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

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

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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

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Cord Langner MD Institute of Pathology Medical University Graz / Austria www.medunigraz.at/ENGIP

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

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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

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Diagnosis I:

2

Mycophenolate mofetil (MMF) associated colitis

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  • Wong. Histopathology 2015
  • 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)

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Selbst et al. Mod Pathol 2009

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Liapis et al. Histopathology 2013

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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%).

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Liapis et al. Histopathology 2013

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Lee et al. J Clin Pathol 2013

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Your diagnosis?

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CMV immunohistochemistry

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Diagnosis II:

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Mycophenolate mofetil (MMF) associated colitis plus CMV infection

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Is this all ?

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Diagnosis III:

2

Mycophenolate mofetil (MMF) associated colitis plus CMV infection plus cryptosporidiosis

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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)

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Parfitt & Driman. Hum Pathol 2007

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

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McCarthy et al. Histopathology 2015

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ENGIP Case 3/2015

Chemotherapy-induced colitis (oxaliplatin/capecitabine)

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Langner und Ott, Histopathology 2007

MIB-1 p53

Mitotic Arrest („Ring Mitoses“) with Paclitaxel and Docetaxel

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Daniels et al. Am J Surg Pathol 2008

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Crowder et al. Am J Surg Pathol 2009

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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)
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Please save the following date: 3rd 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)

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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