplasia (HGD) or villous component (VC) defines an advanced adenoma (AA) in patients with 1 or 2 adenomas <1 cm in size. Current consensus guidelines recommend that patients with AA undergo more intense postpolypectomy surveillance. In these clinical situations, the interobserver reliability in determining VC and HGD would play a major role in the credibility of these consensus guidelines. Therefore, the purpose of this study was to evaluate interobserver variability of VC and HGD in polyps <1 cm before and after the development of consensus criteria among gastrointestinal (GI) pathologists. Five GI pathologists independently evaluated 107 colorectal adenomas <1 cm, and classified them into tubular adenomas or adenomas with a VC (A-VC) and into low-grade dysplasia or HGD. Then a consensus conference was held and consensus criteria for VC and HGD were developed by group review. The same set of 107 slides were rereviewed independently by the same 5 GI pathologists. Interobserver variability using κ statistical analysis before and after the application of consensus criteria was assessed. A 1-sided z-test was used to determine whether κ scores increased after the consensus conference. Interobserver agreement before and after the consensus conference was poor for assessment of A-VC, HGD, and AA. These data calls into question the validity of basing clinical decisions on this distinction.

Distinguishing Barrett gastric foveolar dysplasia from reactive cardiac mucosa in gastroesophageal reflux disease.

Morphologic dysplasia remains the criterion standard of cancer risk in Barrett esophagus but poses many challenges including distinction from reactive inflammatory change. Gastric foveolar dysplasia, a newly described subtype comprising 15% to 20% of Barrett dysplasia, overlaps with reactive cardiac mucosa in gastroesophageal reflux disease (GERD). Despite the clinical importance of accurate distinction, the issue has not been studied. Review of 3698 biopsies from 461 Barrett patients yielded 160 biopsies with Barrett gastric foveolar dysplasia (74 low grade and 86 high grade). These were compared with inflamed cardia from 80 patients with GERD. Immunohistochemistry was performed for Lgl2, MUC2, MUC5AC, and MUC6. Comparing GERD with Barrett gastric foveolar dysplasia, surface nuclear stratification (85% versus 0%, P < .00001), upper mucosa-limited atypia (80% versus 0%, P < .0001), villiform architecture (52% versus 4%; P < .0001), full-thickness mucosal atypia (0% versus 100%, P < .00001), and crowded glandular architecture (0% versus 75%, P < .00001) all proved useful. Cytologic features were less helpful. Comparing low-grade gastric dysplasia alone, because its distinction from reactive cardia may be even more challenging, the listed features all remained significant. Loss or aberrant Lgl2 expression was much more typical of dysplasia (12% versus 99%; P = .0001). MUC proteins did not distinguish the groups. Surface nuclear stratification, "top-heavy" atypia, and noncrowded, villiform architecture were highly characteristic of reactive cardiac atypia in GERD, in comparison with the monolayered nuclei in crowded glands occupying the full mucosal thickness in Barrett gastric foveolar dysplasia. Loss or aberrant Lgl2 staining was useful in identifying Barrett gastric foveolar dysplasia.

Lymphocytic colitis and collagenous colitis: a review of clinicopathologic features and immunologic abnormalities.

Lymphocytic colitis (LC) and collagenous colitis (CC), 2 histologic forms of microscopic colitis, were recognized as rare disease entities 4 decades ago. An increasing body of evidence accumulated in the past 40 years reveals increasing incidence and prevalence rates, a wide spectrum of clinical presentations, and several histologic variants. Although several recent randomized clinical trials confirmed the efficacy of oral budesonide in treating LC and CC, disease relapse after a short-duration treatment is common. Despite their common clinical presentations and well-defined histologic diagnostic criteria, there are only few studies on the immunologic abnormalities in colonic tissue. The aim of this review is to (1) familiarize the pathologists in general practice with histomorphology of LC and CC, including the rare histologic variants and the clinical implication associated with these 2 diagnoses, (2) summarize the data from recent randomized clinical trials of oral budesonide, and (3) review immunological studies on colonic tissue. Overall, immunologic abnormalities of colonic tissue seem to explain for the histomorphologic features and the clinical symptomatology of LC and CC. Advances in the understanding of the underlying immunologic abnormalities in the colonic tissue may help develop novel and effective therapies for these 2 diseases.

Acral soft tissue tumors: a review.

Acral soft tissue tumors may present significant diagnostic challenges both for the pathologist and the clinician. This review discusses the most common benign and malignant entities that characteristically present in an acral location. Clinical, histologic, and immunohistochemical features are discussed along with prognosis and differential diagnosis.

Grading of gastric foveolar-type dysplasia in Barrett's esophagus.

Dysplasia is the gold standard biomarker of cancer risk in Barrett's esophagus, but its diagnosis remains difficult. This is due in part to its multitude of histological appearances. One aspect receiving little attention concerns gastric-type Barrett's dysplasia, which is distinctly different from the well-established intestinal variant. Recognition of gastric-type dysplasia and development of separate grading criteria are required. The prevalence, diagnostic criteria, and natural history of gastric-type Barrett's dysplasia were systematically evaluated in 1854 endoscopic biopsies from a cohort of 200 consecutive Barrett's dysplasia patients. Goblet cells were present in all cases, confirming the utility of this defining feature of Barrett's esophagus. The prevalence of Barrett's gastric-type dysplasia was 15% at the patient level (30 of 200 patients) and 20% at the biopsy level (166 of 852 dysplastic biopsies). Gastric-type dysplasia uniformly showed non-stratified, basally oriented nuclei as the major criterion for distinguishing it from intestinal-type Barrett's dysplasia. As such, loss of nuclear polarity, as the most objective criterion to distinguish intestinal-type low- and high-grade dysplasia, cannot be applied to gastric-type dysplasia. Rather, discriminatory features included increased nuclear size with a high-grade dysplasia cutoff by receiver operating characteristic (ROC) analysis approximating 3-4 times the size of a mature lymphocyte, providing an optimal sensitivity, specificity, and area under the curve of 0.78, 0.90, and 0.90 (95% CI: (0.87, 0.93)), respectively. Crowded, irregular glandular architecture (P<0.001) was more common in high-grade lesions (P<0.001), as was eosinophilic and oncocytic cytoplasm relative to the mucinous cytoplasm (P<0.001), prominent nucleoli (P<0.001), mild nuclear pleomorphism (P<0.001), and villiform architecture (P<0.001). During follow-up, 64% (7 of 11) of patients with pure gastric and 26% (5 of 19) with mixed gastric and intestinal dysplasia underwent neoplastic progression. The recognition of Barrett's gastric-type dysplasia and use of the proposed grading criteria should promote better diagnostic classification of the Barrett's neoplastic spectrum.

Repeated molecular testing in gliomas: a retrospective study of 53 cases.

The value of repeated molecular testing in patients with multiple resections of gliomas is unclear. The purpose of this study was to assess for evidence of molecular changes for chromosome 1p/19q deletions and epidermal growth factor receptor (EGFR) amplification by fluorescence in situ hybridization in 53 glioma cases in which repeated testing was done. Paired results for 1p evaluation demonstrated a change in the profile from intact to loss in 1 (2%) of 50 cases; 19q evaluation demonstrated a change in profile in 4 (10%) of 41 cases. There was no change in the EGFR expression in any of the cases tested. There was no change in the clinical management based on the repeated molecular tests in patients with discrepant repeated results. Hence, there seems to be no indication for reflex repeated 1p/19q or EGFR testing in gliomas at the time of repeated biopsy or resection.

Ovarian adenomyoma mimicking an ovarian malignancy: a case report with literature review.

Smooth muscle tumors of the ovary are rare, and ovarian adenomyoma are even rarer. It is a well-circumscribed biphasic tumor composed of benign glands and smooth muscle cells, as well as a variety of pseudoneoplastic glandular lesion. After extensive literature search, the case presented in this article appears to be the third case of an ovarian adenomyoma and the first case in a postmenopausal woman.

Incidental reduction in the size of liver hemangioma following use of VEGF inhibitor bevacizumab.

BACKGROUND/AIMS: Hepatic cavernous hemangioma is the second most common liver tumor after metastases. Vascular endothelial growth factor (VEGF) is recognized as an essential regulator of blood vessel growth. High VEGF expression leads to increased angiogenic activity in cavernous hemangioma endothelial cells. The use of specific antibodies directed against VEGF abolishes this vascular endothelial growth-promoting activity in vitro. Bevacizumab is a recombinant humanized monoclonal antibody directed against VEGF which is used for the treatment of metastatic colorectal cancer in combination with 5-fluorouracil-based regimens. METHODS: We report a patient with invasive colorectal adenocarcinoma and suspected liver metastasis on radiological examination, who showed a significant decrease in the size of his liver lesions after bevacizumab treatment. Histology of the liver lesions revealed hemangioma with a strong staining for VEGF and anti-VEGFr2 antibody in the hemangioma endothelial cells. To date, surgical resection provides the only consistently effective method for treatment of hepatic hemangioma. CONCLUSIONS: This is the first documented case of hepatic hemangioma responsive to antiangiogenic therapy, suggesting a possible use for these agents in treating symptomatic patients without surgery. VEGF-signaling blockade including bevacizumab use poses a potential new treatment modality for vascular neoplasms in the liver and other sites.

Osteomyelosclerosis with thalassemia trait: report of a rare association, study of platelet function tests and review of literature.

Idiopathic myelofibrosis is a chronic myeloproliferative disorder characterized by excessive connective tissue deposition in the bone marrow. It presents with leucoerythroblastic anemia and massive splenomegaly. It is termed osteomyelosclerosis in the presence of primitive bone formation in the bone marrow and radiological presence of osteosclerosis. A 40-year-old male, known case of thalassemia trait presented with fatigue and lump in the abdomen for two months. Physical examination showed splenomegaly 8.5 cm below costal margin. X-ray examination revealed multiple osteosclerotic lesions involving the pelvis and long bones. Hemogram showed: hemoglobin 7.8 gm/dl, TLC 47,500/mm(3); DLC was polymorphs 49%, lymphocytes 7%, eosinophils 4%, basophils 4%, blasts 5%, promyelocytes 2%, myelocytes 14%, metamyelocytes 10%. Platelet count was 60,000/mm(3). Peripheral blood film showed leucoerythroblastic blood picture with features of dysmyelopoiesis. Bone marrow aspiration was diluted with peripheral blood. Bone marrow biopsy showed replacement of marrow by grade III reticulin fibrosis. Bony trabaculae were wide and thick. Platelet function studies were abnormal. The clinical, radiological and hematological features suggested a diagnosis of osteomyelosclerosis. We present this case because no similar association of osteomyelosclerosis with thalassemia trait has been described in English literature to date. This is the first study from India, which describes platelet function tests in a patient with osteomyelosclerosis.

Fibroma with minor sex cord elements--an incidental finding in a normal sized ovary. A case report with literature review.

Ovarian fibroma with minor sex cord element is a rare neoplasm. Microscopically it is composed of predominantly fibromatous or a thecomatous tumor containing scattered minor sex cord elements in less than 10% of the tumor area.A case of fibroma with minor sex cord elements discovered incidentally in a normal sized ovary in a patient who presented with dysfunctional uterine bleeding is being presented. This is the first case report describing this entity in a normal sized ovary as an incidental finding.

Abdominal tuberculosis presenting as ileocolic intussusception in an infant.

Intussusception is the most common cause of intestinal obstruction in children, with a peak in children 5 to 7 months of age. Identifiable causes are found in 90% of adults, whereas in infants and young children the majority are idiopathic. We report a case of abdominal tuberculosis (ATB) presenting as an ileocolic intussusception in an infant. A 6-month-old infant presented with features of acute intestinal obstruction. Peroperatively, ileocolic intussusception was found. Histological examination revealed caseating epitheloid cell granulomas with positivity for acid-fast bacilli. Only 3 cases of ATB presenting as intussusception have been previously reported in the literature, with only 1 case presenting in a child. This appears to be the 2nd case of ATB presenting as an intussusception in a child and also in an infant. Tuberculosis should also be kept in the differential diagnosis of lead point of intussusception, even in the age group in which most cases are idiopathic, especially in endemic areas.

Sialadenoma papilliferum in a young patient: a case report and review of the literature.

Sialadenoma papilliferum is a rare exophytic tumor of salivary gland origin, accounting for less than 1% of minor salivary gland tumors. It usually occurs in males older than 50 years as a painless papillary intraoral lesion. An 18-year-old male patient presented with an exophytic intraoral lesion present for approximately 12 years. The tumor was excised with a clinical diagnosis of infected hemangioma. However, histopathological diagnosis was consistent with sialadenoma papilliferum. The patient was followed up at regular intervals and no evidence of recurrence was noted. Our patient, aged 18 years, with tumor lasting for 12 years becomes the youngest case of intraoral sialadenoma papilliferum yet reported. This case highlights the importance of keeping sialadenoma papilliferum as a differential diagnosis of an intraoral exophytic proliferative lesion even in a young patient.

Coexistence of salivary gland cysticercosis with squamous cell carcinoma of the mandible.

Cysticercosis is a parasitic infestation caused by the pork tapeworm larval stage, Cysticercus cellulosae. The majority of the cases present in ocular, cerebral, and subcutaneous locations. We report the presence of cysticercosis inside the submandibular gland in association with squamous cell carcinoma of the inferior alveolar ramus of the mandible. To the best of our knowledge, this is the first case report documenting cysticercosis inside a salivary gland. A 65-year-old male presented with complaints of an ulcerative lesion on the inferior alveolar ramus present for 2 months. Histological examination revealed a keratinizing well-differentiated squamous cell carcinoma involving the alveolar margin and mandible. The histopathological examination of the submandibular gland revealed cysticercosis. This case emphasizes the importance of adequate sampling of all the tissues obtained for associated infectious disorders, more so in immunosuppressed patients, which will help the clinician to manage the case appropriately.