Gastrointestinal Pathology: SY10-2Gastric pseudocarcinomatous regeneration
Review articleOpen access
2014/01/01 Abstract DOI: 10.1097/01.PAT.0000454105.73318.45
IntroductionNSAID and ASA intake for various reasons is a widespread worldwide phenomenon. The first gastroscopic observation of ASA effects in the stomach dates back to 1938. Up till the beginning of the 1990s before the era of Helicobacter eradication 70% of all gastric ulcers were connected to Helicobacter infection. From the beginning of the 21st century almost 70% of gastric ulcers are now believed to be based on NSAID/ASA intake.NSAID damages the epithelium in three ways: a) direct damage by inhibition of prostaglandin, b) inducing complications in preexisting ulcers, c) enhanced bleeding (due to inhibition of platelet aggregation). Besides these systemic effects, topical effects may play a role in ulcer etiogenesis with entrapment of H+ ions within the cells by ion trapping. In conjunction with swelling of the cappilary endothelium these processes lead to the typical ischemic necrosis in NSAID ulcerations. It has been shown earlier that such typical necrosis may help to identify the etiology of gastric erosions and ulcerations. Regernating cells and ischemic damage may lead to hyperchromatic, pleomorphic cells that may sometimes be mixed up with carcinomatous changes. We aimed to answer the question how many gastric biopsies were erroneously assigned representing neoplastic changes instead of regenerative changes in cases that were sent in for second opinion.Patients and methodsWithin ten years 738 gastric biopsy cases with suspicion for neoplasia were sent in for second opinion. Among these 228 cases were downstaged to pseudoneoplastic regeneration, 489 clear cut gastric carcinomas and 19 cases were diagnosed as tubular adenoma (LGD).ResultsThere were no gender differences in cases with regenerative changes (1.1:1) and adenomas (0.9:1) but carcinomas were more likely to be diagnosed in males (1.6:1). Patients with regernative changes significantly younger than carcinoma patients (62.8 vs 68.3 years). Regenerative lesions were found in 80% of the cases in the antrum whereas only 62% of the carcinomas occurred in the antrum. Following the time line from 2001 to 2011 it became evident that the overdiagnosis of regenerative changes as carcinomatous lesions decreased to 20% from the intial number in 2001. In parallel an increase in correct carcinoma diagnoses was observed. The gastritis status may help in a questionable situation since in regenerative changes less than 20% of the individuals had an active Helicobacter gastritis whereas this was in more than 70% the case in carcinoma patients.DiscussionThe diagnosis of pseudocarcinomatous regeneration is an important differential diagnosis of neoplastic gastric lesions. In some cases it can be really hard to distinguish bizarre epithelial changes due to drug incuded lesions from carcinomatous foci. Without Helicobacter gastritis the diagnosis of carcinoma should be made even more carefully and the differential diagnosis of pseudocarcinomatous changes should be considered. Fortunatly with time the number of erroneously carcinoma diagnoses went down in 2011 to 20% compared to the year 2001. Nevertheless gastric ulcerations should always receive proper follow-up with biopsies until healed. In difficult cases a second opinion by an experienced GI-pathologist may be helpful to confirm pseudocarcinomatous changes vs carcinomatous lesions.
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