Mimics of Neoplasia in the GI Tract Slide Seminar Ismail Matalka - PowerPoint PPT Presentation

Mimics of Neoplasia in the GI Tract Slide Seminar Ismail Matalka Ayat Aloqaily School of Medicine & King Abdullah University Hospital Jordan University of Science and Technology

Clinical Data • A 55 year old male previously healthy. • Presented with epigastric abdominal pain. • Clinical examination is unremarkable. • Upper gastrointestinal endoscopy revealed small hiatal hernia, bulge and swelling at the gastroesophageal junction .

Histology

Differential Diagnosis • Viral infection (CMV). • Poorly differentiated adenocarcinoma. • Lymphoma (DLBCL) • Melanoma • Leiomyosarcoma or GIST

Immunohistochemistry • CK, CAM5.2, HMWCK,CK5/6, P63 • EMA • CMV, HSV • Vimentin • P53, P16 • SMA, Desmin, CD117, Cyclin‐D1 • CD31, CD34 • LCA, CD68, CD1a, PAX5, CD138, CD3, CD15, CD30,ALK • Melan‐A, S100, HMB45 • Chromogranin, Synaptophysin.

Diagnosis Benign Bizarre Stromal Cells of the esophagus.

Follow‐up Biopsy

Follow‐up biopsy

Discussion • Atypical stromal cells are commonly seen in tissues such as vagina and nasal cavity, breast, genitourinary and GI ulcers and polyps and they are known pitfalls for misdiagnosis of malignancy. • Recognition of the bizarre stromal cells will prevent a potentially serious diagnostic pitfall. • Bizarre stromal cells in the esophagus show no sex predilection. The mean age is 44. Patients usually present with abdominal distension, regurgitation, heart‐burn and epigastric pain.* • Endoscopic examination mainly shows ulcers or polyp like structure (mostly less than 2cm) at the GEJ.

Table 1. Summary of clinicopathological features No Age Sex Symptoms Location Surgical Procedure 1 50 F Abdominal distension ECJ B and ESD 2 39 M Sour regurgitation ECJ B and ESD 3 34 M Abdominal distension ECJ B and ESD 4 48 F Belching E B and ESD 5 54 M Heartburn and belching ECJ B and ESD 6 36 F Abdominal distension ECJ B and ESD 7 52 M Abdominal distension ECJ B and ESD 8 45 M Heartburn E B 9 40 F Abdominal distension ECJ B F, female; M, Male; E: esophagus; ECJ, esophagoscardiac junction; ESD, endoscopy submucosal dissection; B, biopsy.

• The largest group of bizarre stromal cells described in the GI are present in inflammatory pseudopolyps in cases of IBD (mainly ulcerative colitis). • Bizarre stromal cells in the esophagus is an uncommon finding invariably seen in distal esophagus usually in association with inflammatory polyps, chronic ulcers, reflux esophagitis and granulation tissue. • Right diagnosis helps in avoiding unnecessary excessive treatment, like esophagectomy, gastrectomy and esophago‐gastrectomy. • Awareness of the presence of atypical stromal cells in the esophagus and gastrointestinal tract is crucial to avoid misinterpretation of invasive malignancy.

Table 2. Site and Type of Lesion Site Polyps Ulcers Esophagus 1 1 GE junction 4 ‐‐‐‐‐ Stomach 3 2 Large intestine 17 4 Anal canal 1 ‐‐‐‐‐ Total 26 7 GE: Gastroesophageal

Table 3. Results of Immunohistochemical studies and Cytomegalovirus DNA Probe Substance Positive Total* Vimentin 20 23 Muscle‐specific actin 7 23 Smooth‐muscle actin 0 13 Cytokeratin AE1/AE3 0 23 High molecular weight keratin 0 23 Pig kidney keratin (PKKI) 0 23 Desmin 0 21 S‐100 protein 0 23 Factor VIII‐related antigen 0 23 Lysozyme 0 23 Alpha‐1‐antitryspin 0 20 Alpha‐1‐antichymotryspin 0 17 Neurone specific enolase 0 23 Leukocyte‐common antigen 0 19 EMA 0 4 CEA 0 7 Ulex europeus 0 8 Cytomegaloviral antigen 0 17 Cytomegaloviral DNA probe 0 17

References: 1‐Shekitka KM, Helwig EB. Deceptive bizarre stromal cells in polyps and ulcers of the gastrointestinal tract. Cancer. 1991 Apr 15;67(8):2111‐7. 2‐Ando K 1 , Fujiya M, Ito T, Sugiyama R, Nata T, Nomura Y, Ueno N, Kashima S, Ishikawa C, Inaba Y, Moriichi K, Okamoto K, Ikuta K, Tanabe H, Tokusashi Y, Miyokawa N, Watari J, Mizukami Y, Kohgo Y. A pseudosarcomatous lesion resembling a malignant tumor of the esophagocardiac junction, diagnosed by a total biopsy with endoscopic surgery. Endoscopy. 2012;44 Suppl 2 UCTN:E21‐2. doi: 10.1055/s‐0031‐1291502. Epub 2012 Mar 6. 3‐ cases Xinqing Ye1*, Congyang Li2*, Yuan Tian2 , Changsheng Guo2 , Xianchu Yi2. Bizarre stromal cells of the esophagus polyp or papilloma: clinical and pathologic studies of nine cases. Int J Clin Exp Pathol 2017;10(3):3739‐3745 4‐ E.M. Wolf, C. Högenauer, M. Asslaber, C. Langne. Bizarre Stromazellen in einem inflammatorischen Ösophaguspolypen Ein möglicher diagnostischer Fallstrick. Der Pathologe 2013, Volume 34, Issue 2, pp 159–161

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