Superficial oeso-gastric cancer and endoscopic mucosal resection: the pathologist's approach.

Dysplasia is the earliest phase in cancer development that can be recognized by routine morphology. High grade dysplasia, intraepithelial carcinoma and in situ carcinoma are synonymous terms identifying a non invasive lesion whereas superficial (early) carcinoma is defined as a lesion confined to the mucosa or to the mucosa and sub-mucosa with or without lymph node metastasis. In the Vienna classification, proposed by a panel of Western and Japanese experts in 2000, the term "dysplasia" was replaced by the term "intraepithelial neoplasia" because this term defines more clearly the nature and the extent of the lesion, allowing recommendations for further diagnostic and therapeutic measures. Intraepithelial neoplasia is divided into two groups: low grade and high grade. Superficial oeso-gastric cancer can be treated by endoscopic mucosal resection (EMR). EMR provides specimens that must be handled and reported as surgical specimens by the pathologist.

Survival of rectal cancer patients in Belgium 1997-98 and the potential benefit of a national project.

BACKGROUND: PROCARE, a Belgian multidisciplinary project on rectal cancer (RC), will be launched in 2006. Guidelines have been developed, but remain to be implemented. AIM: A population-based study on RC treatment and outcome in Belgium and comparison with recent international benchmarks in order to better define targets that should be reached. PATIENTS AND METHODS: Anonymous data of 3079 patients with rectal cancer registered in the National Cancer Registry in 1997 and 1998 were analysed. Observed (OS) and relative survival (RS) were compared with figures from nationwide projects and multi-centre studies. RESULTS: The 5-yr OS and RS were 46.6% and 58.5%, respectively. For patients with stage I-III tumours 5-yr OS was 57.1% and 5-yr RS 70.1%. Adjuvant or neo-adjuvant treatment was given in 54.8% stage II-III patients who were < 70 years old. There were marked differences between the provinces in the use of radiotherapy for stage II-III patients and in 5-yr RS for all stages. In stage IV, the median OS was 13 months and the 2-yr OS was 28%. Comparison with recent multi-centre trials indicates significant potential benefits from the PROCARE project: an absolute increase of the 5-yr OS by 10 to 20% after chemoradiotherapy and TME in stage II-III patients 75 years old or less, a 7-month increase of the median OS and an absolute 15% increase of the 2-yr OS in unresectable stage IV patients with combined chemotherapy. CONCLUSION: Significant improvement seems to be achievable. Implementation of the PROCARE guidelines with quality assurance through prospective registration in a specific database, however, is a crucial prerequisite for credible audit of performance and feedback to individual teams.

[Critical study of digestive tract dysplasia]. / Etude critique de la dysplasie dans le tube digestif.

Dysplasia designate the presence in a tissue of atypical architectural and cytological features similar to those observed in carcinogenesis. It must be clearly distinguished from metaplasia which is, in itself, a benign state characterized by the progressive replacement of a normal tissue by an other, normally foreign to this organ. Although the theoretical definition of dysplasia and its relation to carcinogenesis is well demonstrated, numerous difficulties remain regarding its classification and clinical applications. Recent research based on follow-up studies and on diagnostic reproducibility have somewhat clarified the problem, leading to a simplification of the classification in two tiers (high and low grade). High grade dysplasia can be considered as a high cancer risk necessitating a follow-up at short intervals and possibly requiring surgery. Low grade dysplasia, which can regress or progress very slowly represents a low cancer risk. After a first control at one or two months, it is suggested that endoscopic follow-up can be proposed at larger intervals (one or two years). The authors study the aspects of the dysplasia at the different levels of the gastrointestinal tract and summarise the clinical implication of this diagnosis.

[Celiac disease in adults: clinical aspects--role of endoscopy]. / La maladie coeliaque de l'adulte: aspects cliniques--rôle de l'endoscopie.

Adult coeliac disease has a broad clinical spectrum and remains undetected for years. Among subclinical deficiency states, attributable to coeliac enteropathy, combined iron and folic acid malabsorption is predominant. An unexplained recurrent iron anaemia is an indication for small intestinal biopsy. Gastro-intestinal disorders are present in only 50% of the cases. Coeliac disease is frequently associated with other major histocompatibility complex (MMC)-linked diseases which are mediated by immunological mechanisms: dermatitis herpetiformis, oral ulcerations, IgA nephropathy, rheumatoid arthritis, sarcoidosis. Dermatitis herpetiformis is a useful model for examination of the spectrum of mucosal changes that typify gluten sensitivity and subliminal lesions without villous atrophy. An increased interest is devoted to the intra-epithelial T-lymphocyte population, not only in the small intestine, but at the level of the stomach and the colon. A "rectal challenge" test has been proposed for detecting gluten sensitivity in coeliac patients. Such a test could be an original method of screening, reducing so the need of small intestinal biopsy. The preliminary results are to be confirmed. Until now, jejunoscopy remains mandatory for the diagnosis and the survey of intestinal lesions related to coeliac disease.

Ménétrier's disease with lymphocytic gastritis: an unusual association with possible pathogenic implications.

Ménétrier's disease is a rare form of hypertrophic or hyperplastic gastropathy, characterized by conspicuous thickening of the gastric mucosal folds and foveolar (crypt) hyperplasia. The pathogenesis of Ménétrier's disease remains unresolved. Lymphocytic gastritis is a newly described entity which corresponds endoscopically to varioliform gastritis and is marked by T-lymphocyte infiltration of the surface epithelium and crypts. Five surgical cases and one autopsy case combining the gross and microscopic features of Ménétrier's disease and lymphocytic gastritis are presented. This unusual and hitherto previously undescribed association raises the possibility of a common pathogenesis for Ménétrier's disease and lymphocytic gastritis.

Lymphocytic gastritis--prospective study of its relationship with varioliform gastritis.

Lymphocytic gastritis is a new histopathological entity characterised by a dense lymphocytic infiltration of surface and pit gastric epithelium. Previous retrospective work has suggested that lymphocytic gastritis is related to an endoscopic form of gastropathy comprising enlarged folds, nodules and erosions, commonly denoted as varioliform gastritis. In the present prospective study, the relationship is clearly shown; nearly 82% (54/66) of the varioliform gastritis observed in four different endoscopy units correspond histologically to lymphocytic gastritis. The correlation is even better if cases showing strictly antral localisation are excluded (53/55) - that is, more than 96%. The histological concept of lymphocytic gastritis seems, however, to extend beyond varioliform gastritis as of 67 cases of lymphocytic gastritis diagnosed during the period under study, one third had no particular endoscopic expression.

[Lymphocytic gastritis]. / La gastrite lymphocytaire.

Lymphocytic gastritis is a new histopathological entity characterized by a dense lymphocytic infiltration of the gastric surface and pit epithelium. The diagnosis relies upon lymphocyte counts which are always far beyond the values obtained in other types of gastritis. The clinical presentation of lymphocytic gastritis is characterized, in the majority of cases, by weight loss and anorexia. Endoscopically it corresponds to a complex pattern of enlarged rugae and often eroded (aphthoïd) nodules. Our studies have shown a close correlation between lymphocytic gastritis and diffuse or corporeal varioliform gastritis. On the contrary, there is no relationship between lymphocytic gastritis and antral varioliform gastritis which exhibits heterogeneous histological features. Lymphocytic gastritis is a chronic disease which can evolve over long periods; it can however cure spontaneously (about half of the cases) after a delay of one to two years. The aetiology and pathogenesis are unknown. The histological similarity with coeliac disease suggests a possible role of immunological factors.

[Immunological aspects of lymphocytic gastritis]. / Aspects immunologiques de la gastrite lymphocytaire.

Diffuse and corporeal varioliform gastritis represent the usual endoscopic expression of lymphocytic gastritis. Referring to the work of other authors on varioliform gastritis, immunocytochemical studies have been made on the plasma cells of the lamina propria in two comparative series of lymphocytic and chronic atrophic gastritis. We could not demonstrate any significant variation in the number of IgE plasma cells between the two types of gastritis. In another study, the lymphocytic populations of the lamina propria and of the epithelium were characterized by peroxidase immunocytochemical methods on frozen sections. In agreement with other authors we confirmed that, in lymphocytic gastritis, the intraepithelial lymphocytes belong to the T group with a predominance of the T8 subgroup. In the lamina propria, the lymphocytes were mostly T with a slight preponderance of the T4 subgroup. B lymphocytes were scarce. The distribution of B and T lymphocytes was the same as that observed in coeliac disease.

[Anatomopathological criteria of progression in chronic idiopathic colitis]. / Critères anatomopathologiques d'évolution des colites chroniques idiopathiques.

Idiopathic inflammatory colitis are diseases of remissions and exacerbations of various severity. The criteria of activity are based on a conjunction of clinical, radiologic, endoscopic and anatomopathological data. From the macroscopical point of view, they are different in ulcerative colitis and Crohn's disease. Ulcerative colitis is characterized by a diffuse and uniform mucosal inflammation; any biopsy outside an ulcerative area can be used to evaluate the inflammatory components which are in the acute phase (chronic active phase): oedema, vascular congestion and an inflammatory infiltrate composed of a mixture of lymphocytes, plasma cells and polymorphs with partial destruction of the glands (crypt abscesses). In the revolving phase, the inflammation regresses; the crypts are distorted, the crypt abscesses gradually disappear. In ulcerative colitis in remission, the inflammation vanishes but there is loss of parallelism and branching of the crypts. In Crohn's disease, the inflammation is often discontinuous and focal; biopsies must be taken from multiple sites. It is not rare to see a coincidence of lesions at different stages of activity. The criteria of activity are less reliable than in ulcerative colitis. Acute lesions present with oedema and infiltration of the lamina propria by polymorphs, neutrophils as well as eosinophils. Granulomas probably represent a particular reactional status. There features and number do not very significatively in the course of the disease.

Bilateral ureteral endometriosis with end-stage renal failure.

Only 16 cases of bilateral ureteral endometriosis have been reported to date. A contiguous spread of the disease is generally thought to be the mechanism of ureteral involvement. We report a case in which the left ureter contains both intrinsic and separated extrinsic forms and the right one an extrinsic form of endometriosis, giving us the opportunity to discuss the different pathogenetic mechanisms and to suggest that dissemination of endometriosis by lymphatic pathways is the most probable explanation.