Differential diagnosis of traditional serrated adenomas and tubulovillous adenomas: a compartmental morphologic and immunohistochemical analysis.

AIM: Traditional serrated adenomas are the rarest member of the serrated polyps, that have endoscopic and morphologic similarities with conventional adenomas, tubulovillous adenomas, in particular. We aimed to compare the histopathologic and immunohistochemical features of TSAs showing overt dysplasia with conventional TVAs in a compartmental manner using digitalized images. PATIENTS AND METHODS: For 25 TSAs and 25 TVAs, extent of the morphologic features including cytoplasmic eosinophilia, mid-zonal nuclei, ECFs, slit-like serration, brush border, gastric foveolar-like epithelium and goblet cells were evaluated. Immunohistochemistry was perfomed using primary antibodies including CK7, CK20, MUC2, MUC5AC, MUC6, B-catenin, Ki67, p53, p16, MLH1, MSH2, MSH6 and PMS2. RESULTS: Eosinophilic cells, mid-zonal nuclei, slit-like serration and ECF were significantly more extensive in TSAs compared to TVAs (p<0,001) while gastric epithelium was also more extensive in TSA cohort with a lower significance (p<0,01). Cut-offs for these features yielding the highest sensitivity and specificity in discriminating TSAs from TVAs were determined ; mid-zonal nucleus resulted as the best discriminating histopathologic feature (100%, 92%) followed by eosinophilia (88%, 92%),and slit-like serration (84%, 92%) with highest sensitivity and specificities, respectively. Compartmental immunohistochemical evaluation revealed that CK20 and CK7 were mainly expressed in ECF while MUC5AC together with CK7 were found in epithelial compartment more frequently in TSAs compared to TVAs. P16 was more common in TSAs in all compartments whereas Ki67 and p53 were restricted to dysplastic compartments in both polyp groups. CONCLUSIONS: The present study demonstrated that mid-zonal nuclei, eosinophilic cells and slit-like serration followed by ECF proved to be the most discriminatory features for TSAs.The correct diagnosis of TSAs will allow to develop appropriate treatment and follow up modalities which seem to be crucial as their progression rate may be different from TVAs.

INFLAMMATORY BOWEL DISEASE-LIKE PHENOTYPE IN A YOUNG GIRL WITH PROLIDASE DEFICIENCY: A NEW SPECTRUM OF CLINICAL MANIFESTATION.

Prolidase deficiency (PD) is an inherited disorder associated with cutaneous ulcers, intellectual disability, unusual facial appearance, skeletal deformities, hematological anomalies, splenomegaly, and chronic infections. We report a girl with PD who presented with early inflammatory bowel disease (IBD). A 2-month-old girl with a dysmorphic face presented with recurrent respiratory tract infections, vomiting, diarrhea and hepatosplenomegaly. She had steatorrhea, abnormal liver enzymes, hypergammaglobulinemia, autoantibody positivity and steatohepatitis in liver biopsy. On follow-up, skin lesions, pruritus and developmental delay were added. At the age of 21 months, IBD was diagnosed with persistent diarrhea, fever, hypoalbuminemia, elevated inflammatory markers, fecal leukocytes and aphthous ulcers in colon. Remission was achieved with prednisone and continued with mesalasine. Thrombocytopenia developed after 3 years. Her findings prompted us to further investigations. PD as the underlying molecular cause of the disease was detected by exome sequencing. In conclusion, PD should be considered in the differential diagnosis of some IBD patients.

Diagnosing oesophagitis in children: how discriminative is histology?

BACKGROUND AND STUDY AIMS: We set out to evaluate the discriminatory value of currently available histologic criteria in the differential diagnosis of reflux oesophagitis and eosinophilic oesophagitis in children. PATIENTS AND METHODS: We evaluated the oesophageal biopsies of 145 children and selected 28 demonstrative cases of clinically confirmed eosinophilic oesophagitis (n = 7), and reflux oesophagitis (n = 11) with a control group with normal histology (n = 10). Histological assessment was performed for the presence of papillary elongation, dilatation of intercellular spaces, basal cell hyperplasia and the number of intraepithelial eosinophils, lymphocytes and neutrophils. RESULTS: Among 28 children, there were 3 boys and 4 girls in eosinophilic oesophagitis group, 8 boys and 3 girls in reflux group, and 5 boys and 5 girls in normal group. The mean age was 10,4 years. Basal cell hyperplasia was observed in 12 cases while papillary elongation was found in 25, and dilated intercellular spaces were present in 20 cases. Lymphocyte and neutrophil counts were significantly higher in reflux group when compared to eosinophilic oesophagitis and normal group. Eosinophil counts were significantly higher in eosinophilic group. CONCLUSIONS: Results of the present study suggest that, basal cell hyperplasia, papillary elongation, and dilated intercellular spaces all seem to be markers of oesophagitis regardless of the underlying pathology and etiology, thereby, highlighting their rather nonspecific nature in the differential diagnosis of various types of oesophagitis. The additional information on inflammatory cell counts may help to distinguish reflux oesophagitis from other causes of oesophagitis including EoO.

European consensus on the histopathology of inflammatory bowel disease.

The histologic examination of endoscopic biopsies or resection specimens remains a key step in the work-up of affected inflammatory bowel disease (IBD) patients and can be used for diagnosis and differential diagnosis, particularly in the differentiation of UC from CD and other non-IBD related colitides. The introduction of new treatment strategies in inflammatory bowel disease (IBD) interfering with the patients' immune system may result in mucosal healing, making the pathologists aware of the impact of treatment upon diagnostic features. The European Crohn's and Colitis Organisation (ECCO) and the European Society of Pathology (ESP) jointly elaborated a consensus to establish standards for histopathology diagnosis in IBD. The consensus endeavors to address: (i) procedures required for a proper diagnosis, (ii) features which can be used for the analysis of endoscopic biopsies, (iii) features which can be used for the analysis of surgical samples, (iv) criteria for diagnosis and differential diagnosis, and (v) special situations including those inherent to therapy. Questions that were addressed include: how many features should be present for a firm diagnosis? What is the role of histology in patient management, including search for dysplasia? Which features if any, can be used for assessment of disease activity? The statements and general recommendations of this consensus are based on the highest level of evidence available, but significant gaps remain in certain areas.

Evaluation of Barrett's esophagus with CK7, CK20, p53, Ki67, and COX2 expressions using chromoendoscopical examination.

Barrett's esophagus (BE) is a complication of chronic gastroesophageal reflux disease and can be diagnosed when there is an endoscopically irregular Z-line and intestinal metaplasia (IM) in a biopsy obtained lower esophagus. It is still not clear whether IM in the gastric cardia or columnar mucosa without IM in the lower esophagus have any significance as BE, which is considered as preneoplastic. The aim of the study was to determine the immunohistochemical features of BE and columnar mucosa in the distal esophagus and also to evaluate the value of chromoendoscopy in the diagnosis of BE in a prospective manner. A total of 12 chromoendoscopic biopsies (six from normal-looking unstained esophagus and six from esophageal mucosa stained with methyl blue suspicious of BE) were taken from 111 cases who underwent endoscopy because of a variety of upper gastrointestinal symptoms. Immunohistochemical analysis was performed using CK7, CK20, p53, Ki67, and cyclooxygenase 2 (COX2). Of the 111 cases, 19 cases with carcinoma (nine adeno, six squamous, four undifferentiated carcinomas) and 17 cases with normal squamous epithelium were excluded, while 75 cases showing columnar epithelium, including 46 (61.3%) with IM and 29 (38,7%) without IM, were further evaluated immunohistochemically. CK7 was observed in surface, crypt, and glandular epithelium, whereas CK20 was expressed in surface and superficial crypt epithelium. No significant difference was observed between the Barrett and non-Barrett type of CK7/20 staining pattern (P > 0,05). Expression of p53 did not show any difference between BE and columnar mucosa without IM, whereas COX2 expression was significantly increased in BE (P < 0.05) in comparison with columnar mucosa without IM. Ki67 expression was significiantly higher both in upper and lower crypts in BE (P < 0.05). The present study showed that a Barrett pattern does not seem to exist; however, the analysis of COX2 expression and the Ki67 proliferation fraction by immunohistochemistry can be used to separate BE from non-Barrett's metaplasia of the distal esophagus. In our point of view, the immunohistochemical detection of p53 expression in Barrett's metaplasia stage is useless as a marker for early detection of high-risk patients.

Management of precancerous conditions and lesions in the stomach (MAPS): guideline from the European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter Study Group (EHSG), European Society of Pathology (ESP), and the Sociedade Portuguesa de Endoscopia Digestiva (SPED).

Atrophic gastritis, intestinal metaplasia, and epithelial dysplasia of the stomach are common and are associated with an increased risk for gastric cancer. In the absence of guidelines, there is wide disparity in the management of patients with these premalignant conditions. The European Society of Gastrointestinal Endoscopy, the European Helicobacter Study Group, the European Society of Pathology, and the Sociedade Portuguesa de Endoscopia Digestiva have therefore combined efforts to develop evidence-based guidelines on the management of patients with precancerous conditions and lesions of the stomach. A multidisciplinary group of 63 experts from 24 countries developed these recommendations by means of repeat online voting and a meeting in June 2011 in Porto, Portugal. The recommendations emphasize the increased cancer risk in patients with gastric atrophy and metaplasia and the need for adequate staging in the case of high-grade dysplasia, and they focus on treatment and surveillance indications and methods.

Management of precancerous conditions and lesions in the stomach (MAPS): guideline from the European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter Study Group (EHSG), European Society of Pathology (ESP), and the Sociedade Portuguesa de Endoscopia Digestiva (SPED).

Atrophic gastritis, intestinal metaplasia, and epithelial dysplasia of the stomach are common and are associated with an increased risk for gastric cancer. In the absence of guidelines, there is wide disparity in the management of patients with these premalignant conditions. The European Society of Gastrointestinal Endoscopy (ESGE), the European Helicobacter Study Group (EHSG), the European Society of Pathology (ESP) and the Sociedade Portuguesa de Endoscopia Digestiva (SPED) have therefore combined efforts to develop evidence-based guidelines on the management of patients with precancerous conditions and lesions of the stomach (termed MAPS). A multidisciplinary group of 63 experts from 24 countries developed these recommendations by means of repeat online voting and a meeting in June 2011 in Porto, Portugal. The recommendations emphasize the increased cancer risk in patients with gastric atrophy and metaplasia, and the need for adequate staging in the case of high grade dysplasia, and they focus on treatment and surveillance indications and methods.

Eosinophilic oesophagitis versus reflux oesophagitis.

Reflux oesophagitis (RO) is defined as the inflammation of the lower oesophagus due to damage caused by acid reflux from the stomach. Histopathologic features of acid reflux include epithelial hyperplasia, baloon cells, basal cell hyperplasia, papillary elongation, dilated intercellular spaces representing epithelial oedema, vascular congestion, and inflammatory cell infiltration comprising lymphocytes, neutrophils and eosinophils, most of which are nonspecific. Eosinophils, on the other hand, are considered to be important in the differential diagnosis of RO and EoO which is a chronic inflammatory disorder characterized by eosinophil infiltration of the oesophageal mucosa associated with a history of atopy or allergy. A cut off value of more than 15 eosinophils per high power field is suggestive of EoO with a tendency of eosinophils to concentrate in the superficial parts of squamous mucosa just below the luminal surface where they tend to form eosinophilic microabsesses. Dense fibrosis is seen in up to one-third of the patients with EoO together with an increase in the number of eosinophils in the lamina propria. In patients with intermediate levels of eosinophil counts (7-15 eos/hpf) immunohistochemistry for eosinophil secretory products could prove useful as it highlights degranulated eosinophils. In conclusion, distinguishing EoO from RO requires a thorough clinical, endoscopic and histologic evaluation of the patient which can only be achieved when close communication between pathologist and gastroenterologist is established.

Quantitative endoscopic and histologic activity assessment of ulcerative colitis.

BACKGROUND: Correct assessment of the severity and activity of ulcerative colitis (UC) is necessary for determining effective treatment and predicting prognosis. The correlation between histologic activity and endoscopic activity, however, has not yet been determined by using a quantitative scoring system. STUDY AIMS: To compare the endoscopic activity index (EAI), detected during colonoscopy, with the histologic activity index (HAI) detected in biopsy samples taken from the same colon segments of UC patients in order to determine the degree of agreement between both assessments. PATIENTS AND METHODS: Ninety-six UC patients participated in this prospective study. EAIs and HAIs were obtained by summing the scores given for each mucosal/histological change to produce a total score between 1 and 12. The correlation between EAI and HAI was calculated. RESULTS: There was a positive correlation between HAI and EAI (r = 0.78; p < 0.001). There was no statistical inconsistency between the EAI and HAI results (p = 0.625, using the McNemar test). The whole group kappa coefficient was 0.607 (p < 0.001). CONCLUSION: Endoscopic and histologic activity of mucosal disease in patients with UC are generally consistent. Measuring both histologic and endoscopic activity with a quantitative scoring system during patient follow-up would be a more accurate method for monitoring UC patients.

KRAS mutation testing for predicting response to anti-EGFR therapy for colorectal carcinoma: proposal for an European quality assurance program.

Novel therapeutic agents targeting the epidermal growth factor receptor (EGFR) have improved outcomes for patients with colorectal carcinoma. However, these therapies are effective only in a subset of patients. Activating mutations in the KRAS gene are found in 30-40% of colorectal tumors and are associated with poor response to anti-EGFR therapies. Thus, KRAS mutation status can predict which patient may or may not benefit from anti-EGFR therapy. Although many diagnostic tools have been developed for KRAS mutation analysis, validated methods and standardized testing procedures are lacking. This poses a challenge for the optimal use of anti-EGFR therapies in the management of colorectal carcinoma. Here we review the molecular basis of EGFR-targeted therapies and the resistance to treatment conferred by KRAS mutations. We also present guideline recommendations and a proposal for a European quality assurance program to help ensure accuracy and proficiency in KRAS mutation testing across the European Union.

The usefulness of chromoendoscopy with methylene blue in Barrett's metaplasia and early esophageal carcinoma.

BACKGROUND: Barrett's esophagus is a condition that is premalignant for adenocarcinoma of the esophagus and the esophagogastric junction. Early detection of Barrett's metaplasia and dysplasia is very important to decrease the mortality and morbidity from esophageal adenocarcinoma cancer. This study aimed to evaluate the effectiveness of methylene blue-targeted biopsies in the differential diagnosis of intestinal metaplasia, dysplasia, and superficial esophageal carcinoma. METHODS: A total of 109 patients (43 women and 66 men; average age, 62.32 +/- 10.61 years; range, 33-82 years) were enrolled for the study. Four groups were designed before endoscopic examinations. The patients for these groups were selected at the conventional endoscopy, and then chromoendoscopy was performed. The esophagus was stained with methylene blue, after which six biopsies were taken from stained and unstained areas. RESULTS: Conventional and chromoendoscopic assessments were compared with histopathologic examination. The sensitivity of chromoendoscopy for Barrett's epithelium was superior to that of conventional endoscopy (p < 0.05). However, there was no statistical difference between the two methods in the diagnosis of esophagitis or esophageal carcinoma (p > 0.05). Stained biopsies were superior to unstained biopsies in terms of sensitivity for Barrett's epithelium and esophageal carcinoma (p < 0.001). CONCLUSION: Chromoendoscopy is useful for delineating Barrett's epithelium and for indicating the correct location for securing biopsies where dysplasia or early esophageal cancer is suspected.

Behçet's disease-like presentation of bullous pyoderma gangrenosum associated with Crohn's disease.

A 47-year-old woman presented with a 2-month history of generalized arthralgia and a 10-day history of oral aphthous ulcers. After hospitalization, papulopustular lesions and perianal ulcerations developed. Pathergy test was positive and ophthalmological examination was normal. The presence of oral aphthous ulcers, genital ulcerations, papulopustular lesions and arthralgia, and the positive pathergy test suggested the diagnosis of Behçet's disease (BD). In a few days, positive pathergy reactions and papulopustular lesions evolved into bullous lesions, which were diagnosed dermatopathologically as pyoderma gangrenosum. Two days after the presentation of papulopustular lesions, the patient experienced diarrhoea accompanied by bloody stools and mucus. Histopathological examination of biopsy specimens showed no vasculitis but revealed findings suggestive of Crohn's disease. The patient responded well to treatment with systemic steroids and 5-aminosalicylic acid. Our case demonstrates that the differential diagnosis of BD and inflammatory bowel disease may be perplexing and that these two diseases may be closely related.

Prognostic significance of tumor angiogenesis in epithelial ovarian cancer: in association with transforming growth factor beta and vascular endothelial growth factor.

We aimed to evaluate the prognostic significance of microvessel density (MVD), vascular endothelial growth factor (VEGF), and transforming growth factor beta (TGFbeta), as well as to find out the relationship between MVD, and VEGF and TGFbeta in epithelial ovarian cancer (EOC). Surgical specimens of 47 patients with stage I-IV primary EOC, who underwent extended surgical staging according to FIGO, were investigated. Five- micro m thick tissue sections were immunostained with antibody to factor VIII-related antigen, and MVD was assessed at three separate areas of x200 magnification. Expressions for VEGF and TGFbeta were evaluated by immunohistochemical staining using related monoclonal antibodies. Results were correlated with clinicopathologic factors and survival. We did not find any correlation between MVD and clinicopathologic factors, or patient survival. Similarly, there was no association between the degree of VEGF staining and survival or clinicopathologic factors, except preoperative ascites volume, which was higher in patients showing moderate and intense VEGF staining than those with weak VEGF staining (P = 0.052). The expression of TGFbeta was inversely correlated with preoperative CA-125 levels (P < 0.05). Furthermore, there was no correlation between MVD and the staining intensity of VEGF or TGFbeta. In conclusion, angiogenesis does not appear as a prognostic factor in EOC. We suggest that VEGF is an important mediator of ascites formation, and that TGFbeta, which is supposed to have tissue-specific actions in tumorigenesis, may have growth-inhibitory functions in EOC.

Prognostic value of p53 accumulation in epithelial ovarian carcinomas.

AIM: To evaluate the prognostic significance of p53 expression in epithelial ovarian carcinomas (EOC), and to look for correlations between p53 and other disease parameters. MATERIAL AND METHODS: Immunohistochemical techniques were used to evaluate p53 expression in paraffin-embedded tissue specimens of 50 EOC cases. RESULTS: p53 immunoreactivity was present in 33 of the 50 cases (66%). The expression of the p53 did not show any association with the tumor histologic type, grade or with the disease stage. However, p53 accumulation was significantly more prevalent among tumors with high mitotic index ( p<0.01). Although median survival was low in the p53 negative cases, this biologic marker did not reveal as an independent prognostic factor in Cox's regression analysis. CONCLUSION: Abnormalities of p53 expression which is an inducer of apoptosis occur commonly in EOC. Although we could not find it as an independent prognostic factor, p53 expression should be studied in larger series to reveal its accurate prognostic significance.

Prognostic significance of apoptotic index and bcl-2 and p53 expression in epithelial ovarian carcinoma.

PURPOSE OF THE STUDY: To determine if bcl-2 and p53 expression, and apoptotic index (AI) were associated with patient outcome in epithelial carcinomas of the ovary (EOC) and therefore useful as prognostic factors to predict survival. METHODS: A total of 50 women with epithelial carcinomas of the ovary were retrospectively analyzed. The archival paraffin-embedded material of of these cases were evaluated for expression of p53 and bcl-2 by immunohistochemical techniques. Apoptotic cells were detected with an in situ hybridisation method. RESULTS: A total of 33 (66%) of 50 cases showed positive immunoreactivity for the p53 antibody. Twenty-four of the 50 cases showed positive bcl-2 protein expression. Median value for AI was found to be 2.48. No statistically significant association was found between bcl-2 and p53 expression and clinicopathologic features. Univariate survival analysis of AI failed to reveal any effect on prognosis in the study population. CONCLUSION: We found neither p53 nor bcl-2 immunoreactivity to be of prognostic significance in patients with EOC. In addition, AI was not found to be an independent prognostic factor.