食管梭形细胞型异型增生临床病理学特征分析

Spindle cell type squamous dysplasia of the esophagus:a clinicopathological analysis

目的探讨食管鳞状上皮梭形细胞型异型增生的临床病理学特征及其意义。方法收集解放军联勤保障部队第九八九医院平顶山医疗区(原第一五二中心医院)2009—2019年食管鳞状上皮梭形细胞型异型增生37例,收集患者的临床病理资料,观察组织形态学特征和免疫表型,并结合文献进行探讨。结果37例患者中位年龄65岁(范围47~81岁),男女比为1.5∶1.0。食管上段4例,中段31例,下段2例。肿瘤中位直径14.0 mm(范围3~40 mm)。按巴黎分型0~Ⅱa型11例,0~Ⅱb型14例,0~Ⅱb+Ⅱa型3例,0~Ⅱc型9例。内镜下病变黏膜发红,微血管增粗,形态不一,密度不均。组织学上,肿瘤细胞及细胞核呈梭形或长梭形,细胞形态基本一致,核深染,染色质细腻或轻度增粗,核分裂象易见,并可见病理性核分裂象;细胞质嗜酸,细胞间桥明显。细胞密集,极向轻度紊乱,仍呈平行排列,多垂直于基底膜。梭形细胞经常累及鳞状上皮全层,无正常鳞状上皮的梯度成熟分化,肿瘤边界清楚。常见梭形细胞上皮突向固有膜,浸润性生长。15例肿瘤内伴有灶状的普通型高级别异型增生和浅表浸润性鳞状细胞癌。免疫组织化学染色显示肿瘤p53蛋白突变型表达突变率为41.4%(12/29)。Ki-67阳性指数中位数值为40%(范围20%~80%)。Ki-67异常分布模式29例(100%)。原病理诊断为低级别异型增生6例,不典型性上皮细胞4例,高级别异型增生及浅表浸润性鳞状细胞癌27例。结论梭形肿瘤细胞具有中-重度异型性,一些肿瘤呈浸润性生长,以及p53的突变,表明它们是食管鳞状上皮的高级别异型增生;梭形肿瘤细胞的独特特征提示它们可能代表了食管鳞状上皮异型增生形态学谱系中的一种梭形细胞亚型。当对该肿瘤认识不足时,病理上易误诊或漏诊。

Objective To investigate the clinicopathological features and significance of spindle cell type squamous dysplasia of the esophagus.Methods The clinicopathological data of 37 cases of spindle cell type squamous dysplasia of esophagus were collected retrospectively at People′s Liberation Army Joint Logistics Support Force 989 Hospital(formerly 152 Hospital),Pingdingshan,China,from 2009 to 2019.The histological and immunohistochemical characteristics were analyzed,with a literature review.Results The median age of the 37 patients was 65 years(range 47-81 years),while the ratio of men to women was 1.5∶1.0.There were 4 cases in the upper esophagus,31 in the middle esophagus and 2 in the lower esophagus.The median diameter of the lesions was 14 mm(range 3-40 mm).According to the Paris classification,11 cases were 0-Ⅱa,14 cases were 0-Ⅱb,3 cases were 0-Ⅱb and 0-Ⅱa,and 9 cases were 0-Ⅱc.Under endoscope,the lesional mucosa was reddish.The micro-vessels were dilated,with various shapes and density.Histologically,tumor cells and nuclei were spindle shaped or elongated spindle shaped,with considerable homogeneity,dark nuclei and delicate or slightly thickened chromatin.The mitosis was conspicuous,and atypic mitoses were seen;the cytoplasm was acidophilic,and the intercellular bridge was obvious.The cells were dense and often lost polarity,but still arranged in parallel,mostly perpendicular to the basement membrane.Spindle cells often involved the whole layer of epithelium,with no gradient maturation and differentiation of normal squamous epithelium.The tumor was well demarcated.The spindle cells often invaded lamina propria.There were 15 cases with focal high-grade dysplasia and superficial invasive squamous cell carcinoma.Immunohistochemical staining showed that the mutation rate of p53 was 41.4%(12/29),the median of Ki-67 labeling index was 40%(range 20%-80%),and the abnormal distribution pattern of Ki-67 was 29(100%).According to the initial pathological diagnosis,there were 6 cases of low-grade dysplasia,4 cases of atypical epithelial cells and 27 cases of high-grade dysplasia and superficial invasive squamous cell carcinoma.Conclusions Spindle tumor cells have moderate to severe atypia,and some tumors show invasive pattern.P53 mutation and Ki-67 abnormal distribution pattern indicate that they are high-grade dysplasia of esophageal squamous epithelium.The unique characteristics of spindle tumor cells suggest that they may represent a spindle cell subtype in the morphological spectrum of esophageal squamous dysplasia.When the knowledge of the lesion is insufficient,it can be easily misdiagnosed or missed.