SL-11 Mimics of neoplasia in the GI tract Case 4 XXXII Congress of - PowerPoint PPT Presentation

SL-11 Mimics of neoplasia in the GI tract – Case 4 XXXII Congress of the International Academy of Pathology (IAP) Dead Sea / Jordan – October 14-18, 2018 Cord Langner MD Institute of Pathology Medical University Graz / Austria www.medunigraz.at/ENGIP

Patient History  Colonic biopsies from a 44-year-old male patient  Symptoms: non-bloody diarrhoea since approximately three months  Endoscopy: mild erythematous pancolitis, no mucosal breaks  The patient is under mycophenolate mofetil (MMF) therapy which was initiated after renal transplantation five years previously

Diagnosis I: 2 Mycophenolate mofetil (MMF) associated colitis

1. Graft versus Host Disease 2. Drug reactions (e.g. mycophenolate mofetil, MMF) 3. Infections related to immunosuppressive therapy (commonly due to viral agents, but also bacteria, e.g. Clostridium difficile ) 4. Post-Transplant Lymphoproliferative Disorder (PTLD) Wong. Histopathology 2015

Selbst et al. Mod Pathol 2009

Liapis et al. Histopathology 2013

Crypt distortion and loss as well as increased apoptosis constituted the main features, their degree and combination leading either to an inflammatory bowel disease (IBD)-like (82%) or to a graft-versus host-disease-like pattern (18%). Liapis et al. Histopathology 2013

Liapis et al. Histopathology 2013

Lee et al. J Clin Pathol 2013

Your diagnosis?

CMV immunohistochemistry

Diagnosis II: 2 Mycophenolate mofetil (MMF) associated colitis plus CMV infection

Is this all ?

Diagnosis III: 2 Mycophenolate mofetil (MMF) associated colitis plus CMV infection plus cryptosporidiosis

Is this a common association? Two out of seven cases were on H&E positive for CMV (confirmed by immunohistochemistry) Five out of ten cases were on H&E positive for CMV (confirmed by immunohistochemistry)

Parfitt & Driman. Hum Pathol 2007

Drug reactions need to be considered in the differential diagnosis of mimics of neoplasia

McCarthy et al. Histopathology 2015

ENGIP Case 3/2015 Chemotherapy-induced colitis (oxaliplatin/capecitabine)

Mitotic Arrest („Ring Mitoses“) with Paclitaxel and Docetaxel MIB-1 p53 Langner und Ott, Histopathology 2007

Daniels et al. Am J Surg Pathol 2008

Crowder et al. Am J Surg Pathol 2009

Take Home Messages  Drug induced injury may be seen in all parts of the gastrointestinal tract and may show a variety of morphological patters  Many of these are unspecific (e.g. necrosis, ulceration), while others are suspicious (e.g. increased epithelial apoptosis)  Drug effects may mimic neoplastic change both on the macroscopic (ulceration, stenosis) and the histological (nuclear atypia, increased mitosis, apoptosis) level  In patients after organ transplantation / under immunosuppression the following conditions need to be considered  Drug reactions (e.g. mycophenolate mofetil, MMF)  Infections related to immunosuppressive therapy (commonly due to viral agents, but also bacteria, e.g. Clostridium difficile)  Graft versus Host Disease  Post-Transplant Lymphoproliferative Disorder (PTLD)

Please save the following date: 3 rd meeting of the Pannonian Working Group of Gastrointestinal Pathology Where and when: Budapest / Hungary, May 10-11, 2019 Topic: Pathology of the small bowel Local organizer: Prof. Bence Kövari (kovari.bence.p@gmail.com)

Thank you very much for your kind attention! Cord Langner MD Institute of Pathology Medical University of Graz / Austria cord.langner@medunigraz.at European Network of Gastrointestinal Pathology www.medunigraz.at/ENGIP www.facebook.com/ENGIP Advanced Training Center of Gastrointestinal Pathology European Society of Pathoogy