Handling difficult cases and possible referral service

Professor Neil A ShepherdGloucester, 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 polypsManagement may depend on depth of submucosal infiltration

sm1 1-3% chance of LN metastasissm2 3-12% chance of LN metastasissm3 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 expertisedouble reportingnetworktraditional second opinionnational 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