Hirschsprung hastalığındaki kantitatif morfolojik değişiklerin immunohistokimya eşliğinde dijital morfometrik ölçümü

Öz

Amaç: Hirschsprung hastalığı 5000 doğumda bir görülme sıklığıyla önemli bir çocukluk dönemi hastalığıdır. Morfolojik tanı altın standart olup cerrahi tedaviyi önemli derecede etkilemektedir. Bu çalışmanın amacı; morfolojik değişikliklerin dijital morfometrik olarak kantifiye edilmesi ve patolojik incelemenin tanısal katkısının geliştirilmesidir.

Gereç ve Yöntem: Bu prospektif çalışmaya; hastanemizde klinik olarak Hirschsprung tanısı alan 7 olgu dahil edildi. Olgularda immunohistokimya eşliğinde submukozal alanda ve muskularis propriadaki sinir pleksuslarının ortalama maksimum çapı ve sayısı, transizyonel zonda eozinofil lökositlerin sayısı ve damar değişikliklerinin varlığı morfometrik olarak incelenmiştir.

Bulgular: PGP 9.5 immunohistokimyasal boyaması ile submukozal pleksus başına düşen ortalama ganglion sayısı 1.1 ile 12.9 arasında değişiyordu. Ganglionik zondaki submukozal ve myenterik pleksuslarda ortalama ganglion hücre çapı hipoganglionik kısımdaki pleksuslardaki ortalama ganglion hücre çapından daha büyüktür (p=0.002, p=0.002). Ganglion sayısı da ganglionik zonda hipoganglionik zona göre daha fazladır (p=0.003, p=0.002). H&E boyalı kesitlerde submukozal pleksus ortalama çapı sırasıyla ganglionik, geçiş ve aganglionik zonlar için istatistiksel olarak anlamlı şekilde 32.8µ, 58.9µ ve 84.0µ (p<0.001); myenterik pleksus için ise 42.2µ, 77.4µ ve 96.1µ’ dur (p<0.001). Geçiş zonundaki myenterik pleksuslarda eosinofilik infiltrat 6 olguda (%85.7) saptandı. C-kit immunohistokimyasal boyamasında muskularis propriadaki Cajal hücre dansitesi her üç zonda anlamlı farklılık göstermedi. Kalretinin immunohistokimyasal boyamasında, lamina propriada ve submukozada kolinerjik sinir fibrillerinin aganglionik zonda anlamlı olarak ortadan kalktığı gözlendi (p<0,001).

Sonuç: Hirschsprung hastalığının histolojik tanısında morfometrik kantifikasyon ve kalretinin immunohistokimyası yararlı yöntemlerdir. Özellikle submukozal alanda ganglion hücresi sayısı ve pleksus çapının değerlendirilmesi önemlidir

Anahtar Kelimeler

• dijital patoloji,Hirschsprung hastalığı,immunohistokimya,morfometri

DIGITAL MORPHOMETRIC MEASUREMENT OF QUANTITATIVE MORPHOLOGICAL CHANGES WITH IMMUNOHISTOCHEMISTRY IN HIRSCHSPRUNG DISEASE

Öz

Objective: Hirschsprung disease is an important childhood disease with an incidence of one per 5000 births. Morphological diagnosis is the gold standard and plays a crucial role on the prognosis of surgical treatment. The purpose of this study is to quantitate the morphological changes using digital morphometry and improve the histological diagnostic impact for this disease. Material and Method:  This retrospective study enrolled seven cases of resection material due to the diagnosis of Hirschsprung disease. The mean maximum diameter and number of nerve plexuses in the submucosal area and muscularis propria, the number of eosinophil leukocytes and the presence of vascular changes in the transition zone were evaluated morphometrically using immunohistochemistry. Results: PGP 9.5 immunostaining showed that the mean ganglion cell number per submucosal plexus ranged between 1.1 and 12.9. The mean ganglion cell diameter in the submucosal and myenteric plexus in ganglionic is greater than the mean ganglion cell diameter in the hypoganglionic plexus (p=0.002, p=0.002). The number of ganglion is also higher in the ganglionic zone than in the hypoganglionic zone (p=0.003, p=0.002). H&E stained sections revealed that the mean submucosal plexus diameter in the ganglionic, transition and aganglionic zones was 32.8µ, 58.9µ and 84.0µ, respectively(p<0.001); whereas for the myenterik plexus 42.2µ,77.4µ and 96.1µ respectively(p<0.001). Eosinophilic infiltrate in the myenterik plexus of the transition zone was found in six cases (85.7%). Cajal cell density evaluated with c-kit immunohistochemistry in the muscularis propria was not significantly different in any of three zones. Calretinin immunohistochemical staining showed that cholinergic nerve fibrils both in the lamina propria and submucosa of the aganglionic zone were significantly absent (p<0.001). Conclusion: Morphometric quantification and calretinin immunohistochemistry is a useful method in the diagnosis of Hirschsprung disease. Especially evaluation of the submucosal ganglion cell number and plexus diameter appears to be valuable.

Anahtar Kelimeler

• digital pathology,Hirschsprung disease,immunohistochemistry,morphometry

Kaynakça

1. Kaçar A, Arıkök AT, Azılı MN, et al. Calretinin immunohistochemistry in Hirschsprung’s disease: An adjunct to formalin-based diagnosis. Turk J Gastroenterol 2012; 23: 226-233.
2. Langer JC. Hirschsprung disease. Curr Opin Pediatr. 2013; 25:368-374.
3. Schäppi MG, Staiano A, Milla PJ, et al. A practical guide for the diagnosis of primary enteric nervous system disorders. J Pediatr Gastroenterol Nutr 2013; 57:677-686.
4. Kapur RP. Histology of the Transition Zone in Hirschsprung Disease. Am J Surg Pathol 2016; 40:1637-1646.
5. Knowles CH, De Giorgio R, Kapur RP, et al. Gastrointestinal neuromuscular pathology: guidelines for histological techniques and reporting on behalf of the Gastro 2009 International Working Group. Acta Neuropathol 2009; 118:271-301.
6. Friedmacher F, Puri P. Classification and diagnostic criteria of variants of Hirschsprung's disease. Pediatr Surg Int 2013; 29:855-872.
7. Kapur RP. Practical pathology and genetics of Hirschsprung's disease. Semin Pediatr Surg 2009; 18:212-223.
8. Kapur RP. Practical Pathology of Hirschsprung Disease. PNWSP 2011. https://pnwsp.org/Fall2011/handouts/kapur.pdf (20.06.2018)

9. Feichter S, Meier-Ruge WA, Bruder E. The histopathology of gastrointestinal motility disorders in children. Semin Pediatr Surg 2009; 18:206-211.
10. Piotrowska AP, Solari V, Puri P. Distribution of interstitial cells of Cajal in the internal anal sphincter of patients with internal anal sphincter achalasia and Hirschsprung disease. Arch Pathol Lab Med 2003; 127:1192-1195.
11. Gfroerer S, Rolle U. Interstitial cells of Cajal in the normal human gut and in Hirschsprung disease. Pediatr Surg Int 2013; 29:889-897.
12. Guinard-Samuel V, Bonnard A, De Lagausie P, et al. Calretinin immunohistochemistry: a simple and efficient tool to diagnose Hirschsprung disease. Mod Pathol 2009; 22:1379–1384.
13. Moore SW. Total colonic aganglionosis and Hirschsprung's disease: a review. Pediatr Surg Int 2015; 31:1-9.
14. Kapur RP, Kennedy AJ. Transitional zone pull through: surgical pathology considerations. Semin Pediatr Surg 2012; 21:291-301.
15. Best KE, Addor MC, Arriola L, et al. Hirschsprung's disease prevalence in Europe: a register based study. Birth Defects Res A Clin Mol Teratol 2014; 100:695-702.
16. Kapur RP. Calretinin-immunoreactive mucosal innervation in very short-segment Hirschsprung disease: a potentially misleading observation. Pediatr Dev Pathol 2014; 17:28-35.
17. Knowles CH, Veress B, Kapur RP, et al. Quantitation of cellular components of the enteric nervous system in the normal human gastrointestinal tract--report on behalf of the Gastro 2009 International Working Group. Neurogastroenterol Motil 2011; 23:115-124.
18. Lowichik A, Weinberg AG. Eosinophilic infiltration of the enteric neural plexuses in Hirschsprung's disease. Pediatr Pathol Lab Med 1997; 17:885-891
19. Umeda S, Kawahara H, Yoneda A,et al. Impact of cow's milk allergy on enterocolitis associated with Hirschsprung's disease. Pediatr Surg Int 2013; 29:1159-1163.
20. Knowles CH, De Giorgio R, Kapur RP, et al. The London Classification of gastrointestinal neuromuscular pathology: report on behalf of the Gastro 2009 International Working Group. Gut 2010; 59:882-887.
21. Jiang M, Li K, Li S, et al. Calretinin, S100 and protein gene product 9.5 immunostaining of rectal suction biopsies in the diagnosis of Hirschsprung' disease. Am J Transl Res 2016; 8:3159-3168.
22. Kannaiyan L, Madabhushi S, Malleboyina R, et al. Calretinin immunohistochemistry: a new cost-effective and easy method for diagnosis of Hirschsprung’s disease. J Indian Assoc Pediatr Surg 2013; 18:66–68.
23. Wedel T, Spiegler J, Soellner S, et al. Enteric nerves and interstitial cells of Cajal are altered in patients with slow-transit constipation and megacolon. Gastroenterology 2002; 123:1459-1467.