3/30/2017. Disclosure of Relevant Financial Relationships. Case 5: Polypoid mass in ulcerative colitis. Case 5. TC Smyrk
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1 Case 5: Polypoid mass in ulcerative colitis TC Smyrk Disclosure of Relevant Financial Relationships USCAP requires that all faculty in a position to influence or control the content of CME disclose any relevant financial relationship WITH COMMERCIAL INTERESTS which they or their spouse/partner have, or have had, within the past 12 months, which relates to the content of this educational activity and creates a conflict of interest. Dr. Smyrk declares he has no conflict(s) of interest to disclose. Case 5 22 M with ulcerative colitis resistant to therapy Endoscopy revealed pseudopolyps throughout the colon 6 cm area of matted pseudopolyps at hepatic flexure Biopsies showed no dysplasia Symptoms continued unabated Subtotal colectomy with end ileostomy 3 weeks after scope 6.5 x 4 x 3 cm polypoid mass covered in pseudopolyps Multiple sections submitted, diagnosis deferred The next day, an expert GI pathologist was consulted 1
2 Intestinal low grade tubuloglandular adenocarcinoma in inflammatory bowel disease Levi and Harpaz, Am J Surg Pathol 2006;30: /149 IBD patients with resected carcinoma Mucosal dysplasia in all but one Well differentiated tubular, circular or ameboid glands Single layer of cuboidal/low columnar epithelium Goblet cells sometimes interspersed Desmoplasia absent or inconspicuous 2
3 Signed out as well differentiated adenocarcinoma, T3N0 Case added to CRC tumor board Expert GI pathologist takes photos, begins to worry.. 3
4 Diagnosis Pseudoinvasion/epithelial misplacement (colitis cystica profunda)in an inflammatory pseudopolyp, in the setting of inflammatory bowel disease 4
5 Goodall HB, Sinclair ISR. Colitis cystica profunda. J Pathology and Bacteriology 1957;73:33 42 Goodall HB, Sinclair ISR. Colitis cystica profunda. J Pathology and Bacteriology 1957;73:33 42 Wayte DM, Helwig EB. Colitis cystica profunda. AJCP 1967;48: Goodall HB, Sinclair ISR. Colitis cystica profunda. J Pathology and Bacteriology 1957;73:33 42 Wayte DM, Helwig EB. Colitis cystica profunda. AJCP 1967;48: Since the first description in 1766 of submucosal cysts of the colon, they have been described in association with dysentery. Goodall HB, Sinclair ISR. Colitis cystica profunda. J Pathology and Bacteriology 1957;73:33 42 Wayte DM, Helwig EB. Colitis cystica profunda. AJCP 1967;48: Magidson JG, Lewin KJ. Diffuse colitis cystica profunda. AJSP 1981;5: M with UC for 2 years. Found five similar cases in the literature. Ddx: Colitis cystica profunda vs ADCA Year Age/sex Years Histologic clues 1967 M, M 3,4 No cytologic atypia M 2 No cytologic atypia, no desmoplasia M 0 None (acellular mucin pools) M na Not discussed M 10 No cytologic atypia; IHC for p53 negative F 20 No mucosal dysplasia; lobulated architecture Pseudoinvasion/epithelial misplacement Adenoma Sessile serrated adenoma/polyp Rectal prolapse Peutz Jeghers syndrome 5
6 Pseudoinvasion/epithelial misplacement Adenoma Sessile serrated adenoma/polyp Rectal prolapse Peutz Jeghers syndrome Epithelial Misplacement in Peutz Jeghers Polyps: A Diagnostic Pitfall Site # polyps #PEM SM MP Serosa Stomach 88 0 Duodenum Jejunum/Ileum Colon Shepherd NA, Bussey HJR, Jass JR. AJSP 1987;11:743 Epithelial misplacement in Peutz Jeghers Polyps Villous architecture often preserved No cytologic atypia Specialized cells present (goblet, absorptive cells, endocrine) Brush border present Lamina propria usually present No desmoplasia; some fibrosis in subserosa, especially around ruptured mucus cysts 6
7 Wayte DM, Helwig EB: Colitis cystica profunda the pathologist must remain aware of the lesion in order not to mistake the finding of glandular elements within the submucosa for evidence of malignant invasion..glandular elements within the submucosa should not be regarded as being a malignant invasion without confirmatory cytologic evidence. Fact or Fiction For the disbelievers among you. A. Dr. Smyrk called his wife to ask what she thought was interesting about him, and she hasn t called him back yet B. Dr. Smyrk flunked out of college C. Dr. Smyrk skipped out of the meeting here in San Antonio to play chicken s**t bingo 7
8 Answers Although a group of folks did sneak off for bingo, Dr. Smyrk was not among them Dr. Panarelli, not Dr. Smyrk, waited 3 days for her mother to remind her of the Sinatra story; her sister has yet to respond In the summer of his 20 th year, Dr. Smyrk flunked out of college, was drafted into the Army, and got married The military stint lasted two years The marriage lasted 44 years (and still counting) Important Information Regarding CME/SAMs The Online CME/Evaluations/SAMs claim process will only be available on the USCAP website until September 30, No claims can be processed after that date! After September 30, 2017 you will NOT be able to obtain any CME or SAMs credits for attending this meeting. 8
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