Monographs in pathology最新文献

This chapter reviews the pathologic aspects of gastroesophageal reflux and reflux esophagitis. High-grade and low-grade changes due to reflux are discussed in the context of peptic complications such as hemorrhage, ulcer, stricture, and acquisition of Barrett mucosa. The limitations of histopathologic criteria in squamous epithelium for the diagnosis of reflux esophagitis, such as elongated vascular papillae and widened basal zone, are described. The pathogenesis of and criteria for diagnosis of Barrett esophagus are addressed. The neoplastic complication of adenocarcinoma arising in Barrett esophagus is discussed. Finally, the implications of columnar epithelial dysplasia and potential markers in Barrett mucosa for surveillance of Barrett patients are reviewed.

The schema for histologic reporting of malignant melanoma outlined above is incomplete. A number of variables, including quantification of tumor cell pigmentation, description of solar degeneration in surrounding stroma, and extent of S-100 protein immunoreactivity by tumor cells, have not been addressed. In addition, it is likely that within the next several years, additional parameters, including those identified by the use of in situ genomic probes (Chapter 3), will become known to confer prognostic information when assessed histologically in biopsy material. Nonetheless, this approach represents a start, an attempt to achieve uniformity in histologic reporting of melanoma. It represents a three-tiered approach. First is the establishment of a malignant melanocytic lesion (malignant melanoma) and the assessment of the anatomic level and extent of invasion of the dermis, which correlates directly with metastatic potential (the vertical growth phase measured in millimeters). Subclassification of the radial growth phase is optional and, by convention, is also reported in this "above the line" portion of the diagnostic assessment. Second, a number of subsidiary diagnostic statements, usually in the form of notes or comments, are recommended. These include assessment of overlying epidermal ulceration, a description of the morphology and mitotic activity of the vertical growth phase nodule, an assessment of the presence or absence of vascular invasion and microscopic satellite formation, a description of the host mononuclear cell response and/or regression, and mention of associated pathology. Finally, an additional narrative statement may be included to describe such things as extent of S-100 immunoreactivity or to modify in a more descriptive manner the database provided above. Although this last category is neither crucial nor mandatory, it serves to add to a collective database from which future determinations concerning the prognostic significance of new histologic parameters may be formulated. Table 6.3 provides a sample report based on the above considerations. This method of histologic reporting is recommended because it includes important diagnostic information as well as parameters for prognosis. Although certain details of less impelling current significance are included, these are of potential future importance as a greater number of patients with malignant melanoma are followed prospectively for prolonged periods of time. These factors may also prove to be significant in the accumulation of a database for research.

Review of the currently available data would indicate that the measurement of tumor thickness in millimeters, especially those greater than 1.5 mm in thickness, is the single most important prognostic variable, closely followed by sex and location of the tumor. On the other hand, in thinner tumors, the level of invasion takes precedence over tumor thickness, especially in the setting of the "thin level IV" tumor. The microstaging must therefore include measurements of both level and thickness (keeping in mind the problems involved in thickness measurements noted above), as well as notation of special features of prognostic value (mitotic index, ulceration, microsatellites, etc.). Only with such refinements and the continued study of parameters from large databases can the estimates of prognosis in patients with primary malignant melanoma be made sufficiently accurate to be useful in planning appropriate therapy.