Histo-Meeting 3.09 - Mucosal Immunology...•Esophagectomy and proximal gastrectomy for squamous...

Histo-Meeting 3.09.2015

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HF 64 yr male• Esophagectomy and proximal gastrectomy for squamous

esophageal carcinoma 2013

• 03.2015-dysphagia- upper endoscopy : stenosis at the level of theanastomosis, submucosal tumor with central erosion in antrum

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Gastroscopy 2015Submucosal antral tumor withcentral erosionStenosis of the anastomosis

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Atypische Infiltrate von Plattenepithel-Ca Becherzellmetaplasie

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55yo maleCowden syndrom with PTEN germ line mutation• Father CRC at age 67• 2002 Thyroidectomy• Multiple upper endoscopies and colonoscopies with polypectomy• 07.01.15 Upper endoscopy and colonoscopy multiple

polypectomies in both upper GI tract and colon. • 02.04.15

Morbid obesity• 1998 Mason’s Vertical-banded gastroplasty• 2011 Laparotomy and conversion to Omega-loop-Magenbypass

with subtotal gastrectomy

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Colonoscopy 01/2015Multiple small polyps were resected

Piecemeal resection of a 2cm polyp by the hepatic flexure

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Upper endoscopy 01/2015Multiple polyps were resected 1.2 cm polyp in the

gastrojejunal anastomosis with irregular mucosa

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Endosonography 04/2015• No clear demarcation of the polyp. Muscolaris propria not

demarcated.• EMR

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Histology Polyp GJ-Anastomosis

Folveolar hyperplasia in theLamina propria Typical histology of a Spindelcell

lesion, Hyperplasia displaces thecrypts

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Ganglion cells.Findingpathognomonic fora Ganglioneuroma

Histology Polyp GJ-Anastomosis

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55 yo female• Hospitalisation because of an acute (sub)ileus with a long-

segment stenosis

• St.post. IC-resection 1996, suspected M.Crohnno treatment / symptoms for the past 20 years

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CT / EUS 01.09.15No thickend wall, no signsof an inflammatory reaction

Dilated intestines, airwithin the colon/rectum

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Histologie

Terminales Ileum: fissuierendesUlcus

Terminales Ileum: keine transmuralen Entzündungszeichendamit kein M.Crohn

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77 years old female patient

• Surveillance Colonoscopy 2/15• Tubular Adenoma in Coeocum (low grade) and

Diverticulosis in Sigma

• Re-Colonoscopy 8/15 • 2 Polyps in C.transversum

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Polyp in C. transversum

Coloscopy 8/15

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Entzündliche Veränderungen ohne Dysplasie

Gestörte Kryptenarchitektur

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Granulierende entzündliche Erosion

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Siegelringzellen

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Nester von atypischen monomorphen Zellen

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Panzytokeratin-Färbung

Die Nester sind Lymphgefässe (eine Art lymphogener Tumorthrombus)

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46 year old male• 2x liver transplantation because of PSC (Prograf & Cellcept)• Pancolitis ulcerosa, Montreal classification E 3

– St.n. total colectomy 05/2009– Relapsing pouchitis (1x/year), clinic: anal blood– Therapy with Salofalk enema & Budenofalk rectal

• Diabetes mellitus• Allergies/Intolerances for multiple antibiotics

– Ciprofloxacin– Cotrimoxazol– Ceftriaxon– Rifampicin– Metronidazol

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Sigmoidoscopy 12/2014Moderate Pouchitis Histology of Ileum, pouch an cuff No ileitis, BUT: pouchitis, no viral inclusions, PCR for CMV 425

copies/ml Therapy with Augmentin 10-14 d, local therapy Remission

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Histology• Im Überblick deutliche Architekturstörung• Viele Entzündungszellen (Plasmazellen)• Keine viralen Inclusionen und

Immunhistochemie negativ (kein CMV)• Pouchitis (histologisch nicht differenzierbar,

ob durch IBD oder infektiös verursacht)

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26yo male• 01/2015 main problem: eosinophil pancolitis, chronification

erythema nodosum, aphtous ulcerations, abdominal pain, postprandial diarrhea, CRP!, >38,5°

OTHER:

• st. p. kidney-contusion 2011• hyporegenerative, microcytic, hypochrome anaemia• malnutrition• hypomagesemia• autosomal dominant, polycystic renal pathology

• 02/2015 septated pleural effusion (total remission)• 03/2015 stress-related bronchial asthma (no therapy needed)

• 07/2015: acute episode with typicial symptomspersisting diarrhea since RITUXIMAB-therapy, occult faecal blood new

medication with decrease of symptoms

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• colonoscopy/rectoscopy: chronic inflammation of colorectal mucousmembrane

• abdominal MRI/CT: thickened intestinal wall (caecal, ascending colon), mesenterial lymphadenitis

• head MRI: no indication of vasculitis

• gastroscopy: antrum-gastritis, small axial hernia

• PR3-specific-ANCA-positivity

• ETIOLOGY?

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CU & not-specifiable IBD? vs. ANCA-associated vasculitis?

• CRP up to 280 mg/L• thrombocytosis• Mabthera ≠ effective

• PR3-specific-ANCA-positive• granulomatosis• polyangiitis

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Colonoscopy 01/2015colitis, crooked neo-formations with pus

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Recto-sigmoidoscopy 07/2015inflammation, fibrin-coating

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Infiltration von eosinophilenGranulozyten

C.Ulcerosa mit AktivitätBasale Lymphozytose

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69yo male• Presentation with hematochezia

PMH: • NSCLC pT3 pN1 L1 V1 Pn1 G3 R0 06/2015; pneumonectomy 07/15• Prostate adeno carcinoma, TUR-P 01/2015• sleep apnea. Epworth Sleepiness Scale 9• atrial fibrillation > therapeutic LMWH• Tubular low grade colon adenoma

Lab: Hb 121g/l>76g/l, Tc 270 G/l, INR 1.0, Lc

normal gastroscopy

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Colonoscopy 08/2015Non-gangrenous colitis

Sharp demarcation between viable and necrotic colonic mucosa

Edema & focal mucosalhemorrhage

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Early lesions characterized by superficial mucosal hemorrhage, edema and necrosis. Necrosis usually spares base of crypts and muscularis propria

Histology: Ischemic ColitisLater lesions may exhibit granulation tissue, submucosalfibrosis and atrophy. Frequent hyalinization of lamina propria