Robert H. Riddell

Dysplasia in Barrett's esophagus

SummaryIn a retrospective histological study, resected specimens obtained from 23 patients with adenocarcinoma in Barretts esophagus (Group I) and endoscopic multiple (step) biopsis from 38 patients without carcinoma in Barretts esophagus (Group II) were investigated for dysplastic changes. Dysplasia was most frequently found in the type of mucosa comprising intestinal metaplasia. There seem to be two pathways to dysplasia in Barretts esophagus. In Group I dysplasia was found in 18 out of 23, and in Group II in 2 out of 38 patients. In Barretts esophagus, dysplasia may be considered not only a precursor of carcinoma, but also a marker for coexisting carcinoma.

Ulcerative colitis and colonic cancer. Problems in assessing the diagnostic usefulness of mucosal dysplasia.

To assess the association of mucosal dysplasia and colonic cancer in patients with ulcerative colitis and to avoid bias in biopsy interpretation that may have affected results of previous studies, the authors examined coded histology slides from colectomy specimens of 22 patients who had ulcerative colitis and colonic cancer and 22 patients who had ulcerative colitis but no colonic cancer. As expected, it was found that dysplasia occurred contiguous to each cancer. However, at a distance from the cancer (i.e., in histology blocks not containing cancer), some dysplasia was found (low or high grade) in 16/22 cases (73 percent), and high grade dysplasia in 11/22 cases (50 percent). These results suggest that there may be a somewhat weaker association than previously reported between colonic cancer and dysplasia at a distance from the colonic cancer. Further, these results suggest that, in studies of dysplasia, it is important to avoid bias in biopsy interpretation and to describe sampling methods.

Peritoneal malignant mesothelioma in a patient with recurrent peritonitis

A patient is presented who developed a peritoneal malignant mesothelioma in association with severe persistent and recurrent diverticulitis. The case is unusual in that a spectrum of mesothelial proliferation was documented beginning initially as benign foci of mesothelial proliferation and passing through a stage of atypical proliferation before terminating as a malignant process. The possible role of the diverticular disease in the pathogenesis of the tumor is discussed.

Ultrastructure of the "transitional" mucosa adjacent to large bowel carcinoma.

The transitional mucosa immediately adjacent to large bowel carcinoma was examined in 13 patients by scanning electron microscopy (SEM), and this was correlated with transmission electron microscopy (TEM) and light microscopy (LM). Marked abnormalities were present in this mucosa in 9/13 patients with distortion and loss of the normal architecture. Examination of adenomas showed abnormalities also to be present adjacent to the neoplastic mucosa. In all patients, the transitional mucosa was compared with two pieces of normal mucosa; in one patient, typical changes of transitional mucosa were found in this region. In the remaining patients, normal mucosa by SEM was found to consist of large deep furrows (primary crypts) as well as the crypts of Lieberkuhn (secondary crypts). The secondary crypt structure showed marked individual variation between patients but one type was present in nine patients. It is uncertain whether this is a pattern with a high incidence in the general population, or whether patients with this type of mucosa are particularly predisposed to large bowel carcinoma. SEM may, therefore, play a part in identifying patients particularly likely to develop large bowel carcinoma.

Malignant transformation of esophageal columnar epithelium.

This report describes two patients with esophageal columnar epithelium (Barretts esophagus) in which microinvasive adenocarcinoma developed. Case 1 had multiple foci of carcinoma in situ contiguous with epithelium resembling gastric and intestinal mucosa. Case 2 had signet‐ring type adenocarcinoma. Surveillance for malignant transformation in columnar esophageal epithelium should be routinely performed, and because of its focal nature, multiple biopsies and cytologic examination should be carried out. The presence of carcinoma in situ should lead to consideration of excision of the affected esophagus.

Crohn's disease and adenocarcinoma of the bowel

We present six cases of cancer associated with Crohns disease and stress the importance of the earlier age of onset than spontaneously arising small-bowel carcinoma, the long period of latency from the time of diagnosis of Crohns disease to that of carcinoma, and the generally poor prognosis. We emphasize, furthermore, the frequent association with fistulas and the predisposition of bypassed or excluded segments of bowel to undergo malignant transformation. The occurrence of carcinoma in an excluded rectal stump has not previously been reported and stresses the necessity of resecting, rather than excluding, segments of bowel involved with Crohns disease. These tumors are often not readily apparent by radiographic or endoscopic examination and in fact, may be discovered only after microscopic examination of resected or biopsied tissue.

Composition of the refluxed material determines the degree of reflux esophagitis in the dog

Abstract To evaluate the influence of the composition of refluxed material in the pathogenesis of esophagitis, a dog model was used to allow esophageal reflux of gastric secretions, duodenal pancreaticobiliary secretions, and a combination of both. Control dogs had only an esophageal incision. Incompetence of the cardia was established in five other groups by transecting the distal sphincter and creating a hiatal hernia. Two groups received moderate or maximal histamine stimulation of gastric secretion. A gastroje-junostomy, pyloromyotomy, and duodenal closure distal to the papilla were added in the other three groups, creating duodenogastric reflux; two were stimulated with histamine and one had a truncal vagotomy and no histamine. Radiologic, manometric, and pH studies showed that incompetence of the cardia was obtained. The dogs were killed 4 wk postoperatively and evaluated for gross and microscopic evidence of esophagitis. Erosive esophagitis was found only in dogs with reflux of gastric juice following maximal acid stimulation. Microscopic reflux changes in esophageal mucosa were seen in all groups; again, changes were most pronounced in dogs with maximal gastric stimulation. The combination of duodenogastric reflux and moderate gastric stimulation produced more significant alterations in microscopic reflux criteria than did moderate gastric stimulation alone. Our conclusions are as follows: In a dog model of gastroesophageal reflux of various combinations of gastric and duodenal secretory components, erosive esophagitis occurred only with maximal gastric stimulation in the absence of duodenogastric reflux. All reflux combinations, however, produced some degree of microscopic changes, suggesting they could eventually cause gross changes with a lengthened experimental time span.

Chromosome analysis of primary large bowel tumors: a new method for improving the yield of analyzable metaphases.

Colon tumors were processed immediately after surgical resection. Using L‐Arterenol and sodium citrate in combination with standard chromosome culture techniques, 12 of 17 consecutive tumors (75%) had countable figures ranging from 5 cells to 59 cells. Seven of the 12 cases had over 25 countable cells. Chromosome counts did not vary more than ±4 for any one case. Seven tumors were karyotyped, 6 with banding techniques. One of these specimens had mosaic patterns. The chromosome counts varied: 2 were hypodiploid; 1 was pseudodiploid and 4 were hyperdyploid. There were some similarities in the karyotypes although no identical karyotypes were seen in this series.

Radiological detection of colonic dysplasia (precarcinoma) in chronic ulcerative colitis

Epithelial dysplasia occurring in long-standing ulcerative colitis is a precancerous lesion. Macroscopically it has a nodular or villous appearance or may be indistinguishable from the surrounding mucosa. An investigation into the radiological diagnosis of dysplasia, using in vivo and in vitro doublecontrast examinations with magnification radiographic studies, correlated with the histological analysis, has been made in four patients. Characteristic radiological abnormalities have been identified in the areas of the mucosa associated with histologically proven dysplasia. These appearances include nodularity and irregular areas with sharply angulated edges which may represent enlarged areae colonicae. The demonstration of these changes is an indication for endoscopie examination and biopsy of the suspicious area.

Adenomatous polyposis coli and multiple endocrine neoplasia type 2b. A pathogenetic relationship

A young man presenting with Cushings syndrome was found to have multiple endocrine neoplasia type 2b MEN 2b and adenomatous colonic polyposis with duodenal and gastric polyps. The entire syndrome of MEN 2b was present, including metastatic medullary carcinoma of the thyroid, a pheochromocytoma, and peripheral nerve abnormalities. The concurrence of these two inherited multiple neoplasia syndromes may reflect a common pathogenetic step in this patient.