Gastrointestinal tract polyps: Difference between revisions

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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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*Adenomatous - premalignant, several types (see below).
*Adenomatous - premalignant, several types (see below).
Mnemonic: ''HHI-A''.
Mnemonic: ''HHI-A''.
Diagnostic variability for colorectal polyps is substantial among community pathologists.<ref name=pmid10502165>{{Cite journal  | last1 = Rex | first1 = DK. | last2 = Alikhan | first2 = M. | last3 = Cummings | first3 = O. | last4 = Ulbright | first4 = TM. | title = Accuracy of pathologic interpretation of colorectal polyps by general pathologists in community practice. | journal = Gastrointest Endosc | volume = 50 | issue = 4 | pages = 468-74 | month = Oct | year = 1999 | doi =  | PMID = 10502165 }}</ref>


=Basic approach=
=Basic approach=
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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]] vs. HP|L=Normal vs. VA}}
{{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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! Image
! Image
|-
|-
| Normal mucosa / no pathology
| [[Normal colorectal mucosa|Normal mucosa]] / no pathology
| test tubes in a rack-like morphology
| test tubes in a rack-like morphology
| small nuclei, abundant goblet cells
| small nuclei, abundant goblet cells
| 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]]
| [http://www.pathology.med.ohio-state.edu/paxit/deptbase/Paxit/Images/10534/PAXIT032.JPG Normal - low mag. (ohio-state.edu)]
| [[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]]
| [http://commons.wikimedia.org/wiki/File:Hyperplastic_polyp2.jpg HP (WC)]
| [[Image:Hyperplastic polyp -- intermed mag.jpg |thumb|center|150px| HP (WC)]]
|-
|-
| [[Traditional adenoma]]
| [[Traditional adenoma]]
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| [[tubular adenoma of the gastrointestinal tract|tubular adenoma]], [[tubulovillous adenoma]], [[villous adenoma]]
| [[tubular adenoma of the gastrointestinal tract|tubular adenoma]], [[tubulovillous adenoma]], [[villous adenoma]]
| [[traditional serrated adenoma]], reactive changes (inflammation)
| [[traditional serrated adenoma]], reactive changes (inflammation)
| [http://commons.wikimedia.org/wiki/File:Tubular_adenoma_2_high_mag.jpg TA - high mag. (WC)], [http://commons.wikimedia.org/wiki/File:Tubular_adenoma_4_low_mag.jpg TA - low mag. (WC)]
| [[Image:Tubular_adenoma_4_low_mag.jpg|thumb|center|150px| TA (WC)]]
|}
|}


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| AKA sessile serrated polyp
| AKA sessile serrated polyp
| hyperplastic polyp
| hyperplastic polyp
| [http://commons.wikimedia.org/wiki/File:Sessile_serrated_adenoma_2_low_mag.jpg SSA - low mag. (WC)]
| [[Image:Sessile_serrated_adenoma_2_low_mag.jpg|thumb|center|150px|SSA (WC)]]
|-
|-
| [[Traditional serrated adenoma]] (TSA)
| [[Traditional serrated adenoma]] (TSA)
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| called "traditional" to differentiate from SSA
| called "traditional" to differentiate from SSA
| traditional serrated adenoma (esp. villous adenoma)
| traditional serrated adenoma (esp. villous adenoma)
| [http://commons.wikimedia.org/wiki/File:Traditional_serrated_adenoma_low_mag.jpg TSA - low mag. (WC)], [http://commons.wikimedia.org/wiki/File:Traditional_serrated_adenoma_very_high_mag.jpg TSA - high mag. (WC)]  
| [[Image:Traditional_serrated_adenoma_low_mag.jpg|thumb|center|150px|TSA (WC)]]
|-
|-
| [[Juvenile polyp]] (retention polyp)
| [[Juvenile polyp]] (retention polyp)
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| may be part of [[juvenile polyposis syndrome]]
| may be part of [[juvenile polyposis syndrome]]
| inflammatory pseudopolyp
| inflammatory pseudopolyp
| [http://commons.wikimedia.org/wiki/File:Gastric_juvenile_polyp_-_very_low_mag.jpg Gastric JP - low mag. (WC)]
| [[Image:Gastric_juvenile_polyp_-_very_low_mag.jpg|thumb|center|150px|Gastric JP (WC)]]
|-
|-
| [[Inflammatory pseudopolyp]]
| [[Inflammatory pseudopolyp]]
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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
| [http://commons.wikimedia.org/wiki/File:Peutz-Jeghers_syndrome_polyp.jpg PJP - low mag. (WC)]
| [[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''' ||'''Hyperplastic polyp (HP)''' ||'''Sessile serrated adenoma (SSA)''' ||'''Traditional serrated adenoma (TSA)''' ||'''Traditional adenoma'''<br>-tubular adenoma<br>-tubulovillous adenoma<br>-villous adenoma
! Attribute
! Hyperplastic polyp (HP)
! Sessile serrated adenoma (SSA)
! Traditional serrated adenoma (TSA)
! Traditional adenoma'''<br>-tubular adenoma<br>-tubulovillous adenoma<br>-villous adenoma
|-
|-
|Classic location ||rectum/left colon ||right colon ||rectum/left colon ||rectum/left colon
|Classic location ||rectum/left colon ||right colon ||rectum/left colon ||rectum/left colon
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|-
|-
|Image(s)
|Image(s)
| [http://commons.wikimedia.org/wiki/File:Hyperplastic_polyp2.jpg low mag.]
| [[Image:Hyperplastic polyp -- intermed mag.jpg |thumb|center|150px|HP (WC)]]
| [http://commons.wikimedia.org/wiki/File:Sessile_serrated_adenoma_2_low_mag.jpg low mag], [http://commons.wikimedia.org/wiki/File:Sessile_serrated_adenoma.jpg low mag.]
| [[Image:Sessile_serrated_adenoma_2_low_mag.jpg|thumb|center|150px|SSA (WC)]]
| [http://commons.wikimedia.org/wiki/File:Traditional_serrated_adenoma_low_mag.jpg low mag], [http://commons.wikimedia.org/wiki/File:Traditional_serrated_adenoma_very_high_mag.jpg very high mag.]
| [[Image:Traditional_serrated_adenoma_low_mag.jpg|thumb|center|150px|TSA (WC)]]
|[http://commons.wikimedia.org/wiki/File:Tubular_adenoma_2_low_mag.jpg low mag.], [http://commons.wikimedia.org/wiki/File:Tubular_adenoma_2_high_mag.jpg high mag.]
|[[Image:Tubular_adenoma_2_low_mag.jpg|thumb|center|150px|TA (WC)]]
|}
|}
Normal colonic mucosa:  
Normal colonic mucosa:  
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*Abundant goblet cells.
*Abundant goblet cells.
*Moderate inflammation.
*Moderate inflammation.
*Paneth cells - present in right colon.
*[[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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=Normal=
=Normal=
==Normal colorectal mucosa==
===General===
===General===
*Endoscopists go after anything that is polypoid... and that may be normal.
*Endoscopists go after anything that is polypoid... and that may be normal.


==Normal colon==
===Microscopic===
===Microscopic===
Features:
Features:
*Test tube like glands.
*Test tube like glands.
*Minimal palisading.
*Minimal palisading.
**Nuclei <3:1 height:width, width < 1 resting lymphocyte.
**Nuclei <3:1 = height:width.
*No nuclear pseudostratification.
*No nuclear pseudostratification. †
*Deep part of crypt more hyperchromatic than superficial component.
*Deep part of crypt is more hyperchromatic than superficial component - '''important'''.
**The surface should be lighter staining than the deeper aspect, i.e. the deeper glands are dark blue and the superficial gland are light blue.


Images:
Note:
* † May be seen in [[reactive changes]].
 
DDx (colorectal mucosa with minimal changes):
*[[CMV colitis]].
*[[Cryptosporidiosis]].
*[[Intestinal spirochetosis]].
*[[Lymphocytic colitis]].
*[[Collagenous colitis]].
 
====Images====
<gallery>
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>
www:
*[http://www.lab.anhb.uwa.edu.au/mb140/CorePages/GIT/images/col10he.jpg Normal colorectal mucosa (uwa.edu.au)].<ref>URL: [http://www.lab.anhb.uwa.edu.au/mb140/CorePages/GIT/git.htm http://www.lab.anhb.uwa.edu.au/mb140/CorePages/GIT/git.htm]. Accessed on: 18 October 2012.</ref>
*[http://www.lab.anhb.uwa.edu.au/mb140/CorePages/GIT/images/col10he.jpg Normal colorectal mucosa (uwa.edu.au)].<ref>URL: [http://www.lab.anhb.uwa.edu.au/mb140/CorePages/GIT/git.htm http://www.lab.anhb.uwa.edu.au/mb140/CorePages/GIT/git.htm]. Accessed on: 18 October 2012.</ref>
*[http://www.siumed.edu/~dking2/erg/GI027b.htm Colon (siumed.edu)].
*[http://www.siumed.edu/~dking2/erg/GI027b.htm Colon (siumed.edu)].
*[http://www.gwc.maricopa.edu/class/bio202/Digestive/DigestHisto/ColonA.htm Normal colorectal mucosa (maricopa.edu)].
===Sign out===
====Normal====
<pre>
Cecum, Biopsy:
- Colorectal-type mucosa within normal limits.
</pre>
<pre>
Right Colon, Biopsy:
- Colonic mucosa within normal limits.
</pre>


=Hyperplastic polyp=
<pre>
:''The [[stomach]] lesion is dealt with in [[hyperplastic polyp of the stomach]]''.
Transverse Colon, Biopsy:
===General===
- Colonic mucosa within normal limits.
*Most common type of polyp:
</pre>
**Approximately 90% of all colonic polyps.<ref name=Ref_PBoD858/>
**Most common type of [[gastric hyperplastic polyp|gastric polyp]].<ref name=pmid19037727>{{Cite journal  | last1 = Jain | first1 = R. | last2 = Chetty | first2 = R. | title = Gastric hyperplastic polyps: a review. | journal = Dig Dis Sci | volume = 54 | issue = 9 | pages = 1839-46 | month = Sep | year = 2009 | doi = 10.1007/s10620-008-0572-8 | PMID = 19037727 }}</ref>
*May be part of [[hyperplastic polyposis syndrome]].<ref name=pmid21045813>{{Cite journal  | last1 = Huang | first1 = CS. | last2 = Farraye | first2 = FA. | last3 = Yang | first3 = S. | last4 = O'Brien | first4 = MJ. | title = The clinical significance of serrated polyps. | journal = Am J Gastroenterol | volume = 106 | issue = 2 | pages = 229-40; quiz 241 | month = Feb | year = 2011 | doi = 10.1038/ajg.2010.429 | PMID = 21045813 }}</ref>


===Microscopic===
<pre>
Features:<ref name=Ref_PBoD858/>
Left Colon, Biopsy:
*Irregular crypt architecture - tortuosity.
- Colonic mucosa within normal limits.
*Serrated epithelial cells (at the surface of the gland) - only colorectal polyps - '''key feature'''.
</pre>
**''Serrated'' appearance = ''saw-tooth'' appearance, epithelium has jagged edge.


Notes:
<pre>
*Significant negatives:
Rectum, Biopsy:
**No nuclear atypia.  
- Colorectal mucosa within normal limits.
**In the colon goblet cells should be present (as is usual).
</pre>


DDx:
=====Block letters=====
*[[Sessile serrated adenoma]].
<pre>
SIGMOID COLON, BIOPSY:
- COLORECTAL-TYPE MUCOSA WITHIN NORMAL LIMITS.
</pre>


Images:
<pre>
*[[WC]]:
COLON, 70 CM, BIOPSY:
**[http://commons.wikimedia.org/wiki/File:Hyperplastic_polyp1.jpg HP - high mag. (WC)].
- COLORECTAL-TYPE MUCOSA WITHIN NORMAL LIMITS.
**[http://commons.wikimedia.org/wiki/File:Hyperplastic_polyp2.jpg HP - lower mag. (WC)].
</pre>
*www:
**[http://www.flickr.com/photos/jthetzel/4317282727/ Microvesicular HP (flickr.com/jhetzel)].
**[http://www.flickr.com/photos/jian-hua_qiao_md/3984355417/ HP of colon (flickr.com/jian-hua_qiao_md)].


====Subclassification====
=====Polypoid fragments=====
*Usually '''not subclassified''' as there is no demonstrated prognostic significance;<ref name=pmid21045813/> the subtyping is an academic exercise.
<pre>
POLYP, SIGMOID COLON, BIOPSY:
- POLYPOID FRAGMENT OF COLORECTAL-TYPE MUCOSA WITHIN NORMAL LIMITS.
</pre>


HPs may be subclassified into two groups:<ref name=pmid21045813/>
=====Mucosa and submucosa=====
#Microvesicular serrated polyps (MVSPs).
<pre>
#Goblet cell serrated polyps (GCSPs).
POLYP, SIGMOID COLON, BIOPSY:
- COLONIC MUCOSA AND SUBMUCOSA WITHIN NORMAL LIMITS.
</pre>


Features of the HP subtypes:<ref name=pmid21045813/>
====Lymphoid nodule present====
{| class="wikitable sortable"
*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.
| '''Subtype'''
| '''Histology'''
| '''Mutations'''
| '''Clinical relevance'''
|-
| Microvesicular
| microvesicles at the surface, serration<br> at the surface to the mid portion of glands
| BRAF V600E, CIMP
| possible [[sessile serrated adenoma]] precursor
|-
| Goblet cell
| superficial goblet cells, serration at <br>the surface
| KRAS
| unknown; probably benign
|}
Notes:
*CIMP = CpG island methylation phenotype.


===Sign out===
<pre>
<pre>
COLONIC POLYP, 35 CM, BIOPSY:  
POLYP, RECTUM, BIOPSY:
- HYPERPLASTIC POLYP.
- RECTAL MUCOSA WITHIN NORMAL LIMITS WITH A MORPHOLOGICALLY BENIGN LYMPHOID AGGREGATE.
</pre>
</pre>


<pre>
<pre>
COLONIC POLYP(S), BIOPSY:  
COLON, RIGHT SIDE, BIOPSY:
- HYPERPLASTIC POLYP, SEE COMMENT.
- COLONIC MUCOSA WITH MORPHOLOGICALLY BENIGN LYMPHOID AGGREGATES,
  NO SIGNIFICANT PATHOLOGY.
</pre>


COMMENT:
=====Submucosa present=====
Eight pieces of tissue were received.  On microscopy eight pieces of tissue
<pre>
are identified and all eight (individually) have the diagnostic features of a
POLYP, ASCENDING COLON, BIOPSY:
hyperplastic polyp.  If these fragments all represent individual polyps and more
- COLONIC MUCOSA AND SUBMUCOSA WITHIN NORMAL LIMITS WITH A MORPHOLOGICALLY BENIGN
polyps of this type are present in the individual, it raises the possibility of
LYMPHOID NODULE.
a serrated polyposis syndrome.
</pre>
</pre>


====Micro====
====Suspected missed lesion====
=====Goblet cell type=====
<pre>
The sections show colonic-type mucosa with superficial serrations rich in goblet cells. There are no serrations in the crypt base and there is no crypt base dilation. No dysplasia is present.
RECTOSIGMOID, BIOPSY:
- COLORECTAL-TYPE MUCOSA WITH A LYMPHOID AGGREGATE.
- NEGATIVE FOR ACTIVE COLITIS.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY -- SEE COMMENT.
 
COMMENT:
The clinical history is noted. This biopsy does not show neoplastic tissue;
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 suggest a chronic colitis.
 
Correlation with imaging may be useful. A re-biopsy is suggested.
</pre>


=====Generic=====
====Micro - suspected IBD====
The sections show colonic-type mucosa with superficial serrations.  There are no serrations in the crypt base and there is no crypt base dilation.  No dysplasia is present.
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.


=Inflammatory pseudopolyp=
====Rare PMNs - no cryptitis====
*[[AKA]] ''inflammatory polyp''.
The sections show colorectal mucosa with rare lymphoid aggregates. The architecture is
===General===
within normal limits. The epithelium matures normally to the surface. Very rare neutrophils
*Not a true polyp.
are present within the lamina propria. A very small number of crypts have one or two
*The label ''inflammatory pseudopolyp'' = [[inflammatory bowel disease]] (IBD).
neutrophils. No definite cryptitis is present.
**If there is no history of IBD... reconsider the diagnosis.


===Microscopic===
==Fecal material==
Features:
{{Main|Fecal material}}
*Polypoid shape.
*Inflammation - '''key feature'''.


Negatives:
=Hyperplastic polyp=
*No nuclear atypia.
:''The [[stomach]] lesion is dealt with in [[hyperplastic polyp of the stomach]]''.
*No dilated glands.
{{Main|Hyperplastic polyp}}


DDx:
=Inflammatory pseudopolyp=
*[[Juvenile polyp]].
{{Main|Inflammatory pseudopolyp}}
*[[Solitary rectal ulcer]].


=Adenomatous polyps=
=Adenomatous polyps=
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==Pseudoinvasion in colorectal adenomatous polyps==
==Pseudoinvasion in colorectal adenomatous polyps==
*[[AKA]] ''pseudoinvasion''.
*[[AKA]] ''pseudoinvasion''.
===General===
*[[AKA]] ''epithelial misplacement''.
*Mimic of invasion.
{{Main|Pseudoinvasion in colorectal adenomatous polyps}}
*Pedunculated polyps.<ref>{{Cite journal  | last1 = Byun | first1 = TJ. | last2 = Han | first2 = DS. | last3 = Ahn | first3 = SB. | last4 = Cho | first4 = HS. | last5 = Eun | first5 = CS. | last6 = Jeon | first6 = YC. | last7 = Sohn | first7 = JH. | last8 = Oh | first8 = YH. | title = Pseudoinvasion in an adenomatous polyp of the colon mimicking invasive colon cancer. | journal = Gut Liver | volume = 3 | issue = 2 | pages = 130-3 | month = Jun | year = 2009 | doi = 10.5009/gnl.2009.3.2.130 | PMID = 20431736 | PMC = PMC2852693 | URL = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2852693/ }}</ref>
*Left-sided lesions, esp. sigmoid colon.<ref name=Ref_Odze512>{{Ref Odze|512}}</ref>
 
===Microscopic===
Features:<ref name=pmid4540378>{{Cite journal  | last1 = Muto | first1 = T. | last2 = Bussey | first2 = HJ. | last3 = Morson | first3 = BC. | title = Pseudo-carcinomatous invasion in adenomatous polyps of the colon and rectum. | journal = J Clin Pathol | volume = 26 | issue = 1 | pages = 25-31 | month = Jan | year = 1973 | doi =  | PMID = 4540378 | PMC = 477644 | URL = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC477644/?tool=pubmed }}</ref>
#Glands surrounded by lamina propria.
#Hemosiderin.
#Lack of desmoplastic reaction.
 
Memory device ''LDH'':
*'''L'''amina propria.
*'''D'''esmoplasia lacking.
*'''H'''emosiderin.


==High-risk features in (colorectal) adenomatous polyps with carcinoma==
==High-risk features in (colorectal) adenomatous polyps with carcinoma==
Line 386: Line 405:
#[[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/bud -- it would be 24.68 buds/0.950 mm<sup>2</sup>.
#***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/bud -- it would be 6.17 buds/0.238 mm<sup>2</sup>.
#***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==
:''Includes '''tubular adenoma''', '''tubulovillous adenoma''', and '''villous adenoma'''.''
:''Includes '''tubular adenoma''', '''tubulovillous adenoma''', and '''villous adenoma'''.''
{{Main|Traditional adenoma}}


===General===
==Traditional serrated adenoma==
*Most common group of ''adenomas'' in GI tract.
{{Main|Traditional serrated adenoma}}
===Microscopic===
#Nuclear changes at the surface (of the mucosa) - '''key feature'''.
#*Cigar-shaped (elongated) nucleus (usu. length:width > 3:1) - '''key feature'''.
#**Normal nuclei are round.
#*Nuclear crowding/pseudostratification - '''key feature'''.
#*Nuclear hyperchromasia (more blue).
#*+/-Loss of nuclear polarity (nuclei no longer on basement membrane).
#Loss/decrease of goblet cells (common).
#Cytoplasmic hyperchromasia.


Notes:
==Sessile serrated adenoma==
*Nuclear changes deep to the surface are non-neoplastic if normal appearing mucosa (with small round nuclei) is superficial to it; mucosa that is more blue and atypical deep ''and'' less blue without nuclear atypia at the surface is said to be "maturing".
{{Main|Sessile serrated adenoma}}
**Classically, adenomatous polyps have "reverse maturation":
***The surface is more hyperchromatic (more blue).
***The base is more mature (more globlet cells, no nuclear changes -- less blue).
*[[Ampullary adenoma]]s often have less prominent pseudostratification and fine chromatin.


Images:
=Malignant polyps=
*[[WC]]:
==Colorectal adenocarcinoma==
**[http://commons.wikimedia.org/wiki/File:Tubular_adenoma_high_mag.jpg Small tubular adenoma - high mag. (WC)].
{{Main|Colorectal adenocarcinoma}}
**[http://commons.wikimedia.org/wiki/File:Tubular_adenoma_2_intermed_mag.jpg Tubular adenoma - intermed. mag. (WC)].
**[http://commons.wikimedia.org/wiki/File:Tubulovillous_adenoma.jpg Tubulovillous adenoma (WC)].
*www:
**[http://www.flickr.com/photos/jian-hua_qiao_md/3984353527/in/photostream/ TA (flickr.com)].
**[http://www.flickr.com/photos/jian-hua_qiao_md/3985116686/ TA with HGD (flickr.com)].
**[http://media.daveproject.org/media/images/pathology_img/fullsize/gsraju-flat_lession_emr-path.jpeg TA with HGD (daveproject.org)].<ref>URL: [http://daveproject.org/colon-cancer-prevention-flat-lesion-and-endoscopic-mucosal-resection/2011-06-10/ http://daveproject.org/colon-cancer-prevention-flat-lesion-and-endoscopic-mucosal-resection/2011-06-10/]. Accessed on: 24 August 2012.</ref>


===Typing===
===General===
Subclassified as:<ref name=pbod860>{{Ref PBoD|860}}</ref>
*Diagnosis may be a challenging on a small biopsy.
*''Tubular adenoma'' (most common), tubular component >75%.
*''Villous adenoma'' (least common ~= 1% of (traditional) adenomas), villous component >50%.
*''Tubulovillous adenoma'' (uncommon ~5-10% of (traditional) adenomas), villous component >=25% & <=50%.


In other words:
====Clinical====
*Tubular T/V >75% / <25%; Tubulovillous T/V <=75%-50% / 25%-<50%; Villous T/V <=50% / >50%.
Invasion can be predicted based on endoscopic findings:
*[[Kudo pit pattern]].<ref name=pmid18458845>{{Cite journal  | last1 = Onishi | first1 = T. | last2 = Tamura | first2 = S. | last3 = Kuratani | first3 = Y. | last4 = Onishi | first4 = S. | last5 = Yasuda | first5 = N. | title = Evaluation of the depth score of type V pit patterns in crypt orifices of colorectal neoplastic lesions. | journal = J Gastroenterol | volume = 43 | issue = 4 | pages = 291-7 | month =  | year = 2008 | doi = 10.1007/s00535-008-2161-1 | PMID = 18458845 }}</ref>
*Non-lifting sign.<ref name=pmid7926542>{{Cite journal  | last1 = Uno | first1 = Y. | last2 = Munakata | first2 = A. | title = The non-lifting sign of invasive colon cancer. | journal = Gastrointest Endosc | volume = 40 | issue = 4 | pages = 485-9 | month =  | year =  | doi =  | PMID = 7926542 }}</ref>
**Presence predicts deeper invasion.<ref name=pmid10462651>{{Cite journal  | last1 = Ishiguro | first1 = A. | last2 = Uno | first2 = Y. | last3 = Ishiguro | first3 = Y. | last4 = Munakata | first4 = A. | last5 = Morita | first5 = T. | title = Correlation of lifting versus non-lifting and microscopic depth of invasion in early colorectal cancer. | journal = Gastrointest Endosc | volume = 50 | issue = 3 | pages = 329-33 | month = Sep | year = 1999 | doi = 10.1053/ge.1999.v50.98591 | PMID = 10462651 }}</ref>


Note 1:<ref name=pbod860/>
===Microscopic===
*Most villous adenomas are sessile, i.e. flat.<ref name=emed_va>URL: [http://emedicine.medscape.com/article/170283-overview http://emedicine.medscape.com/article/170283-overview].</ref>
One of the two following:
*Tubular adenomas tend to be pedunculated, i.e. have a stalk.
#Dysplasia and evidence of invasion - features:<ref name=pmid22827760>{{Cite journal  | last1 = Kimura | first1 = R. | last2 = Fujimori | first2 = T. | last3 = Ichikawa | first3 = K. | last4 = Ajioka | first4 = Y. | last5 = Ueno | first5 = H. | last6 = Ohkura | first6 = Y. | last7 = Kashida | first7 = H. | last8 = Togashi | first8 = K. | last9 = Yao | first9 = T. | title = Desmoplastic reaction in biopsy specimens of early colorectal cancer: a Japanese prospective multicenter study. | journal = Pathol Int | volume = 62 | issue = 8 | pages = 525-31 | month = Aug | year = 2012 | doi = 10.1111/j.1440-1827.2012.02840.x | PMID = 22827760 }}</ref>
*Villous adenomas have a worse prognosis and warrant closer follow-up.
#*Nuclear changes seen in adenomatous polyps - malignant-appearing cells.
*One needs only to remember the criteria for ''tubular adenomas'' and ''villous adenomas'', as tubulovillous adenomas are what is left over.
#**Enlarged nuclei.
**Tubular adenomas >75% tubular, Villous adenoma >=50% villous.
#**Chromatin hyperchromatic ''or'' vesicular.
*Historically, there were different definitions for tubular adenoma, tubulovillous adenoma, and villous adenomas.<ref name=emed_va/>
#**Round-shape ''or'' cigar-shaped and pseudostratified.
**Health Organization (WHO) criteria: villous adenomas >80% villous architecture.
#*Architectural changes - usually those of high-grade dysplasia:
#**Cribriforming - most common.
#**Papillary tufting.
#**Budding.
#**Sheeting.
#*Deep involvement - one of the two following - '''key feature''':
#*#Malignant-appearing cells in the submucosa.
#*#*Pseudoinvasion must be excluded.  
#*#[[Desmoplastic stromal response]].  
#*#*Spindle cells with:
#*#**Large nuclei (nucleus ~ size of a plasma cell).
#*#**Eosinophilic cytoplasm.
#[[Signet ring cell carcinoma|Signet ring cells]].  


Note 2:
DDx:
*There is no formal definition of "villous" architecture.<ref>R. Riddell. 12 August 2011.</ref>
*[[Pseudoinvasion]] - surrounded by lamina propria, desmoplasia lacking, hemosiderin-laden macrophages.
**[[VL]] suggests: slender finger-like projections with length-to-width ratio greater than 4.
*[[Reactive changes]].


Note 3:
Note:
*The term ''tubular adenoma'' is used in different contexts; it should not be confused with [[Sertoli cell nodule]] ([[AKA]] ''testicular tubular adenoma'').
*Desmoplastic response is ''not'' predictive of submucosal invasion in pedunculated polyps.<ref name=pmid20665053>{{Cite journal | last1 = Hirose | first1 = M. | last2 = Fukui | first2 = H. | last3 = Igarashi | first3 = Y. | last4 = Fujimori | first4 = Y. | last5 = Katake | first5 = Y. | last6 = Sekikawa | first6 = A. | last7 = Ichikawa | first7 = K. | last8 = Tomita | first8 = S. | last9 = Imura | first9 = J. | title = Detection of desmoplastic reaction in biopsy specimens is useful for predicting the depth of invasion of early colorectal cancer: a Japanese collaborative study. | journal = J Gastroenterol | volume = 45 | issue = 12 | pages = 1212-8 | month = Dec | year = 2010 | doi = 10.1007/s00535-010-0288-3 | PMID = 20665053 }}
 
</ref>
===Grading===
Adenomas are usually graded adenomas with a two-tier system:<ref name=driman>{{cite journal | last1 = Driman | first1 = DK. | last2 = Marcus | first2 = VA. | last3 = Hilsden | first3 = RJ | last4 = Owen | first4 = DA |title=Pathologic reporting of colorectal polyps: pan-Canadian consensus guidelines |journal=Canadian Journal of Pathology |volume=4 |issue=3 |pages=81-90 |year=2012 |month= |pmid= |doi= |url= }}</ref>
 
{| class="wikitable sortable"
!Feature
!Low grade dysplasia (LGD)
!High grade dysplasia (HGD)
!Importance
|-
|Architecture
|tubular, minimal focal gland fusion acceptable
|any of the following: (gland) cribriforming, glandular budding, intraluminal papillary tufting, sheeting (of epithelium), lamina propria invasion †
|'''key feature'''
|-
|Cytology
|usu. no features of HGD
|any of the following: loss of nuclear stratification, enlarged nuclei, loss of cell polarity, prominent nucleoli, open (clear) chromatin
|supportive feature, not sufficient alone for HGD
|}
 
Low power colour can be suggestive of HGD:
{| class="wikitable sortable"
!Feature
!Low grade
!High grade
|-
| Colour
| light blue
| dark blue
|}


Note:
====Image====
*† In the colon, unlike other areas of the GI tract, invasive carcinoma is defined by neoplastic cells through the muscularis mucosae.  In all other places, e.g. small bowel, invasive carcinoma is defined by neoplastic cells through the basement membrane.
<gallery>
 
Image:Cecal_adenocarcinoma.jpg | Colorectal carcinoma. (WC/Nephron)
Image:
</gallery>
*[http://commons.wikimedia.org/wiki/File:Tubular_adenoma_high_mag.jpg Tubular adenoma, negative for high-grade dysplasia - high mag. (WC)].
 
===Margins===
{{Main|Surgical margins}}
*Some pathologists believe it is impossible to determine margins in polypectomies.
*Others comment on what they see and then disclaim based on limitations with something like "... margin clear in plane of section."
 
The ''Haggitt classification'' is margin call taken to the extreme.
Surgeons may ask about it 'cause a guy (who probably didn't do a lot of pathology) put it in a widely read surgery textbook.
In short:<ref>URL: [http://www.ganfyd.org/index.php?title=Haggitt_classification http://www.ganfyd.org/index.php?title=Haggitt_classification]. Accessed on: 19 March 2011.</ref><ref name=pmid4007423>{{Cite journal  | last1 = Haggitt | first1 = RC. | last2 = Glotzbach | first2 = RE. | last3 = Soffer | first3 = EE. | last4 = Wruble | first4 = LD. | title = Prognostic factors in colorectal carcinomas arising in adenomas: implications for lesions removed by endoscopic polypectomy. | journal = Gastroenterology | volume = 89 | issue = 2 | pages = 328-36 | month = Aug | year = 1985 | doi =  | PMID = 4007423 }}</ref>
*0 - intramucosal carcinoma.
*1 - in submucosa but in head of polyp.
*2 - neck of polyp.
*3 - stalk of polyp.
*4 - submucosa of the bowel wall but above muscularis propria.
It is a little scheme that is mostly useless. In the real world surgical pathology most polyps do not have a discernible neck or stalk.
 
Note:
*Dr. Haggitt is know for his tragic demise. He was shot by a resident that was about to be fired.<ref>Two die in UW medical school shooting. seattlepi.com. URL: [http://www.seattlepi.com/local/pathweb.shtml http://www.seattlepi.com/local/pathweb.shtml]. Accessed on: April 23, 2009.</ref>


===Sign out===
===Sign out===
<pre>
<pre>
COLONIC POLYP, SIGMOID COLON, BIOPSY:  
RECTOSIGMOID TUMOUR, BIOPSY:
- TUBULAR ADENOMA, NEGATIVE FOR HIGH-GRADE DYSPLASIA.
- INVASIVE ADENOCARCINOMA, MODERATELY DIFFERENTIATED.
</pre>
</pre>


<pre>
<pre>
COLONIC POLYP, SIGMOID COLON, BIOPSY:  
RECTUM, BIOPSY:
- TUBULAR ADENOMA WITH HIGH-GRADE DYSPLASIA.
- INVASIVE ADENOCARCINOMA, MODERATELY DIFFERENTIATED.
</pre>
 
<pre>
SIGMOID LESION, 25 CM, BIOPSY:
- TUBULAR ADENOMA, NEGATIVE FOR HIGH-GRADE DYSPLASIA, SEE COMMENT. 
 
COMMENT:
No definite submucosa is present; thus, the presence or absence of invasion cannot be assessed.
</pre>
</pre>


<pre>
<pre>
COLONIC POLYP, TRANSVERSE COLON, BIOPSY:
RECTUM, BIOPSY:
- TUBULAR ADENOMA, NEGATIVE FOR HIGH-GRADE DYSPLASIA (IN 1/3 TISSUE FRAGMENTS).
- HIGHLY SUSPICIOUS FOR INVASIVE ADENOCARCINOMA, SEE MICROSCOPIC.
- TUBULOVILLOUS ADENOMA WITH HIGH-GRADE DYSPLASIA.
</pre>
</pre>


Notes:
#"Negative for high-grade dysplasia and malignancy" is recommended in the Canadian consensus.<ref name=driman>{{cite journal | last1 = Driman | first1 = DK. | last2 = Marcus | first2 = VA. | last3 = Hilsden | first3 = RJ | last4 = Owen | first4 = DA |title=Pathologic reporting of colorectal polyps: pan-Canadian consensus guidelines |journal=Canadian Journal of Pathology |volume=4 |issue=3 |pages=81-90 |year=2012 |month= |pmid= |doi= |url= }}</ref> The reasoning for the first part is: "with low-grade dysplasia" may lead to over treatment by physicians that are not aware that all (traditional) adenomas have low-grade dysplasia.
#The phrase "negative for [...] malignancy" is also recommended in the Canadian consensus. This is not endorsed here, as one very frequently does not get submucosa.  It is like reporting "negative for submucosal invasion" on gastric biopsies. Further, they do not advise "negative for dysplasia and malignancy" for [[SSA]]s.  If there is clinical suspicion of an invasive malignancy, it is useful to comment that no submucosa is present.
====Micro====
====Micro====
=====Tubular-tubulovillous interface=====
The sections shows colorectal-type mucosa with a tubule-forming epithelium that has cellular pseudostratification and enlarged hyperchromatic nuclei, from the crypt base to the luminal aspect (dysplasia).
The sections shows colorectal-type mucosa with a tubule-forming epithelium that has cellular pseudostratification and enlarged hyperchromatic nuclei, from the crypt base to the luminal aspect (dysplasia). 
 
No cribriforming of glands, epithelial budding or intraluminal papillary tufting is identified.  Goblet cells are present in the dysplastic epithelium.  Dysplastic nuclei have an ellipsoid-shape and basally stratified.
 
A small number of rare finger-like epithelial projections (villi) are noted; however these appear to comprise less than 20% of the sampled tissue.  It is possible that the villous component is higher, due to sampling error; thus, this could represent a tubulovillous adenoma.
 
=====Tubulovillous adenoma=====
The sections shows 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).
 
No cribriforming of glands, epithelial budding or intraluminal papillary tufting is identified. Goblet cells are rare in the dysplastic epithelium. Dysplastic nuclei have an ellipsoid-shape and basally stratified.
 
The villous component is over 25% of the lesion but less than 50% of the lesion.
 
==Traditional serrated adenoma==
===General===
*Very rare.
 
===Microscopic===
Features:
*Serrated.
*Nuclear atypia (as in tubular adenoma).
*Villous architecture.
 
DDx:
*[[Villous adenoma]].
 
Images:
*[http://commons.wikimedia.org/wiki/File:Traditional_serrated_adenoma_low_mag.jpg TSA - low mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Traditional_serrated_adenoma_intermed_mag.jpg TSA - intermed. mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Traditional_serrated_adenoma_very_high_mag.jpg TSA - very high mag. (WC)].
 
==Sessile serrated adenoma==
*Often abbreviated ''SSA''.
*[[AKA]] ''sessile serrated polyp'', abbreviated ''SSP''.
*[[AKA]] ''sessile serrated lesion''.
*[[AKA]] ''sessile serrated adenoma/polyp'', abbreviated ''SSA/P''.
 
===General===
*Colonic lesion.
*More common in the right colon, i.e. ascending colon.
*May be seen in the context of ''[[serrated polyposis syndrome]]''.
 
Epidemiology:
*Thought to lead to colorectal cancer through a different pathway that most tumours in the left colon/rectum.
*''Microvesicular [[hyperplastic polyp]]s'' are hypothesized to be the the precursor of SSAs.<ref name=pmid21045813>{{Cite journal  | last1 = Huang | first1 = CS. | last2 = Farraye | first2 = FA. | last3 = Yang | first3 = S. | last4 = O'Brien | first4 = MJ. | title = The clinical significance of serrated polyps. | journal = Am J Gastroenterol | volume = 106 | issue = 2 | pages = 229-40; quiz 241 | month = Feb | year = 2011 | doi = 10.1038/ajg.2010.429 | PMID = 21045813 }}</ref>
 
===Microscopic===
Features:
*Serrated.
*Crypt dilation at base - a '''key feature''' - very common.
**"Boot"-shape or "L"-shaped glands.
*Crypt branching.
*Horizontal crypts (crypts that run along the muscular mucosae).
 
Notes:
*Typically do not have nuclear atypia, i.e. no nuclear crowding, no nuclear hyperchromasia, no cigar-shaped nuclei.
**SSAs with nuclear atypia may be referred to as ''advanced sessile serrated adenomas''.
*The ''Stanford Surgical Pathology Criteria''<ref>URL: [http://surgpathcriteria.stanford.edu/gitumors/sessile-serrated-polyp-adenoma/ http://surgpathcriteria.stanford.edu/gitumors/sessile-serrated-polyp-adenoma/]. Accessed on: 26 September 2012.</ref> require three adjacent crypts to be abnormal.
 
DDx:
*[[Hyperplastic polyp]].
*[[Tubular adenoma of the gastrointestinal tract|Tubular adenoma]] - for ''SSA with dysplasia'', TAs often less than 1 cm (uncommon for SSAs).


Images:
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.
*[http://commons.wikimedia.org/wiki/File:Sessile_serrated_adenoma.jpg SSA - low mag. (WC/Nephron)].
*[http://commons.wikimedia.org/wiki/File:Sessile_serrated_adenoma2.jpg SSA - intermed. mag. (WC/Nephron)].
*[http://commons.wikimedia.org/wiki/File:Sessile_serrated_adenoma3.jpg SSA - high mag. (WC/Nephron)].
*[http://commons.wikimedia.org/wiki/File:Sessile_serrated_adenoma_3_low_mag.jpg SSA - low mag. (WC/Nephron)].


===Sign out===
=====Suspicious=====
<pre>
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
COLONIC POLYP, ASCENDING COLON, BIOPSY:
the crypt base to the luminal aspect (dysplasia).
- SESSILE SERRATED ADENOMA, NEGATIVE FOR DYSPLASIA.
</pre>


<pre>
Cribriforming of glands is identified at multiple foci. Goblet cells are rare in the
COLONIC POLYP, ASCENDING COLON, BIOPSY:
dysplastic epithelium.
- SESSILE SERRATED ADENOMA WITH DYSPLASIA.
</pre>


Note:
One fragment of tissue, measuring approximately 2 millimetres, has increased numbers of plump stromal cells (desmoplastic response); this is suspicious for invasive adenocarcinoma.
*The above exactly mirrors the Canadian consensus.<ref name=driman>{{cite journal | last1 = Driman | first1 = DK. | last2 = Marcus | first2 = VA. | last3 = Hilsden | first3 = RJ | last4 = Owen | first4 = DA |title=Pathologic reporting of colorectal polyps: pan-Canadian consensus guidelines |journal=Canadian Journal of Pathology |volume=4 |issue=3 |pages=81-90 |year=2012 |month= |pmid= |doi= |url= }}</ref>


=Hamartomatous polyps=
=Hamartomatous polyps=
Line 635: Line 521:


==Juvenile polyp==
==Juvenile polyp==
*[[AKA]] ''retension polyp'' in adults.
{{Main|Juvenile polyp}}
===General===
May be part of a syndrome:
*[[Juvenile polyposis syndrome]] (JPS) - see JPS article for criteria.
*[[Cronkhite-Canada syndrome]].
*[[Cowden syndrome]].
 
===Gross===
*Mushroom-like shape.
 
===Microscopic===
Features:<ref name=Ref_PBoD859>{{Ref PBoD|859}}</ref><ref name=pmid12692201>{{Cite journal  | last1 = Bronner | first1 = MP. | title = Gastrointestinal inherited polyposis syndromes. | journal = Mod Pathol | volume = 16 | issue = 4 | pages = 359-65 | month = Apr | year = 2003 | doi = 10.1097/01.MP.0000062992.54036.E4 | PMID = 12692201 | url = http://www.nature.com/modpathol/journal/v16/n4/full/3880773a.html }}</ref>
*Eroded, smooth or lobulated surface.
*Pedunculated.
*Increased lamina propria (LP) +/- edema.
*Cystically dilated gland.
*Often inflammed.
 
Mnemonic ''DIES'' = dilated glands, increased LP & inflammation of the LP, eroded/smooth surface, stalk.
 
Notes:
*May have nuclear changes like those seen in adenomatous polyps.
 
DDx:
*Inflammatory polyp.
 
Images:
*[http://www.nature.com/modpathol/journal/v16/n4/fig_tab/3880773f4.html Juvenile polyp (nature.com)].
*[http://commons.wikimedia.org/wiki/File:Gastric_juvenile_polyp_-_very_low_mag.jpg Juvenile polyp of the stomach - very low mag. (WC)]
*[http://commons.wikimedia.org/wiki/File:Gastric_juvenile_polyp_-_2_-_very_low_mag.jpg Juvenile polyp of the stomach - very low mag. (WC)].
 
===IHC===
*Usually none.
 
Notes:
*IHC can be used if it is suspected to have dysplasia (p53, Ki-67).
**p53 mutations in dysplastic epithelium -- negative stain (normal).


==Peutz-Jeghers polyp==
==Peutz-Jeghers polyp==
===General===
{{Main|Peutz-Jeghers polyp}}
====Epidemiology====
Features:<ref name=Ref_PBoD859/><ref name=pmid12692201>{{Cite journal  | last1 = Bronner | first1 = MP. | title = Gastrointestinal inherited polyposis syndromes. | journal = Mod Pathol | volume = 16 | issue = 4 | pages = 359-65 | month = Apr | year = 2003 | doi = 10.1097/01.MP.0000062992.54036.E4 | PMID = 12692201 | url = http://www.nature.com/modpathol/journal/v16/n4/full/3880773a.html }}</ref>
*[[Peutz-Jeghers syndrome]] is autosomal dominant.
*Altered gene: STK11.
 
====Clinical====
Features:<ref>URL: [http://www.ncbi.nlm.nih.gov/omim/175200 http://www.ncbi.nlm.nih.gov/omim/175200]. Accessed on: 13 July 2010.</ref>
*Melanocytic macules.
**Lips, buccal mucosa, and digits.
**Multiple Peutz-Jeghers polyps.
 
Increased risk of various neoplasms - primarily:
*Breast and gastrointestinal cancer.<ref name=pmid20581245>{{cite journal |author=Beggs AD, Latchford AR, Vasen HF, ''et al.'' |title=Peutz-Jeghers syndrome: a systematic review and recommendations for management |journal=Gut |volume=59 |issue=7 |pages=975–86 |year=2010 |month=July |pmid=20581245 |doi=10.1136/gut.2009.198499 |url=}}</ref>
*Others tumours:<ref>URL: [http://www.ncbi.nlm.nih.gov/omim/175200 http://www.ncbi.nlm.nih.gov/omim/175200]. Accessed on: 22 December 2010.</ref>
**[[Granulosa cell tumour]].
**[[Sertoli cell tumour]] - esp. with calcification.
 
===Microscopic===
Features:<ref name=Ref_PBoD859/><ref name=pmid12692201>{{Cite journal  | last1 = Bronner | first1 = MP. | title = Gastrointestinal inherited polyposis syndromes. | journal = Mod Pathol | volume = 16 | issue = 4 | pages = 359-65 | month = Apr | year = 2003 | doi = 10.1097/01.MP.0000062992.54036.E4 | PMID = 12692201 | url = http://www.nature.com/modpathol/journal/v16/n4/full/3880773a.html }}</ref>
*Frond-like polyp with all three components of mucosa:
*# Muscosal epithelium (melanotic mucosa, goblet cells).
*# Lamina propria.
*# M. mucosae.
 
Notes:
*''Frond'' = leaflike expansion.<ref>URL: [http://dictionary.reference.com/browse/frond http://dictionary.reference.com/browse/frond]. Accessed on: 26 July 2011.</ref>
**The '''key''' is "thick" smooth muscle bundles - if one is lucky one sees branching.<ref>C. Streutker. 26 July 2011.</ref>
***"Thick" ~= thickness of muscularis mucosae.
 
Images:
*[http://commons.wikimedia.org/wiki/File:Peutz-Jeghers_syndrome_polyp.jpg Peutz-Jeghers polyp - intestine (WC)].
*[http://commons.wikimedia.org/wiki/File:Gastric_Peutz-Jeghers_polyp_-_very_low_mag.jpg Peutz-Jeghers polyp - stomach (WC)].
*[http://www.nature.com/modpathol/journal/v16/n4/fig_tab/3880773f3.html Peutz-Jeghers polyp (nature.com)].


==Cowden disease==
==Cowden disease==
Line 732: Line 549:
==Cronkhite-Canada syndrome==
==Cronkhite-Canada syndrome==
*Abbreviated ''CCS''.
*Abbreviated ''CCS''.
 
{{Main|Cronkhite-Canada syndrome}}
===General===
Clinical features:<ref>{{Ref PBoD|858-9}}</ref>
*Hamartomatous polyps.
*Ectodermal abnormalities (nail atrophy, skin pigment, alopecia).
 
===Microscopic===
Features:
*Polyps have same morphology as juvenile polyp/retension polyp.
*Crypt dilation and edema in non-polypoid mucosa<ref>{{Ref PCPBoD8|430}}</ref> - '''key feature'''.
 
Images:
*[http://www.surgicalpathologyatlas.com/glfusion/mediagallery/media.php?f=0&sort=0&s=20090508151729401 CCS (surgicalpathologyatlas.com)].


==Ganglioneuroma==
==Ganglioneuroma==
Line 755: Line 560:
**Large cells with a round nucleus and a prominent nucleolus.
**Large cells with a round nucleus and a prominent nucleolus.


Images:
DDx:
*[http://commons.wikimedia.org/wiki/File:Ganglioneuroma_-_intermed_mag.jpg Ganglioneuroma - intermed. mag. (WC)].
*[[Hyperplastic polyp with perineuromatous stroma]].
*[http://commons.wikimedia.org/wiki/File:Ganglioneuroma_-_high_mag.jpg Ganglioneuroma - high mag. (WC)].
 
*[http://commons.wikimedia.org/wiki/File:Ganglioneuroma_-_very_high_mag.jpg Ganlioneuroma - very high mag. (WC)].
====Images====
<gallery>
Image:Ganglioneuroma_-_intermed_mag.jpg | Ganglioneuroma - intermed. mag. (WC/Nephron)
Image:Ganglioneuroma_-_high_mag.jpg | Ganglioneuroma - high mag. (WC/Nephron)
Image:Ganglioneuroma_-_very_high_mag.jpg | Ganglioneuroma - very high mag. (WC/Nephron)
</gallery>


==Inflammatory myoglandular polyp==
==Inflammatory myoglandular polyp==
Line 778: Line 588:
*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=
Line 788: Line 621:
*[[Small bowel]].
*[[Small bowel]].
*[[Colon]].
*[[Colon]].
*[[Polypectomy]].


=References=
=References=
Retrieved from "https://librepathology.org/wiki/Gastrointestinal_tract_polyps"