Practice question answers B stomach pathology

Practice question answers B
Stomach pathology
Updated: 03/08/2019
© Jun Wang, MD, PhD

1. D. Ulcer with indurated edge is likely tumor. Microscopic findings of irregular glands with cytological atypia (for this case, dark nuclei with various shape and size) is intestinal type adenocarcinoma. Curling ulcer occurs in patients with severe burn or trauma. Cushing ulcer is defined as esophageal, gastric and duodenal ulcers associated with intracranial disease. Diffuse type adenocarcinoma does not have discrete mass or ulcer, but has signet ring cells. Peptic ulcer has sharp edge without induration or atypical glands.

2. C. Risk factors for intestinal type adenocarcinoma include autoimmune gastritis, helicobacter gastritis, pickled vegetables, cigarette smoking, etc. For this patient, the only thing relevant is helicobacter gastritis. Coronary bypass, diabetes and hypertension are not known risk factors for stomach cancer.

3. A. Helicobacter promotes translocation of beta-catenin to nuclei, that likely promote proliferation and carcinogenesis in intestinal type adenocarcinoma. Mutation of CDH1 and subsequent loss of E-cadherin is seen in diffuse type adenocarcinoma. C-KIT overexpression is seen in gastrointestinal stromal tumor. Over expression of gastrin is seen in Zollinger-Ellison syndrome. MEN1 mutation resulted multiple endocrine neoplasia may be associated with gastric carcinoid.

4. B. For the major pathogenic components of helicobacter, it attaches to epithelium through adhesins. CagA promotes inflammation and mitogenesis. VacA forms vacuoles and membrane channels and affects mitochondria functions. Urease hydrolyzes urea into CO2 and ammonia that raising pH for its own survival.   

5. C. Thickening of gastric wall without discrete mass and presence of signet ring cells in the stroma are consistent with diffuse type adenocarcinoma. Acute gastritis has neutrophilic infiltration. Chronic gastritis has diffuse lymphoplasmacytic infiltration. Intestinal type adenocarcinoma has discrete mass, and irregular glands lined by atypical cells. Menetrier disease has gastric hyperplasia that may presents as thickened mucosa, but does not have signet ring cells.

6. C. Mutation of CDH1 and subsequent loss of E-cadherin is seen in diffuse type adenocarcinoma. APC and beta-catenin abnormalities may be seen in intestinal type adenocarcinoma and colon cancers. EGFR mutation may be seen various disorders, including adenocarcinoma of lung. Her2 amplification can be seen in various neoplasms, including breast cancer, endometrial serous carcinoma and many others, but only in a small portion of gastric diffuse type adenocarcinoma.

7. A. Tumor with round nuclei and stippled chromatin (salt and pepper pattern) is likely carcinoid, as further supported by expression of chromogranin, a neuroendocrine marker. Diffuse type adenocarcinoma has thickening of gastric wall without discrete mass and signet ring cells in the stroma. Helicobacter gastritis has lymphoplasmacytic infiltration, neutrophilic infiltration and glandular atrophy and helicobacter identified by special stains. Intestinal type adenocarcinoma has discrete mass and irregular glands lined by atypical cells. Small cell carcinoma is a poorly differentiated neuroendocrine tumor with sheets of cells with scant cytoplasm, regardless of the location.

8. B. Gastric spindle cell neoplasms with positive reactivity to CD34 is most likely gastrointestinal stromal tumor. Chronic gastritis with smooth muscle proliferation, leiomyoma and leiomyosarcoma are usually negative for CD34. Intestinal type adenocarcinoma has discrete mass and irregular glands lined by atypical cells.

9. D. C-KIT mutation is seen in gastrointestinal stromal tumor. APC and beta-catenin abnormalities may be seen in intestinal type adenocarcinoma and colon cancers.Mutation of CDH1 and subsequent loss of E-cadherin is seen in diffuse type adenocarcinoma. Her2 amplification can be seen in various neoplasms, including breast cancer, endometrial serous carcinoma and many others.

10. C. Gastric mass composed of clonal B cells (light chain restriction) with negative CD5 and CD10 reactivity is consistent with MALToma. This patient has helicobacter infection, as suggested by positive carbon 13/14 urea breath test. Autoimmune gastritis has diffuse lymphoplasmacytic infiltration, intestinal metaplasia and glandular atrophy, in stomach fundus and body. Diffuse large B cell lymphoma has marked cytological atypia. Peptic ulcer has sharp edge without induration or atypical glands or lymphocytes. All carcinomas, including poorly differentiated carcinomas, are usually negative for CD20 and CD45, regardless of the location.

11. C. Helicobacter gastritis is a risk factor for intestinal type adenocarcinoma and MALToma, etc. Androgen is a risk factor for prostate hyperplasia and cancer. Autoantibody against parietal cells causes autoimmune gastritis and may be associated with intestinal type adenocarcinoma. Hypergastrinemia and NSAID are associated with peptic ulcer and various gastritis.

12. B. See discussion of question 10. Zollinger-Ellison syndrome has tumor cells that produce gastrin, but not express CD20. It usually causes multiple peptic ulcers, not neoplastic ulcers.

13. C. Diffuse large B cell lymphoma of stomach may be associated with helicobacters, probably through transformation of MALToma. There is no known associations between gastric diffuse large B cell lymphoma and COPD, diabetes, hypergastrinemia or hypertension.




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