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Handling difficult cases and possible referral service

Handling difficult cases and possible referral service. Professor Neil A Shepherd Gloucester, UK NHSBCSP Pathology Day, London, November 21, 2007. Handling difficult cases. Pathology and the NHSBCSP: the subconscious thoughts of a Gloucester pathologist. it’ll be a doddle

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Handling difficult cases and possible referral service

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  1. Handling difficult cases and possible referral service Professor Neil A Shepherd Gloucester, UK NHSBCSP Pathology Day, London, November 21, 2007

  2. Handling difficult cases

  3. Pathology and the NHSBCSP: the subconscious thoughts of a Gloucester pathologist • it’ll be a doddle • 130 extra polyps a year – piffle • OK, a few more cancer resections but all Dukes A and easy • and Julietta is going to give us a wad of dosh to do it…

  4. BCSP: what are the difficult cases? • the great majority of polyps are adenomas and HPs • differentiating the different types of serrated pathology • epithelial misplacement in serrated pathology • is it epithelial misplacement in an adenoma or is it cancer? • when is it cancer?

  5. Epithelial misplacement in adenomas • 85% in sigmoid colon • unusual in rectum (unless there has been previous meddling) • same epithelium as surface, accompanied by lamina propria, haemosiderin deposition • what about misplaced epithelium at the diathermy margin?

  6. Epithelial misplacement vs invasive carcinoma There is a very important adage in pathology: why make two diagnoses when one will do?

  7. Definite epithelial misplacement but what about those dodgy glands?

  8. BSCP case • sigmoid colonic polyp in 62M • superficial ulceration and inflammation • with epithelial misplacement

  9. BSCP case • 68F. Sigmoid colonic polyp • I’m convinced this is all epithelial misplacement • but it went to the margin….

  10. 62M. Sigmoid colonic polyp – difficult endoscopic resection (left) – site tattooed • subsequent perforation and resection (left) • do we allow epithelial misplacement in the muscularis propria?

  11. 67M. BCSP. Sigmoid colonic polyp. • the changes of epithelial misplacement can be made to look much worse by diathermy artefact • and it’s at that margin again…

  12. 64M. BCSP. Descending colonic polyp • epithelial misplacement in a lympho-glandular complex • just like in inverted hyperplastic polyps…

  13. The Shepherd-Williams classification of difficult BSCP polyps • definite epithelial misplacement (remember 85% are in the sigmoid colon) • definite cancer • definite epithelial misplacement and cancer (don’t make this diagnosis too often, please) • haven’t a clue whether this is epithelial misplacement or cancer (I think even Professor Williams will be making this diagnosis every now and then)

  14. What are the difficult cases? • the great majority of polyps are adenomas and HPs • differentiating the different types of serrated pathology • epithelial misplacement in serrated pathology • is it epithelial misplacement in an adenoma or is it cancer? • when is it cancer?

  15. Artefactual epithelial misplacement

  16. ‘Intramucosal carcinoma’:two BSCP cases

  17. ‘Intramucosal carcinoma’

  18. ‘Enhancement’ of dysplastic change with inflammation and superficial ulceration

  19. ‘Enhancement’ of dysplastic change with inflammation and superficial ulceration

  20. ‘Intramucosal carcinoma’ A case from 4pm yesterday afternoon

  21. Thickened muscularis mucosae – is this true invasive cancer?

  22. Is this cancer? Is it in a blood vessel?

  23. The issues • overcalling of malignancy in ‘other polyps’ (stromal lesions, carcinoid, etc) • when is it cancer? • epithelial misplacement vs cancer • artefacts vs true findings, especially with vascular involvement • when is further surgery justified?

  24. Carcinoma in polyps Management may depend on depth of submucosal infiltration sm1 1-3% chance of LN metastasis sm2 3-12% chance of LN metastasis sm3 15-28% chance of LN metastasis Then an MDTM assessment of the risk of LN metastasis against the risk of surgery

  25. Handling difficult cases and possible referral service • you know some of the issues now • referral service: local expertise double reporting network traditional second opinion national referral service

  26. Take home messages • the three big diagnostic issues in NHSBCSP are serrated pathology, epithelial misplacement vs cancer and when does a cancer demand further surgery • although most polyps are straightforward, there are plenty of taxing cases around • sometimes we just have to say we don’t know • we need data on the implications of margin involvement by misplaced epithelium in adenomatous polyps • we are open to suggestions concerning the national referral service

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