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PATHOLOGY Dr.

Yañez
SRS ESOPHAGUS & STOMACH December 3, 2013

1. The depicted lesion is characterized by:  HENCE the most logical answer is letter A - alcoholic cirrhosis
B. Barrett's esophagus does not cause esophageal varices
C. Extrahepatic portal vein obstruction does not cause varices
D. Esophagitis will not present with worm-like dilatations of the
vessels

3. A 68-year old female has suffered from gastro-esophageal reflux disease


with Barrett’s esophagus can develop this type of esophageal malignancy?

A. columnar metaplasia of esophageal squamous epithelium


B. presence of longitudinal mucosal tears and ulceration
C. atypical glandular cells
D. lower esophageal sphincter spasm

Rationale
A. This is known as Barrett's esophagus
B. This is compatible with the diagnosis of Mallory Weiss Tear
 Mallory Weiss Tear: there is presence of longitudinal mucosal A. Squamous cell carcinoma
tears and ulceration B. Leiomyosarcoma
 The lesion seen is a longitudinal tear associated with vomiting C. Adenocarcinoma
and this is what we call severe bleeding (Mechanical tearing D. Lymphoma
of the mucosa)
C. Seen in adenocarcinoma - usually see a large fungating mass of the Rationale
lower esophagus A. SCCA arises in the middle portion of the esophagus, not in the
D. Sphincter spasm - seen in achalasia lower third; but it can also arise in the lower third wherein its
histology is one of malignant squamous
2. The most common cause of the depicted lesion is? B. Leiomyosarcomas of the esophagus are rare, malignant, smooth-
muscle tumors. The presenting symptoms are indistinguishable
from other esophageal neoplasms, though the history may be
longer due to the slow growth of these tumors. Barium studies
may show large intramural masses with ulceration or tracking,
expansile intraluminal masses or areas of luminal narrowing.
Endoscopic biopsies may give a high false negative rate especially
in cases where the mucosa is intact. The treatment of choice is
surgical excision. Prognosis is better than in patients with
squamous esophageal cancer.
C. Adenocarcinoma
 Shown is a composite picture of gross wherein you can see
the nodular mass on the lower esophagus
 What we are seeing here in the slide are complex glandular
A. Alcoholic cirrhosis structures that are inflitrating the squamous columnar
B. Barrett’s esophagus epitheliumthis is an adenocarcinoma arising from Barrett's
C. Extra-hepatic portal vein obstruction esophagus
D. Esophagitis  The typical location of the mass is on the lower esophagus
because many of these is associated with Barrett's esophagus
Rationale wherein there is the change from squamous to glandular cells
A. Alcoholic cirrhosis (glandular metaplasia)
 Diagnosis: Esophageal varices  Pathogenesis of adenocarcinoma of the esophagus is from
 Right picture shows the esophagus Barrett's esophagu (squamous columnar metaplasia) to
 Middle picture is a microscopic picture which shows the dysplasia to adenocarcinoma
overlying mucosa and beneath that you will see a dilated D. Esophageal lymphoma is rare, accounting for less than 1% of all
channel which are blood vessels gastrointestinal lymphomas. Involvement of the esophagus is most
 Hence these are esophageal blood vessels that are commonly the result of contiguous spread from the proximal
abnormally dilated (varices) stomach, adjacent mediastinal lymph nodes, or cervical lymph
 Left picture shows a mucosa wherein you can see two snake- nodes. Primary esophageal lymphoma is even rarer. Persons with
like prominences that projects in the mucosa lumen esophageal lymphoma have varying presentations and a relatively
 What causes these? Anything that is usually associated with poor prognosis. Invasion of the esophagus may result in
portal hypertension hemorrhage, obstruction, or perforation with a tracheoesophageal
fistula.
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PATHOLOGY SRS ESOPHAGUS & STOMACH

4. A young patient had several episodes of dysphagia with aspiration of C. Curling's ulcer—Associated with burns and trauma (as was
previously ingested food difficulty of swallowing. The depicted lesion is indicated in the history)
shown which is consistent with diagnosis of: D. Decubitus ulcers - ulcers seen in pressure points like for example,
patients that are long immobilized and are in a lying position
(ischiopubic area)

6. The depicted lesion is consistent with diagnosis of:

A. Linitis plastica
B. gastric lymphoma
A. Barrett esophagus
C. gastric carcinoid
B. Meckel’s diverticulum
D. GIST (Gastrointestinal stromal tumor)
C. Achalasia
D. Hirschsprung’s disease
Rationale
A. Linitis plastica
Rationale
 “Leather bottle” wherein there is diffuse tumoral infiltration
A. This is associated associated with squamo-columnar metaplasia
of the wall of the stomach producing a very rigid, very tense
B. Meckle's diverticulum is a congenital form of saccular dilatation in
noncontractile stomach
the ileum
C. Achalasia  Microscopic picture shows large, pale, signet-ring cells
consistent with a signet ring adenocarcinoma
 This is the esophagus and seen here is the long segment of
B. Gastric lymphoma- tumors that we see in the lymphoma are
the esophagus connected to the stomach
usually atypical immature lymphoid cells inconsistent with the
 There is a ring-like spastic area producing obstruction to the
mircoscopic picture here
distal esophagus and proximal to this is marked dilatation of
C. Gastric carcinoid- tumor arising from the neuroendocrine cells -
esophagus
this is not the histologic picture
D. Hirschsprung's disease is not a consideration here because this is
 Looks like smooth muscle elongated cell
seen in the rectum (colon) megacolon
D. Most GISTs are well-circumscribed lesions arising within the wall
of the stomach or intestine.
5. Ulceration occurring in the stomach in a patient with severe burns and
trauma in the lesion shown is consistent with:
7. The most frequent complication of this lesion is:

A. Stress ulcers
B. Cushing’s ulcer A. Malignant transformation
C. Curling’s ulcer B. Perforation
D. Decubitus ulcer C. Bleeding
D. Obstruction from scarring
Rationale
A. Stress ulcer - all of them are multiple shallow ulcers that are Rationale
located in any portion of the stomach -usually in the lesser A. Benign peptic ulcer has no malignant transformation as its
curvature because this is where the maximum exposure of HCl is complication
B. Cushing's ulcer is associated with CNS tumors, postcranial surgery, B. Perforation from benign peptic ulcer can happen, however it is not
etc. as common and frequent as bleeding
C. Bleeding—most common complication

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PATHOLOGY SRS ESOPHAGUS & STOMACH

 Benign gastric ulcer shows very big ulceration of the mucosa Rationale
 Ulcer—classical necrotic granulation tissue and fibrous  Diagnosis: Reflux esophagitis or Gastroesophageal reflux disease
connective tissue of the ulcer base (GERD)
 Classical punch out effect of the benign ulcer  Reflux esophagitis is an esophageal mucosal injury that occurs
 Bleeding and nodulations at the rim of the ulceration is secondary to retrograde flux of gastric contents into the
associated with malignant form of ulcer esophagus. Clinically, this is referred to as gastroesophageal reflux
 Because there is no evidence of malignant cells in the ulcer disease (GERD). Typically, the reflux disease involves the distal 8-
microscopically, therefore, this is consistent with the 10 cm of the esophagus and the gastroesophageal junction. The
diagnosis of a benign peptic ulcer disease is patchy in distribution.
D. Scarring can also happen, however, like perforation, is not as  The endoscopic findings in gastroesophageal reflux disease (GERD)
common and frequent as bleeding range from normal esophageal mucosa to erosions and ulcerations.
 Microscopic features include squamous (basal) cell hyperplasia,
8. The depicted lesion is/are associated in the pathogenesis of the elongation of vascular papillae, presence of intraepithelial
following disorders: inflammatory cells, dilated intercellular spaces (intercellular
edema), ballooning degeneration of squamous cells (due to
accumulation of intracellular plasma proteins), vascular lakes
(dilated small blood vessels in superficial lamina propria/vascular
papillae), acanthosis, mucosal erosions and ulcerations.

10. The cell origin of this tumor:

A. Gastric lymphoma
B. Chronic gastritis
C. PUD
D. All of the above

Rationale
D: All of the above
 We see in the left picture a benign gastric mucosa. In the
lamina propria there is inflammation of mostly
monolymphocytic, plasmacytic infiltrates, suggesting that this
is a case of chronic inflammation
 The right photo is presented with a special stain to see or
identify the causative organism for the gastritis (H. pylori) A. Smooth muscle cells
 Infection with H. pylori is associated with the occurrence of B. Mucosa associated lymphoid tissue
gastric lymphoma, chronic gastritis , and peptic ulcer disease . C. Nerve sheath
D. Interstitial cells of Cajal
9. The following histologic finding/s is/are seen in the depicted lesion:
Rationale
 Diagnosis: Gastrointestinal Stromal Tumor (GIST)
 This is a stomach consisting of a modified fleshy tumor on the
submucosa. Histologically, they look like spindle cell myoma cells.
They used to be classified as myoma but because of the adverse of
HIV these tumor cells actually arise from the interstitial cells of
Cajal.
 Most GISTs are well-circumscribed lesions arising within the wall
of the stomach or intestine. They typically exhibit a tan-white,
fleshy cut-surface with foci of cystic degeneration, hemorrhage, or
necrosis. Large tumors may show ulceration of the overlying
mucosa. Microscopically, most GISTs demonstrate 3 main
A. Intraepithelial leukocyte infiltration histologic subtypes: spindle cell type (most common), epithelioid
B. presence of basal cell hyperplasia type, and mixed spindle and epithelioid type. In general, GISTs are
C. Squamous cell hyperplasia characterized by a uniform, monotonous appearance with minimal
D. All of the above cytologic atypia or mitotic activity. Nuclear pleomorphism is
occasionally evident in a GIST and, when present, is often admixed
with the more conventional cytologic features.

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PATHOLOGY SRS ESOPHAGUS & STOMACH

11. The cell origin/histogenesis of this tumor is:

A. Mucosa associated lymphoid tissue


B. T-cells lymphoid tissue
C. Histiocytes
D. Plasma cells

Rationale
A. What we are seeing here are lymphogenous secretions of the
mucosa
 Diagnosis: MALToma
 Gastric MALTomas are the most common and well-studied
MALTomas. These neoplasms are intimately associated with
H pylori, which is present in more than 90% of pathologic
specimens of MALTomas.
 Extranodal marginal zone B-cell lymphoma of mucosa-
associated lymphoid tissue (MALT lymphoma) is an
extranodal lymphoma comprising morphologically
heterogeneous small B-cell including marginal zone
(centrocyte-like) cells, cells resembling monocytoid cells,
small lymphocytes, and scattered immunoblast and
centroblast-like cells
 The infiltrate is in the marginal zone of reactive B-cell follicles
and extends into the interfollicular region. The neoplastic
cells typically infiltrate the epithelium, forming
lymphoepithelial lesions.
 Gastric MALToma symptoms may mimic those of peptic ulcer
disease or gastritis. Chronic fatigue, low-grade fevers, nausea,
constipation, tarry stool, epigastric pain, weight loss, anemia,
and shortness of breath are some of the more nonspecific
symptoms that may occur in patients with gastric MALTomas.
B. T-cell origin is not associated with maltomas
C. Malignant histocytosis in the stomach is practically unheard of
D. Plasma cell differentiation is only seen in a small proportion of
MALToma cases

References:
 SRS Slides & Recording
 Dra. Yañez PPT on Disorders of Esophagus & Stomach
 2015B’s SRS Trans on Pathology of GIT
 Archives of Pathology & Laboratory Medicine
 Medscape
 NCBI
 Archives of Oncology

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