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
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