Histopathological Spectrum of Intestinal Lesions at a Tertiary Care Center in South India

Original Research Article

Histopathological spectrum of intestinal lesions at a tertiary care center in south India

Sunil Kumar Katari1, K Lakshmi2*, S Suneetha3, T Khadeeja4, C Aparna5, G Baleswari6

1,3Assistant Professor, 2Associate Professor, 4P.G., 5Professor, 6Proffesor and HOD, Department of Pathology, Kurnool Medical College, Kurnool, 518002 Andhra Pradesh, INDIA. Email: [email protected]

Abstract Background: Small intestine and colon constitute the majority of GI tract and hence sites for broad array of lesions. Being a cause for severe morbidity and mortality universally, intestinal biopsies for histopathology are the preferred choice for investigation. Intestinal lesions are remarkable for their histological diversity and pose a particular challenge to the pathologist. Aim of the study: To know the incidence and spectrum of intestinal lesions. To do the histopathological analysis and to know the Age, Sex and Site distribution. Material and Methods: This is a retrospective study of the intestinal lesions in the department of Pathology, Kurnool Medical College, Kurnool from May 2019 to April 2021. About 540 specimens from all the patients with intestinal lesions, treated at Govt. General Hospital, Kurnool were fixed in 10% formalin, processed into paraffin embedded sections and stained with H and E. IHC was done wherever necessary for confirmation. Results: Out of 540 specimens received most commonly received specimens were of appendix (400) constituting 74.1%. Small intestine specimens were 78 constituting 14.4%. Large intestine specimens were 62 comprising of 11.48%. Male patients in the present study were 294 (54.4%) and females were 246 (45.56%). Most of the lesions were nonneoplastic (509) comprising of 94.25% out of which appendicitis were the majority (399) constituting 78.3%. Neoplastic lesions were 31 comprising 5.74% in which 2 were benign tumors (0.37%) and 29 were malignant (5.37%). Most common malignant tumor was well differentiated adenocarcinoma (25.8%) and next in line were mucinous adenocarcinoma (23.59%) and moderately differentiated adenocarcinoma (23.59%). Also, very rare tumors like the low grade fibromyxoid sarcoma of the mesentery infiltrating into the intestine, osteoclastoma of sacrum with secondaries in colon were noticed. Conclusion: Intestinal lesions at times have vague and extreme presentations. Histopathological study along with clinical and radiological correlation is the gold standard for the diagnosis of intestinal lesions which in turn helps the clinician in apt post-surgical management of the patients. Key Words: Intestinal lesions, Tumors, Histopathology, Malignant, Adenocarcinoma, low grade fibromyxoidsarcoma.

*Address for Correspondence: Dr K Lakshmi, Associate Professor, Department of Pathology, Kurnool Medical College, Kurnool, 518002 Andhra Pradesh, INDIA. Email: [email protected] Received Date: 12/05/2021 Revised Date: 10/06/2021 Accepted Date: 22/07/2021 DOI: https://doi.org/10.26611/1051934 This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

morbidity and mortality universally. Small intestine and Access this article online colon constitute the majority of GI tract and hence sites for 1 2 Quick Response Code: a wide variety of diseases ranging from congenital , Website: infectious and inflammatory to malignant neoplasms. www.medpulse.in Colon is the most common site of GI neoplasia in Western population1. Intestinal lesions are remarkable for their histological diversity and pose a particular challenge to the

Accessed Date: pathologist. Intestinal biopsies for histopathology are the preferred choice for investigation3. Histopathology is 09 September 2021 considered gold standard for the early detection of intestinal lesions (especially malignant cases) and plays an important role in the diagnosis and therefore helps in their INTRODUCTION early management.2 This study was done to know the Intestinal diseases are frequently encountered in everyday histopathological spectrum of intestinal lesions and to clinical practice. They are known cause for severe analyze their age wise, sex wise and site wise distribution.

How to cite this article: Sunil Kumar Katari et al. Histopathological spectrum of intestinal lesions at a tertiary care center in south India. MedPulse International Journal of Pathology. September 2021; 19(3): 71-76. https://www.medpulse.in/Pathology/ MedPulse International Journal of Pathology, Print ISSN: 2550-7605, Online ISSN: 2636-4697, Volume 19, Issue 3, September 2021 pp 71-76

AIM OF THE STUDY: To know the incidence and colon, transverse colon, descending colon and sigmoid spectrum of intestinal lesions. To do the histopathological colon were included in the present study. analysis and to know the Age, Sex and Site distribution. Exclusion criteria: Reports from the specimens of oral cavity, esophagus, stomach, liver, pancreas, rectum and MATERIAL AND METHODS anus were excluded from the present study. With the approval of the Ethics Committee, this study was All specimens were fixed in 10% formalin, processed in conducted in the department of Pathology, Kurnool Automatic tissue processor into paraffin embedded Medical College, Kurnool from 1st May 2019 to 30th April sections and stained with routine Hematoxylin and Eosin 2021. This is a retrospective study of the intestinal lesions stain and examined under light microscopy and correlated where 540 specimens from all the patients with intestinal with clinical and radiological findings. IHC was done diseases, treated at Govt. General Hospital, Kurnool were wherever necessary for confirmation. The evaluated. histopathological impressions were analyzed with respect Inclusion criteria: Reports from the resected specimens to age, sex and site wise distribution of lesions along with of Small Intestine extending from Duodenum to Ileocecal their incidences in their histopathological spectrum. The junction and large intestine including cecum, ascending data was properly tabulated and analyzed. Results and Conclusion were derived from such analysis. The data shown in charts was a replica of Microsoft Excel Software. OBSERVATIONS An analysis of 540 specimens referred to our histopathology department. Total no. of Surgical specimens received 5299 Total no. of Intestinal biopsies studied 540 (10.19%) Total no. of Small intestinal lesions (out of 540) 78 (14.4%) Total no. of Colon lesions excluding appendix (out of 540) 62 (11.48%) Total no. of specimens of Appendix (out of 540) 400 (74.1%) Total No. of Non-neoplastic lesions (out of 540) 509 (94.25%) Total No. of Neoplastic lesions (out of 540) 31 (5.74%) No. of Benign tumors 2 (0.37%) No. of Malignant tumors 29 (5.37%)

RESULTS Table 1: Site wise distribution of Intestinal lesions Site No. of Cases Percentage Small Intestine 78 14.444% Large Intestine 62 11.48% Appendix 400 74.07% Total 540 100%

Chart 1: Site wise distribution of Intestinal lesions Table 1 and Chart 1 imply that most common specimens received were from appendix (400 out of 540 specimens; 74%) followed by small intestine (78 out of 540; 14%) and large intestine (62 out of 540; 12%).

Table 2. Age wise and sex wise distribution of intestinal lesions AGE MALE FEMALE TOTAL Nonneoplastic Neoplastic Total Nonneoplastic Neoplastic Total (A+B) % (A) (B) (A+B) (C) (D) (C+D) +(C+D) 0-10 38 0 38 42 0 42 80 14.8% 11-20 81 0 81 79 0 79 160 29.6% 21-30 73 2 75 68 2 70 145 27% 31-40 31 3 34 20 3 23 57 10.5%

MedPulse International Journal of Pathology, Print ISSN: 2550-7605, Online ISSN: 2636-4697, Volume 19, Issue 3, September 2021 Page 72 Sunil Kumar Katari et al.

41-50 26 2 28 7 4 11 39 7.2% 51-60 14 5 19 8 7 15 34 6.3% 61-70 12 3 15 3 0 3 18 3.3% >70 4 0 4 3 0 3 7 1.3% TOTAL 279 15 294 230 16 246 540 100% Table 2 shows age wise variation in the overall incidence of intestinal lesions. The age of the patients ranged from 1 day to 75 years. In our study peak incidence of intestinal lesions were seen in the age group between 11-20 years (29.6%) followed by 21- 30 years (27%). Least incidence was seen in the age group of above 70 years (1.3%). The same table highlights the sex wise distribution too. Except for the age group segment of 0 -10 years, in all the other age group segments mentioned above, the incidence of intestinal lesions was more in males than females. Peak incidence of non-neoplastic lesions was seen in the age group of 11-20 years (29.6%) followed by 21-30 years (26%). Peak incidence of neoplastic lesions was seen in the age group of 51-60 years (2.2%) followed by the age groups 31-40 and 41-50 with an incidence of 1.1% each. Non-neoplastic lesions were seen more in males than in females with a M:F ratio of 1.21:1 while neoplastic lesions were negligibly more in females than in males. Male patients in the present study were 294 (54.4%) and females were 246 (45.56%).

Chart 2: Gender Distribution Chart 3: Spectrum of Nonneoplastic Lesions Chart 4: Spectrum of Neoplastic Lesions

Table 3: Histological spectrum of non-neoplastic lesion TYPE SITE TOTAL Percentage (%) Small Intestine Large Intestine Appendix Nonspecific inflammation 50 14 - 64 12.78% Gangrene - 8 - 8 1.57% Tuberculosis 5 3 1 9 1.77% Juvenile polyp 1 2 - 3 0.59% Ulcerative colitis - 1 - 1 0.2% Hirschsprung’s disease - 14 - 14 2.75% Necrotizing enterocolitis 3 - - 3 0.59% Intussusception 2 - - 2 0.39% Meckel’s diverticulum 4 - - 4 0.78% Lymphangectatia 1 - - 1 0.2% Corrosive Injury 1 - - 1 0.2% Meconium cyst 1 - - 1 0.2% Acute Appendicitis - - 313 313 61.3% Acute on Chronic Appendicitis - - 30 30 5.9% Chronic Nonspecific Appendicitis - - 32 32 6.28% Acute Necrotic Appendicitis - - 13 13 2.54% Acute Gangrenous Appendicitis - - 10 10 1.96% Total 68 42 399 509 100% Table 3 shows the spectrum of nonneoplastic lesions. Out of the 509 nonneoplastic lesions observed, maximum was seen in specimens from appendix (398;78%) followed by lesions from small intestine (68;13.4%). Least number of nonneoplastic lesions were seen in the specimens from the large intestine (43;8%). In our study, the most commonly observed nonneoplastic lesion was Acute appendicitis (61.3%) followed by nonspecific inflammation (12.78%). Hirschsprung’s disease was noticed in 14 cases accounting for 2.75%. Tuberculosis of intestine which is a common extrapulmonary lesion was observed in 9 cases accounting for 1.77%. The least found lesions were ulcerative colitis, intestinal lymphangiectasia and meconium cyst with an incidence of 0.2% each.

Copyright © 2021, Medpulse Publishing Corporation, MedPulse International Journal of Pathology, Volume 19, Issue 3 September 2021 MedPulse International Journal of Pathology, Print ISSN: 2550-7605, Online ISSN: 2636-4697, Volume 19, Issue 3, September 2021 pp 71-76

Table 4: Histological spectrum of Neoplastic lesions TYPE SITE % Small Large Appendix TOTAL Intestine Intestine Mucinous Adenocarcinoma 2 5 - 7 22.58 Well Diff. Adenocarcinoma 2 7 - 9 29 Mod. Diff. Adenocarcinoma 3 4 - 7 22.58 Poorly Diff. Adenocarcinoma - 1 - 1 3.22 Adenosquamous Carcinoma - 1 - 1 3.22 Well Diff Squamous Carcinoma of Omentum - 1 - 1 3.22 Low Grade Fibromyxoid Sarcoma of Mesentery Infiltrating into Intestine 1 - - 1 3.22 Multiple Lipomatosis of Intestine - 1(B) - 1 3.22 Neurendocrine Tumor of Intestine 2 - - 2 6.45 Osteoclastoma of Sacrum with secondaries deposits in Colon - 1 - 1 3.22 Mucocele of Appendix - - 1(B) 1 3.22 TOTAL 10 20 1 31 100% Table 4 shows the spectrum of Neoplastic intestinal lesions. Out of 31 neoplastic lesions observed only 2 were benign and 29 were malignant. A rare lesion, Multiple lipomatosis of intestine in large intestine and Mucocele of Appendix were the two benign lesions.

Figure 1 Figure 2 Figure 3 Figure 4

Figure 5 Figure 6 Figure 7 Legend Figure 1: H&E Tuberculosis of Intestine showing granulomas; Figure 2: Multiple Lipomatosis of Intestine(Gross); Figure 3: H&E Well formed gland patterns in Well diff. adenocarcinoma (10X); Figure 4: H&E Mucinous adenocarcinoma (40X); Figure 5: H&E Low grade fibromyxoid sarcoma of mesentery infiltrating intestine (10X); Figure 6: (Gross) Osteoclastoma of Sacrum infiltrating into the Colon (Arrow); Figure 7: H&E Osteoclastoma infiltrating the muscularis propria of Colon

Neoplastic lesions were maximum seen in large intestine (20;64.5%) followed by small intestines (10;32%). Most commonly observed lesion was well differentiated adenocarcinoma (9;29%) followed by mucinous adenocarcinoma and moderately differentiated adenocarcinoma with an incidence of 23% each. Rare lesions like the Low grade fibromyxoid sarcoma of mesentery infiltrating into intestine and Osteoclastoma of sacrum with secondary deposits in Colon were noticed.

DISCUSSION Out of 5299 biopsy specimens overall referred to our histopathology department during the period of present study, 540 specimens were from patients with intestinal lesions which was 10.19% compared to Nwafor CC et al4. 2019 study which was only 4.3% which included all GIT lesions. In the present study commonly received specimens were of appendix (400) constituting 74.1% which correlates with the study done by Neha et al5, Patel V et al6 and Prasad PR et al7 where appendix was the most common specimen.

MedPulse International Journal of Pathology, Print ISSN: 2550-7605, Online ISSN: 2636-4697, Volume 19, Issue 3, September 2021 Page 74 Sunil Kumar Katari et al.

Chart 5 Chart 6

Chart 7 Chart 8 Chart 5: Percentage of Specimens of Appendix received; Chart 6: Gender Distribution; Chart 7: Nonneoplastic : Neoplastic; Chart 8: Benign: Malignant

In most of the previous studies large intestine specimens mesentery infiltrating into the intestine and osteoclastoma outnumbered the small intestine specimens. But in the of sacrum with secondaries in colon were noticed. present study Small intestine specimens were 78 constituting 14.4 % and Large intestine specimens were 62 CONCLUSION comprising of 11.48% correlating with studies of Chaudari This present study shows the pattern of intestinal lesions in T et al8 and Nwafor CC et al. 4 Male patients in the present our institution which implies that at times they have vague study were 294 (54.4%) and females were 246 (45.56%) and extreme presentations. The present study correlated correlating with Prasad PR et al7 and Nwafor CC et al4 but with most of the previous studies in many aspects though differed with Neha et al.5 it differed on few occasions. We strongly believe that this Out of the 540 specimens received, most of the lesions study will be a benchmark for future studies on the were nonneoplastic (509) comprising of 94.25% which spectrum of intestinal lesions. We conclude that correlated with rest of the other studies4,5,6,7,8,9 taken for histopathological study along with clinical and comparison. radiological correlation is always the gold standard for the Out of the nonneoplastic lesions acute appendicitis were diagnosis of intestinal lesions which in turn helps in the apt the most common (313) constituting 61.3% which post-surgical management of the patients. correlated with clinical diagnosis and studies of Prasad PR et al7, Nwafor CC et al4, Patel V et al6 and Neha et al5. REFERENCES Other common lesions were Nonspecific inflammation (64 1. Manoj K. Singh Vinay Kumar, Abbas, Aster Robbins and cases;12.78%) Neoplastic lesions were 31 comprising Cortan Pathologic Basis of Disease 10th Edition 5.74% in which 2 were benign tumors (0.37%) and 29 were 2. Berrocal T, Lamas M, Gutierrez J, Torres I, Prieto C, Luisa malignant (5.37%). del hoyo M. Congenital anomalies of the small intestine, Out of the two benign tumors a rare benign tumor, Multiple colon and rectum. Scientific exhibit 1999;19:1219-1236. 3. Mills SE, Carter D, Greenson JK, Oberman HA, Reuter V, lipomatosis of intestine was diagnosed along with Stoler MH. In:Sternberg’s diagnostic surgical pathology. commonly occurring mucocele of appendix. Out of the 29 4th ed. Philadelphia: Lippincott Williams and Wilkins. malignant tumors, most common malignant tumor was 2004 well differentiated adenocarcinoma (9 cases; 29%) 4. Nwafor CC, Nwafor NN, Etuk EB, Kanu O. followed by mucinous adenocarcinoma (7 cases; 22.58%) Histopathological spectrum of gastrointestinal lesions and moderately differentiated adenocarcinoma (7 cases; seen in university of uyo teaching hospital, South–South Nigeria. Ann Trop Pathol 2019;10:27-33 22.58%) which correlated with all other studies 5. Neha Mukesh Goel, Abhay Y Desai, Waghmare Rohan 4,5,6,7,8,9 compared . Two cases of neuroendocrine tumor of Mohan, Vijay D Dombale. A study of histopathological intestine were noticed accounting for 6.54%. Very rare spectrum of gastrointestinal tract lesions in a rural tertiary tumors like the low grade fibromyxoid sarcoma of the care centre. MedPulse International Journal of Pathology. December 2019; 12(3): 153-160.

6. Patel V, Parikh M, Suthar N. Histopathological evaluation 11. Pavani M, Raghu K, Srikanthbabu Y, et al. of gastrointestinal lesions- An experience in a tertiary care Histopathological study of lesions of colon A- 5 year centre in west India. Med Pulse International Journal of study. Int J Scientific Study 2017;5(2):65-8. Pathology March 2018; 5(3): 89-93. 12. Das C, Maity N, Mukhopadhyay M, Mukhopadhyay B, 7. Prasaad PR, Rao B. Histopathological spectrum of Basu K, Madhukumari. A Histopathological Spectrum of gastrointestinal lesions- an experience in a tertiary care Gastrointestinal Tract Lesions In A Tertiary Care Hospital: centre in South India. Int J Res Med Sci 2016;4:3407-12 An Epidemiological Study For Four Years. IOSR-JDMS 8. Chaudhari T, Bhalara R, Dhruva G. A histopathological 2016;15(2):74-77. study of spectrum of gastrointestinal tract lesions: Two- 13. Thakur RY, Nikumbh DB, Swami SY. year study. MedPulse International Journal of Pathology Clinicohistopathological overview of GIT lesions in a 2018;7(2):50-56. rural hospital. Indian J Pathol Oncol 2016;3:305-14. 9. Histopathological spectrum of intestinal lesions 14. Sulegaon R,Shete S, Kulkarni D. Histological Spectrum of Meenakshi Masgal, Vishali Vaddadi, Anuradha Patil, Large Intestinal Lesions with Clinicopathological Anita AM Journal of Diagnostic Pathology and Oncology, Correlation. JCDR 2015; 9(11): 30-34. October-December, 2018;3(4):330-334 DOI: 15. Nanavati MG, Parikh JH, Gamit KS. A Histopathological 10.18231/2581-3706.2018.0066 study of intestinal lesions. Int J Sci Res 2014; 3:326-330. 10. John R. Goldblum, Laura W. Lamps, Jesse K. McKenny, 16. Umap PS, Dhamne BK. Malignant Gastrointestinal tract Jeffery L. Myers Rosai and Ackerman’s, Surgical tumours in Central India. Indian Medical Gazette 1995; Pathology, 11th Edition, Vol-1, Elsevier, 568. Vol. CXXIX, No.2 :47-51.

Source of Support: None Declared

Conflict of Interest: None Declared

MedPulse International Journal of Pathology, Print ISSN: 2550-7605, Online ISSN: 2636-4697, Volume 19, Issue 3, September 2021 Page 76