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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| 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]]
| [[Image:Hyperplastic_polyp2.jpg|thumb|center|150px| HP (WC)]]
| [[Image:Hyperplastic polyp -- intermed mag.jpg |thumb|center|150px| HP (WC)]]
|-
|-
| [[Traditional adenoma]]
| [[Traditional adenoma]]
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| only seen in [[IBD]]; Dx implies IBD
| only seen in [[IBD]]; Dx implies IBD
| juvenile polyp
| juvenile polyp
| Image
| [[Image:Inflammatory polyp -- low mag.jpg|thumb|center|120px|IP (WC)]]
|-
|-
| [[Peutz-Jeghers polyp]] (PJP)
| [[Peutz-Jeghers polyp]] (PJP)
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| PJP not pre-malignant lesion in itself; see ''[[Peutz-Jeghers syndrome]]''
| PJP not pre-malignant lesion in itself; see ''[[Peutz-Jeghers syndrome]]''
| normal, classically in the small bowel
| normal, classically in the small bowel
| [[Image:Peutz-Jeghers_syndrome_polyp.jpg|thumb|center|150px|PJP (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
! Attribute
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|-
|-
|Image(s)
|Image(s)
| [[Image:Hyperplastic_polyp2.jpg|thumb|center|150px|HP (WC)]]
| [[Image:Hyperplastic polyp -- intermed mag.jpg |thumb|center|150px|HP (WC)]]
| [[Image:Sessile_serrated_adenoma_2_low_mag.jpg|thumb|center|150px|SSA (WC)]]
| [[Image:Sessile_serrated_adenoma_2_low_mag.jpg|thumb|center|150px|SSA (WC)]]
| [[Image:Traditional_serrated_adenoma_low_mag.jpg|thumb|center|150px|TSA (WC)]]
| [[Image:Traditional_serrated_adenoma_low_mag.jpg|thumb|center|150px|TSA (WC)]]
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*Abundant goblet cells.
*Abundant goblet cells.
*Moderate inflammation.
*Moderate inflammation.
*Paneth 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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====Images====
====Images====
<gallery>
<gallery>
Image:Tubular_adenoma_2_intermed_mag.jpg| Normal colon adjacent to a tubular adenoma. (WC/Nephron)
Image:Rectum - low mag.jpg | Rectum - low mag. (WC)
Image:Rectum - intermed mag.jpg | Rectum - intermed. mag. (WC)
Image:Rectum - alt - intermed mag.jpg | Rectum - intermed. mag. (WC)
Image:Rectum - high mag.jpg | Rectum - high mag. (WC)
</gallery>
</gallery>
www:
www:
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===Sign out===
===Sign out===
====Normal====
====Normal====
<pre>
Cecum, Biopsy:
- Colorectal-type mucosa within normal limits.
</pre>
<pre>
Right Colon, Biopsy:
- Colonic mucosa within normal limits.
</pre>
<pre>
Transverse Colon, Biopsy:
- Colonic mucosa within normal limits.
</pre>
<pre>
Left Colon, Biopsy:
- Colonic mucosa within normal limits.
</pre>
<pre>
Rectum, Biopsy:
- Colorectal mucosa within normal limits.
</pre>
=====Block letters=====
<pre>
<pre>
SIGMOID COLON, BIOPSY:
SIGMOID COLON, BIOPSY:
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COLON, 70 CM, BIOPSY:
COLON, 70 CM, BIOPSY:
- COLORECTAL-TYPE MUCOSA WITHIN NORMAL LIMITS.
- COLORECTAL-TYPE MUCOSA WITHIN NORMAL LIMITS.
</pre>
=====Polypoid fragments=====
<pre>
POLYP, SIGMOID COLON, BIOPSY:
- POLYPOID FRAGMENT OF COLORECTAL-TYPE MUCOSA WITHIN NORMAL LIMITS.
</pre>
</pre>


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====Lymphoid nodule present====
====Lymphoid nodule present====
*Lymphoid nodules manifest endoscopically as a small polypoid protuberances. It is worthwhile to report the presence of lymphoid nodules as they reassure the endoscopist that they probably sampled the abnormality they saw.
<pre>
POLYP, RECTUM, BIOPSY:
- RECTAL MUCOSA WITHIN NORMAL LIMITS WITH A MORPHOLOGICALLY BENIGN LYMPHOID AGGREGATE.
</pre>
<pre>
COLON, RIGHT SIDE, BIOPSY:
- COLONIC MUCOSA WITH MORPHOLOGICALLY BENIGN LYMPHOID AGGREGATES,
  NO SIGNIFICANT PATHOLOGY.
</pre>
=====Submucosa present=====
<pre>
<pre>
POLYP, ASCENDING COLON, BIOPSY:
POLYP, ASCENDING COLON, BIOPSY:
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</pre>
</pre>


Note:
*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.
====Suspected missed lesion====
====Suspected missed lesion====
<pre>
<pre>
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COMMENT:
COMMENT:
The clinical history is noted. This biopsy does not show neoplastic tissue; however, the
The clinical history is noted. This biopsy does not show neoplastic tissue;  
biopsy may not be representative of the lesion seen.
however, the biopsy may not be representative of the lesion seen.


Levels were cut and these did not yield additional information. There are no changes to
Levels were cut and these did not yield additional information. There are  
suggest a chronic colitis.
no changes to suggest a chronic colitis.


Correlation with imaging may be useful. A re-biopsy is suggested.
Correlation with imaging may be useful. A re-biopsy is suggested.
</pre>
</pre>


==Fecal material==
====Micro - suspected IBD====
:''Fecal matter'' redirects here.
The sections show colorectal-type mucosa. The glands show no significant architectural
===General===
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.
*Common.
*Associated with poor bowel preparation.
*Endoscopists go after anything that is polypoid and that may be nothing more than poo.
 
===Microscopic===
Features:
*Plant material:
**Yellow staining chicken wire-like material - may be linear.
***Thick cell walls often without cytoplasm and usually without a nucleus.
*Meat:
**Eosinophilic honeycomb-like material without nuclei and without inflammation.
***Essentially ischemic skeletal muscle without inflammation.
*+/-Microorganisms.
*+/-Inflammatory cells.


DDx:
====Rare PMNs - no cryptitis====
*Necrosis.
The sections show colorectal mucosa with rare lymphoid aggregates. The architecture is
**[[Gastrointestinal tract polyps#Colorectal adenocarcinoma|Colorectal adenocarcinoma]].
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.


===Sign out===
==Fecal material==
<pre>
{{Main|Fecal material}}
TRANSVERSE COLON, BIOPSY:
- FECAL MATERIAL.
- NO DEFINITE COLONIC MUCOSA IDENTIFIED.
</pre>
 
====Rectum====
<pre>
RECTUM, BIOPSY:
- FECAL MATERIAL.
- NO DEFINITE RECTAL MUCOSA IDENTIFIED.
</pre>


=Hyperplastic polyp=
=Hyperplastic polyp=
:''The [[stomach]] lesion is dealt with in [[hyperplastic polyp of the stomach]]''.
:''The [[stomach]] lesion is dealt with in [[hyperplastic polyp of the stomach]]''.
*Abbreviated ''HP''.
{{Main|Hyperplastic polyp}}
===General===
*Most common type of polyp:
**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>
 
===Gross===
Features:<ref name=pmid22710576>{{Cite journal  | last1 = Rex | first1 = DK. | last2 = Ahnen | first2 = DJ. | last3 = Baron | first3 = JA. | last4 = Batts | first4 = KP. | last5 = Burke | first5 = CA. | last6 = Burt | first6 = RW. | last7 = Goldblum | first7 = JR. | last8 = Guillem | first8 = JG. | last9 = Kahi | first9 = CJ. | title = Serrated lesions of the colorectum: review and recommendations from an expert panel. | journal = Am J Gastroenterol | volume = 107 | issue = 9 | pages = 1315-29; quiz 1314, 1330 | month = Sep | year = 2012 | doi = 10.1038/ajg.2012.161 | PMID = 22710576 }}</ref>
*Flat lesion, usually <= 5mm.
*Typically in the distal large bowel (rectum, sigmoid colon).
 
===Microscopic===
Features:<ref name=Ref_PBoD858/>
*Irregular crypt architecture - tortuosity.
*Serrated epithelial cells (at the surface of the gland) - only colorectal polyps - '''key feature'''.
**''Serrated'' appearance = ''saw-tooth'' appearance, epithelium has jagged edge.
 
Notes:
*Significant negatives:
**No nuclear atypia; glands ''d''arker staining ''d''eep... ''l''ighter staining ''l''uminal.
**In the colon goblet cells should be present (as is usual).
*Inflammation -- cryptitis or even crypt abscesses -- is considered to arise due to trauma.{{fact}}
**It is usually ''not'' reported.
 
DDx:
*[[Sessile serrated adenoma]].
*[[Normal colon]].
 
====Images====
<gallery>
Image:Hyperplastic_polyp1.jpg | HP - high mag. (WC/Nephron)
Image:Hyperplastic_polyp2.jpg | HP - lower mag. (WC/Nephron)
Image:Hyperplastic_polyp_of_the_colon,_HE.jpg | HP (WC/Patho)
</gallery>
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====
*Usually '''not subclassified''' as there is no demonstrated prognostic significance;<ref name=pmid21045813/> the subtyping is an academic exercise.
 
HPs may be subclassified into two groups:<ref name=pmid21045813/>
#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>
COLONIC POLYP, 35 CM, BIOPSY:
- HYPERPLASTIC POLYP.
</pre>
 
<pre>
COLONIC POLYP, SIGMOID COLON, BIOPSY:
- HYPERPLASTIC POLYP.
</pre>
 
<pre>
POLYP, RECTUM, BIOPSY:
- HYPERPLASTIC POLYP.
</pre>
 
=====Numerous hyperplastic polyps=====
<pre>
COLONIC POLYP(S), BIOPSY:
- HYPERPLASTIC POLYP, SEE COMMENT. 
 
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>
 
====Micro====
=====Goblet cell type=====
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.
 
=====Generic=====
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.


=Inflammatory pseudopolyp=
=Inflammatory pseudopolyp=
*[[AKA]] ''inflammatory polyp''.
{{Main|Inflammatory pseudopolyp}}
===General===
*Not a true polyp.
*The label ''inflammatory pseudopolyp'' = [[inflammatory bowel disease]] (IBD).
**If there is no history of IBD... reconsider the diagnosis.
 
===Microscopic===
Features:
*Polypoid shape.
*Inflammation - esp. neutrophils - '''key feature'''.
 
Negatives:
*No nuclear atypia.
**May have focal nuclear hyperchromasia and nuclear enlargement.
*No dilated glands.
 
DDx:
*[[Juvenile polyp]].
*[[Solitary rectal ulcer]].
 
Images:
*[http://www.humpath.com/spip.php?article8234&id_document=18554 Pseudopolyp (humpath.com)].
*[http://missinglink.ucsf.edu/lm/IDS_106_LowerGI/Lower_GI_histo_small/24-UC-pseudoplp.jpg Pseudopolyp (ucsf.edu)].
 
===Sign out===
<pre>
SIGMOID COLON POLYP, PERI-DIVERTICULAR, BIOPSY:
- INFLAMMATORY PSEUDOPOLYP.
</pre>
 
====Micro====
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.


=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 - classic:<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>
#Dysplastic glands surrounded by lamina propria.
#Hemosiderin.
#Lack of [[desmoplastic reaction]].
*+/-Cystic spaces with rounded contours without cells floating in them.
 
Memory device (classic features) ''LDH'':
*'''L'''amina propria.
*'''D'''esmoplasia lacking.
*'''H'''emosiderin.
 
DDx:
*[[Gastrointestinal_tract_polyps#Colorectal_adenocarcinoma|Colorectal adenocarcinoma]].
 
===Sign out===
<pre>
COLON POLYP, SIGMOID COLON AT 45 CM, EXCISION:
- TUBULAR ADENOMA.
-- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
- SUBMUCOSA PRESENT, NO EVIDENCE OF INVASION.
- ABUNDANT HEMOSIDERIN-LADEN MACROPHAGES.
</pre>


==High-risk features in (colorectal) adenomatous polyps with carcinoma==
==High-risk features in (colorectal) adenomatous polyps with carcinoma==
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#[[Lymphovascular invasion]].
#[[Lymphovascular invasion]].
#High-grade [[tumour budding]].
#High-grade [[tumour budding]].
#*Tumour bud = 1-4 cell(s); "high-grade budding" is >=10 tumour buds in a field of 0.385 mm<sup>2</sup>.<ref name=pmid11952856>{{Cite journal  | last1 = Ueno | first1 = H. | last2 = Murphy | first2 = J. | last3 = Jass | first3 = JR. | last4 = Mochizuki | first4 = H. | last5 = Talbot | first5 = IC. | title = Tumour 'budding' as an index to estimate the potential of aggressiveness in rectal cancer. | journal = Histopathology | volume = 40 | issue = 2 | pages = 127-32 | month = Feb | year = 2002 | doi =  | PMID = 11952856 }}</ref>
#*Tumour bud = 1-4 cell(s); "high-grade budding" is >=10 tumour buds in a field of 0.385 mm<sup>2</sup>.<ref name=pmid11952856>{{Cite journal  | last1 = Ueno | first1 = H. | last2 = Murphy | first2 = J. | last3 = Jass | first3 = JR. | last4 = Mochizuki | first4 = H. | last5 = Talbot | first5 = IC. | title = Tumour 'budding' as an index to estimate the potential of aggressiveness in rectal cancer. | journal = Histopathology | volume = 40 | issue = 2 | pages = 127-32 | month = Feb | year = 2002 | doi =  | PMID = 11952856 }}</ref>‡
#**If the microscope has a 22 mm eye piece and...  
#**If the microscope has a 22 mm eye piece and...  
#***A 20x objective, the field is approximately 0.950 mm<sup>2</sup> -- to match the area/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==
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==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====
<gallery>
Image:Traditional_serrated_adenoma_low_mag.jpg | TSA - low mag. (WC/Nephron)
Image:Traditional_serrated_adenoma_intermed_mag.jpg | TSA - intermed. mag. (WC/Nephron)
Image:Traditional_serrated_adenoma_very_high_mag.jpg | TSA - very high mag. (WC/Nephron)
</gallery>
==Sessile serrated adenoma==
==Sessile serrated adenoma==
{{Main|Sessile serrated adenoma}}
{{Main|Sessile serrated adenoma}}
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RECTOSIGMOID TUMOUR, BIOPSY:
RECTOSIGMOID TUMOUR, BIOPSY:
- INVASIVE ADENOCARCINOMA, MODERATELY DIFFERENTIATED.
- INVASIVE ADENOCARCINOMA, MODERATELY DIFFERENTIATED.
</pre>
<pre>
RECTUM, BIOPSY:
- INVASIVE ADENOCARCINOMA, MODERATELY DIFFERENTIATED.
</pre>
<pre>
RECTUM, BIOPSY:
- HIGHLY SUSPICIOUS FOR INVASIVE ADENOCARCINOMA, SEE MICROSCOPIC.
- TUBULOVILLOUS ADENOMA WITH HIGH-GRADE DYSPLASIA.
</pre>
</pre>


Line 629: 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 646: 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).
*[[Cronkhite-Canada syndrome]] - have changes in the surrounding mucosa, clinical findings (nail atrophy, skin pigment, alopecia).
 
====Images====
www:
*[http://www.nature.com/modpathol/journal/v16/n4/fig_tab/3880773f4.html Juvenile polyp (nature.com)].
<gallery>
Image:Gastric_juvenile_polyp_-_very_low_mag.jpg | Juvenile polyp of the stomach - very low mag. (WC/Nephron)
Image:Gastric_juvenile_polyp_-_2_-_very_low_mag.jpg | Juvenile polyp of the stomach - very low mag. (WC/Nephron)
</gallery>
===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====
<gallery>
Image:Peutz-Jeghers_syndrome_polyp.jpg | Peutz-Jeghers polyp - intestine (WC/Nephron)
Image:Gastric_Peutz-Jeghers_polyp_-_very_low_mag.jpg | Peutz-Jeghers polyp - stomach (WC/Nephron)
</gallery>
www:
*[http://www.nature.com/modpathol/journal/v16/n4/fig_tab/3880773f3.html Peutz-Jeghers polyp (nature.com)].
 
===Sign out===
====Duodenum====
<pre>
POLYPS, DUODENUM, EXCISION:
- PEUTZ-JEGHERS POLYPS (x2) WITH BRUNNER'S GLANDS.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.
</pre>
 
====Colon====
<pre>
POLYP, COLON (40 CM), EXCISION:
- PEUTZ-JEGHERS POLYP.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.
</pre>


==Cowden disease==
==Cowden disease==
Line 771: 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]]s/retension polyps.
*Crypt dilation and edema in non-polypoid mucosa<ref>{{Ref PCPBoD8|430}}</ref> - '''key feature'''.
 
DDx:
*[[Juvenile polyp]].
 
Images:
*[http://www.surgicalpathologyatlas.com/glfusion/mediagallery/media.php?f=0&sort=0&s=20090508151729401 CCS (surgicalpathologyatlas.com)].


==Ganglioneuroma==
==Ganglioneuroma==
Line 796: Line 559:
*Ganglion cells - '''key feature'''.
*Ganglion cells - '''key feature'''.
**Large cells with a round nucleus and a prominent nucleolus.
**Large cells with a round nucleus and a prominent nucleolus.
DDx:
*[[Hyperplastic polyp with perineuromatous stroma]].


====Images====
====Images====
Line 803: Line 569:
Image:Ganglioneuroma_-_very_high_mag.jpg | Ganglioneuroma - very high mag. (WC/Nephron)
Image:Ganglioneuroma_-_very_high_mag.jpg | Ganglioneuroma - very high mag. (WC/Nephron)
</gallery>
</gallery>
==Inflammatory myoglandular polyp==
==Inflammatory myoglandular polyp==
===General===
===General===
Line 821: 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 831: Line 621:
*[[Small bowel]].
*[[Small bowel]].
*[[Colon]].
*[[Colon]].
*[[Polypectomy]].


=References=
=References=

Latest revision as of 23:51, 18 March 2018

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.

Endoscopic image of a gastrointestinal polyp.

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

  • Rectum - low mag. (WC)

  • Rectum - intermed. mag. (WC)

  • Rectum - intermed. mag. (WC)

  • Rectum - high mag. (WC)

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

Main article: Fecal material

Hyperplastic polyp

The stomach lesion is dealt with in hyperplastic polyp of the stomach.
Main article: Hyperplastic polyp

Inflammatory pseudopolyp

Main article: 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.
Main article: Pseudoinvasion in colorectal adenomatous polyps

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.
Main article: Traditional adenoma

Traditional serrated adenoma

Main article: Traditional serrated adenoma

Sessile serrated adenoma

Main article: Sessile serrated adenoma

Malignant polyps

Colorectal adenocarcinoma

Main article: 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

  • Colorectal carcinoma. (WC/Nephron)

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

Main article: Juvenile polyp

Peutz-Jeghers polyp

Main article: Peutz-Jeghers polyp

Cowden disease

Main article: Cowden syndrome
  • 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.
Main article: Cronkhite-Canada syndrome

Ganglioneuroma

Main article: Ganglioneuroma

General

Microscopic

Features - see ganglioneuroma:

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

DDx:

Images

  • Ganglioneuroma - intermed. mag. (WC/Nephron)

  • Ganglioneuroma - high mag. (WC/Nephron)

  • Ganglioneuroma - very high mag. (WC/Nephron)

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

Main article: Colonic leiomyoma
Main article: 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.
  3. ↑ Rex, DK.; Alikhan, M.; Cummings, O.; Ulbright, TM. (Oct 1999). "Accuracy of pathologic interpretation of colorectal polyps by general pathologists in community practice.". Gastrointest Endosc 50 (4): 468-74. PMID 10502165.
  4. ↑ 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. 860. ISBN 0-7216-0187-1.
  5. ↑ Li SC, Burgart L (March 2007). "Histopathology of serrated adenoma, its variants, and differentiation from conventional adenomatous and hyperplastic polyps". Arch. Pathol. Lab. Med. 131 (3): 440-5. PMID 17516746. http://journals.allenpress.com/jrnlserv/?request=get-abstract&issn=0003-9985&volume=131&page=440.
  6. ↑ URL: http://www.lab.anhb.uwa.edu.au/mb140/CorePages/GIT/git.htm. Accessed on: 18 October 2012.
  7. ↑ 7.0 7.1 Levine JS, Ahnen DJ (December 2006). "Clinical practice. Adenomatous polyps of the colon". N. Engl. J. Med. 355 (24): 2551–7. doi:10.1056/NEJMcp063038. PMID 17167138. http://content.nejm.org/cgi/reprint/355/24/2551.pdf.
  8. ↑ Laiyemo, AO.; Murphy, G.; Albert, PS.; Sansbury, LB.; Wang, Z.; Cross, AJ.; Marcus, PM.; Caan, B. et al. (Mar 2008). "Postpolypectomy colonoscopy surveillance guidelines: predictive accuracy for advanced adenoma at 4 years.". Ann Intern Med 148 (6): 419-26. PMID 18347350.
  9. ↑ Winawer, SJ.; Zauber, AG. (Jan 2002). "The advanced adenoma as the primary target of screening.". Gastrointest Endosc Clin N Am 12 (1): 1-9, v. PMID 11916153.
  10. ↑ 10.0 10.1 Ueno, H.; Mochizuki, H.; Hashiguchi, Y.; Shimazaki, H.; Aida, S.; Hase, K.; Matsukuma, S.; Kanai, T. et al. (Aug 2004). "Risk factors for an adverse outcome in early invasive colorectal carcinoma.". Gastroenterology 127 (2): 385-94. PMID 15300569.
  11. ↑ Ueno, H.; Murphy, J.; Jass, JR.; Mochizuki, H.; Talbot, IC. (Feb 2002). "Tumour 'budding' as an index to estimate the potential of aggressiveness in rectal cancer.". Histopathology 40 (2): 127-32. PMID 11952856.
  12. ↑ Lugli, A.; Kirsch, R.; Ajioka, Y.; Bosman, F.; Cathomas, G.; Dawson, H.; El Zimaity, H.; Fléjou, JF. et al. (Sep 2017). "Recommendations for reporting tumor budding in colorectal cancer based on the International Tumor Budding Consensus Conference (ITBCC) 2016.". Mod Pathol 30 (9): 1299-1311. doi:10.1038/modpathol.2017.46. PMID 28548122.
  13. ↑ Onishi, T.; Tamura, S.; Kuratani, Y.; Onishi, S.; Yasuda, N. (2008). "Evaluation of the depth score of type V pit patterns in crypt orifices of colorectal neoplastic lesions.". J Gastroenterol 43 (4): 291-7. doi:10.1007/s00535-008-2161-1. PMID 18458845.
  14. ↑ Uno, Y.; Munakata, A.. "The non-lifting sign of invasive colon cancer.". Gastrointest Endosc 40 (4): 485-9. PMID 7926542.
  15. ↑ Ishiguro, A.; Uno, Y.; Ishiguro, Y.; Munakata, A.; Morita, T. (Sep 1999). "Correlation of lifting versus non-lifting and microscopic depth of invasion in early colorectal cancer.". Gastrointest Endosc 50 (3): 329-33. doi:10.1053/ge.1999.v50.98591. PMID 10462651.
  16. ↑ Kimura, R.; Fujimori, T.; Ichikawa, K.; Ajioka, Y.; Ueno, H.; Ohkura, Y.; Kashida, H.; Togashi, K. et al. (Aug 2012). "Desmoplastic reaction in biopsy specimens of early colorectal cancer: a Japanese prospective multicenter study.". Pathol Int 62 (8): 525-31. doi:10.1111/j.1440-1827.2012.02840.x. PMID 22827760.
  17. ↑ Hirose, M.; Fukui, H.; Igarashi, Y.; Fujimori, Y.; Katake, Y.; Sekikawa, A.; Ichikawa, K.; Tomita, S. et al. (Dec 2010). "Detection of desmoplastic reaction in biopsy specimens is useful for predicting the depth of invasion of early colorectal cancer: a Japanese collaborative study.". J Gastroenterol 45 (12): 1212-8. doi:10.1007/s00535-010-0288-3. PMID 20665053.
  18. ↑ 18.0 18.1 Iacobuzio-Donahue, Christine A.; Montgomery, Elizabeth A. (2005). Gastrointestinal and Liver Pathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 345. ISBN 978-0443066573.
  19. ↑ Online 'Mendelian Inheritance in Man' (OMIM) 153480
  20. ↑ Allibone, RO.; Nanson, JK.; Anthony, PP. (Jul 1992). "Multiple and recurrent inflammatory fibroid polyps in a Devon family ('Devon polyposis syndrome'): an update.". Gut 33 (7): 1004-5. PMID 1644320.
  21. ↑ 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. 858-9. ISBN 0-7216-0187-1.
  22. ↑ URL: http://www.pathologyexpert.com/boards/onlinefiles/syndromes.htm. Accessed on: 6 December 2011.
  23. ↑ 23.0 23.1 Bhathal, PS.; Chetty, R.; Slavin, JL. (Aug 1993). "Myoglandular polyps.". Am J Surg Pathol 17 (8): 852-3. PMID 8338196.
  24. ↑ 24.0 24.1 Meniconi, RL.; Caronna, R.; Benedetti, M.; Fanello, G.; Ciardi, A.; Schiratti, M.; Papini, F.; Farelli, F. et al. (2010). "Inflammatory myoglandular polyp of the cecum: case report and review of literature.". BMC Gastroenterol 10: 10. doi:10.1186/1471-230X-10-10. PMC 2828397. PMID 20102635. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2828397/.
  25. ↑ Nakamura, S.; Kino, I.; Akagi, T. (Aug 1992). "Inflammatory myoglandular polyps of the colon and rectum. A clinicopathological study of 32 pedunculated polyps, distinct from other types of polyps.". Am J Surg Pathol 16 (8): 772-9. PMID 1309176.
  26. ↑ Kemp, CD.; Arnold, CA.; Torbenson, MS.; Stein, EM. (2011). "An unusual polyp: a pedunculated leiomyoma of the sigmoid colon.". Endoscopy 43 Suppl 2 UCTN: E306-7. doi:10.1055/s-0030-1256640. PMID 21915840.

External links

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