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[[Image:Polyp-2.jpeg|thumb|right|Endoscopic image of a gastrointestinal polyp.]] | |||
'''Gastrointestinal tract polyps''', also '''gastrointestinal polyps''' or '''GI polyps''', are the bread & butter of a GI pathologists workload. Some of 'em are benign... some pre-malignant... some malignant... some weird. Most GI polyps are from the intestine, i.e. intestinal polyps. | '''Gastrointestinal tract polyps''', also '''gastrointestinal polyps''' or '''GI polyps''', are the bread & butter of a GI pathologists workload. Some of 'em are benign... some pre-malignant... some malignant... some weird. Most GI polyps are from the intestine, i.e. intestinal polyps. | ||
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{{familytree | D | | | | E | | | | F | | G |D=Nuclear changes|E=No nuc. change|F=Serrated|G=Not serrated}} | {{familytree | D | | | | E | | | | F | | G |D=Nuclear changes|E=No nuc. change|F=Serrated|G=Not serrated}} | ||
{{familytree | |!| | | |,|-|^|-|.| | | |!| | | |!| |}} | {{familytree | |!| | | |,|-|^|-|.| | | |!| | | |!| |}} | ||
{{familytree | H | | I | | J | | K | | L |H=Polypoid adenoma<br>(below)|I=Serrated|J=Not serrated|K=[[sessile serrated adenoma|SSA]] | {{familytree | H | | I | | J | | K | | L |H=Polypoid adenoma<br>(below)|I=Serrated|J=Not serrated|K=[[sessile serrated adenoma|SSA]] versus HP|L=Normal versus VA}} | ||
{{familytree | | | | | |!| | | |!| | | | | | | | | |}} | {{familytree | | | | | |!| | | |!| | | | | | | | | |}} | ||
{{familytree | | | | | M | | N | | | | | | | | |M=[[Hyperplastic polyp|HP]]|N=See misc.<br>polyps (below)}} | {{familytree | | | | | M | | N | | | | | | | | |M=[[Hyperplastic polyp|HP]]|N=See misc.<br>polyps (below)}} | ||
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| common / benign | | common / benign | ||
| moderate inflammation is normal | | moderate inflammation is normal | ||
| [[colonic spirochetes]], [[cryptosporidiosis]], [[microscopic colitis]], [[CMV colitis]] | | missed lesion, [[colonic spirochetes]], [[cryptosporidiosis]], [[microscopic colitis]], [[CMV colitis]] | ||
| [ | | [[Image:Rectum - intermed mag.jpg|thumb|center|150px| Normal rectum (WC)]] | ||
|- | |- | ||
| [[Hyperplastic polyp]] | | [[Hyperplastic polyp]] | ||
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| may be syndromic, e.g. [[hyperplastic polyposis syndrome]] | | may be syndromic, e.g. [[hyperplastic polyposis syndrome]] | ||
| [[sessile serrated adenoma]] | | [[sessile serrated adenoma]] | ||
| [[Image: | | [[Image:Hyperplastic polyp -- intermed mag.jpg |thumb|center|150px| HP (WC)]] | ||
|- | |- | ||
| [[Traditional adenoma]] | | [[Traditional adenoma]] | ||
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| only seen in [[IBD]]; Dx implies IBD | | only seen in [[IBD]]; Dx implies IBD | ||
| juvenile polyp | | juvenile polyp | ||
| Image | | [[Image:Inflammatory polyp -- low mag.jpg|thumb|center|120px|IP (WC)]] | ||
|- | |- | ||
| [[Peutz-Jeghers polyp]] (PJP) | | [[Peutz-Jeghers polyp]] (PJP) | ||
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| PJP not pre-malignant lesion in itself; see ''[[Peutz-Jeghers syndrome]]'' | | PJP not pre-malignant lesion in itself; see ''[[Peutz-Jeghers syndrome]]'' | ||
| normal, classically in the small bowel | | normal, classically in the small bowel | ||
| [[Image:Peutz-Jeghers_syndrome_polyp.jpg|thumb|center| | | [[Image:Peutz-Jeghers_syndrome_polyp.jpg|thumb|center|120px|PJP (WC)]] | ||
|} | |} | ||
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===Adenomatous vs. hyperplastic=== | ===Adenomatous vs. hyperplastic=== | ||
Adenomatous polyps & hyperplastic polyps - a comparison (adapted from Li and Burgart<ref>{{cite journal |author=Li SC, Burgart L |title=Histopathology of serrated adenoma, its variants, and differentiation from conventional adenomatous and hyperplastic polyps |journal=Arch. Pathol. Lab. Med. |volume=131 |issue=3 |pages=440-5 |year=2007 |month=March |pmid=17516746 |doi= |url=http://journals.allenpress.com/jrnlserv/?request=get-abstract&issn=0003-9985&volume=131&page=440}}</ref>): | Adenomatous polyps & hyperplastic polyps - a comparison (adapted from Li and Burgart<ref name=pmid17516746>{{cite journal |author=Li SC, Burgart L |title=Histopathology of serrated adenoma, its variants, and differentiation from conventional adenomatous and hyperplastic polyps |journal=Arch. Pathol. Lab. Med. |volume=131 |issue=3 |pages=440-5 |year=2007 |month=March |pmid=17516746 |doi= |url=http://journals.allenpress.com/jrnlserv/?request=get-abstract&issn=0003-9985&volume=131&page=440}}</ref>): | ||
{| class="wikitable" | {| class="wikitable" | ||
! Attribute | ! Attribute | ||
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|- | |- | ||
|Image(s) | |Image(s) | ||
| [[Image: | | [[Image:Hyperplastic polyp -- intermed mag.jpg |thumb|center|150px|HP (WC)]] | ||
| [[Image:Sessile_serrated_adenoma_2_low_mag.jpg|thumb|center|150px|SSA (WC)]] | | [[Image:Sessile_serrated_adenoma_2_low_mag.jpg|thumb|center|150px|SSA (WC)]] | ||
| [[Image:Traditional_serrated_adenoma_low_mag.jpg|thumb|center|150px|TSA (WC)]] | | [[Image:Traditional_serrated_adenoma_low_mag.jpg|thumb|center|150px|TSA (WC)]] | ||
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*Abundant goblet cells. | *Abundant goblet cells. | ||
*Moderate inflammation. | *Moderate inflammation. | ||
*Paneth | *[[Paneth cell]]s - present in right colon. | ||
*Glands - straight, no branching; "test tube" shape. | *Glands - straight, no branching; "test tube" shape. | ||
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====Images==== | ====Images==== | ||
<gallery> | <gallery> | ||
Image: | Image:Rectum - low mag.jpg | Rectum - low mag. (WC) | ||
Image:Rectum - intermed mag.jpg | Rectum - intermed. mag. (WC) | |||
Image:Rectum - alt - intermed mag.jpg | Rectum - intermed. mag. (WC) | |||
Image:Rectum - high mag.jpg | Rectum - high mag. (WC) | |||
</gallery> | </gallery> | ||
www: | www: | ||
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===Sign out=== | ===Sign out=== | ||
====Normal==== | ====Normal==== | ||
<pre> | |||
Cecum, Biopsy: | |||
- Colorectal-type mucosa within normal limits. | |||
</pre> | |||
<pre> | |||
Right Colon, Biopsy: | |||
- Colonic mucosa within normal limits. | |||
</pre> | |||
<pre> | |||
Transverse Colon, Biopsy: | |||
- Colonic mucosa within normal limits. | |||
</pre> | |||
<pre> | |||
Left Colon, Biopsy: | |||
- Colonic mucosa within normal limits. | |||
</pre> | |||
<pre> | |||
Rectum, Biopsy: | |||
- Colorectal mucosa within normal limits. | |||
</pre> | |||
=====Block letters===== | |||
<pre> | <pre> | ||
SIGMOID COLON, BIOPSY: | SIGMOID COLON, BIOPSY: | ||
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COLON, 70 CM, BIOPSY: | COLON, 70 CM, BIOPSY: | ||
- COLORECTAL-TYPE MUCOSA WITHIN NORMAL LIMITS. | - COLORECTAL-TYPE MUCOSA WITHIN NORMAL LIMITS. | ||
</pre> | |||
=====Polypoid fragments===== | |||
<pre> | |||
POLYP, SIGMOID COLON, BIOPSY: | |||
- POLYPOID FRAGMENT OF COLORECTAL-TYPE MUCOSA WITHIN NORMAL LIMITS. | |||
</pre> | </pre> | ||
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====Lymphoid nodule present==== | ====Lymphoid nodule present==== | ||
*Lymphoid nodules manifest endoscopically as a small polypoid protuberances. It is worthwhile to report the presence of lymphoid nodules as they reassure the endoscopist that they probably sampled the abnormality they saw. | |||
<pre> | |||
POLYP, RECTUM, BIOPSY: | |||
- RECTAL MUCOSA WITHIN NORMAL LIMITS WITH A MORPHOLOGICALLY BENIGN LYMPHOID AGGREGATE. | |||
</pre> | |||
<pre> | |||
COLON, RIGHT SIDE, BIOPSY: | |||
- COLONIC MUCOSA WITH MORPHOLOGICALLY BENIGN LYMPHOID AGGREGATES, | |||
NO SIGNIFICANT PATHOLOGY. | |||
</pre> | |||
=====Submucosa present===== | |||
<pre> | <pre> | ||
POLYP, ASCENDING COLON, BIOPSY: | POLYP, ASCENDING COLON, BIOPSY: | ||
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</pre> | </pre> | ||
====Suspected missed lesion==== | ====Suspected missed lesion==== | ||
<pre> | <pre> | ||
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COMMENT: | COMMENT: | ||
The clinical history is noted. This biopsy does not show neoplastic tissue; however, the | The clinical history is noted. This biopsy does not show neoplastic tissue; | ||
biopsy may not be representative of the lesion seen. | however, the biopsy may not be representative of the lesion seen. | ||
Levels were cut and these did not yield additional information. There are no changes to | Levels were cut and these did not yield additional information. There are | ||
suggest a chronic colitis. | no changes to suggest a chronic colitis. | ||
Correlation with imaging may be useful. A re-biopsy is suggested. | Correlation with imaging may be useful. A re-biopsy is suggested. | ||
</pre> | </pre> | ||
== | ====Micro - suspected IBD==== | ||
The sections show colorectal-type mucosa. The glands show no significant architectural | |||
=== | abnormalities and mature normally to the surface. Rare apoptotic epithelial cells are seen. There is no cryptitis. Neutrophils are not apparent in the lamina propria. | ||
=== | ====Rare PMNs - no cryptitis==== | ||
The sections show colorectal mucosa with rare lymphoid aggregates. The architecture is | |||
within normal limits. The epithelium matures normally to the surface. Very rare neutrophils | |||
are present within the lamina propria. A very small number of crypts have one or two | |||
neutrophils. No definite cryptitis is present. | |||
==Fecal material== | |||
{{Main|Fecal material}} | |||
=Hyperplastic polyp= | =Hyperplastic polyp= | ||
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=Inflammatory pseudopolyp= | =Inflammatory pseudopolyp= | ||
{{Main|Inflammatory pseudopolyp}} | |||
=Adenomatous polyps= | =Adenomatous polyps= | ||
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==Pseudoinvasion in colorectal adenomatous polyps== | ==Pseudoinvasion in colorectal adenomatous polyps== | ||
*[[AKA]] ''pseudoinvasion''. | *[[AKA]] ''pseudoinvasion''. | ||
*[[AKA]] ''epithelial misplacement''. | |||
* | {{Main|Pseudoinvasion in colorectal adenomatous polyps}} | ||
==High-risk features in (colorectal) adenomatous polyps with carcinoma== | ==High-risk features in (colorectal) adenomatous polyps with carcinoma== | ||
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#[[Lymphovascular invasion]]. | #[[Lymphovascular invasion]]. | ||
#High-grade [[tumour budding]]. | #High-grade [[tumour budding]]. | ||
#*Tumour bud = 1-4 cell(s); "high-grade budding" is >=10 tumour buds in a field of 0.385 mm<sup>2</sup>.<ref name=pmid11952856>{{Cite journal | last1 = Ueno | first1 = H. | last2 = Murphy | first2 = J. | last3 = Jass | first3 = JR. | last4 = Mochizuki | first4 = H. | last5 = Talbot | first5 = IC. | title = Tumour 'budding' as an index to estimate the potential of aggressiveness in rectal cancer. | journal = Histopathology | volume = 40 | issue = 2 | pages = 127-32 | month = Feb | year = 2002 | doi = | PMID = 11952856 }}</ref> | #*Tumour bud = 1-4 cell(s); "high-grade budding" is >=10 tumour buds in a field of 0.385 mm<sup>2</sup>.<ref name=pmid11952856>{{Cite journal | last1 = Ueno | first1 = H. | last2 = Murphy | first2 = J. | last3 = Jass | first3 = JR. | last4 = Mochizuki | first4 = H. | last5 = Talbot | first5 = IC. | title = Tumour 'budding' as an index to estimate the potential of aggressiveness in rectal cancer. | journal = Histopathology | volume = 40 | issue = 2 | pages = 127-32 | month = Feb | year = 2002 | doi = | PMID = 11952856 }}</ref>‡ | ||
#**If the microscope has a 22 mm eye piece and... | #**If the microscope has a 22 mm eye piece and... | ||
#***A 20x objective, the field is approximately 0.950 mm<sup>2</sup> -- to match the area | #***A 20x objective, the field is approximately 0.950 mm<sup>2</sup> -- to match the buds/area -- it would be 24.68 buds/0.950 mm<sup>2</sup>. | ||
#***A 40x objective, the field is approximately 0.238 mm<sup>2</sup> -- to match the area | #***A 40x objective, the field is approximately 0.238 mm<sup>2</sup> -- to match the buds/area -- it would be 6.17 buds/0.238 mm<sup>2</sup>. | ||
#Extensive submucosal invasion. | #Extensive submucosal invasion. | ||
#*>= 4 mm width ''or'' >= 2 mm depth. | #*>= 4 mm width ''or'' >= 2 mm depth. | ||
If none of the above factors is present the risk of [[lymph node]] metastasis is < 1%. The presence of one risk factor increases the risk to ~20%. If multiple risk factors are present the chance of [[lymph node metastases]] is greater than 35%.<ref name=pmid15300569/> | If none of the above factors is present the risk of [[lymph node]] metastasis is < 1%. The presence of one risk factor increases the risk to ~20%. If multiple risk factors are present the chance of [[lymph node metastases]] is greater than 35%.<ref name=pmid15300569/> | ||
Note: | |||
*‡Tumour budding as per international consensus is now assessed in field area of 0.785 mm<sup>2</sup>.<ref name=pmid28548122>{{Cite journal | last1 = Lugli | first1 = A. | last2 = Kirsch | first2 = R. | last3 = Ajioka | first3 = Y. | last4 = Bosman | first4 = F. | last5 = Cathomas | first5 = G. | last6 = Dawson | first6 = H. | last7 = El Zimaity | first7 = H. | last8 = Fléjou | first8 = JF. | last9 = Hansen | first9 = TP. | title = Recommendations for reporting tumor budding in colorectal cancer based on the International Tumor Budding Consensus Conference (ITBCC) 2016. | journal = Mod Pathol | volume = 30 | issue = 9 | pages = 1299-1311 | month = Sep | year = 2017 | doi = 10.1038/modpathol.2017.46 | PMID = 28548122 }}</ref> | |||
==Traditional adenoma== | ==Traditional adenoma== | ||
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RECTOSIGMOID TUMOUR, BIOPSY: | RECTOSIGMOID TUMOUR, BIOPSY: | ||
- INVASIVE ADENOCARCINOMA, MODERATELY DIFFERENTIATED. | - INVASIVE ADENOCARCINOMA, MODERATELY DIFFERENTIATED. | ||
</pre> | |||
<pre> | |||
RECTUM, BIOPSY: | |||
- INVASIVE ADENOCARCINOMA, MODERATELY DIFFERENTIATED. | |||
</pre> | |||
<pre> | |||
RECTUM, BIOPSY: | |||
- HIGHLY SUSPICIOUS FOR INVASIVE ADENOCARCINOMA, SEE MICROSCOPIC. | |||
- TUBULOVILLOUS ADENOMA WITH HIGH-GRADE DYSPLASIA. | |||
</pre> | </pre> | ||
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There is cribriforming of glands and epithelial budding. Plump spindle cells with eosinophilic cytoplasm surround the abnormal epithelium (desmoplastic stroma). No definite submucosa is identified; the diagnosis is based on the stromal desmoplasia. | There is cribriforming of glands and epithelial budding. Plump spindle cells with eosinophilic cytoplasm surround the abnormal epithelium (desmoplastic stroma). No definite submucosa is identified; the diagnosis is based on the stromal desmoplasia. | ||
=====Suspicious===== | |||
The sections shows multiple fragments of colorectal-type mucosa with a tubule-forming and villous-forming epithelium that has cellular pseudostratification and enlarged hyperchromatic nuclei, from | |||
the crypt base to the luminal aspect (dysplasia). | |||
Cribriforming of glands is identified at multiple foci. Goblet cells are rare in the | |||
dysplastic epithelium. | |||
One fragment of tissue, measuring approximately 2 millimetres, has increased numbers of plump stromal cells (desmoplastic response); this is suspicious for invasive adenocarcinoma. | |||
=Hamartomatous polyps= | =Hamartomatous polyps= | ||
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==Juvenile polyp== | ==Juvenile polyp== | ||
{{Main|Juvenile polyp}} | |||
==Peutz-Jeghers polyp== | ==Peutz-Jeghers polyp== | ||
{{Main|Peutz-Jeghers polyp}} | |||
==Cowden disease== | ==Cowden disease== | ||
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==Cronkhite-Canada syndrome== | ==Cronkhite-Canada syndrome== | ||
*Abbreviated ''CCS''. | *Abbreviated ''CCS''. | ||
{{Main|Cronkhite-Canada syndrome}} | |||
==Ganglioneuroma== | ==Ganglioneuroma== | ||
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*Ganglion cells - '''key feature'''. | *Ganglion cells - '''key feature'''. | ||
**Large cells with a round nucleus and a prominent nucleolus. | **Large cells with a round nucleus and a prominent nucleolus. | ||
DDx: | |||
*[[Hyperplastic polyp with perineuromatous stroma]]. | |||
====Images==== | ====Images==== | ||
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Image:Ganglioneuroma_-_very_high_mag.jpg | Ganglioneuroma - very high mag. (WC/Nephron) | Image:Ganglioneuroma_-_very_high_mag.jpg | Ganglioneuroma - very high mag. (WC/Nephron) | ||
</gallery> | </gallery> | ||
==Inflammatory myoglandular polyp== | ==Inflammatory myoglandular polyp== | ||
===General=== | ===General=== | ||
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*Polypoid prolaping mucosal fold in [[diverticular disease]]. | *Polypoid prolaping mucosal fold in [[diverticular disease]]. | ||
*[[Inflammatory cloacogenic polyp]]. | *[[Inflammatory cloacogenic polyp]]. | ||
*Inflammatory cap polyp. | *[[Inflammatory cap polyp]]. | ||
Image: | Image: | ||
*[http://www.biomedcentral.com/1471-230X/10/10/figure/F3 IMP (biomedcentral.com)].<ref name=pmid20102635/> | *[http://www.biomedcentral.com/1471-230X/10/10/figure/F3 IMP (biomedcentral.com)].<ref name=pmid20102635/> | ||
==Leiomyoma== | |||
{{Main|Colonic leiomyoma}} | |||
{{Main|Leiomyoma}} | |||
*May present as a polyp in the colon.<ref name=pmid21915840>{{Cite journal | last1 = Kemp | first1 = CD. | last2 = Arnold | first2 = CA. | last3 = Torbenson | first3 = MS. | last4 = Stein | first4 = EM. | title = An unusual polyp: a pedunculated leiomyoma of the sigmoid colon. | journal = Endoscopy | volume = 43 Suppl 2 UCTN | issue = | pages = E306-7 | month = | year = 2011 | doi = 10.1055/s-0030-1256640 | PMID = 21915840 }}</ref> | |||
==Colonic polyp with reactive subepithelial cells== | |||
===Microscopic=== | |||
Features: | |||
*Surface epithelium with a reduced quantity of cytoplasm and less goblets (regenerative appearance). | |||
*Mildly atypical subepithelial cells with pale moderate-to-abundant cytoplasm and nuclear enlargement +/-nuclear hyperchromasia. | |||
===Sign out=== | |||
<pre> | |||
POLYP, ASCENDING COLON, POLYPECTOMY: | |||
- POLYPOID FRAGMENT OF COLONIC-TYPE MUCOSA WITH REACTIVE SUBEPITHELIAL | |||
CELLS, SEE COMMENT. | |||
- NEGATIVE FOR DYSPLASIA. | |||
COMMENT: | |||
A pankeratin and CK7 immunostains are non-concerning. A CD68 immunostain | |||
highlights lamina propria macrophages. | |||
</pre> | |||
=See also= | =See also= | ||
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*[[Small bowel]]. | *[[Small bowel]]. | ||
*[[Colon]]. | *[[Colon]]. | ||
*[[Polypectomy]]. | |||
=References= | =References= |
edits