Colorectal dysplasia in chronic inflammatory bowel disease: a contemporary consensus classification and interobserver study

The clinical management of patients with dysplasia in chronic inflammatory bowel disease (IBD) is currently guided by Riddell et al.'s grading system (negative, indefinite, low grade, high grade) from 1983 which was based primarily on nuclear cytoarchitectural characteristics. Although most dysplasia in IBD resembles sporadic adenomas morphologically, other distinctive potential cancer precursors in IBD have been described over time. Recognizing the need for a updated comprehensive classification for IBD-associated dysplasia, an international working group of pathologists with extensive clinical and research experience in IBD devised a new classification system and assessed its reproducibility by having each participant assess test cases selected randomly from a repository of electronic images of potential cancer precursor lesions. The new classification system now encompasses three broad categories and nine sub-categories: 1) intestinal dysplasia (tubular/villous adenoma-like, goblet cell deficient, crypt cell, traditional serrated adenoma-like, sessile serrated lesion-like and serrated NOS), 2) gastric dysplasia (tubular/villous and serrated), and 3) mixed intestinal-gastric dysplasia. In the interobserver analysis, 67% of the diagnoses were considered definitive and achieved substantial inter-rater agreement. The key distinctions between intestinal and gastric lesions and between serrated and non-serrated lesions achieved substantial and moderate inter-rater agreement overall, respectively, however, the distinctions among certain serrated sub-categories achieved only fair agreement. Based on the Riddell grading system, definite dysplasia accounted for 86% of the collective responses (75% low grade, 11% high grade). Based on these results, this new classification of dysplasia in IBD can provide a sound foundation for future clinical and basic IBD research.

Histologic Features of Syphilitic Gastritis: A Rare but Resurging Imitator of Common Diseases

OBJECTIVES

The range of histopathologic features of gastric syphilis is not well described. Here we describe the clinicopathologic findings of eight patients with syphilitic gastritis.

METHODS

A search of our Pathology Data System (2003-2022) and multiple other institutions identified eight patients with syphilitic gastritis. Clinical information, pathology reports, and available slides were reviewed.

RESULTS

Lesions predominated in middle-aged adults (mean age, 47.2 years; range, 23-61 years) with a propensity for men (n = 7). Three patients had a documented history of human immunodeficiency virus. Clinical presentations included weight loss, abdominal pain, hematochezia, fever, dyspepsia, nausea and vomiting, hematemesis, anemia, and early satiety. Endoscopic findings included ulcerations, erosions, abnormal mucosa, and nodularity. All specimens shared an active chronic gastritis pattern with intense lymphohistiocytic infiltrates, variable plasma cells, and gland loss. Prominent lymphoid aggregates were seen in four specimens. The diagnosis was confirmed either by immunostain for Treponema pallidum (n = 7) or by direct immunofluorescence staining and real-time polymerase chain reaction (n = 1). All patients with available follow-up data showed resolution of symptoms after antibiotic therapy (n = 4).

CONCLUSIONS

Recognition of the histologic pattern of syphilitic gastritis facilitates timely treatment, prevents further transmission, and avoids unnecessarily aggressive treatment.

Beyond Neutrophils for predicting relapse and remission in ulcerative colitis

BACKGROUND AND AIMS

This study examines colonic histologic features in ulcerative colitis (UC) in endoscopic remission to determine which cell types and biopsy sites best predict a patient's likelihood of remaining in remission.

METHODS

This is a retrospective chart, endoscopy and histology review of 166 persons with UC in endoscopic remission followed in a single IBD practice over a median of 6 years (range, 2-11 years). Clinical remission was based on global physician assessment and colonoscopy reports, and clinical relapse on chart review. Histologic features of previous injury and also number and location of plasma cells and eosinophils were assessed. We evaluated all semi-quantitatively using a standard set of illustrations for the grade to maintain consistency. Multiple logistic regression analysis and survival analysis were used to identify features associated with relapse.

RESULTS

Clinical relapse occurred in 44 persons. Ulceration, especially in the left colon. was highly predictive of relapse. In the absence of acute inflammation of ulceration, the variables most predictive of relapse were increased plasma cells in the basal 20% of the lamina propria, and eosinophils in the left colon. The variable most predictive of persistent remission was the presence of intraepithelial eosinophils whether in the surface epithelium or within crypts, especially in the right colon. Lamina propria eosinophils (grade>2) throughout the colon predicted relapse.

CONCLUSION

In the absence of neutrophils or ulceration, left-sided plasmacytosis in the basal 20% of the lamina propria and increased lamina propria eosinophils provide the best indicators of relapse in UC in clinical and endoscopic remission.

An International Consensus to Standardize Integration of Histopathology in Ulcerative Colitis Clinical Trials

BACKGROUND & AIMS

Histopathology is an emerging treatment target in ulcerative colitis (UC) clinical trials. Our aim was to provide guidance on standardizing biopsy collection protocols, identifying optimal evaluative indices, and defining thresholds for histologic response and remission after treatment.

METHODS

An international, interdisciplinary expert panel of 19 gastroenterologists and gastrointestinal pathologists was assembled. A modified RAND/University of California, Los Angeles appropriateness methodology was used to address relevant issues. A total of 138 statements were derived from a systematic review of the literature and expert opinion. Each statement was anonymously rated as appropriate, uncertain, or inappropriate using a 9-point scale. Survey results were reviewed and discussed before a second round of voting.

RESULTS

Histologic measurements collected using a uniform biopsy strategy are important for assessing disease activity and determining therapeutic efficacy in UC clinical trials. Multiple biopsy strategies were deemed acceptable, including segmental biopsies collected according to the endoscopic appearance. Biopsies should be scored for architectural change, lamina propria chronic inflammation, basal plasmacytosis, lamina propria and epithelial neutrophils, epithelial damage, and erosions/ulcerations. The Geboes score, Robarts Histopathology Index, and Nancy Index were considered appropriate for assessing histologic activity; use of the modified Riley score and Harpaz Index were uncertain. Histologic activity at baseline should be required for enrollment, recognizing this carries operational implications. Achievement of histologic improvement or remission was considered an appropriate and realistic therapeutic target. Current histologic indices require validation for pediatric populations.

CONCLUSIONS

These recommendations provide a framework for standardized implementation of histopathology in UC trials. Additional work is required to address operational considerations and areas of uncertainty.

Prognostic and Predictive Value of Tumor Budding in Colorectal Cancer

BACKGROUND

Tumor budding (TB) is an adverse prognostic factor in colorectal cancer (CRC). International consensus on a standardized assessment method has led to its wider reporting. However, uncertainty regarding its clinical value persists. This study aimed to (1) confirm the prognostic significance of TB, particularly in stage II CRC; (2) to determine optimum thresholds for TB risk grouping; and (3) to determine whether TB influences responsiveness to chemotherapy.

METHODS

TB was assessed in CRC sections from 1575 QUASAR trial patients randomized between adjuvant chemotherapy and observation. Optimal risk group cutoffs were determined by maximum likelihood methods, with their influence on recurrence and mortality investigated in stratified log-rank analyses on exploratory (n = 504), hypothesis-testing (n = 478), and final (n = 593) data sets.

RESULTS

The optimal threshold for high-grade TB (HGTB) was ≥ 10 buds per 1.23 mm². High-grade TB tumors had significantly worse outcomes than those with lower TB: 10-year recurrence 36% versus 22% (risk ratio, 2.00 [95% CI, 1.62-2.45]; 2P < .0001) and 10-year mortality 50% vs. 37% (risk ratio, 1.53 [95% CI, 1.34-1.76]; 2P < .0001). The prognostic significance remained equally strong after allowance for other pathological risk factors, including stage, grade, lymphovascular invasion, and mismatch repair status. There was a nonsignificant trend toward increasing chemotherapy efficacy with increasing bud counts.

CONCLUSIONS

TB is a strong independent predictor of recurrence. Chemotherapy efficacy is comparable in patients with higher and lower TB; hence, absolute reductions in recurrence and death with chemotherapy should be about twice as large in patients with ≥ 10 than < 10 TB counts.

Beyond Helicobacter: dealing with other variants of gastritis-an algorithmic approach

In daily practice, the presence of inflammation in gastric biopsies prompts a mental algorithm, an early question being whether the lesion present is Helicobacter-associated. If Helicobacter organisms are not found, then there is a further algorithm, governed by the predominant type of inflammatory cells present, and the presence of other features such as intraepithelial lymphocytosis, a subepithelial collagen band, granulomas, coexisting chronic inflammation, focality, and superimposed reactive changes including erosions and ulcers. Each of these generates its own differential diagnosis. If no inflammation is present, then the two major changes specifically looked for are the changes associated with hypergastrinaemia, by far the most common cause of which is treatment with proton pump inhibitors, and reactive changes. These may be present with and without accompanying inflammation, and, when the epithelial changes dominate, the term gastropathy is preferred. In this article, we present an approach to non-Helicobacter inflammation and gastropathies.

DALM, rest in peace: a pathologist's perspective on dysplasia in inflammatory bowel disease in the post-DALM era

There are few abbreviations in surgical pathology that are associated with as much immediate recognition, frustration, and confusion as DALM (dysplasia-associated lesion or mass). DALM is used to describe endoscopically visible dysplastic lesions in the surveillance of patients with inflammatory bowel disease. However, the diagnosis of DALM has been complicated by the inconsistent criteria and use of terminology for describing dysplasia in inflammatory bowel disease, and a tendency to relate DALM with the need for colectomy. Fortunately, advancements in both endoscopic visualization and local excision capability have allowed for a more defined management of dysplasia in inflammatory bowel disease. In 2015, the Surveillance for Colorectal Endoscopic Neoplasia Detection and Management in Inflammatory Bowel Disease Patients International Consensus Recommendations (SCENIC) Development Panel, a panel of predominantly expert gastroenterologists and endoscopists in surveillance of inflammatory bowel disease, published a consensus statement. One recommendation was to abandon DALM-related terminology in favor of endoscopic descriptors modified from the Paris endoscopic classification. Recommendations on surveillance and management of dysplastic lesions were also provided. Nevertheless, interval carcinomas and metachronous neoplasia remain persistent issues. This review aims to provide an update on the post-DALM terminology and management recommendations for inflammatory bowel disease-associated dysplasia necessary for a meaningful communication between pathologists and clinicians.

Cytokeratin-based assessment of tumour budding in colorectal cancer: analysis in stage II patients and prospective diagnostic experience

Tumour budding in colorectal cancer is an important prognostic factor. A recent consensus conference elaborated recommendations and key issues for future studies, among those the use of pan‐cytokeratin stains, especially in stage II patients. We report the first prospective diagnostic experience using pan‐cytokeratin for tumour budding assessment. Moreover, we evaluate tumour budding using pan‐cytokeratin stains and disease‐free survival (DFS) in stage II patients. To this end, tumour budding on pan‐cytokeratin‐stained sections was evaluated by counting the number of tumour buds in 10 high‐power fields (0.238 mm²), then categorizing counts as low/high‐grade at a cut‐off of 10 buds, in two cohorts. Cohort 1: prospective setting with 236 unselected primary resected colorectal cancers analysed by 17 pathologists during diagnostic routine. Cohort 2: retrospective cohort of 150 stage II patients with information on DFS. In prospective analysis of cohort 1, tumour budding counts correlated with advanced pT, lymph node metastasis, lymphovascular invasion, perineural invasion (all p < 0.0001), and distant metastasis (p = 0.0128). In cohort 2, tumour budding was an independent predictor of worse DFS using counts [p = 0.037, HR (95% CI): 1.007 (1.0–1.014)] and the low‐grade/high‐grade scoring approach [p = 0.02; HR (95% CI): 3.04 (1.2–7.77), 90.7 versus 73%, respectively]. In conclusion, tumour budding assessed on pan‐cytokeratin slides is feasible in a large pathology institute and leads to expected associations with clinicopathological features. Additionally, it is an independent predictor of poor prognosis in stage II patients and should be considered for risk stratification in future clinical studies.

HtrA3 stromal expression is correlated with tumor budding in stage II colorectal cancer

Tumor budding is a well-established adverse prognostic factor in colorectal carcinoma (CRC). It may represent a form of epithelial-to-mesenchymal transition (EMT), although the underlying mechanisms remain unclear. High-temperature requirement A3 (HtrA3) is an inhibitor of the bone morphogenetic protein pathway, the suppression of which has been linked to EMT. Since HtrA3 is highly expressed in the desmoplastic stroma at the CRC invasive front, we sought to evaluate the relationship between tumor budding and HtrA3 expression in 172 stage II CRC resection specimens. All tumors were evaluated for tumor budding, with the highest budding slide selected for pan-keratin (CK) and HtrA3 immunohistochemistry. Representative areas of tumor core and invasive front, including budding and non-budding areas, were marked on CK stained slides, and then evaluated on HtrA3 stained slides. HtrA3 expression in tumor cells (tHtrA3) and peritumoral stroma (sHtrA3) was assessed for staining percentage and intensity (the product yielding a final score). Tumors with high-grade tumor budding (HGTB) showed increased expression of sHtrA3 in budding areas compared to non-budding areas at the invasive front (P<0.001). In addition, sHtrA3 expression at the invasive front was significantly higher in HGTB tumors compared to minimally budding tumors (P<0.05). tHtrA3 expression at the invasive front was significantly associated with high histological grade (P<0.05). Higher sHtrA3 expression in the tumor core (but not invasive front) was significantly associated with decreased 5-year overall survival on univariate analysis (P<0.05), but not multivariate analysis. HtrA3 expression in the peritumoral stroma of patients with stage II CRC is associated with HGTB and may be a novel marker of poor outcome.

Budesonide Multimatrix Is Efficacious for Mesalamine-refractory, Mild to Moderate Ulcerative Colitis: A Randomised, Placebo-controlled Trial

BACKGROUND AND AIMS

Safety and efficacy of budesonide multimatrix, an oral extended-release second-generation corticosteroid designed for targeted delivery throughout the colon, were examined for induction of remission in patients with mild to moderate ulcerative colitis refractory to baseline mesalamine therapy.

METHODS

A randomised, double-blind, placebo-controlled, multicentre trial evaluated efficacy and safety of budesonide multimatrix for induction of remission [ulcerative colitis disease activity index score ≥ 4 and ≤ 10] in 510 adults randomised to once-daily oral budesonide multimatrix 9 mg or placebo for 8 weeks. Patients continued baseline treatment with oral mesalamine ≥ 2.4 g/day.

RESULTS

Combined clinical and endoscopic remission at Week 8 was achieved by 13.0% and 7.5% of patients receiving budesonide multimatrix [n = 230] or placebo [n = 228], respectively, in the modified intention-to-treat population [p = 0.049]. Clinical remission [ulcerative colitis disease activity index rectal bleeding and stool frequency subscale scores of 0] was similar in both groups [p = 0.70]. More patients receiving budesonide multimatrix vs placebo achieved endoscopic remission [ulcerative colitis disease activity index mucosal appearance subscale score of 0; 20.0% vs 12.3%; p = 0.02] and histological healing [27.0% vs 17.5%; p = 0.02]. Adverse event rates were similar [budesonide multimatrix, 31.8%; placebo, 27.1%]. Mean morning cortisol concentrations decreased at Weeks 2, 4, and 8 with budesonide multimatrix but remained within the normal range.

CONCLUSION

Budesonide multimatrix was safe and efficacious for inducing clinical and endoscopic remission for mild to moderate ulcerative colitis refractory to oral mesalamine therapy.

Macroscopy predicts tumor progression in gastric cancer: A retrospective patho-historical analysis based on Napoleon Bonaparte's autopsy report

BACKGROUND

The cause of Napoleon Bonaparte's death remains controversial. Originally suggested to be gastric cancer, whether this was truly neoplastic or a benign lesion has been recently debated.

AIMS

To interpret findings of original autopsy reports in light of the current knowledge of gastric cancer and to highlight the significance of accurate macroscopy in modern-day medicine.

METHODS

Using original autopsy documents, endoscopic images and data from current literature, Napoleon's gastric situation was reconstructed. In a multicenter collection of 2071 gastric cancer specimens, the relationship between tumor size and features of tumor progression was assessed.

RESULTS

Greater tumor size was associated with advanced pT, nodal metastases and Borrmann types 3-4 (p<0.001). The best cut-off for predicting pT3-4 tumors was 6.5cm (AUC 0.8; OR 1.397, 95% CI 1.35-1.446), and 6cm for lymph node metastases (AUC 0.775; OR 1.389, 95% CI 1.338-1.442). The 6cm cut-off of had a positive predictive value of 0.820 for nodal metastases and a negative predictive value of 0.880 for distant metastases.

CONCLUSION

This analysis combines Napoleon's autopsy with present-day knowledge to support gastric cancer as his terminal illness and emphasizes the role of macroscopy, which may provide valuable information on gastric cancer progression and aid patient management.

Observations of different patterns of dysplasia in barretts esophagus - a first step to harmonize grading

We reviewed a set of cases of early neoplasia (low grade / high grade dysplasia / IEN and mucosal carcinoma) to reach better defined criteria for subtypes of dysplasia/differentiation in the columnar lined (Barretts) esophagus. We discuss criteria that we categorized for recognizing low and high-grade dysplasia and mucosal carcinoma in patterns of neoplasia that we regarded as intestinal, gastric and mixed.

Review article: the histological assessment of disease activity in ulcerative colitis

BACKGROUND

In patients with ulcerative colitis (UC), mucosal healing has emerged as a major therapeutic goal, and is usually assessed endoscopically. Histological healing does not correlate very well with endoscopic mucosal healing in UC and persistent histological inflammation might be a better predictor of future clinical relapse than the endoscopic appearance alone.

AIM

To define how histological assessment of disease activity should be best done in UC.

METHODS

Electronic (PubMed/Embase) and manual search.

RESULTS

At least 18 histological indices to assess disease activity in UC have been described, though none are fully validated. However, histological assessment is increasingly used as a secondary endpoint in clinical trials in UC. After reviewing and discussing existing histological scoring systems for UC activity, we describe features of histological response and define three grades of activity: (i) histological healing - complete resolution of abnormalities; (ii) quiescent disease, - lack of mucosal neutrophils but chronic inflammation may remain; (iii) active disease - presence of neutrophils plus possible epithelial damage. It is recommended that two biopsies are taken from each colonic segment which should include always biopsy of the rectum and the most affected segments. There is to date no agreed preferable scoring system but the Geboes Index is the best validated (kappa for interobserver variation 0.59-0.70).

CONCLUSION

Histological assessment of disease activity in UC is increasingly used, but needs to be carefully defined.

Progression of esophageal dysplasia to cancer

The following, from the 12th OESO World Conference: Cancers of the Esophagus, includes commentaries on the evolution of low-grade squamous and glandular dysplasia to invasive carcinoma; the mutational spectra of Barrett's esophagus and adenocarcinoma; the risk of p53-immunoreactive glandular dysplasia compared to non-immunoreactive mucosa for progression to cancer; the role of lectins in progression to adenocarcinoma; and the role of racemase immunoreactivity in the prediction of risk of adenocarcinoma.

Bone morphogenetic protein antagonist gremlin-1 regulates colon cancer progression

Bone morphogenetic proteins (BMP) are phylogenetically conserved signaling molecules of the transforming growth factor-beta (TGF-beta) superfamily of proteins, involved in developmental and (patho)physiological processes, including cancer. BMP signaling has been regarded as tumor-suppressive in colorectal cancer (CRC) by reducing cancer cell proliferation and invasion, and by impairing epithelial-to-mesenchymal transition (EMT). Here, we mined existing proteomic repositories to explore the expression of BMPs in CRC. We found that the BMP antagonist gremlin-1 (GREM1) is secreted from heterotypic tumor-host cell interactions. We then sought to investigate whether GREM1 is contextually and mechanistically associated with EMT in CRC. Using immunohistochemistry, we showed that GREM1-expressing stromal cells harbor prominent features of myofibroblasts (i.e., cancer-associated fibroblasts), such as expression of α-smooth muscle actin and laminin-beta-1, and were in contextual proximity to invasion fronts with loss of the tight junction protein occludin and parallel nuclear accumulation of β-catenin, two prominent EMT hallmarks. Furthermore, in vitro assays demonstrated that GREM1-dependent suppression of BMP signaling results in EMT induction, characterized by cadherin switching (loss of E-cadherin-upregulation of N-cadherin) and overexpression of Snail. Collectively, our data support that GREM1 promotes the loss of cancer cell differentiation at the cancer invasion front, a mechanism that may facilitate tumor progression.

Optimizing the detection of venous invasion in colorectal cancer: the ontario, Canada, experience and beyond

Venous invasion (VI) is a well-established independent prognostic indicator in colorectal cancer (CRC). Its accurate detection is particularly important in stage II CRC as it may influence the decision to administer adjuvant therapy. The Royal College of Pathologists (RCPath) of the United Kingdom state that VI should be detected in at least 30% of CRC resection specimens. However, our experience in Ontario, Canada suggests that this (conservative) benchmark is rarely met. This article highlights the “Ontario experience” with respect to VI reporting and the key role that careful morphologic assessment, elastin staining and knowledge transfer has played in improving VI detection provincially and beyond.

Systematic review: histological remission in inflammatory bowel disease. Is 'complete' remission the new treatment paradigm? An IOIBD initiative

BACKGROUND AND AIMS

Advances in the medical management of inflammatory bowel disease (IBD) have altered treatment targets. Endoscopic mucosal healing is associated with better outcomes in IBD, though less is known about the significance of achieving histological remission. Our aim was to perform a systematic review to investigate whether histological or 'complete' remission constitutes a further therapeutic target in IBD.

METHODS

A bibliographic search was performed on the 1st of October 2013 and subsequently on the 1st of March 2014 of online databases (OVID SP MEDLINE, OVID EMBASE, National Pubmed Central Medline, Cochrane Library, ISI, conference abstracts), using MeSH terms and key words: ("inflammatory bowel diseases" OR "crohn disease" OR "ulcerative colitis" OR "colitis") AND ("mucosal healing" OR "histological healing" OR "pathological healing" OR "histological scoring" OR "pathological scoring").

RESULTS

The search returned 2951 articles. 120 articles were cited in the final analysis. There is no validated definition of histological remission in IBD. There are 22 different histological scoring systems for IBD, none of which are fully validated. Microscopic inflammation persists in 16-100% of cases of endoscopically quiescent disease. There is evidence that histological remission may predict risk of complications in ulcerative colitis beyond endoscopic mucosal healing, though data are scarce in Crohn's disease.

CONCLUSIONS

Histological remission in IBD represents a target distinct from endoscopic mucosal healing, not yet routinely sought in clinical trials or practice. There remains a need for a standardized and validated histological scoring system and to confirm the prognostic value of histological remission as a treatment target in IBD.

Inflammatory pseudotumours of the oesophagus--histological and immunohistochemical findings

AIMS

Inflammatory oesophageal pseudotumours are rare lesions, thought to be reactive. Due to marked atypia of the stromal cells, these can be misdiagnosed as malignancies. The objective of this study was to characterize histological and immunohistochemical features of a series of inflammatory pseudotumours of the oesophagus.

METHODS AND RESULTS

We present 12 cases of inflammatory oesophageal pseudotumours, occurring in seven females and five males, with a mean age of 57.3 years. Clinical presentations were variable; dysphagia, abdominal pain and weight loss and upper gastrointestinal bleed. In a majority of the cases, nodules or masses in the distal oesophagus were identified at endoscopy. Microscopically, the lamina propria in all 12 cases contained inflammation and granulation tissue. Ten of 12 cases showed mucosal ulceration and 11 of 12 cases had acutely inflamed epithelium. Markedly atypical pleomorphic stromal cells with prominent nucleoli were identified in all 12 cases. Immunohistochemistry showed uniform positivity for vimentin in 11 of 11 cases, and two of seven cases demonstrated weak focal positivity for smooth muscle actin. The cells were negative for all other markers.

CONCLUSIONS

Reactive oesophageal lesions can show marked nuclear atypia in stromal fibroblasts/myofibroblasts, which are easily mistaken for malignancies. Pathologists must consider the diagnosis of an inflammatory pseudotumour if stromal atypia is present in an inflammatory background.

Distinctive histopathologic phenotype in resection specimens from patients with Crohn's disease receiving anti-TNF-α therapy

Anti-tumor necrosis factor α (anti-TNF-α) therapy can result in endoscopic healing, reduction of symptoms, and reduced need for surgery and hospitalization in many patients with Crohn's disease (CD). Earlier data suggested that anti-TNF-α therapy may be associated with fibrosis and stricturing. We sought to determine whether anti-TNF-α therapy affects histologic inflammation, fibrosis, and granuloma formation. Hematoxylin and eosin sections from 62 patients with CD treated with either infliximab or adalimumab and 80 controls undergoing the same surgery but without prior exposure to anti-TNF-α therapy were compared. All patients with CD had undergone surgery within 6 months of therapy; CD controls were matched for steroid exposure, procedure, and indication for surgery and were subcategorized and case matched. Blinded histologic assessment of all slides was performed using a semiquantitative scoring system to assess inflammatory changes and fibrosis in all bowel layers. Compared with controls, the group treated with anti-TNF-α showed a reduction in mucosal and submucosal inflammation (P < .05), a decrease in granuloma formation (P < .05), and an increase in duplication of the muscularis mucosae (P < .05). A notable feature was a distinct pattern of hyalinizing submucosal fibrosis that was often devoid of inflammatory cells and that started directly below the muscularis mucosae; this pattern was not observed in the control group (P < .05). Resection specimens from patients with CD treated with anti-TNF-α therapy showed (a) reduced mucosal and submucosal inflammation; (b) a decrease in granuloma formation; and (c) a distinct pattern of submucosal hyaline fibrosis, with increased fibrosis in the muscularis mucosae and muscularis propria.

Expression patterns of bone morphogenetic protein antagonists in colorectal cancer desmoplastic invasion fronts

Bone morphogenetic proteins (BMPs) are a group of growth factors with dual functions in cancer development and progression. Recently, certain tumor-promoting roles have been identified for selected antagonists/inhibitors (BMPIs) of this developmental pathway. A recent focus on the implication of BMP in colorectal cancer progression has emerged, mainly due to the presence of inactivating mutations in several members of the canonical signaling cascade. However, the detailed expression profiles of BMPIs remain largely unknown. Based on our previous work, whereby three specific BMPIs, gremlin-1 (GREM1), high-temperature requirement A3 (HTRA3) and follistatin (FST) were collectively overexpressed in desmoplastic cocultures of colorectal cancer (CRC), here, we undertook an immunohistochemical approach to describe the patterns of their expression in CRC patients. Two major characteristics described the BMPI expression signature: First, the synchronous and coordinated stromal and epithelial overexpression of individual BMPIs in desmoplastic lesions, which demonstrated that all three of them contribute to increasing levels of BMP antagonism in such areas. Second, the presence of microenvironmental polarity in the BMPI pattern of expression, which was indicated through the preferential expression of HTRA3 in the stromal, and the parallel FST/GREM1 expression in the epithelial component of the investigated sections. In addition, expression of HTRA3 in the epithelial compartment of the tumors demonstrated a significant predictive power to discriminate between tumor-budding-bearing and tumor-budding-free desmoplastic microenvironments. Together, these findings contribute to the understanding of signaling dynamics of BMP antagonism in the colorectal cancer desmoplastic invasion front.

Colorectal dysplasia in inflammatory bowel disease: a clinicopathologic perspective

Surveillance for neoplasia in colitis is the most challenging diagnostic colonoscopic procedure. The detection and treatment of colorectal dysplasia in inflammatory bowel disease remain problematic to the point that unsuspected colorectal cancers (CRCs) are still identified. Excellent bowel preparation and use of high-resolution colonoscopes with chromoendoscopy facilitate the detection and characterization of subtle neoplasia. This approach is superior to taking random biopsy specimens and should be the standard of care for surveillance but requires adequate training. Suspicious lesions should be assessed carefully and described using objective terminology. The terms dysplasia-associated lesions/masses and flat dysplasia are best avoided because they may be open to misinterpretation. Most suspicious lesions detected during surveillance can be removed endoscopically, precluding the need for surgery. Nevertheless, endotherapy in colitis can be difficult as a result of underlying inflammation and scarring. Lesions that are not endoscopically resectable need to be removed surgically, although the possibility that some lesions might be amenable to local resection (including lymphadenectomy) rather than subtotal colectomy may need to be re-evaluated. Despite surveillance programs, patients still present clinically with CRC. This may occur because lesions are missed (possibly because of the failure to use optimal techniques), lesions are not adequately removed, patients fail to return for colonoscopy, or CRCs arise rapidly in mucosa that is minimally dysplastic and the CRCs are not recognized as being potentially invasive even on biopsy. Future advances in, for example, stool DNA assays, use of confocal endomicroscopy, or use of endoscopic ultrasound, may help in the identification of high-risk patients and the assessment of dysplastic lesions.

Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: report of a Working Party of the 2005 Montreal World Congress of Gastroenterology

The discovery of a series of genetic and serological markers associated with disease susceptibility and phenotype in inflammatory bowel disease has led to the prospect of an integrated classification system involving clinical, serological and genetic parameters. The Working Party has reviewed current clinical classification systems in Crohn's disease, ulcerative colitis and indeterminate colitis, and provided recommendations for clinical classification in practice. Progress with respect to integrating serological and genetic markers has been examined in detail, and the implications are discussed. While an integrated system is not proposed for clinical use at present, the introduction of a widely acceptable clinical subclassification is strongly advocated, which would allow detailed correlations among serotype, genotype and clinical phenotype to be examined and confirmed in independent cohorts of patients and, thereby, provide a vital foundation for future work.

Collective migration of cancer-associated fibroblasts is enhanced by overexpression of tight junction-associated proteins claudin-11 and occludin

It has been suggested that cancer-associated fibroblasts (CAFs) positioned at the desmoplastic areas of various types of cancer are capable of executing a migratory program, characterized by accelerated motility and collective configuration. Since CAFs are reprogrammed derivatives of normal progenitors, including quiescent fibroblasts, we hypothesized that such migratory program could be context-dependent, thus being regulated by specific paracrine signals from the adjacent cancer population. Using the traditional scratch assay setup, we showed that only specific colon cancer cell lines (i.e. HT29) were able to induce collective CAF migration. By performing quantitative proteomics (SILAC), we identified a 2.7-fold increase of claudin-11, a member of the tight junction apparatus, in CAFs that exerted such collectivity in their migratory pattern. Further proteomic investigations of cancer cell line secretomes revealed a specific signature, involving TGF-β, as potential mediator of this effect. Normal colonic fibroblasts stimulated with TGF-β exerted myofibroblastic differentiation, occludin (OCLN) and claudin-11 (CLDN11) overexpression and cohort formation. Subsequently, inhibition of TGF-β attenuated all the previous effects. Immunohistochemistry of the universal tight junction marker occludin in a cohort of 30 colorectal adenocarcinoma patients defined a CAF subpopulation expressing tight junctions. Overall, these data suggest that cancer cells may induce CLDN11 overexpression and subsequent collective migration of peritumoral CAFs via TGF-β secretion.

Cancer-associated fibroblasts drive the progression of metastasis through both paracrine and mechanical pressure on cancer tissue

Neoplastic cells recruit fibroblasts through various growth factors and cytokines. These "cancer-associated fibroblasts" (CAF) actively interact with neoplastic cells and form a myofibroblastic microenvironment that promotes cancer growth and survival and supports malignancy. Several products of their paracrine signaling repertoire have been recognized as tumor growth and metastasis regulators. However, tumor-promoting cell signaling is not the only reason that makes CAFs key components of the "tumor microenvironment," as CAFs affect both the architecture and growth mechanics of the developing tumor. CAFs participate in the remodeling of peritumoral stroma, which is a prerequisite of neoplastic cell invasion, expansion, and metastasis. CAFs are not present peritumorally as individual cells but they act orchestrated to fully deploy a desmoplastic program, characterized by "syncytial" (or collective) configuration and altered cell adhesion properties. Such myofibroblastic cohorts are reminiscent of those encountered in wound-healing processes. The view of "cancer as a wound that does not heal" led to useful comparisons between wound healing and tumorigenesis and expanded our knowledge of the role of CAF cohorts in cancer. In this integrative model of cancer invasion and metastasis, we propose that the CAF-supported microenvironment has a dual tumor-promoting role. Not only does it provide essential signals for cancer cell dedifferentiation, proliferation, and survival but it also facilitates cancer cell local invasion and metastatic phenomena.

Barrett's esophagus: prevalence-incidence and etiology-origins

Although the prevalence of Barrett's esophagus (BE) is rising no data exist for racial minorities on prevalence in the general population. Minorities have a lower prevalence than Caucasians, and yet age, smoking, abdominal obesity, and Helicobacter pylori are all risk factors. Metabolic changes induced by adipocytokines and the apparently strong association between obesity, central adiposity, and BE may lead to reconsideration of some aspects of the natural history of BE. There is lack of experimental evidence on acid sensitivity and BE, which is hyposensitive compared to esophageal reflux disease. Reactive nitrogen and oxygen species lead to impaired expression of tumor suppressor genes, which can lead to cancer development; thus, antioxidants may be protective. Gastroesophageal reflux disease may be considered an immune-mediated disease starting at the submucosal layer; the cytokine profile of the mucosal immune response may explain the different outcome of gastroesophageal reflux.

Current practice patterns among pathologists in the assessment of venous invasion in colorectal cancer

AIMS

Venous invasion (VI) is a known independent prognostic indicator of recurrence and survival in colorectal cancer. The guidelines of the Royal College of Pathologists (RCPath) state that, in a series of resections, extramural VI should be detected in at least 25% of specimens. However, there is widespread variability in the reported incidence, and this may affect patient access to adjuvant therapy. This study aims to clarify the current practice patterns of pathologists regarding the assessment of VI and to identify factors associated with an increased self-reported VI detection rate.

METHODS

A population-based survey was mailed to 361 pathologists in the province of Ontario, Canada.

RESULTS

The overall response rate was 64.9%. Most pathologists were practicing in community-based centres (66.2%) and approximately half had been in practice for over 15 years (53.5%). A subspecialist interest in gastrointestinal (GI) pathology was declared by 27.3% of pathologists. The majority of pathologists (70.2%) reported that they detected VI in less than 10% of resection specimens, with only 9.1% reporting VI detection rates above 20%. Standardised reporting criteria were applied by 62.1%. Special stains were employed by 57.6% if VI was suspected on H&E-stained sections. Practice in a university-affiliated centre, a subspecialist interest in GI pathology and the acceptance of the 'orphan arteriole' sign were all independently associated with a self-reported VI detection rate above 10% on multivariate analysis.

CONCLUSIONS

Self-reported VI detection rates are low among most pathologists. Even among specialist GI pathologists practicing in university-affiliated centres, few reported a detection rate close to that recommended by the RCPath. Strategies to increase the detection of VI may be required.

Safety and tolerability of the direct renin inhibitor aliskiren: a pooled analysis of clinical experience in more than 12,000 patients with hypertension

While the safety of renin-angiotensin system (RAS)-blocking drugs such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers is well known, less is known about the new direct renin inhibitor aliskiren. The authors pooled data from 12 randomized controlled trials of aliskiren in patients with hypertension and analyzed the incidence and types of adverse events (AEs) and laboratory abnormalities. Studies were characterized as short-term (≤2 months) placebo-controlled or long-term (>2 months) active-controlled. Relative risks for AEs of particular interest for RAS blockers were calculated. In short-term studies, AEs occurred in similar proportions of aliskiren 150 mg and 300 mg (33.6% and 31.6%, respectively) and placebo treatment groups (36.8%). In long-term studies, a lower proportion of patients treated with aliskiren 150 mg and 300 mg had AEs (33.7% and 43.2%, respectively) than those treated with ACE inhibitors (60.1%), angiotensin receptor blockers (53.9%), and thiazide diuretics (48.9%). Events of special interest, including angioedema, hyperkalemia, and diarrhea occurred in similar proportions of patients taking aliskiren, placebo, and comparator agents. In studies of up to 36 weeks, patients treated with aliskiren were significantly less likely to develop cough than those treated with ACE inhibitors. At the registered doses of 150 mg and 300 mg daily, aliskiren has safety and tolerability profiles similar to placebo, other RAS blockers, and diuretics. Cough rates are lower with aliskiren compared with ACE inhibitors.

Definition of Barrett's esophagus: time for a rethink--is intestinal metaplasia dead?

The definition of Barrett's esophagus (BE) varies worldwide, particularly with regard to the need to identify goblet cells in esophageal biopsies in order to diagnose this condition. Problems related to the need to identify goblet cells to diagnose BE include the facts that goblet cells are uncommon in pediatric patients with BE, a small percentage of adults with columnar metaplasia of the esophagus do not contain goblet cells, the chances of detecting goblet cells are proportional to the length of columnar metaplasia, sampling error is common, and interpretation and differentiation of goblet cells vs. pseudogoblet cells may be difficult in some circumstances. In addition, goblet cells have been shown to wax and wane over the natural history of BE. Recent studies suggest that the background nongoblet epithelium in BE is biologically intestinalized, and shows a variety of molecular abnormalities similar to the goblet cell-containing epithelium. In addition, several retrospective and outcome studies suggest a well-defined risk of neoplasia in patients with esophageal columnar metaplasia, but without goblet cells. There are important clinical and economic implications to these findings and also with regard to the definition of BE. This review provides evidence to suggest that a diagnosis of BE should not require demonstration of goblet cells in mucosal biopsies, and offers considerable data to support the notion that a nongoblet epithelium is also at risk of malignancy. Guidelines for the diagnosis of BE need to consider revisions that take into account new data regarding nongoblet cell epithelium in BE, and the difficulties in recognizing columnar metaplasia that measures less than 1 cm in length.

Precursor lymphoblastic lymphoma reoccurring as a donor-derived neoplasm: a case report and review of the literature

Precursor lymphoblastic lymphoma is an uncommon neoplasm. We report the case of a man who presented with precursor T lymphoblastic lymphoma and ultimately received an allogeneic bone marrow transplant from his human leukocyte antigen-identical sister. Four years later he developed recurrent disease. By means of DNA probing for the amelogenin locus and fluorescence in situ hybridization, the neoplastic cells of the recurrent lesion were found to be of donor origin. We offer the report of a patient with an unusual lymphoblastic lymphoma who, after successful bone marrow transplantation, developed the same disease of donor cell origin; further, we offer a literature review on donor cell lymphoma.

Pathological features of colorectal carcinomas in MYH-associated polyposis

AIMS

MYH is a DNA glycosylase in the base excision repair pathway. Germ-line biallelic mutations in the MYH gene are associated with the development of multiple colorectal adenomas and colorectal carcinoma (CRC). A slightly increased risk of CRC is suggested in monoallelic MYH mutation carriers. The aim was to characterize the histopathological features of carcinomas from biallelics and monoallelics.

METHODS AND RESULTS

Clinicopathological features of 57 colorectal carcinomas from 50 patients identified in familial CRC registries were recorded. These included 16 cancers from 14 MYH biallelics; 25 cancers from 22 MYH monoallelics; and 16 cancers from 14 controls. Carcinomas in biallelics demonstrated tubular, papillary or cribriform patterns as the predominant histological subtype, and main histological groups differed according to mutation status (P = 0.0053). All biallelic cancers were low grade, with high-grade tumours more common in monoallelics and controls (P = 0.002). Synchronous polyps were observed in 75% of biallelics, 33% of monoallelics and 43% of controls (P = 0.035). Serrated carcinoma was the predominant type in 12% (3/25) of the monoallelics but in none of the biallelics or controls. MYH immunohistochemistry failed to distinguish between groups.

CONCLUSIONS

Neither pathological features nor immunohistochemistry could predict the MYH mutation status of CRCs in this study.

Indeterminate colitis: a review of the concept--what's in a name?

The precise diagnosis of colitis cannot always be established with the available diagnostic tools. The subgroup of patients with an uncertain diagnosis has been classified as "indeterminate colitis" (IC). The definition of "indeterminate," however, has changed over the years. Originally, IC was proposed by pathologists for colectomy specimens, usually from patients operated on for severe colitis, showing overlapping features of ulcerative colitis (UC) and Crohn's disease (CD). Later, the same terminology was used for patients showing no clear clinical, endoscopic, histologic, and other features allowing a diagnosis of either UC or CD. Therefore, it is difficult to compare different studies. An International Organization of Inflammatory Bowel Diseases (IOIBD) working party confirmed 1) the ambiguous nature of the term, and 2) proposes an updated classification for the category of patients with an unclear diagnosis. According to this, the term IBD unclassified (IBDU) is confirmed, as suggested by the Montreal Working Party 2005 for patients with clinically chronic colitis, that clearly have IBD but when definitive features of CD or UC are absent. In resected specimens the term "colitis of uncertain type or etiology" (CUTE) is preferred. It is accepted that most of the time this may have a prefix, such as severe, chronic. The classification of IBD varies when based only on biopsies rather than on a colectomy specimen. The vast majority of these have severe colitis. For those that cannot bear to abandon the highly ambiguous term IC, if it is used at all, this is where it can be used parenthetically.

Colorectal cancer prevention in inflammatory bowel disease and the role of 5-aminosalicylic acid: a clinical review and update

A roundtable consensus meeting was held to consolidate current knowledge on the etiology of colorectal cancer in patients with inflammatory bowel disease and to review current strategies, both diagnostic and preventive, specifically addressing the role of 5-aminosalicylic acid. Specific topics that were addressed included: the epidemiology of colorectal cancer, including an assessment of risk factors and the impact of colonoscopy on colorectal cancer incidence and mortality; the origin and evolution of dysplasia nomenclature and the natural history of dysplasia; review of the experience of St. Mark's Hospital (London) as gleaned from its surveillance database; mechanisms by which 5-aminosalicylic acid is thought to exert a chemopreventive effect; the potential future role of 5-aminosalicylic acid in chemopreventive strategies; chemoprevention in familial adenomatous polyposis; and other future research directions. This article provides a comprehensive overview of the issues discussed and should act as a guide to shaping the design of future studies in this area.

Benign hidradenoma: magnetic resonance and ultrasound features of two cases

Tumors of sweat gland origin are rare in the hand but should be considered in the differential diagnosis when certain imaging features are present. We present a case of nodular hidradenoma of the hand, with previously unreported magnetic resonance imaging features, and a further case in the thigh, both with ultrasound and histopathological correlation. The imaging literature of this tumor is reviewed, and its significance is discussed with respect to the current understanding of its malignant potential.

Interstitial cells of Cajal in health and disease. Part I: normal ICC structure and function with associated motility disorders

Ramon y Cajal (1852-1934) is considered to be one of the founders of the field of neuroscience. In 1911, he described interstitial neurons in the gut, noting that they were primitive accessory components that perhaps modify smooth muscle contraction, themselves subject to regulation from principle neurons. The accuracy of his description of their appearance and activities has led to these cells now being called the interstitial cells of Cajal (ICC). Thuneberg and Faussone-Pellegrini were instrumental in bringing these cells to the attention of gastroenterologists and pathologists in the early 1980s. Subsequently, the development of antibodies to c-kit has allowed routine identification of the ICC in pathology specimens. c-Kit is a transmembrane protein kinase which has as ligand stem cell factor and is involved in cell development in a variety of cell lineages. In the gut musculature, ICC and mast cells are the only cells that have prominent c-kit expression. The ICC are now known to play an important role in gut motility and absent or disordered ICC networks have been identified in a variety of motility disorders.

Recommendations for the reporting of surgically resected specimens of colorectal carcinoma

The reporting of colorectal cancer is facilitated by the provision of a checklist giving the features required for good patient care. However, the practicalities of applying such a checklist may not be straightforward. Familiar examples include finding the prescribed number of lymph nodes, distinguishing mesenteric tumor deposits from replaced lymph nodes, and deciding if a cluster of malignant cells in a lymph node sinus counts as metastasis. Checklists have traditionally focused on prognostic factors and, particularly, tumor stage. It is becoming increasingly clear that additional factors, whether morphological or molecular, will be needed for future clinical management. It is also evident that prognosis is strongly influenced by the surgical technique used, most notably by the introduction of total mesorectal excision in the case of rectal cancer. Adjuvant therapy is playing an increasingly important role in the management of colorectal cancer, and it is inevitable that morphological and molecular markers will be used to predict responses to the expanding range of therapeutic modalities. Neoadjuvant or preoperative radiotherapy is being offered to patients with advanced rectal cancer and can greatly modify the pathologic findings in operative specimens. For all the preceding reasons, the work of diagnostic pathologists has become increasingly complex and demanding. The 6th edition of the TNM classification fails to meet many of the challenges posed by the realities of modern cancer management. In fact, by changing the rules for staging without strong justification and introducing diagnostic criteria that are unhelpful and lack a good evidence base, there is a real danger that the community of pathologists will fail to engage with reporting recommendations in a standardized manner and that the quality of reporting will decline.

Interstitial cells of Cajal in health and disease. Part II: ICC and gastrointestinal stromal tumours

Mesenchymal tumours in the gastrointestinal tract have long been problematic in terms of diagnosis, prognosis and therapy, but recent advances in immunohistochemistry and related therapies have allowed more specific diagnosis. In particular, the recognition that both the interstitial cells of Cajal (ICC) and many gastrointestinal stromal tumours (GISTs) are positive for c-kit and CD34 and have other features similar to those of ICC has led to the use of imatinib, a novel small molecule therapy that blocks the CD117/c-kit tyrosine kinase receptor, which shows remarkable efficacy in treatment of malignant and metastatic GISTs as well as other malignancies.

Histopathological alterations in irritable bowel syndrome

Irritable bowel syndrome is a common disorder defined by a symptom complex including abdominal pain and altered bowel habit. The etiopathogenesis appears to be multifactorial and to involve altered gastrointestinal motor function, enhanced perception of visceral stimuli and psychosocial factors. More recently a role for mucosal immune activation has been suggested. Routine histologic examination reveals no mucosal abnormality in the majority of cases but quantitative histological, immunohistochemical and ultrastructural analyses reveal subtle morphologic changes involving lymphocytes, mast cells, enterochromaffin cells and enteric nerves. The recent appreciation of these changes has led to new hypotheses linking central and enteric nervous systems to immune processes. This review highlights the spectrum of morphologic changes that occur in irritable bowel syndrome, examines their relationship to the pathophysiology of irritable bowel syndrome and considers their relevance to daily pathology practice.