Transcript A Talk About Bowels And Other Interesting Organs

Handling difficult cases
and possible referral service
Professor Neil A Shepherd
Gloucester, UK
NHSBCSP Pathology Day,
London, November 21, 2007
Handling difficult cases
Pathology and the NHSBCSP: the subconscious
thoughts of a Gloucester pathologist
• it’ll be a doddle
• 130 extra polyps a year – piffle
• OK, a few more cancer resections but all Dukes A and
easy
• and Julietta is going to give us a wad of dosh to do it…
BCSP: what are the difficult cases?
• the great majority of polyps are adenomas and HPs
• differentiating the different types of serrated
pathology
• epithelial misplacement in serrated pathology
• is it epithelial misplacement in an adenoma or is it
cancer?
• when is it cancer?
Epithelial misplacement in adenomas
• 85% in sigmoid colon
• unusual in rectum (unless
there has been previous
meddling)
• same epithelium as
surface, accompanied by
lamina propria,
haemosiderin deposition
• what about misplaced
epithelium at the
diathermy margin?
Epithelial misplacement vs invasive carcinoma
There is a very important adage in pathology:
why make two diagnoses when one will do?
Definite epithelial misplacement but what
about those dodgy glands?
BSCP case
• sigmoid colonic polyp in
62M
• superficial ulceration
and inflammation
• with epithelial
misplacement
BSCP case
• 68F. Sigmoid colonic
polyp
• I’m convinced this is all
epithelial misplacement
• but it went to the
margin….
• 62M. Sigmoid colonic polyp – difficult endoscopic resection (left) –
site tattooed
• subsequent perforation and resection (left)
• do we allow epithelial misplacement in the muscularis propria?
67M. BCSP. Sigmoid colonic polyp.
• the changes of
epithelial misplacement
can be made to look
much worse by
diathermy artefact
• and it’s at that margin
again…
64M. BCSP. Descending colonic polyp
• epithelial
misplacement in a
lympho-glandular
complex
• just like in inverted
hyperplastic polyps…
The Shepherd-Williams classification of
difficult BSCP polyps
• definite epithelial misplacement (remember 85% are
in the sigmoid colon)
• definite cancer
• definite epithelial misplacement and cancer (don’t
make this diagnosis too often, please)
• haven’t a clue whether this is epithelial misplacement
or cancer (I think even Professor Williams will be
making this diagnosis every now and then)
What are the difficult cases?
• the great majority of polyps are adenomas and HPs
• differentiating the different types of serrated
pathology
• epithelial misplacement in serrated pathology
• is it epithelial misplacement in an adenoma or is it
cancer?
• when is it cancer?
Artefactual epithelial misplacement
‘Intramucosal carcinoma’:
two BSCP cases
‘Intramucosal carcinoma’
‘Enhancement’ of dysplastic change with
inflammation and superficial ulceration
‘Enhancement’ of dysplastic change with
inflammation and superficial ulceration
‘Intramucosal carcinoma’
A case from 4pm yesterday afternoon
Thickened muscularis mucosae – is this true
invasive cancer?
Is this cancer? Is it in a blood vessel?
The issues
• overcalling of malignancy in ‘other polyps’ (stromal
lesions, carcinoid, etc)
• when is it cancer?
• epithelial misplacement vs cancer
• artefacts vs true findings, especially with vascular
involvement
• when is further surgery justified?
Carcinoma in polyps
Management may depend on depth of submucosal infiltration
sm1
sm2
sm3
1-3% chance of LN metastasis
3-12% chance of LN metastasis
15-28% chance of LN metastasis
Then an MDTM assessment of the risk of LN metastasis
against the risk of surgery
Handling difficult cases and possible
referral service
• you know some of the issues now
• referral service:
local expertise
double reporting
network
traditional second opinion
national referral service
Take home messages
• the three big diagnostic issues in NHSBCSP are
serrated pathology, epithelial misplacement vs cancer
and when does a cancer demand further surgery
• although most polyps are straightforward, there are
plenty of taxing cases around
• sometimes we just have to say we don’t know
• we need data on the implications of margin
involvement by misplaced epithelium in adenomatous
polyps
• we are open to suggestions concerning the national
referral service