Biopsy Interpretation of the Gastrointestinal Tract Mucosa: Volume 2: Neoplastic

344 Pages·2012·19.044 MB·English

by  Elizabeth A. Montgomery MD, Lysandra Voltaggio MD

BIOPSY INTERPRETATION SERIES
BIOPSY INTERPRETATION
OF THE GASTROINTESTINAL
TRACT MUCOSA
Volume 2: Neoplastic
Second Edition
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BIOPSY INTERPRETATION SERIES
Series Editor: Jonathan I. Epstein, M.D.
Biopsy Interpretation of the Gastrointestinal Tract Mucosa: Neoplastic, 2/e (Vol. 2)
Elizabeth A. Montgomery and Lysandra Voltaggio, 2012
Biopsy Interpretation of the Upper Aerodigestive Tract and Ear, 2/e
Edward B. Stelow and Stacey E. Mills, 2012
Biopsy Interpretation of the Breast, 2/e
Stuart J. Schnitt and Laura C. Collins, 2012
Biopsy Interpretation of the Lung
Saul Suster and Cesar Moran, 2012
Biopsy Interpretation of the Gastrointestinal Tract Mucosa:
Non-Neoplastic, 2/e (Vol. 1)
Elizabeth A. Montgomery and Lysandra Voltaggio, 2011
Biopsy Interpretation of the Central Nervous System
Matthew J. Schniederjan and Daniel J. Brat, 2011
Biopsy Interpretation of the Bladder, 2/e
Jonathan I. Epstein, Mahul B. Amin, and Victor E. Reuter, 2010
Biopsy Interpretation of Soft Tissue Tumors
Cyril Fisher, Elizabeth A. Montgomery, and Khin Thway, 2010
Biopsy Interpretation of the Thyroid
Scott L. Boerner and Sylvia L. Asa, 2009
Biopsy Interpretation of the Skin
A. Neil Crowson, Cynthia M. Magro, and Martin C. Mihm, 2009
Biopsy Interpretation: The Frozen Section
Jerome B. Taxy, Aliya N. Husain, and Anthony G. Montag, 2009
Biopsy Interpretation of the Uterine Cervix and Corpus
Anais Malpica, Michael T. Deavers, and Elizabeth D. Euscher, 2009
Biopsy Interpretation of the Liver, 2/e
Stephen A. Geller and Lydia M. Petrovic, 2009
Biopsy Interpretation of the Breast
Stuart J. Schnitt and Laura C. Collins, 2008
Biopsy Interpretation of the Prostate, 4/e
Jonathan I. Epstein and George Netto, 2007
Biopsy Interpretation of the Upper Aerodigestive Tract and Ear
Edward B. Stelow and Stacey E. Mills, 2007
Biopsy Interpretation of the Gastrointestinal Tract Mucosa
Elizabeth A. Montgomery, 2005
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BIOPSY INTERPRETATION SERIES
BIOPSY INTERPRETATION
OF THE GASTROINTESTINAL
TRACT MUCOSA
Volume 2: Neoplastic
Second Edition
Elizabeth A. Montgomery, M.D.
Department of Pathology
Johns Hopkins Medical Institutions
Baltimore, Maryland
Lysandra Voltaggio, M.D.
Department of Pathology
George Washington University Hospital
Washington, District of Columbia
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Senior Executive Editor: Jonathan W. Pine, Jr.
Product Manager: Marian A. Bellus
Vendor manager: Alicia Jackson
Senior Manufacturing Manager: Benjamin Rivera
Creative Director: Doug Smock
Production Service: SPi Global
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Library of Congress Cataloging-in-Publication Data
Montgomery, Elizabeth (Elizabeth A.), 1958-
Biopsy interpretation of the gastrointestinal tract mucosa. Volume 2, Neoplastic / Elizabeth A.
Montgomery, Lysandra Voltaggio. — 2nd ed.
p. ; cm.
Neoplastic
Includes bibliographical references and index.
ISBN 978-1-4511-0959-7
I. Voltaggio, Lysandra. II. Title. III. Title: Neoplastic.
[DNLM: 1. Gastric Mucosa—pathology. 2. Gastrointestinal Neoplasms—diagnosis. WI 301]
616.99'4307545—dc23
2012002905
Care has been taken to confi rm the accuracy of the information presented and to describe gener-
ally accepted practices. However, the authors, editors, and publisher are not responsible for errors
or omissions or for any consequences from application of the information in this book and make
no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of
the contents of the publication. Application of the information in a particular situation remains the
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and dosage set forth in this text are in accordance with current recommendations and practice at
the time of publication. However, in view of ongoing research, changes in government regulations,
and the constant fl ow of information relating to drug therapy and drug reactions, the reader is urged
to check the package insert for each drug for any change in indications and dosage and for added
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To my sister, Cassandra
Lysandra Voltaggio
To Sasha, Peter, Sean, and Jonathan
Elizabeth A. Montgomery
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ACKNOWLEDGMENTS
The authors acknowledge their fellow pathologists, residents, and fellows
for their help in identifying and collecting cases from their daily sign out
and gastroenterology colleagues for supplying wonderful endoscopic pho-
tos. We also want to thank Louise Bierig for her role as development edi-
tor, Marian Bellus for her role as a product manager, Anoop Kumar for
overseeing production, and Jonathan Pine, Senior Executive Editor, for
encouraging me to undertake this project. Finally, writing a book is a time-
consuming process that often takes time away from other life duties, and
we thank our husbands for their patience during this endeavor.
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INTRODUCTION TO
GASTROINTESTINAL TRACT BIOPSY
INTERPRETATION
GENERAL FEATURES OF GI BIOPSY INTERPRETATION
Probably the key principle of gastrointestinal (GI) biopsy interpretation is
that the GI tract has a limited repertoire of responses to a host of injuries,
and diagnosing the type of injury in any given biopsy often requires cor-
relation with clinical and endoscopic information. On the other hand, nor-
mal biopsies may be obtained from symptomatic patients, and pathologists
should not succumb to the temptation of reporting “infl ammation,” which
serves little purpose since infl ammatory cells are a normal constituent of
the lamina propria. Other patients may be very ill from diseases that are
mural or extraintestinal, and mucosal biopsies offer little information to the
treating physician. However, some systemic diseases include GI tract mani-
festations that can be identifi ed if a consistent, systematic approach is used.
When dealing with mucosal biopsies of the GI tract, it should also be
noted that the vast majority of specimens display the mucosa and, rarely,
a small amount of submucosa. This is especially signifi cant when dealing
with lesions that are usually limited to the submucosa and beyond (e.g.,
lipomas, infl ammatory fi broid polyps). Both pathologists and clinicians
should be aware that lack of histologic fi ndings does not preclude underly-
ing pathology. Of course, mucosal biopsies should not include muscularis
propria. When they do, it is a good practice to contact the endoscopist and
discuss the possibility of endoscopic perforation.
OVERVIEW COMMENTS ON THE GI TRACT
Before a discussion of mucosal biopsies can ensue, it is worthwhile to
review the overall microscopic anatomy of the GI tract in general.
The innermost layer of the GI tract is the mucosa, consisting of three
components:
1. Epithelium (with protective, secretory, or absorptive properties).
2. Lamina propria. This is a loose connective tissue zone support-
ing the avascular epithelium. In the esophagus, stomach, and small
bowel, it is rich in lymphatics, whereas it is less so in the lower tract.
This is of clinical signifi cance in evaluating carcinomas because they
can attain lymphatic access with minimal invasion in the upper tract.
In the esophagus and stomach, there are few immune cells (lymphoid
and plasma cells) in the lamina propria. Some observers regard the
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x INTRODUCTION TO GASTROINTESTINAL TRACT BIOPSY INTERPRETATION
presence of plasma cells, no matter how few, as an abnormal fi nd-
ing in gastric biopsies. It is our practice to report infl ammation in
this site only when there is obvious expansion of the lamina propria
(increased dot density) at low power. In the small bowel and colon,
lamina propria lymphocytes and plasma cells are more abundant.
Neutrophils do not belong in either the lamina propria or the epithe-
lium. Eosinophils are a normal lamina propria constituent and can
be particularly prominent in the right colon in the healthy patient.
Mucosal biopsies from all sites must be assessed for prominence in
the normal infl ammatory components, which is usually identifi ed at
low power as an abnormal expansion of the lamina propria.
3. Muscularis mucosae. This is a slim double layer of smooth muscle
separating the mucosa from the submucosa. It has an inner circular
and outer longitudinal arrangement, and, in this respect, it can be
regarded as a miniaturized muscularis propria. In the normal state,
colonic crypts extend down to the superior aspect of the muscularis
mucosae. Crypt shortening (usually with basal plasmacytosis) is an
indicator of chronic injury.
The mucosa is wholly distinct in the various regions of the GI tract. Note
that the muscularis mucosae is considered a component of the mucosa for
the purposes of staging invasive carcinomas.
The submucosa is composed of connective tissue and houses Meissner
nerve plexus as well as large caliber vessels. The muscularis propria is the
main wall of the GI tract and is composed of an inner circular and outer
longitudinal layer of smooth muscle. Between these layers is Auerbach
nerve plexus. The outermost component is either adventitia or serosa. The
former lacks a mesothelial membrane lining.
Parasympathetic ganglion cells are found in the nerve plexi (both
Meissner and Auerbach), but the submucosal Meissner plexi contain neu-
ronal cell bodies of the intrinsic sympathetic nerve system that function on
the local area of the gut. These are the neurons that have chemoreceptors
and mechanoreceptors. They synapse on both other ganglion cells and
muscle or secretory cells. Ganglion cells are not a normal component of
the mucosa and, when identifi ed, are indicative of chronic injury.
The pathologist should be aware of several points in the GI tract
that lack a serosa, which is an issue mostly in staging tumors in resection
specimens rather than in interpreting biopsies. Most are aware of the lack
of serosal tissue in the esophagus, but several retroperitoneal portions of
the colorectum share this feature. The posterior surfaces of the ascending
and descending colon lack a peritoneal covering and are in direct contact
with the retroperitoneum. In contrast, the anterior and lateral surfaces of
the ascending and descending colon are covered by a visceral peritoneum
(serosa). The transverse colon is entirely intraperitoneal and is supported
on a long mesentery that is attached to the pancreas. The descending
colon becomes the sigmoid colon at the origin of the mesosigmoid, and
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