Difference between revisions of "Gastrointestinal tract polyps"

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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]] 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:
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*Minimal palisading.
*Minimal palisading.
**Nuclei <3:1 = height:width.
**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://commons.wikimedia.org/wiki/File:Tubular_adenoma_2_intermed_mag.jpg Normal colon adjacent to a tubular adenoma (WC)].
*[http://www.gwc.maricopa.edu/class/bio202/Digestive/DigestHisto/ColonA.htm Normal colorectal mucosa (maricopa.edu)].
*[http://www.gwc.maricopa.edu/class/bio202/Digestive/DigestHisto/ColonA.htm Normal colorectal mucosa (maricopa.edu)].


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====Normal====
====Normal====
<pre>
<pre>
COLON, 70 CM, BIOPSY:
Cecum, Biopsy:
- COLORECTAL-TYPE MUCOSA WITHIN NORMAL LIMITS.
- Colorectal-type mucosa within normal limits.
</pre>
</pre>


====Suspected missed lesion====
<pre>
<pre>
RECTOSIGMOID, BIOPSY:
Right Colon, Biopsy:
- COLORECTAL-TYPE MUCOSA WITH A LYMPHOID AGGREGATE.
- Colonic mucosa within normal limits.
- NEGATIVE FOR ACTIVE COLITIS.
</pre>
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY -- SEE COMMENT.


COMMENT:
<pre>
The clinical history is noted. This biopsy does not show neoplastic tissue; however, the
Transverse Colon, Biopsy:
biopsy may not be representative of the lesion seen.
- Colonic mucosa within normal limits.
</pre>


Levels were cut and these did not yield additional information. There are no changes to
<pre>
suggest a chronic colitis.
Left Colon, Biopsy:
- Colonic mucosa within normal limits.
</pre>


Correlation with imaging may be useful. A re-biopsy is suggested.
<pre>
Rectum, Biopsy:
- Colorectal mucosa within normal limits.
</pre>
</pre>


=Hyperplastic polyp=
=====Block letters=====
:''The [[stomach]] lesion is dealt with in [[hyperplastic polyp of the stomach]]''.
<pre>
===General===
SIGMOID COLON, BIOPSY:
*Most common type of polyp:
- COLORECTAL-TYPE MUCOSA WITHIN NORMAL LIMITS.
**Approximately 90% of all colonic polyps.<ref name=Ref_PBoD858/>
</pre>
**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/>
COLON, 70 CM, BIOPSY:
*Irregular crypt architecture - tortuosity.
- COLORECTAL-TYPE 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:
=====Polypoid fragments=====
*Significant negatives:
<pre>
**No nuclear atypia.  
POLYP, SIGMOID COLON, BIOPSY:
**In the colon goblet cells should be present (as is usual).
- POLYPOID FRAGMENT OF COLORECTAL-TYPE MUCOSA WITHIN NORMAL LIMITS.
</pre>


DDx:
=====Mucosa and submucosa=====
*[[Sessile serrated adenoma]].
<pre>
POLYP, SIGMOID COLON, BIOPSY:
- COLONIC MUCOSA AND SUBMUCOSA WITHIN NORMAL LIMITS.
</pre>


Images:
====Lymphoid nodule present====
*[[WC]]:
*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.
**[http://commons.wikimedia.org/wiki/File:Hyperplastic_polyp1.jpg HP - high mag. (WC)].
**[http://commons.wikimedia.org/wiki/File:Hyperplastic_polyp2.jpg HP - lower mag. (WC)].
*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====
<pre>
*Usually '''not subclassified''' as there is no demonstrated prognostic significance;<ref name=pmid21045813/> the subtyping is an academic exercise.
POLYP, RECTUM, BIOPSY:
 
- RECTAL MUCOSA WITHIN NORMAL LIMITS WITH A MORPHOLOGICALLY BENIGN LYMPHOID AGGREGATE.
HPs may be subclassified into two groups:<ref name=pmid21045813/>
</pre>
#Microvesicular serrated polyps (MVSPs).
#Goblet cell serrated polyps (GCSPs).
 
Features of the HP subtypes:<ref name=pmid21045813/>
{| class="wikitable sortable"
| '''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:  
COLON, RIGHT SIDE, BIOPSY:
- HYPERPLASTIC POLYP.
- COLONIC MUCOSA WITH MORPHOLOGICALLY BENIGN LYMPHOID AGGREGATES,
  NO SIGNIFICANT PATHOLOGY.
</pre>
</pre>


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


=====Generic=====
COMMENT:
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 clinical history is noted. This biopsy does not show neoplastic tissue;
however, the biopsy may not be representative of the lesion seen.


=Inflammatory pseudopolyp=
Levels were cut and these did not yield additional information. There are
*[[AKA]] ''inflammatory polyp''.
no changes to suggest a chronic colitis.
===General===
*Not a true polyp.
*The label ''inflammatory pseudopolyp'' = [[inflammatory bowel disease]] (IBD).
**If there is no history of IBD... reconsider the diagnosis.


===Microscopic===
Correlation with imaging may be useful. A re-biopsy is suggested.
Features:
</pre>
*Polypoid shape.
*Inflammation - esp. neutrophils - '''key feature'''.


Negatives:
====Micro - suspected IBD====
*No nuclear atypia.
The sections show colorectal-type mucosa. The glands show no significant architectural
**May have focal nuclear hyperchromasia and nuclear enlargement.
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.
*No dilated glands.


DDx:
====Rare PMNs - no cryptitis====
*[[Juvenile polyp]].
The sections show colorectal mucosa with rare lymphoid aggregates. The architecture is
*[[Solitary rectal ulcer]].
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.


Images:
==Fecal material==
*[http://www.humpath.com/spip.php?article8234&id_document=18554 Pseudopolyp (humpath.com)].
{{Main|Fecal material}}
*[http://missinglink.ucsf.edu/lm/IDS_106_LowerGI/Lower_GI_histo_small/24-UC-pseudoplp.jpg Pseudopolyp (ucsf.edu)].


===Sign out===
=Hyperplastic polyp=
<pre>
:''The [[stomach]] lesion is dealt with in [[hyperplastic polyp of the stomach]]''.
SIGMOID COLON POLYP, PERI-DIVERTICULAR, BIOPSY:
{{Main|Hyperplastic polyp}}
- INFLAMMATORY PSEUDOPOLYP.
</pre>


====Micro====
=Inflammatory pseudopolyp=
The sections show a fragment of colorectal mucosa with focal ulceration, acute inflammation and a well-vascularized stroma with plump stromal cells.  Occasional stromal cells have nuclear hyperchromasia.
{{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''.
===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 428: 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===
*Most common group of ''adenomas'' in GI tract.
===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:
*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".
**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:
*[[WC]]:
**[http://commons.wikimedia.org/wiki/File:Tubular_adenoma_high_mag.jpg Small tubular adenoma - high mag. (WC)].
**[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===
Subclassified as:<ref name=pbod860>{{Ref PBoD|860}}</ref>
*''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:
*Tubular T/V >75% / <25%; Tubulovillous T/V <=75%-50% / 25%-<50%; Villous T/V <=50% / >50%.
 
Note 1:<ref name=pbod860/>
*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>
*Tubular adenomas tend to be pedunculated, i.e. have a stalk.
*Villous adenomas have a worse prognosis and warrant closer follow-up.
*One needs only to remember the criteria for ''tubular adenomas'' and ''villous adenomas'', as tubulovillous adenomas are what is left over.
**Tubular adenomas >75% tubular, Villous adenoma >=50% villous.
*Historically, there were different definitions for tubular adenoma, tubulovillous adenoma, and villous adenomas.<ref name=emed_va/>
**Health Organization (WHO) criteria: villous adenomas >80% villous architecture.
 
Note 2:
*There is no formal definition of "villous" architecture.<ref>R. Riddell. 12 August 2011.</ref>
**[[VL]] suggests: slender finger-like projections with length-to-width ratio greater than 4.
 
Note 3:
*The term ''tubular adenoma'' is used in different contexts; it should not be confused with [[Sertoli cell nodule]] ([[AKA]] ''testicular tubular adenoma'').
 
===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:
*† 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.
 
Image:
*[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===
====Negative for high-grade====
<pre>
COLONIC POLYP, SIGMOID COLON, BIOPSY:
- TUBULAR ADENOMA, NEGATIVE FOR HIGH-GRADE DYSPLASIA.
</pre>
 
====Negative for high-grade - tubulovillous adenoma====
<pre>
COLONIC POLYP, SIGMOID COLON, BIOPSY:
- TUBULOVILLOUS ADENOMA, NEGATIVE FOR HIGH-GRADE DYSPLASIA.
</pre>
 
====Focal high-grade====
<pre>
COLONIC POLYP, TRANSVERSE COLON, BIOPSY:
- TUBULAR ADENOMA WITH FOCAL HIGH-GRADE DYSPLASIA.
</pre>
 
====High-grade====
<pre>
COLONIC POLYP, SIGMOID COLON, BIOPSY:
- TUBULAR ADENOMA WITH HIGH-GRADE DYSPLASIA.
</pre>
 
====Assessment of invasion====
<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>
 
====Fragment counting====
<pre>
COLONIC POLYP, TRANSVERSE COLON, BIOPSY:
- TUBULAR ADENOMA, NEGATIVE FOR HIGH-GRADE DYSPLASIA (IN 1/3 TISSUE FRAGMENTS).
</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====
=====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). 
 
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==
==Traditional serrated adenoma==
===General===
{{Main|Traditional serrated adenoma}}
*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==
==Sessile serrated adenoma==
*Often abbreviated ''SSA''.
{{Main|Sessile serrated adenoma}}
*[[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:
*[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===
<pre>
COLONIC POLYP, ASCENDING COLON, BIOPSY:
- SESSILE SERRATED ADENOMA, NEGATIVE FOR DYSPLASIA.
</pre>
 
<pre>
COLONIC POLYP, ASCENDING COLON, BIOPSY:
- SESSILE SERRATED ADENOMA WITH DYSPLASIA.
</pre>
 
Note:
*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>


=Malignant polyps=
=Malignant polyps=
Line 682: Line 432:


===General===
===General===
*May be a challenging diagnosis on a small biopsy.
*Diagnosis may be a challenging on a small biopsy.
 
====Clinical====
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>


===Microscopic===
===Microscopic===
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>
One of the two following:
*Desmoplastic response - '''key feature'''.
#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>
**Spindle cells with large nuclei.
#*Nuclear changes seen in adenomatous polyps - malignant-appearing cells.
***Nuclei ~ size of a plasma cell.
#**Enlarged nuclei.
**Eosinophilic cytoplasm.
#**Chromatin hyperchromatic ''or'' vesicular.
*Nuclear changes seen in adenomatous polyps.
#**Round-shape ''or'' cigar-shaped and pseudostratified.
**Enlarged.
#*Architectural changes - usually those of high-grade dysplasia:
**Chromatin hyperchromatic ''or'' vesicular.
#**Cribriforming - most common.
**Round-shap ''or'' cigar-shaped and pseudostratified.
#**Papillary tufting.
*Architectural changes - usually those of high-grade dysplasia:
#**Budding.
**Cribriforming.
#**Sheeting.
**Papillary tufting.
#*Deep involvement - one of the two following - '''key feature''':
**Budding.
#*#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]].  


DDx:
DDx:
*[[Pseudoinvasion]] - surrounded by lamina propria, desmoplasia lacking, hemosiderin-laden macrophages.
*[[Pseudoinvasion]] - surrounded by lamina propria, desmoplasia lacking, hemosiderin-laden macrophages.
*[[Reactive changes]].


Note:
Note:
*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 }}
*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>
</ref>
====Image====
<gallery>
Image:Cecal_adenocarcinoma.jpg | Colorectal carcinoma. (WC/Nephron)
</gallery>


===Sign out===
===Sign out===
Line 710: Line 478:
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>


Line 716: Line 495:


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=
Line 733: Line 521:


==Juvenile polyp==
==Juvenile polyp==
*[[AKA]] ''retention 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]].
*[[Hyperplastic polyp of the stomach]] - less lamina propria, foveolar hyperplasia (long tortuous glands).
 
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).
 
===Sign out===
<pre>
RECTOSIGMOID POLYP, BIOPSY:
- RETENTION POLYP.
</pre>


==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 837: 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 860: 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 883: 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 893: Line 621:
*[[Small bowel]].
*[[Small bowel]].
*[[Colon]].
*[[Colon]].
*[[Polypectomy]].


=References=
=References=

Latest revision as of 23:51, 18 March 2018

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.

Overview - there are four basic types:[1]

  • Hyperplastic - harmless, most common - 90% of all colonic polyps.[2]
  • Hamartomatous - weriod stuff, syndromic things.
  • Inflammatory - think inflammatory bowel disease, AKA pseudopolyps.
  • Adenomatous - premalignant, several types (see below).

Mnemonic: HHI-A.

Diagnostic variability for colorectal polyps is substantial among community pathologists.[3]

Basic approach

  1. Sessile (flat) or polypoid (spherical, possibly has a stalk)?
  2. Nuclear features of adenoma & loss of goblets (hyperchromatic nuclei, nuclei round vs. flat, loss of nuclear stratification)?
  3. Inflammation?
  4. Serrated architecture?

A set of decision trees for GI polyps

Decision tree - GI polyps

 
 
 
 
 
 
 
 
GI
polyp
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Polypoid
(Lollipop-like)
 
 
 
 
 
 
 
 
Sessile
(flat)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Nuclear changes
 
 
 
No nuc. change
 
 
 
Serrated
 
Not serrated
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Polypoid adenoma
(below)
 
Serrated
 
Not serrated
 
SSA versus HP
 
Normal versus VA
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
HP
 
See misc.
polyps (below)
 
 
 
 
 
 
 
 

Notes:

  • Polypoid:
    • Stalk visible (lollipop handle visible) or epithelial surface on three sides (or more).
  • Sessile (flat):
    • "Line of muscularis mucosa" visible +/- test tube-like intestinal crypts.
  • Nuclear changes:
    • Nuclear enlargement (elongation), crowding/pseudostratification, hyperchromasia (more blue) - especially at the surface, i.e. adjacent to the lumen (as opposed to the base of the crypt).

Decision tree - polypoid adenoma

 
 
 
 
Polypoid adenoma
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Serrated
 
 
 
 
 
Non-serrated
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TSA
 
Tubular arch.
 
Tubulovillous arch.
 
Villous arch.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TA
 
TVA
 
VA

Notes:[4]

  • TA, tubular component >75%.
  • VA, villous component >50%.


Decision tree - miscellaneous polyps

 
 
 
 
 
 
Misc. polyps
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inflam.
 
 
 
 
 
No inflam.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Benign
 
Inflam. p.
 
Hamart.
 
Benign
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PJP
 
Juvenile
 
Other

Notes:


Hamartomatous polyps - basic DDx:

  • Juvenile polyp/Retention polyp -- DIES (dilated glands, incr. LP, eroded surface, stalk).
  • Peutz-Jeghers polyp (PJP) - frond-like with all mucosa components .

"Other" includes diagnoses which require history or tissue surround the polyp. These include the polyps seen in:

Tabular comparison of colonic polyps

Overview in two tables

Common colonic polyps

Type Key feature(s) Details Prevalence / prognosis Other DDx Image
Normal mucosa / no pathology test tubes in a rack-like morphology small nuclei, abundant goblet cells common / benign moderate inflammation is normal missed lesion, colonic spirochetes, cryptosporidiosis, microscopic colitis, CMV colitis
Normal rectum (WC)
Hyperplastic polyp serrated at the surface abundant goblet cells, usu. left colon; no features of SSA common / benign may be syndromic, e.g. hyperplastic polyposis syndrome sessile serrated adenoma
HP (WC)
Traditional adenoma nuclear hyperchromasia & pseudostratification / crowding at the luminal aspect decreased goblet cells, usu. polypoid - on a stalk, usu. left colon common / premalignant tubular adenoma, tubulovillous adenoma, villous adenoma traditional serrated adenoma, reactive changes (inflammation)
TA (WC)

Less common

Type Key feature(s) Details Prevalence / prognosis Other DDx Image
Sessile serrated adenoma (SSA) basal crypt dilation & serration boot-shaped crypts, horizontal crypts, branching crypts uncommon / pre-malignant AKA sessile serrated polyp hyperplastic polyp
SSA (WC)
Traditional serrated adenoma (TSA) nuclear hyperchromasia & pseudostratification / crowding at the surface, serrated, villous-like architecture decreased goblet cells very rare / premalignant called "traditional" to differentiate from SSA traditional serrated adenoma (esp. villous adenoma)
TSA (WC)
Juvenile polyp (retention polyp) dilated glands, increased lamina propria eroded surface (due to trauma), stalk (polypoid), inflammation - common uncommon / benign if in isolation may be part of juvenile polyposis syndrome inflammatory pseudopolyp
Gastric JP (WC)
Inflammatory pseudopolyp inflammation, erosion/ulceration adjacent to polyp loss of mucosa adjacent to pseudopolyp uncommon / seen in IBD, increased risk of malignancy only seen in IBD; Dx implies IBD juvenile polyp
IP (WC)
Peutz-Jeghers polyp (PJP) branching smooth muscle tree-like growth pattern very rare / syndromic; assoc. with cancer PJP not pre-malignant lesion in itself; see Peutz-Jeghers syndrome normal, classically in the small bowel
PJP (WC)

Common problems

Submucosal invasion

  • This may be difficult to assess histomorphologically; these one should show a friend.

Pseudoinvasion

See pseudoinvasion in colorectal adenomatous polyps.

Early invasion

See high risk features in (colorectal) adenomatous polyps with carcinoma.

Adenomatous vs. hyperplastic

Adenomatous polyps & hyperplastic polyps - a comparison (adapted from Li and Burgart[5]):

Attribute Hyperplastic polyp (HP) Sessile serrated adenoma (SSA) Traditional serrated adenoma (TSA) Traditional adenoma
-tubular adenoma
-tubulovillous adenoma
-villous adenoma
Classic location rectum/left colon right colon rectum/left colon rectum/left colon
Morphology polypoid flat (sessile) polypoid polypoid
Cytologic atypia
-Cigar nuclei
-Hyperchromasia
-Nuclear crowding
absent absent present present
Location of worst atypia - - basal luminal
Cytoplasm eosinophilic prominent eosinophilia eosinophilic basophilic
Goblet cells abundant common less common less common
Luminal Serration present common present absent
SSA architecture
-Basal crypt serration
-Basal crypt dilation
-Horizonatal crypts
-Branched crypts
absent present absent absent
Key feature(s) serrated luminal surf. & goblets abnorm. crypt arch. & sessile nuclear atypia & serrated nuclear atypia (luminal)
Image(s)
HP (WC)
SSA (WC)
TSA (WC)
TA (WC)

Normal colonic mucosa:

  • Nuclei - round and basally located.
  • Abundant goblet cells.
  • Moderate inflammation.
  • Paneth cells - present in right colon.
  • Glands - straight, no branching; "test tube" shape.

Notes: Left colon refers to the sigmoid colon, descending colon and the distal half of the transverse colon; right colon refers to the cecum, ascending colon and proximal half of the transverse colon.

Normal

Normal colorectal mucosa

General

  • Endoscopists go after anything that is polypoid... and that may be normal.

Microscopic

Features:

  • Test tube like glands.
  • Minimal palisading.
    • Nuclei <3:1 = height:width.
  • No nuclear pseudostratification. †
  • 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.

Note:

DDx (colorectal mucosa with minimal changes):

Images

www:

Sign out

Normal

Cecum, Biopsy:
- Colorectal-type mucosa within normal limits.
Right Colon, Biopsy:
- Colonic mucosa within normal limits.
Transverse Colon, Biopsy:
- Colonic mucosa within normal limits.
Left Colon, Biopsy:
- Colonic mucosa within normal limits.
Rectum, Biopsy:
- Colorectal mucosa within normal limits.
Block letters
SIGMOID COLON, BIOPSY:
- COLORECTAL-TYPE MUCOSA WITHIN NORMAL LIMITS.
COLON, 70 CM, BIOPSY:
- COLORECTAL-TYPE MUCOSA WITHIN NORMAL LIMITS.
Polypoid fragments
POLYP, SIGMOID COLON, BIOPSY:
- POLYPOID FRAGMENT OF COLORECTAL-TYPE MUCOSA WITHIN NORMAL LIMITS.
Mucosa and submucosa
POLYP, SIGMOID COLON, BIOPSY:
- COLONIC MUCOSA AND SUBMUCOSA WITHIN NORMAL LIMITS.

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.
POLYP, RECTUM, BIOPSY:
- RECTAL MUCOSA WITHIN NORMAL LIMITS WITH A MORPHOLOGICALLY BENIGN LYMPHOID AGGREGATE.
COLON, RIGHT SIDE, BIOPSY:
- COLONIC MUCOSA WITH MORPHOLOGICALLY BENIGN LYMPHOID AGGREGATES,
  NO SIGNIFICANT PATHOLOGY.
Submucosa present
POLYP, ASCENDING COLON, BIOPSY:
- COLONIC MUCOSA AND SUBMUCOSA WITHIN NORMAL LIMITS WITH A MORPHOLOGICALLY BENIGN
LYMPHOID NODULE.

Suspected missed lesion

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.

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

Hyperplastic polyp

The stomach lesion is dealt with in hyperplastic polyp of the stomach.

Inflammatory pseudopolyp

Adenomatous polyps

Overview

Several types of adenomatous polyps are recognized:

  • Traditional adenomas (have three subtypes):
    1. Tubular adenoma - most common, lowest malignant potential.
    2. Tubulovillous adenoma.
    3. Villous adenoma - highest malignant potential.
  • Sessile serrated adenomas:
    • New kid on the block.
  • Traditional serrated adenomas - nuclear features of 'traditional adenoma' + serrated architecture.

Notes:

Management of (adenomatous colonic) polyps

Follow-up interval for polyps (colonoscopy interval):[7]

  • Normal follow-up (includes presence of hyperplastic polyps): ~10 years.
  • 1-2 low risk (adenomatous) polyps: 5-10 years.
  • 3-10 low risk polyps or a high risk polyp: 3 years.
  • >10 low risk polyps: <3 years.
  • Inadequately removed polyps: <6 months.

Classified as high risk polyp (any of the following):[7]

  • Tubulovillous.
  • Villous.
  • High grade dysplasia.
  • Size >= 1 cm.

Mnemonic: GAS = grade (high), architecture (tubulovillous, villous), size (>1 cm).

Note:

  • High risk polyp, as defined above, is also called advanced adenoma;[8] however, it should be noted that there are different definitions for advanced adenoma (e.g. Winawer & Zauber[9] include early invasive tumours). Thus, it is best to avoid the term.

Pseudoinvasion in colorectal adenomatous polyps

  • AKA pseudoinvasion.
  • AKA epithelial misplacement.

High-risk features in (colorectal) adenomatous polyps with carcinoma

Predictors of poor outcome with early submucosal invasion:[10]

  1. High tumour grade.
  2. Lymphovascular invasion.
  3. High-grade tumour budding.
    • Tumour bud = 1-4 cell(s); "high-grade budding" is >=10 tumour buds in a field of 0.385 mm2.[11]
      • If the microscope has a 22 mm eye piece and...
        • A 20x objective, the field is approximately 0.950 mm2 -- to match the buds/area -- it would be 24.68 buds/0.950 mm2.
        • A 40x objective, the field is approximately 0.238 mm2 -- to match the buds/area -- it would be 6.17 buds/0.238 mm2.
  4. Extensive submucosal invasion.
    • >= 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%.[10]

Note:

  • ‡Tumour budding as per international consensus is now assessed in field area of 0.785 mm2.[12]

Traditional adenoma

Includes tubular adenoma, tubulovillous adenoma, and villous adenoma.

Traditional serrated adenoma

Sessile serrated adenoma

Malignant polyps

Colorectal adenocarcinoma

General

  • Diagnosis may be a challenging on a small biopsy.

Clinical

Invasion can be predicted based on endoscopic findings:

Microscopic

One of the two following:

  1. Dysplasia and evidence of invasion - features:[16]
    • Nuclear changes seen in adenomatous polyps - malignant-appearing cells.
      • Enlarged nuclei.
      • Chromatin hyperchromatic or vesicular.
      • Round-shape or cigar-shaped and pseudostratified.
    • Architectural changes - usually those of high-grade dysplasia:
      • Cribriforming - most common.
      • Papillary tufting.
      • Budding.
      • Sheeting.
    • Deep involvement - one of the two following - key feature:
      1. Malignant-appearing cells in the submucosa.
        • Pseudoinvasion must be excluded.
      2. Desmoplastic stromal response.
        • Spindle cells with:
          • Large nuclei (nucleus ~ size of a plasma cell).
          • Eosinophilic cytoplasm.
  2. Signet ring cells.

DDx:

Note:

  • Desmoplastic response is not predictive of submucosal invasion in pedunculated polyps.[17]

Image

Sign out

RECTOSIGMOID TUMOUR, BIOPSY:
- INVASIVE ADENOCARCINOMA, MODERATELY DIFFERENTIATED.
RECTUM, BIOPSY:
- INVASIVE ADENOCARCINOMA, MODERATELY DIFFERENTIATED.
RECTUM, BIOPSY:
- HIGHLY SUSPICIOUS FOR INVASIVE ADENOCARCINOMA, SEE MICROSCOPIC.
- TUBULOVILLOUS ADENOMA WITH HIGH-GRADE DYSPLASIA.

Micro

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).

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

Overview

There are three well known hamartomatous polyp syndromes:[18]

There are two obscure hamartomatous polyp syndromes:[18]

  • Bannayan-Riley-Ruvalcaba syndrome (BRBS).
  • Devon polyposis syndrome (DPS).

Notes:

  • BRBS is due to a PTEN mutation[19] (the same gene associated with Cowden's disease).
  • DPS is reported in only one family that lives in Devon, UK.[20]

Juvenile polyp

Peutz-Jeghers polyp

Cowden disease

  • AKA Cowden syndrome.

General

Etiology:

  • PTEN gene mutation.

Clinical features:[21]

  • Hamartomatous polyps.
  • Facial trichilemmomas (hair follicle root sheath epithelium tumour).
  • Oral papillomas.
  • Acral keratoses (peripheral keratoses).

Note:

  • Lame mnemonic PATH:[22] Papilloma (oral), Acral keratosis, Trichilemmoma, Hamartomatous polyps.

Microscopic

Features:

  • Hamartomatous polyp - features non-specific. (???)

Weird stuff

Cronkhite-Canada syndrome

  • Abbreviated CCS.

Ganglioneuroma

General

Microscopic

Features - see ganglioneuroma:

  • Ganglion cells - key feature.
    • Large cells with a round nucleus and a prominent nucleolus.

DDx:

Images

Inflammatory myoglandular polyp

General

  • Controversial - probably not a distinct pathologic entity.[23]
  • Rare, benign, non-neoplastic.[24]
  • Large bowel, usually rectosigmoid.

Microscopic

Features:[25]

  1. Granulation tissue within the lamina propria.
  2. Lamina propria smooth muscle.
  3. Irregular gland architecture:
    • Cystic dilatation.
    • Tortuosity.

DDx:[23]

Image:

Leiomyoma

  • May present as a polyp in the colon.[26]

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

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.

See also

References

  1. Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 856. ISBN 0-7216-0187-1.
  2. Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 858. ISBN 0-7216-0187-1.
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