Random Surgical Path FAQ Thread

[LADoc00]

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Im starting this thread to ask little random ?s about daily surg path life.

1.) What is the current opinion on small intestinal biopsies that show patchy villous blunting? For example, what do people do with say 2-3 fragments of ileum and one that shows definitive villous blunting, but 2 that are perfectly normal. I mention it, then raise the possibility of celiac disease in the comment. But can celiac disease truly be patchy like that?

2.) Intraductal papillomas: What the criteria people are using for separating out benign intraductal papillomas, intraductal papillomas with atypia and intraductal carcinoma. Currently Im relying heavily on immunos, but maybe overutilizing. Also, I feel Im calling way too many papillomas "atypical".

 

[b&ierstiefel]

1.) What is the current opinion on small intestinal biopsies that show patchy villous blunting? For example, what do people do with say 2-3 fragments of ileum and one that shows definitive villous blunting, but 2 that are perfectly normal. I mention it, then raise the possibility of celiac disease in the comment. But can celiac disease truly be patchy like that?

Well you would also want to look for intraepithelial lymphcytes too right?

 

[torero]

Im starting this thread to ask little random ?s about daily surg path life.

1.) What is the current opinion on small intestinal biopsies that show patchy villous blunting? For example, what do people do with say 2-3 fragments of ileum and one that shows definitive villous blunting, but 2 that are perfectly normal. I mention it, then raise the possibility of celiac disease in the comment. But can celiac disease truly be patchy like that?

Q1 - Celiac disesase usually manifests in the duodenum / proximal jejunum, and that’s where biopsies are usually taken to rule it out. So if there are definite villous architectural changes in the ileum, I would consider of other potential diagnoses (e.g. Crohn’s) before celiac disease.

If clinically they want to rule out celiac disease in a duodenal biopsy, then I decide if it is a) normal b) mild (non-specific), c) moderate (may be early or partially treated celiac) or d) severe (consistent with celiac disease) villous abnormality.

Celiac disease may be patchy, and you may only find blunting in a proportion of the biopsy fragments. That is one of the reasons they should take multiple biopsies.

Q2- I'm thankfully not dealing with breast pathology these days. 🙂

 

[garfield]

1) Since biopsies are not very orientable (thus may artificially look blunt), should also correlate with other features, namely increased intraepithelial lymphocytes. Even if not blunt but has increased intraepith lymphocytes, may want to mention it so they can correlate with serologies and keep monitoring.

2) Check out this August edition of American Journal Surg Path. Has an article relating to intracystic papillary carcinoma & intraductal papillomas with and without atypia and use of IHC (with standard myoepithelial cell markers).

 

[SLUsagar]

Im starting this thread to ask little random ?s about daily surg path life.

1.) What is the current opinion on small intestinal biopsies that show patchy villous blunting? For example, what do people do with say 2-3 fragments of ileum and one that shows definitive villous blunting, but 2 that are perfectly normal. I mention it, then raise the possibility of celiac disease in the comment. But can celiac disease truly be patchy like that?

2.) Intraductal papillomas: What the criteria people are using for separating out benign intraductal papillomas, intraductal papillomas with atypia and intraductal carcinoma. Currently Im relying heavily on immunos, but maybe overutilizing. Also, I feel Im calling way too many papillomas "atypical".

1) as others sort of alluded to, looking for intraepith lymphs, increased LP cellularity, enterocyte damage, and villous blunt/crypt hyperplasia are 4 key features (w/strong emphasis on 1st one). We currently DO NOT Marsh type Celiac cases - and thank god we don't -- who the hell has the time/patience to count all those IEL's on every suspicious case? For equivocal cases, suggest clinical correlation with serologic markers. Just let them know it's a possibility.

2) LADOC, i'm interested to know what/how are you using IPOX markers (and which ones) to distinguishes the spectrum of papillary lesions?

 

[LADoc00]

1) as others sort of alluded to, looking for intraepith lymphs, increased LP cellularity, enterocyte damage, and villous blunt/crypt hyperplasia are 4 key features (w/strong emphasis on 1st one). We currently DO NOT Marsh type Celiac cases - and thank god we don't -- who the hell has the time/patience to count all those IEL's on every suspicious case? For equivocal cases, suggest clinical correlation with serologic markers. Just let them know it's a possibility.

2) LADOC, i'm interested to know what/how are you using IPOX markers (and which ones) to distinguishes the spectrum of papillary lesions?

Agree with no.1, my point is what do you do with cases just showing blunting...that is my occasional dilemmia. Im a fairly seriously when I look at GI cases if only because they are such a nice source of revenue for me, and have been counting intraepithelial lymphs/enterocyte ratios. So far, my modus operandi has been to be descriptive in those cases where the diagnostic findings of celiac disease are not seen. Even in cases where I strongly suspect celiac disease, Im somewhat reluctant to make a definitive diagnosis without serologic/clinical correlation as Odze does claim a huge list of celiac-morphologic mimics in his text.

I use a fairly advanced (well advanced for the immunos labs Ive seen, and Ive been in some of the best) breast cocktail staining system. It is a mix of 2 basal cell markers (one nuclear and one cytoplasmic) as well as a red reactive product for breast epithelium, producing 1 slide that is in fact x3 professional billing for immunohistochemistry interp. charges. (there is method in my madness) I have access to actually a very large list of cocktail stains and employ them regularly. This is in prelude to what I believe will be multi-colored flour systems that can probe single slides for 8-10 antigens.

Another ?:
Is there a situation that can be imagined where Aspiration+Cytology is somehow superior to Core biopsy+Histology+Immunos?? I cant think of a single one. Please enlighten me. Why the flippin hell are interventional rads still doing FNAs under CT guidance at all???

 

[LADoc00]

2) Check out this August edition of American Journal Surg Path. Has an article relating to intracystic papillary carcinoma & intraductal papillomas with and without atypia and use of IHC (with standard myoepithelial cell markers).

Any chance you hit me up with some of the authors, I currently lack a physical copy subscription. Sounds like a solid read tho. Thanks

 

[Cabbage Head]

Another ?:
Is there a situation that can be imagined where Aspiration+Cytology is somehow superior to Core biopsy+Histology+Immunos?? I cant think of a single one. Please enlighten me. Why the flippin hell are interventional rads still doing FNAs under CT guidance at all???

The only reason that I can think of is that a core might be technically more difficult to take, or have a higher complication rate. As usual, I'm totally making this up.

 

[SLUsagar]

Any chance you hit me up with some of the authors, I currently lack a physical copy subscription. Sounds like a solid read tho. Thanks

Collins, Laura C. MD *; Carlo, Victor P. MD *; Hwang, Harry MD +; Barry, Todd S. MD +; Gown, Allen M. MD +; Schnitt, Stuart J. MD *
(*)Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (+)PhenoPath Laboratories, Seattle, WA
Intracystic Papillary Carcinomas of the Breast: A Reevaluation Using a Panel of Myoepithelial Cell Markers.[Article]
American Journal of Surgical Pathology. 30(8):1002-1007, August 2006.
Intracystic papillary carcinomas (IPC) of the breast have traditionally been considered to be variants of ductal carcinoma in situ (DCIS). However, it is not clear if all lesions categorized histologically as IPC are truly in situ carcinomas, or if some such lesions might represent circumscribed or encapsulated nodules of invasive papillary carcinoma. Given that the demonstration of a myoepithelial cell (MEC) layer around nests of carcinoma cells is a useful means to distinguish in situ from invasive carcinomas of the breast in problematic cases, assessment of the presence or absence of a MEC layer at the periphery of the nodules that comprise these lesions could help resolve this issue. We studied the presence and distribution of MEC at the periphery of the nodules of 22 IPC and, for comparison, 15 benign intraductal papillomas using immunostaining for 5 highly sensitive markers that recognize various MEC components: smooth muscle myosin heavy chain, calponin, p63, CD10, and cytokeratin 5/6. All 22 lesions categorized as IPC showed complete absence of MEC at the periphery of the nodules with all 5 markers. In contrast, a MEC layer was detected around foci of conventional DCIS present adjacent to the nodules of IPC. Furthermore, all benign intraductal papillomas, including those of sizes comparable to those of IPC, showed a MEC layer around virtually the entire periphery of the lesion with all 5 MEC markers. In conclusion we could not detect a MEC layer at the periphery of the nodules of any of 22 lesions categorized histologically as IPC. One possible explanation for this observation is that these are in situ lesions in which the delimiting MEC layer has become markedly attenuated or altered with regard to expression of these antigens, perhaps due to their compression by the expansile growth of these lesions within a cystically dilated duct. Alternatively, it may be that at least some lesions that have been categorized as IPC using conventional histologic criteria actually represent circumscribed, encapsulated nodules of invasive papillary carcinoma. Regardless of whether these lesions are in situ or invasive carcinomas, available outcome data indicate that they seem to have an excellent prognosis with adequate local therapy alone. Therefore, we believe it is most prudent to continue to manage patients with these lesions as they are currently managed (ie, similar to patients with DCIS) and to avoid categorization of such lesions as frankly invasive papillary carcinomas. Given our observations, we favor the term "encapsulated papillary carcinoma" over "intracystic papillary carcinoma" for circumscribed nodules of papillary carcinoma surrounded by a fibrous capsule in which a peripheral layer of MEC is not identifiable.

(C) 2006 Lippincott Williams & Wilkins, Inc.