“MICROSCOPIC/COMMENT”
TEMPLATES
NOTE: This is a list of “microscopic/comment” templates of the most common GI biopsies diagnoses we encounter in our daily surgical pathology practice. However, in about 20-30% of cases the histologic findings are equivocal, complex, the tissue material insufficient or with extensive artifacts, to warrant a specific diagnosis. Moreover, in some cases the age, clinical, radiological, and/or endoscopic findings are critical for the pathologist to reach an accurate diagnosis. For these reasons, some cases warrant a descriptive diagnosis (i.e. suggestive of) in which the following templates may not be useful or appropriate to use. Also, the following templates reflect my particular style of signing-out cases, which other pathologists might not like or feel comfortable. Changes and modifications on these templates during sign-out should be possible to make them even more useful. (CT)
E1 Esophagus, endoscopic biopsy: MILD ACTIVE ESOPHAGITIS
The esophageal biopsy shows squamous mucosa with basal cell hyperplasia, focal squamous ballooning change, and scattered eosinophils infiltrating the squamous epithelium. These findings are consistent with gastroesophageal reflux disease.
E2 Esophagus, endoscopic biopsy: ACTIVE ESOPHAGITIS
The esophageal biopsy shows squamous mucosa with basal cell hyperplasia, keratinocyte ballooning change, and eosinophils and neutrophils infiltrating the squamous epithelium. These findings are consistent with gastroesophageal reflux disease.
E3 Esophagus, endoscopic biopsy: SEVERE ACTIVE ESOPHAGITIS
The esophageal biopsy shows squamous mucosa with ulceration and prominent eosinophilic and neutrophilic infiltrates. No fungal organisms or viral cytopathic effects are identified. These findings are consistent with gastroesophageal reflux disease, in the proper clinical setting.
E4 Esophagus, endoscopic biopsy: ALLERGIC ESOPHAGITIS
The esophageal biopsy shows a prominent eosinophilic infiltrate of the squamous mucosa. These histologic findings and the young age of the patient, are consistent with allergic esophagitis.
E5 Esophagus, endoscopic biopsy: CMV ESOPHAGITIS
The esophageal biopsy shows acute inflammation of the squamous mucosa and nuclear viral inclusions surrounded by a clear halo as well as cytoplasmic eosinophilic inclusions, involving stromal and endothelial cells. These features are consistent with CMV infection.
E6 Esophagus, endoscopic biopsy: HERPES SIMPLEX ESOPHAGITIS
The esophageal biopsy shows ulceration of the squamous mucosa and keratinocytes with nuclear eosinophilic glassy viral inclusions with occasional multinucleation, consistent with Herpes Simplex infection.
E7 Esophagus, endoscopic biopsy: CANDIDA ESOPHAGITIS
The esophageal biopsy shows acute inflammation and GMS-positive fungal yeast and pseudohyphae consistent with Candida species.
E8 Esophagus, distal, endoscopic biopsy: BARRETT’S MUCOSA
The esophageal biopsy shows specialized-columnar epithelium (intestinal metaplasia) admixed with squamous mucosa, consistent with Barrett’s esophagus. There is no evidence of dysplasia or malignancy.
E9 Esophagus, “EGJ”, endoscopic biopsy: BARRETT’S MUCOSA, C/W
The esophageal biopsy shows squamo-columnar junctional mucosa with focal specialized-columnar epithelium (intestinal metaplasia). These histologic findings are consistent with either long-segment Barrett’s, short-segment Barrett’s, or intestinal metaplasia of the gastric cardia. Clinical-endoscopic correlation required. There is no evidence of dysplasia or malignancy.
E10 Esophagus, distal, endoscopic biopsy: BARRETT’S MUCOSA WITH LOW GRADE
DYSPLASIA
The esophageal biopsy shows specialized-columnar epithelium (intestinal metaplasia) with areas showing glandular pseudostratification by hyperchromatic, enlarged nuclei, with no surface maturation. There is no significant glandular architectural abnormalities or reactive stroma as well as no significant acute inflammation. These histologic findings are consistent with low grade dysplasia arising in Barrett’s mucosa. Close endoscopic surveillance is recommended.
E11 Esophagus, distal, endoscopic biopsy: BARRETT’S MUCOSA WITH HIGH GRADE
DYSPLASIA
The esophageal biopsy shows specialized-columnar epithelium (intestinal metaplasia) with areas showing glandular full thickness stratification by hyperchromatic , enlarged nuclei, no surface maturation and glandular architectural abnormalities. No significant glandular cribiforming nor stromal reaction is identified. These histologic findings are consistent with high grade dysplasia arising in Barrett’s mucosa. Close endoscopic surveillance and re-biospsy recommended to rule-out an intramucosal or invasive carcinoma in other areas of Barrett’s mucosa.
E12 Esophagus, distal, endoscopic biopsy: BARRETT’S MUCOSA WITH AREAS
INDEFINITE FOR DYPLASIA
The esophageal biopsy shows specialized-columnar epithelium (intestinal metaplasia) with focal areas showing glandular pseudostratification by hyperchromatic, enlarged nuclei.
However, there is partial surface maturation and significant surrounding acute and chronic inflammation. There is no glandular architectural abnormalities and no stromal reaction. These atypical glandular changes may represent low grade dysplasia arising in Barrett’s mucosa or reactive changes secondary to inflammation. Repeat endoscopy with re-biopsy after anti-reflux medication recommended to rule out dysplasia.
E13 Esophagus, distal, endoscopic biopsy: BARRETT’S MUCOSA WITH INTRAMUCOSAL
CARCINOMA
The esophageal biopsy shows specialized-columnar epithelium (intestinal metaplasia) with areas showing complex cribiform glands with full thickness stratification by hyperchromatic enlarged nuclei. These areas are confined within the lamina propria. These histologic findings are consistent with intramucosal carcinoma arising in Barrett’ mucosa. Due to the superficial nature of the biopsy, a submucosal invasive component cannot be entirely ruled-out.
E14 Esophagus, distal, endoscopic biopsy: BARRETT’S MUCOSA WITH INVASIVE
ADENOCARCINOMA
The esophageal biopsy shows malignant glands surrounded by a desmoplastic stroma infiltrating the submucosa. Areas of specialized-columnar epithelium (intestinal metaplasia) and dysplasia are present adjacent to the invasive adenocarcinoma. Due to the superficial nature of the biopsy, depth of invasion cannot be determined.
S1 Stomach, fundus, endoscopic biopsy: CHRONIC ATROPHIC GASTRITIS
The gastric fundic biopsy shows a marked mucosal lymphoplasmacytic infiltrate, glandular atrophy with loss of parietal and chief cells, intestinal metaplasia, and neuroendocrine cell hyperplasia. No Helicobacter pylori organisms are identified. The differential diagnosis includes type “A” autoimmune atrophic gastritis associated with pernicious anemia vs. a type “C” multifocal atrophic gastritis (enviormental type). Clinical correlation required.
S2 Stomach, antrum, endoscopic biopsy: CHRONIC ACTIVE GASTRITIS
The gastric antral biopsy shows a marked mucosal lymphoplasmacytic infiltrate, as well as multifocal areas with glandular neutrophilic infiltrates. Numerous Helicobacter pylori organisms are present. These histologic features are those of HP-induced diffuse antral gastritis (type B gastritis).
S3 Stomach, antrum, endoscopic biopsy: SEVERE CHRONIC ACTIVE GASTRITIS
The gastric antral biopsy shows a marked mucosal lymphoplasmacytic infiltrate, as well as severe acute inflammation of the mucosa with focal superficial erosions. Numerous Helicobacter pylori organisms are present. These histologic features are those of a severe HP-induced diffuse antral gastritis (type B gastritis).
S4 Stomach, NOS, endoscopic biopsy: CHRONIC INACTIVE GASTRITIS
The gastric biopsy shows an increase lymphoplasmacytic infiltrate in the lamina propria. No acute inflammation is present. No Helicobacter pylori organisms are identified. These histologic findings are non-specific, but may be associated with a treated or mild form of Helicobacter pylori-induced chronic antral gastritis.
S5 Stomach, NOS, endoscopic biopsy: ACUTE EROSIVE GASTRITIS
The gastric biopsy shows multifocal areas of superficial mucosal ischemic necrosis and hemorrage with minimal acute and chronic inflammatory cells. These histologic findings are consistent with either a NSAID’s, alcohol, or stress-induced gastropathy. Clinical correlation required.
S6 Stomach, NOS, endoscopic biopsy: REACTIVE FOVEOLAR HYPERPLASIA
The gastric biopsy shows abundant hyperplastic foveolar glands with reactive nuclear changes, in some areas arranged in a polypoid configuration. There is minimal acute and chronic inflammation. These presence of reactive foveolar hyperplasia may be associated with bile reflux-induced chemical gastropathy, stoma-associated mucosal prolapse, or an adjacent mucosal ulcer or tumor. Clinical correlation required.
S7 Stomach, NOS, endoscopic biospsy: LYMPHOCYTIC GASTRITIS
The gastric biospy shows a prominent intraepithelial lymphocytosis involving the superficial epithelium and glands, increase lamina propria lymphoplasmacytic infiltrate, and hyperplastic foveolar glands. No lymphoepithelial lesions are identified. These histologic findings are consistent with lymphocytic gastritis. This entity may be associated with celiac sprue, Helicobacter pylori infection, or idiopathic. Clinical correlation required.
S8 Stomach, NOS, endoscopic biopsy: EOSINOPHILIC GASTRITIS, C/W
The gastric biopsy shows a diffuse eosinophilic mucosal infiltrate with prominent glandular involvment by eosinophils. No parasites are identified. These histologic findings are consistent with idiopathic or allergic eosinophilic gastritis in the proper clinical setting. However, other causes of mucosal eosinophilia like parasitic infestation, collagen-vascular diseases, and drug reaction cannot be entirely ruled-out by histology alone. Clinical correlation required.
S9 Stomach, NOS, endoscopic biopsy: HYPERPLASTIC POLYP
The gastric biopsy shows a benign polypoid lesion composed of exuberant, branching and cystic mucus-producing foveolar-type glands surrounded by an edematous, mildly inflamed lamina propria and smooth muscle hyperplasia. There is no evidence of dysplasia.
S10 Stomach, NOS, endoscopic biopsy: JUVENILE POLYP, C/W
The gastric biopsy shows a benign polypoid lesion composed of exuberant, branching and cystic mucus-producing foveolar-type glands surrounded by a markedly inflammed and edematous lamina propria. These histologic findings are consistent with a juvenile polyp in the setting of juvenile polyposis syndrome. If the lesion is a single polyp, the differential diagnosis is with a hyperplastic polyp. Clinical correlation required.
S11 Stomach, fundus, endoscopic biopsy: FUNDIC GLAND POLYP
The gastric biopsy shows fundic-type mucosa containing numerous irregular microcysts lined by parietal, chief, and mucous cells.
S12 Stomach, NOS, endoscopic biopsy: ADENOMA
The gastric biopsy shows a polypoid neoplastic lesion composed of intestinal-type dysplastic glands, lined by pseudostratified, hyperchromatic, overlapping nuclei, with no surface maturation. There is no evidence of invasive carcinoma.
S13 Stomach, antrum, endoscopic biopsy: INFLAMMATORY FIBROID POLYP
The antral biopsy shows a submucosal well circumscribed nodule composed of histiocytes, plump myofibroblastic spindle cells and small vessels, admixed with abundant eosinophils and lymphocytes.
S14 Stomach, NOS, endoscopic biopsy: INVASIVE ADENOCARCINOMA,
INTESTINAL TYPE
The gastric biopsy shows an infiltrative carcinoma composed of intestinal type malignant glands lined by hyperchromatic, overlapping nuclei and with focal cribiform pattern. Focal areas of residual surface mucosal dysplastic gland and intestinal metaplasia are also present within a background of chronic atrophic gastritis. Due to the superficial nature of the biospy, depth of invasion cannot be determined.
S15 Stomach, NOS, endoscopic biopsy: INVASIVE ADENOCARCINOMA,
DIFFUSE TYPE
The gastric biopsy shows a poorly differentiated carcinoma composed of diffuse infiltrative aggregates of signet ring and round cells with large hyperchromatic nuclei and eosinophilic mucin positive cytoplasm. Due to the superficial and small nature of the biopsy, depth of invasion cannot be determined.
S16 Stomach, NOS, endoscopic biopsy: MALT LYMPHOMA, C/W
The gastric biopsy shows a dense polymorphic lymphoid infiltrate composed of centrocyte-like, monocytoid, and plasma cells, with germinal center formation, that diffusely infiltrates the submucosa and mucosa. There are multiple foci of lymphoepithelial lesions. These histologic findings are highly suggestive of a low grade MALT lymphoma. Re-biopsy for molecular studies and clinical/endoscopic correlation recommended to confirm the diagnosis.
S17 Stomach, NOS, endoscopic biopsy: GI STROMAL TUMOR OF UNCERTAIN
MALIGNANT POTENTIAL
The gastric biopsy shows a submucosal mass composed of cellular spindle cell fascicles with mild nuclear pleomorphism and occasional mitotic features. The spindle tumor cells are diffusely and strongly for CD-34 and c-kit. Due to the small and superficial nature of the biospy, tumor size and the presence of tumor necrosis cannot be well documented. Therefore, the biologic potential of this tumor cannot be determined with certainty. Complete excision with clear margins recommended.
S18 Stomach, NOS, endoscopic biopsy: MALIGNANT GASTROINTESTINAL STROMAL
TUMOR
The gastric biopsy shows a submucosal mass composed of cellular fascicles of pleomorphic spindle cells with numerous mitotic features ande tumor cell necrosis. The spindle tumor cells are diffusely and strongly positive for CD-34 and c-kit.
S19 Stomach, NOS, endoscopic biopsy: XANTHELASMA
The gastric biopsy show expansion of the lamina propria by PAS-negative foamy histocytes.
S20 Stomach, antrum, endoscopic biopsy: GASTRIC ANTRAL VASCULAR ECTASIA
The gastric antral biospy show dilated capillaries in the superficial lamina propria with occasional fibrin thrombi, and mucosal fibromuscular hyperplasia.
S21 Stomach, fundus, endoscopic biopsy: CARCINOID TUMOR
The gastric biopsy show a tumor composed of uniform cells with round nuclei and granular chromatin arranged in a ribbon-like and trabecular pattern with occasional pseudorosette formation. No nuclear atypia, mitotic activity, or tumor necrosis is present. However, due to the small sample of tumor in this biopsy, its biologic potential cannot be determined.
I1 duodenum, endoscopic biopsy: PEPTIC DUODENITIS
The duodenal biopsy shows focal villous blunting, mucous (pyloric) metaplasia, and increase lamina propria lymphoplasmacytic infiltrates. No acute inflamation is present.
I2 duodenum, endoscopic biopsy: ACTIVE PEPTIC DUODENITIS
The duodenal biopsy shows focal villous blunting, mucous (pyloric) metaplasia, increase lamina propria lymphoplasmacytic infiltrates, and acute cryptitis with focal superficial erosions.
I3 jejunum, endoscopic biopsy: CELIAC SPRUE
The small intestinal biopsy shows prominent intraepithelial lymphocytosis, increase lamina propria lymphoplasmacytic infiltrates, surface epithelium vacuolar degeneration, and diffuse villous blunting.
I4 duodenum, endoscopic biopsy: WHIPPLE DISEASE
The duodenal biospy shows diffuse aggregates of PAS +, AFB - foamy histiocytes that expand the lamina propria, and dilated mucosal lymphatic channels.
I5 duodenum, endoscopic biopsy: MYCOBACTERIUM AVIUM INTRACE-
LLULARE ENTERITIS
The duodenal biopsy shows diffuse aggregates of PAS +, AFB + foamy histiocytes that expand the lamina propria.
I6 NOS, endoscopic biopsy: CRYPTOSPORIDIUM ENTERITIS
The small intestinal biopsy shows numerous 2-4 microns, round PAS + microorganisms adhese to the superficial epithelium’s brush border. There is mild mucosal acute inflammation.
I7 NOS, endoscopic biopsy: GIARDIASIS
The small intestinal biopsy shows numerous 10-14 microns, semilunar hematoxyphilic microorganisms present on the luminal surface. There is no significant mucosal inflammation.
I8 NOS, endoscpic biopsy: MICROSPORIDIUM ENTERITIS
The small intestinal biopsy shows intracellular, supranuclear parasites and Warthin-Starry + spores on the superficial epithelium. There is mild mucosal villous atrophy and chronic inflammation.
I9 NOS, endoscopic biopsy: ISOSPORA ENTERITIS
The small intestinal biopsy shows banana-shaped, infranuclear parasites on the superficial epithelium. There is mild mucosal villous atrophy and chronic inflammation.
I10 NOS, endoscopic biopsy: STRONGYLOIDES ENTERITIS
The small intestinal biopsy shows rhabditiform larvae cysts within the intestinal crypts as well as cross sections of adult worms with external cuticle and internal structures. There is a mixed mucosal inflammatory infiltrate with numerous eosinophils.
I11 ileum, endoscopic biopsy: ACUTE ULCERATING ILEITIS, C/W
SALMONELLOSIS (TYPHOID FEVER)
The ileal biopsy shows mucosal aphtous ulcers overlying Peyer’s patches and submucosal edema and a mixed inflammatory infiltrate. No granulomas are identified. AFB and Gram special stains are negative for microorganisms. These histologic findings are consistent with salmonella ileitis in the proper clinical and serologic setting.
I12 ileum, endoscopic biopsy: ACUTE ULCERATING ILEITIS, C/W
YERSINIOSIS
The ileal biopsy shows mucosal aphtous ulcers overlying Peyer’s patches and a granulomatous reaction around germinal center microabscesses. Numerous colonies of gram-negative coccobacilli are present within the ulcer’s exudate. These histologic findings are consistent with Yersinia enterocolitica enteritis in the proper clinical and serologic setting.
I13 ileum, endoscopic biopsy: TUBERCULOUS ENTERITIS
The ileal biopsy shows mucosal caseating granulomas and ulceration. AFB special stain is positive for mycobacteria.
I14 NOS, endoscopic biopsy: ISCHEMIC ENTERITIS
The small intestinal biopsy shows mucosal superficial glandular degeneration, surface erosion, and lamina propria hyalinization, consistent with ischemic damage. The differential diagnosis includes ischemic bowel disease, shock (hypotension), NSAID’s-induced damage, and Clostridium perfringens-enteritis necroticans. Clinical, radiologic, and endoscopic correlation required.
I15 NOS, endoscopic biopsy: EOSINOPHILIC ENTERITIS
The small intestinal biopsy shows a diffuse mucosal eosinophilic infiltrate with numerous eosinophilic crypt absesses and cryptitis. The villous architecture is normal and no parasites are identified. These histologic findings are consistent with an idiopathic or allergic eosinophilic enteritis in the proper clinical setting. However, other causes of mucosal eosinophilia like parasitic infestation, collagen-vascular diseases, and drug reaction cannot be entirely ruled-out by histology alone. Clinical and endoscopic correlation required.
I16 NOS, endoscopic biopsy: CHRONIC ACTIVE ENTERITIS, C/W
CROHN’S DISEASE
The small intestinal biopsy shows a glandular branching, dilatation, and atrophy, a prominent mucosal lymphoplasmacytic infiltrate, acute cryptitis and crypt absesses with surface mucosal ulceration, and scattered non-caseating granulomas.
I17 “ileoanal pouch”, endoscopic biopsy: ACUTE POUCHITIS
The pouch biopsy shows a prominent neutrophilic mucosal infiltrate with acute cryptitis and crypt abscesses. No chronic mucosal changes or granulomas are present. These histologic findings are consistent with bacterial overgrowth-induced acute pouchitis in the proper clinical setting.
I18 “ileoanal pouch”, endoscopic biopsy: CHRONIC ACTIVE POUCHITIS (1)
The pouch biopsy shows villous blunting, colonic intestinal metaplasia, glandular architectural abnormalities, mucosal lymphoplasmacytic infiltrates, acute cryptitis and crypt abscesses. No granulomas are identified. These histologic findings are suggestive of recurrent ulcerative colitis.
I19 “ileoanal pouch”, endoscopic biopsy: CHRONIC ACTIVE POUCHITIS (2)
The pouch biopsy shows villous blunting, colonic intestinal metaplasia, glandular architectural abnormalities, mucosal lymphoplasmacytic infiltrates, acute cryptitis and crypt abscesses. Scattered non-caseating granulomas are present. These histologic findings are suggestive of Crohn’s disease. Re-review of the clinical history and original colonic resection specimen recommended.
I20 NOS, endoscopic biopsy: LYMPHANGECTASIA
The small intestinal biopsy shows multiple dilated villi lacteals and edema of the lamina propria. The differential diagnosis includes primary (congenital or acquired/idiopathic) or secondary (retroperitoneal lymph node obstruction) lymphangectasia.
I21 duodenum, endoscopic biopsy: PANCREATIC HETEROTOPIA
The duodenal biopsy shows pancreatic exocrine acini and ducts present in the submucosa.
I22 duodenum, endoscopic biopsy: GASTRIC HETEROTOPIA
The duodenal biopsy shows a well circumscribed focus of fundic-type mucosa.
I23 duodenum, endoscopic biopsy: BRUNNER’S GLAND HYPERPLASIA
The duodenal biopsy shows prominent lobules of Brunner’s glands surrounded by bands of muscularis mucosa.
I24 NOS, endoscopic biopsy: PEUTZ-JEGHERS POLYP
The small intestinal biopsy shows a polypoid lesion composed of an arborizing core of muscularis mucosa covered by cytologically normal small intestinal mucosa.
I25 duodenum, endoscopic biopsy: CARCINOID TUMOR
The duodenal biopsy shows a tumor involving the mucosa and submucosa composed of tubules, cords, and rosettes, lined by round, regular nuclei with granular chromatin. Numerous psammomas bodies are present within the tubules and rosettoid structures. These histologic findings are consistent with a duodenal somatostatinoma. No nuclear atypia, mitotic activity, or tumor necrosis is seen. However, due to the small and superficial nature of the biopsy, the biologic potential of this tumor cannot be determined.
I 26 ileum, endoscopic biopsy: CARCINOID TUMOR
The ileal biopsy shows a tumor composed of organoid nests of cells with round, regular nuclei with granular chromatin and amphophilic cytoplasm. No nuclear atypia, mitotic activity, or tumor necrosis is seen. However, due to the small and superficial nature of the biopsy, the biologic potential of this carcinoid tumor cannot be determined.
I 27 NOS, endoscopic biopsy: HIGH GRADE NEUROENDOCRINE
CARCINOMA
The small intestinal biopsy shows sheets and nests of tumor cells with high nuclear/cytoplasmic ratio, granular chromatin, numerous mitotic figures, and tumor cell necrosis. Scaterred pseudorosettes are present. The tumor cells are positive for chromogranin and synaptophysin immunostains.
I28 periampullary region, endoscopic biopsy: ADENOMA
The small intestinal biopsy shows a polyp composed of pseudostratified glands lined by enlarged, hyperchromatic nuclei, consistent with an adenoma. However, due to the small and superficial nature of the biopsy, an underlying invasive ampullary adenocarcinoma cannot be entirely ruled-out. Clinical, radiological, end endoscopic correlation required.
C1 NOS, endoscopic biopsy: CHRONIC ACTIVE COLITIS (1)
The colon biopsy shows glandular architectural distortion and atrophy, a prominent lamina propria lymphoplasmacytic infiltrate, Paneth cell metaplasia, as well as acute cryptitis and crypt absesses. These histologic findings are consistent with inflammatory bowel disease, in the proper clinical setting. There is no evidence of dysplasia or malignancy.
C2 NOS, endoscopic biopsy: CHRONIC ACTIVE COLITIS (2)
The colon biopsy shows glandular architectural distortion and atrophy, a prominent lamina propria lymphoplasmacytic infiltrate, Paneth cell metaplasia, acute cryptitis and crypt absesses, as well as mucosal non-caseating granulomas. These histologic findings are consistent with Crohn’s disease, in the proper clinical setting.
C3 NOS, endoscopic biopsy: CHRONIC INACTIVE COLITIS
The colon biopsy shows glandular architectural distortion and atrophy, a prominent lamina propria lymphoplasmacytic infiltrate, and Paneth cell metaplasia. These histologic findings are consistent with inflammatory bowel disease, in the proper clinical setting.
C4 NOS, endoscopic biopsy: CHRONIC ACTIVE COLITIS WITH LOW
GRADE DYSPLASIA
The colon biopsy shows glandular architecural distortion and atrophy, a prominent lamina propria lymphoplasmacytic infiltrate, Paneth cell metaplasia, acute cryptitis and crypt absesses. These histologic findings are consistent with inflammatory bowel disease, in the proper clinical setting. There are focal areas showing glandular pseudostratification by hyperchromatic, enlarged nuclei, and no surface maturation, consistent with low grade dysplasia. Close endoscopic surveillance is recommended.
C5 NOS, endoscopic biopsy: CHRONIC ACTIVE COLITIS WITH HIGH
GRADE DYSPLASIA
The colon biopsy shows glandular architectural distortion and atrophy, a prominent lamina propria lymphoplasmacytic infiltrate, Paneth cell metaplasia, acute cryptitis and crypt absesses. The histologic findings are consistent with inflammatory bowel disease, in the proper clinical setting. There are focal areas showing glandular full thickness stratification by hyperchromatic, enlarged nuclei, as well as glandular architectural abnormalities and no surface maturation, consistent with high grade dysplasia. Close endoscopic surveillance with repeat biopsy recommended to rule-out a concurrent invasive carcinoma.
C6 NOS, endoscopic biopsy: CHRONIC ACTIVE COLITIS WITH AREAS
INDEFINITE FOR DYSPLASIA
The colon biopsy shows glandular architectural distortion and atrophy, a prominent lamina propria lymphoplasmacytic infiltrate, Paneth cell metaplasia, acute cryptitis and crypt absesses. These histologic findings are consistent with inflammatory bowel disease, in the proper clinical setting. There are focal areas of glandular pseudostratification by hyperchromatic, enlarged nuclei. However, there is partial surface maturation and significant surrounding acute inflammation. These atypical glandular changes may represent IBD-associated low grade dysplasia or inflammation-induced reactive cellular changes. Repeat endoscopy with re-biopsy after anti-inflammatory therapy recommended to rule-out dysplasia.
C7 NOS, endoscopic biopsy: ACTIVE COLITIS
The colon biopsy shows acute cryptitis, crypt absesses, and focal mucosal superficial erosions. No unequivocal chronic mucosal changes nor granulomas are identified. Although these histologic findings are consistent with an acute self-limited (infectious) colitis in the proper clinical setting, an early inflammatory bowel disease, cannot be entirely ruled-out by histology alone. Clinical and endoscopic correlation required.
C8 NOS, endoscopic biopsy: ISCHEMIC COLITIS
The colon biopsy shows multifocal superficial mucosal coagulative necrosis, with glandular degeneration and lamina propria hyalinization. No significant acute inflammation is present. Although these histologic findings are consistent with ischemic bowel disease in the proper clinical setting, a similar histologic appearance can be seen with an E-Coli O157:H7 enterohemorrhagic colitis. Clinical correlation required.
C9 NOS, endoscopic biopsy: PSEUDOMEMBRANOUS COLITIS
The colon biopsy shows acute cryptitis with “exploding” crypts, and an eruptive exudate composed of fibrin and mucin with files of neutrophils arising from eroded superficial mucosa. Althogh these histologic findings are consistent with Clostridium difficile-induced pseudomembranous colitis, a similar histologic appearance can be seen with ischemic bowel disease, E-coli O157:H7 enterohemorrhagic colitis, shigellosis, and amebiasis. Clinical and endoscopic correlation required.
C10 NOS, endoscopic biopsy: LYMPHOCYTIC COLITIS
The colon biopsy shows a prominent lamina propria lymphoplasmacytic infiltrate, marked intraepithelial lymphocytosis, and superficial epithelial degeneration.
C11 NOS, endoscopic biopsy: COLLAGENOUS COLITIS
The colon biopsy shows a prominent lamina propria lymphoplasmacytic infiltrate, intraepithelial lymphocytosis, and marked collagenous thickening of the subepithelial basement membrane.
C12 NOS, endoscopic biopsy: MUCOSAL ULCER, NON-SPECIFIC
The colon biopsy shows fragments of granulation tissue and reactive, edematous colonic mucosa. The differential diagnosis includes infectious colitis, inflammatory bowel disease, ischemic bowel disease, stercoral ulcer, obstructive colopathy, Behcet’s syndrome, Reiter’s syndrome, and NSAID’s-induced colopathy. Clinical and endoscopic correlation required.
C13 NOS, endoscopic biopsy: AMEBIC COLITIS
The colon biopsy shows acute mucosal inflammation with cryptitis and superficial erosions. Within the inflammatory exudate, numerous 10-20 micron trophozoites with phagocytosed erythrocytes, consistent with Entamoeba histolytica, are present.
C14 NOS, endoscopic biopsy: CMV COLITIS
The colon biopsy shows acute mucosal inflammation and erosion. Numerous nuclear viral basophilic inclusions surrounded by a clear halo and eosinophilic granular cytoplasmic inclusions are present within endothelial cells and lamina propria fibroblasts, consistent with cytomegalovirus infection.
C15 NOS, endoscopic biopsy: COLONIC SPIROCHETOSIS
The colon biopsy shows a thickened hematoxiphilic brush border, that stains strongly positive with silver stain. No other mucosal abnormalities are noted.
C16 NOS, endoscopic biopsy: GRAFT VERSUS HOST DISEASE (GVHD)
The colon biopsy shows marked apoptosis of the colonic glandular epitelium and reactive glandular changes. No significant acute inflammation is present.
C17 NOS, endoscopic biopsy: RADIATION COLITIS
The colon biopsy shows vacuolization of the surface epithelium, reactive and degenerative glandular changes, increase eosinophils, edema and hyalinization of the lamina propria, as well as enlarged, hyperchromatic stromal fibroblasts. No significant acute inflammation is present.
C18 NOS, endoscopic biopsy: MELANOSIS COLI
The colon biopsy shows numerous pigmented lipofuscin-laden macrophages in the lamina propria. No other mucosal abnormalities are identified.
C19 diverted segment, endoscopic biopsy: DIVERSION COLITIS
The colon biopsy shows increase lamina propria lymphoplasmacytic infiltrates, lymphoid follicular hyperplasia, focal acute cryptitis and crypt absesses. No granulomas are identified. Although these histologic findings are consistent with diversion colitis in the proper clinical setting, similar histologic features can be seen in recurrent inflammatory bowel disease. Clinical correlation required.
C20 NOS, endoscopic polypectomy: HYPERPLASTIC POLYP
The colon biopsy shows a polyp composed of serrated hyperplastic superficial glands with scant goblet cells, surrounded by unremarkable lamina propria.
C21 NOS, endoscopic polypectomy: ADENOMA
The colon biopsy shows a polyp composed of pseudostratified glands lined by enlarged, mucin-depleted, hyperchromatic cells, showing no surface maturation.
C22 NOS, endoscopic polypectomy: SERRATED ADENOMA
The colon biopsy shows a polyp composed of pseudostratified glands lined by enlarged, mucin-depleted, hyperchromatic cells, showing no surface maturation and a superficial glandular serrated appearance.
C23 NOS, endoscopic polypectomy: JUVENILE POLYP
The colon biopsy shows a polyp composed of numerous irregular, dilated, mucin-filled glands surrounded by exuberant, edematous and inflamed lamina propria.
C24 NOS, endoscopic biopsy: INFLAMMATORY PSEUDOPOLYP
The colon biopsy shows a polypoid lesion composed of markedly inflamed and eroded mucosa with acute cryptitis, glandular architectural changes, and granulation tissue. These histologic features are consistent with an IBD-associated inflammatory pseudopolyp.
C25 cecum, endoscopic biopsy: LIPOMA
The cecal biopsy shows prominent mature adipose tissue covered by intact colonic mucosa.
26 NOS, endoscopic biopsy: ANGIODYSPLASIA
The colon biopsy shows scattered ectatic, thin-walled blood vessels in the mucosa and submucosa.
C27 NOS, endoscopic biopsy: COLONIC ADENOCARCINOMA
The colon biopsy shows fragments of mucosa with malignant stratified and cribiforming glands surrounded by a desmoplastic stroma. Due to the small and superficial nature of the biopsy, depth of invasion cannot be determined.
C28 NOS, endoscopic polypectomy: PEDUNCULATED ADENOMA WITH
INVASIVE ADENOCARCINOMA (1)
The colon biopsy shows a pedunculated adenoma containing a focus of infiltrating malignant glands surrounded by desmoplastic stroma, invading the submucosa of the head of the polyp. This focus of adenocarcinoma is well-differentiated, shows no lympho-vascular invasion, and is > 3mm from the stalk cauterized resection margin. These histologic findings warrant no further therapy on this malignant adenomatous polyp.
C29 NOS, endoscopic polypectomy: PEDUNCULATED ADENOMA WITH
INVASIVE ADENOCARCINOMA (2)
The colon biopsy shows a pedunculated adenoma containing a focus of infiltrating carcinoma, invading the stalk and involving the cauterized resection margin. The invasive focus is poorly differentiated and lympho-vascular invasion is present. The presence of any one of the latter three histologic features warrants a segmental colectomy.
C30 rectum, endoscopic biopsy: SOLITARY RECTAL ULCER SYNDROME
The rectal biopsy shows a polypoid mucosa composed of elongated, branching, and dilated crypts, showing reactive epithelial changes surrounded by a muscularized and congested lamina propria. There is focal surface erosion and hemosiderin deposition. These histologic features are those secondary to mucosal prolapse and consistent with the solitary rectal ulcer syndrome in the proper clinical and endoscopic setting.
C31 Anorectal junction, endoscopic biopsy: INFLAMMATORY CLOACOGENIC POLYP
The anorectal biopsy shows a polypoid mucosa composed of elongated, branching, and dilated crypts, admixed with squamous mucosa, and surrounded by a muscularized and congested lamina propria. There is focal surface erosion and hemosiderin deposition. These histologic features are those secondary to mucosal prolapse and consistent with an inflammatory cloacogenic polyp.
C32 rectosigmoid, endoscopic biopsy: CARCINOID TUMOR
The rectal biopsy shows a tumor composed of anastomosing ribbons, tubulo-acinar structures, and solid nests. The tumor cells nuclei are round, uniform, with granular chromatin. No mitotic activity nor tumor cell necrosis is identified. However, due to the superficial and small nature of the biopsy, the biologic potential of this hindgut carcinoid tumor cannot be determined.
L33 Anal canal, endoscopic biopsy: KERATINIZING SQUAMOUS CELL CARCINOMA
The anal canal biopsy shows glandular, transitional, and squamous-type mucosa containing an invasive squamous cell carcinoma. However, due to the small and superficial nature of the biopsy, depth of invasion cannot be determined.
C34 Anal canal, endoscopic biopsy: BASALOID SQUAMOUS CELL CARCINOMA
The anal canal biopsy shows glandular, transitional, and squamous-type mucosa containing an invasive carcinoma composed of islands of basaloid cells with scant cytoplasm. The tumor cell islands show central necrosis and peripheral palisading. Focal keratinization is present. These histologic features are those of a basaloid (cloacogenic) squamous cell carcinoma. Due to the superficial and small nature of the biopsy, depth of invasion cannot be determined.
C 35 Anal canal, endoscopic biopsy: HIGH GRADE NEUROENDOCRINE CARCINOMA
The anal canal biopsy shows glandular, transitional, and squamous-type mucosa containing an invasive tumor composed of nests and islands of round to oval cells with granular, hyperchromatic nuclei and amphophilic cytoplasm. Numerous pseudorossetes, mitotic figures, and tumor cell necrosis are present. The tumor cells react positively for chromogranin and synaptophysin. These histologic and immunohistochemical features are those of a high grade neuroendocrine carcinoma.
C36 Anal canal, endoscopic biopsy: SMALL CELL UNDIFFERENTIATED CARCINOMA
The anal canal biopsy shows glandular, transitional, and squamous-type mucosa contaning an invasive tumor composed of diffuse sheets of small oval hyperchromatic cells with scant cytoplasm, showing a high mitotic rate, tumor cell necrosis, nuclear molding and crush artifact. These histologic features are consistent with a primary anal canal small cell carcinoma. However, a metastasis from a lung or other primary site cannot be entirely ruled-out by histology alone. Clinical correlation required.