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Recomendaciones Del Club De Patología Digestiva De La SEAP

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Recomendaciones Del Club De Patología Digestiva De La SEAP RECOMENDACIONES DEL CLUB DE PATOLOGÍA DIGESTIVA DE LA SEAP Coordinador: Antonio Ferrández ([email protected]) Informes protocolizados de las piezas neoplásicas de esófago Nuria Baixeras1, Miriam Cuatrecasas2, Carme Ferrer3, Mar Iglesias4, Stefania Landolfi5, Ruth Orellana6, M José Paules1, Socorro Razquín7. (Por orden alfabético). 1 Hospital Universitari de Bellvitge, Hospitalet de Llobregat 2 Hospital Clínic de Barcelona 3 Hospital Universitario Mútua de Terrassa 4 Hospital del Mar, Barcelona 5 Hospital Universitari Vall d’Hebron, Barcelona 6 Hospital Universitari Parc Taulí, Sabadell 7 Complejo Hospitalario de Navarra, Pamplona I. CONSIDERACIONES GENERALES. El informe anatomo-patológico protocolizado de las piezas quirúrgicas de resección de lesiones neoplá- sicas de esófago es esencial para el manejo adecuado de los pacientes. Existen varias guías publicadas que describen los parámetros que deben incluir estos informes. Este documento intenta resumir los datos obligatorios que, basados en el análisis de la literatura, son utilizados como base las guías internacionales ya redactadas, y que deben incluirse en el informe patológico de las piezas quirúrgicas. En la nueva edición del TNM (8ª Edición), cuando la neoplasia afecta a la unión esófago-gástrica, o si se localiza en estómago, a ≤ 2 cm de la unión esófago-gástrica, debe aplicarse el protocolo de tumor esofágico Los cánceres de cardias, sin afectación de la unión esófago-gástrica, deben considerarse en el esquema de tumores gástricos para la estadificación. II. ESTUDIO INTRAOPERATORIO. En las resecciones de tumores esofágicos suele realizarse el estudio peroperatorio para valorar los már- genes laterales de resección, normalmente el que se encuentra más cercano a la neoplasia, para identificar neoplasia infiltrante o displasia epitelial. III. ESTUDIO MACROSCÓPICO. Debería incluir los siguientes datos: Tipo de pieza y tamaño de la misma, localización de la neoplasia y relación con la unión esófago-gástrica, si se encuentra en contacto o cercana, a la misma, configuración de LIBRO BLANCO DE LA ANATOMÍA PATOLÓGICA EN ESPAÑA 2017 215 Recomendaciones del Club de Patología Digestiva de la SEAP la neoplasia, tamaño de la neoplasia (tres dimensiones), presencia de perforación, nivel macroscópico de invasión y distancia a los márgenes (proximal, distal y radial). IV. ESTUDIO MICROSCÓPICO. Se recomienda analizar ampliamente la neoplasia, la mucosa adyacente y cualquier lesión adicional que se identifique macroscópicamente, así cómo los márgenes de resección. Inclusión post-neoadyuvancia: En estos casos se debe incluir la totalidad del área identificada ma- croscópicamente como lecho tumoral. Si la zona identificada como lecho tumoral mide más de 8 cm y macroscópicamente no parece haber una regresión tumoral significativa se incluye, en un primer tiempo, una sección del tumor incluyendo la máxima medida longitudinal y vertical. Si no hay evidencia de tumor viable microscópicamente, toda el área tumoral debe ser estudiada microscópicamente. Diagnóstico microscópico post-neoadyuvancia: Para considerar una respuesta patológica completa se recomienda realizar tres secciones/niveles adicionales de cada bloque. La presencia de acúmulos de mucina acelular y las áreas de necrosis no deben ser interpretadas como evidencia de tumor residual. Si ypN0, es recomendable realizar estudio inmunohistoquímico con un citoqueratina de amplio espectro para comprobarlo. Casos de adenocarcinoma sobre Esófago de Barrett: Realizar inclusión mapeada de toda la lesión com- patible con esófago de Barrett macroscópicamente. En el informe especificar el diagnóstico por separado de cada área para establecer un mapa del diagnóstico. Tratar la zona macroscópicamente tumoral según el protocolo estándar para tumores esofágicos. V. DIAGNÓSTICO El diagnóstico patológico debe incluir estos datos: 1. Tipo histológico: Los informes deben incluir el tipo histológico basándose en la clasificación de la OMS actual.: - Carcinoma escamoso - Carcinoma verrucoso (escamoso) - Carcinoma fusocelular (escamoso) - Adenocarcinoma - Carcinoma adeno-escamoso - Carcinoma adenoide quístico - Carcinoma mucoepidermoide - Carcinoma neuroendocrino de alto grado: • De célula grande • De célula pequeña - Carcinoma indiferenciado - Otros: …….. - Carcinoma, el tipo no se puede especificar 2. Grado histológico: Debe indicarse el grado de diferenciación: - Para el adenocarcinoma: • Grado 1: Bien diferenciado (más del 95% del tumor está constituido por glándulas) • Grado 2: Moderadamente diferenciado (entre el 50 y el 95% constituido por glándulas) • Grado 3: Poco diferenciado (entre el 5 y el 50% constituido por glándulas), • Grado 4: Indiferenciado (menos del 5% constituido por glándulas) - Para el carcinoma escamoso: • Grado 1 (bien diferenciado) • Grado 2 (moderadamente diferenciado) 216 LIBRO BLANCO DE LA ANATOMÍA PATOLÓGICA EN ESPAÑA 2017 Informes protocolizados de las piezas neoplásicas de esófago • Grado 3 (pobremente diferenciado) • Grado 4 (indiferenciado) Cuando exista heterogeneidad en el grado histológico, se debe adjudicar el más elevado. No deben gra- duarse los carcinomas medulares, mucoepidermoides y adenoides quísticos ni aquellos casos, de cualquier otro tipo, que hayan recibido tratamiento neoadyuvante. 3. Extensión de la invasión tumoral (pT): Aplicando la nueva edición del TNM (8ª Edición), utilizando los prefijos y para post-neoadyuvancia, m para tumores sincrónicos y r para recurrencias. 4. Indicar la presencia de invasión perineural, de vasos de pequeño calibre y/o invasión de vasos ve- nosos extramural. 5. Ganglios (pN): Aplicando la nueva edición del TNM (8ª Edición), utilizar los prefijos y para post-neoad- yuvancia, m para tumores sincrónicos y r para recurrencias, así como los conceptos de células aisladas/ micrometástasis: - Identificación de células tumorales aisladas (clusters de células de ≤ 0.2mm de tamaño), mediante HE, IHQ o molecular, se considera N0. - Micrometástasis son clusters de células entre 0.2mm y 2mm que, si son visibles con HE o IHQ, deben considerarse pN1mic. Si se detectan por técnicas NO morfológicas (molecular o citometría de flujo) debe clasificarse como N0 o M0. 6. Estado de los márgenes de resección: Indicando el estado de todos los márgenes: proximal, distal y radial. En caso de que estén libres, indicar la distancia de la neoplasia al margen más cercano en mm. El margen radial representa el margen de tejidos blandos no revestidos por peritoneo, cercanos al punto de infiltración más profundo del tumor. Existe controversia en cuanto a la distancia óptima en el margen radial. Después de la revisión de la literatura consideramos que el margen de 1mm está afecto en piezas de esófago. 7. Grado Regresión post-tratamiento neoadyuvante: En los casos que hayan recibido tratamiento neo- adyuvante se deberá indicar el grado de regresión (clasificación de Mandard): Grado Descripción TRG1 Fibrosis. No tumor. Respuesta total. TRG2 Células sueltas/glándulas aisladas en mucha fibrosis. TRG3 Predomina la fibrosis sobre el tumor TRG4 Predomina el tumor sobre la fibrosis TRG5 No existe regresión tumoral VI. ESTUDIO DE BIOMARCADORES Determinación de HER2 en adenocarcinomas de esófago distal o de la unión esófago-gástrica. El ensayo clínico fase III ToGA internacional y multicéntrico mostró que el anticuerpo monoclonal huma- nizado anti-HER2/neutrastuzumab (Herceptin) prolonga la supervivencia de pacientes con adenocarcinoma gástrico y de la unión gastroesofágica que son HER2–positivos. El tratamiento dirigido contra la diana HER2 se ha aprobado en pacientes con carcinomas gástricos o de la unión gastroesofágica localmente avanzados o metastásicos que tengan sobreexpresión (3+) de HER2 o amplificación por técnicas de Hibridación n situ. El test de HER2 en el carcinoma gástrico o de la unión esófago-gástrica se realiza para determinar si son candidatos a terapia anti-HER2. LIBRO BLANCO DE LA ANATOMÍA PATOLÓGICA EN ESPAÑA 2017 217 Recomendaciones del Club de Patología Digestiva de la SEAP Algoritmo de la Determinación de HER2: IHQ, inmunohistoquímica, HIS, hibridación in situ Fase post-analítica (interpretación) basada en Virchows Arch 2010; 457: 299-307 Se acaba de publicar una nueva guía para la correcta determinación de HER2 en cáncer gástrico o de la unión esófago-gástrica (Bartley A et al., 2016). En ella se establecen diferentes recomendaciones en relación a la determinación de HER2 en estas neo- plasias. Se debe tener en cuenta que no existe modificación en la determinación de HER2 a nivel protéico mediante estudio inmunohistoquímico, sin embargo, existen ciertas diferencias en la determinación mediante técnicas de hibridación in situ. VII. REQUISITOS MÍNIMOS EN EL INFORME DE LA DETERMINACIÓN DE HER2. - Fijación: • Tipo de fijador: • Tiempo de isquemia fría: • Tiempo de fijación: - Anticuerpo y método utilizado: - Idoneidad de la muestra: - Interpretación de los resultados: • Inmunohistoquímica: Negativo (0) Negativo (1) No concluyente (2+) Positivo (3+) Indeterminado • Hibridación in situ: Negativo (No amplificado) Positivo (Amplificado) Indeterminado • Número de células evaluadas: • Media de copias de HER2 por célula: • Media de copias de CEP 17 por célula: • Ratio HER2:CEP17: 218 LIBRO BLANCO DE LA ANATOMÍA PATOLÓGICA EN ESPAÑA 2017 Informes protocolizados de las piezas neoplásicas de esófago - Indicar si es heterogéneo o homogéneo: - Especificar si participa en algún control de calidad: - Nombre de la persona que realiza la determinación: Bibliografía: 1. Washington K, Berlin J, Branton P
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