Gastrointestinal tract polyps: Difference between revisions

{{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 | | | | | M | | N | | | | | | | | |M=[[Hyperplastic polyp|HP]]|N=See misc.<br>polyps (below)}}

{{familytree | D | | E | | F | | G |D=[[Traditional serrated adenoma|TSA]]|E=Tubular arch.|F=Tubulovillous arch.|G=Villous arch.}}

{{familytree | | | | | H | | I | | J |H=[[Tubular adenoma of the gastrointestinal tract|TA]]|I=[[Tubulovillous adenoma|TVA]]|J=[[Villous adenoma|VA]]}}

{{familytree | | | | | H | | I | | J |H=[[Peutz-Jeghers polyp|PJP]]|I=[[Juvenile polyp|Juvenile]]|J=Other}}

*[[Juvenile polyp]]s may have marked inflammation.

===Common colonic polyps===

{| class="wikitable sortable"

! Type

! Key feature(s)

! Details

! Prevalence / prognosis

! Other

! [[DDx]]

! Image

| [[Normal colorectal mucosa|Normal mucosa]] / no pathology

| test tubes in a rack-like morphology

| missed lesion, [[colonic spirochetes]], [[cryptosporidiosis]], [[microscopic colitis]], [[CMV colitis]]

| [[Image:Rectum - intermed mag.jpg|thumb|center|150px| Normal rectum (WC)]]

| [[Hyperplastic polyp]]

| abundant goblet cells, usu. left colon; no features of [[SSA]]

| may be syndromic, e.g. [[hyperplastic polyposis syndrome]]

| [[sessile serrated adenoma]]

| [[Image:Hyperplastic polyp -- intermed mag.jpg |thumb|center|150px| HP (WC)]]

| [[Traditional adenoma]]

| [[tubular adenoma of the gastrointestinal tract|tubular adenoma]], [[tubulovillous adenoma]], [[villous adenoma]]

| [[traditional serrated adenoma]], reactive changes (inflammation)

| [[Image:Tubular_adenoma_4_low_mag.jpg|thumb|center|150px| TA (WC)]]

{| class="wikitable sortable"

! Type

! Key feature(s)

! Details

! Prevalence / prognosis

! Other

! DDx

! Image

| [[Sessile serrated adenoma]] (SSA)

| [[Image:Sessile_serrated_adenoma_2_low_mag.jpg|thumb|center|150px|SSA (WC)]]

| [[Traditional serrated adenoma]] (TSA)

| [[Image:Traditional_serrated_adenoma_low_mag.jpg|thumb|center|150px|TSA (WC)]]

| [[Juvenile polyp]] (retention polyp)

| [[Image:Gastric_juvenile_polyp_-_very_low_mag.jpg|thumb|center|150px|Gastric JP (WC)]]

| [[Inflammatory pseudopolyp]]

| inflammation, [[erosion]]/ulceration adjacent to polyp

| [[Image:Inflammatory polyp -- low mag.jpg|thumb|center|120px|IP (WC)]]

| [[Peutz-Jeghers polyp]] (PJP)

| [[Image:Peutz-Jeghers_syndrome_polyp.jpg|thumb|center|120px|PJP (WC)]]

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

:See ''[[Gastrointestinal_tract_polyps#Pseudoinvasion_in_colorectal_adenomatous_polyps|pseudoinvasion in colorectal adenomatous polyps]]''.

:See ''[[Gastrointestinal_tract_polyps#High-risk_features_in_.28colorectal.29_adenomatous_polyps_with_carcinoma|high risk features in (colorectal) adenomatous polyps with carcinoma]]''.

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>):  

! Attribute

! Hyperplastic polyp (HP)

! Sessile serrated adenoma (SSA)

! Traditional serrated adenoma (TSA)

! Traditional adenoma'''<br>-tubular adenoma<br>-tubulovillous adenoma<br>-villous adenoma

| [[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:Traditional_serrated_adenoma_low_mag.jpg|thumb|center|150px|TSA (WC)]]

|[[Image:Tubular_adenoma_2_low_mag.jpg|thumb|center|150px|TA (WC)]]

*[[Paneth cell]]s - present in right colon.

=Normal=

==Normal colorectal mucosa==

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

 

 

 

 

Image:Rectum - high mag.jpg | Rectum - high mag. (WC)

*[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>

 

====Normal====

</pre>

 

 

 

 

 

 

 

- POLYPOID FRAGMENT OF COLORECTAL-TYPE MUCOSA WITHIN NORMAL LIMITS.

=====Mucosa and submucosa=====

<pre>

POLYP, SIGMOID COLON, BIOPSY:

- COLONIC MUCOSA AND SUBMUCOSA WITHIN NORMAL LIMITS.

*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.

 

 

=====Submucosa present=====

LYMPHOID NODULE.

 

====Suspected missed lesion====

 

 

no changes to suggest a chronic colitis.

 

 

====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.

 

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==

:''The [[stomach]] lesion is dealt with in [[hyperplastic polyp of the stomach]]''.

=Adenomatous polyps=

==Overview==

**New kid on the block.

*If multiple... think about [[familial adenomatous polyposis]] (FAP), attenuated FAP, [[MUTYH polyposis syndrome]], [[serrated polyposis syndrome]].

===Management of (adenomatous colonic) polyps===

Classified as ''high risk polyp'' (any of the following):<ref name=pmid17167138/>

*''High risk polyp'', as defined above, is also called '''advanced adenoma''';<ref name=pmid18347350>{{Cite journal  | last1 = Laiyemo | first1 = AO. | last2 = Murphy | first2 = G. | last3 = Albert | first3 = PS. | last4 = Sansbury | first4 = LB. | last5 = Wang | first5 = Z. | last6 = Cross | first6 = AJ. | last7 = Marcus | first7 = PM. | last8 = Caan | first8 = B. | last9 = Marshall | first9 = JR. | title = Postpolypectomy colonoscopy surveillance guidelines: predictive accuracy for advanced adenoma at 4 years. | journal = Ann Intern Med | volume = 148 | issue = 6 | pages = 419-26 | month = Mar | year = 2008 | doi =  | PMID = 18347350 | URL = http://www.annals.org/content/148/6/419.full.pdf }}</ref> however, it should be noted that there are different definitions for ''advanced adenoma'' (e.g. ''Winawer & Zauber''<ref name=pmid11916153>{{Cite journal  | last1 = Winawer | first1 = SJ. | last2 = Zauber | first2 = AG. | title = The advanced adenoma as the primary target of screening. | journal = Gastrointest Endosc Clin N Am | volume = 12 | issue = 1 | pages = 1-9, v | month = Jan | year = 2002 | doi =  | PMID = 11916153 }}</ref> include early invasive tumours). Thus, it is best to avoid the term.

*[[AKA]] ''pseudoinvasion''.

*[[AKA]] ''epithelial misplacement''.

{{Main|Pseudoinvasion in colorectal adenomatous polyps}}

Predictors of poor outcome with early submucosal invasion:<ref name=pmid15300569>{{Cite journal  | last1 = Ueno | first1 = H. | last2 = Mochizuki | first2 = H. | last3 = Hashiguchi | first3 = Y. | last4 = Shimazaki | first4 = H. | last5 = Aida | first5 = S. | last6 = Hase | first6 = K. | last7 = Matsukuma | first7 = S. | last8 = Kanai | first8 = T. | last9 = Kurihara | first9 = H. | title = Risk factors for an adverse outcome in early invasive colorectal carcinoma. | journal = Gastroenterology | volume = 127 | issue = 2 | pages = 385-94 | month = Aug | year = 2004 | doi =  | PMID = 15300569 }}</ref>

#[[Lymphovascular invasion]].

#High-grade [[tumour budding]].

#*Tumour bud = 1-4 cell(s); "high-grade budding" is >=10 tumour buds in a field of 0.385 mm².<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...  

#***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.

#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%.<ref name=pmid15300569/>

Note:

*‡Tumour budding as per international consensus is now assessed in field area of 0.785 mm².<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==

:''Includes '''tubular adenoma''', '''tubulovillous adenoma''', and '''villous adenoma'''.''

{{Main|Sessile serrated adenoma}}

=Malignant polyps=

==Colorectal adenocarcinoma==

*Diagnosis may be a challenging on a small biopsy.

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===

#*Nuclear changes seen in adenomatous polyps - malignant-appearing cells.

#**Enlarged nuclei.

#**Round-shape ''or'' cigar-shaped and pseudostratified.

#**Cribriforming - most common.

#**Papillary tufting.

#**Budding.

#*#Malignant-appearing cells in the submucosa.

#*#**Large nuclei (nucleus ~ size of a plasma cell).

#[[Signet ring cell carcinoma|Signet ring cells]].  

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

*[[Reactive changes]].

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 }}

</ref>

====Image====

Image:Cecal_adenocarcinoma.jpg | 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.

</pre>

====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).

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.

There are three well known hamartomatous polyp syndromes:<ref name=Ref_GLP345>{{Ref GLP|345}}</ref>  

There are two obscure hamartomatous polyp syndromes:<ref name=Ref_GLP345>{{Ref GLP|345}}</ref>

*Devon polyposis syndrome (DPS).

Notes:

*BRBS is due to a PTEN mutation<ref name=omim153480>{{OMIM|153480}}</ref> (the same gene associated with Cowden's disease).

*DPS is reported in only one family that lives in Devon, UK.<ref name=pmid1644320>{{Cite journal  | last1 = Allibone | first1 = RO. | last2 = Nanson | first2 = JK. | last3 = Anthony | first3 = PP. | title = Multiple and recurrent inflammatory fibroid polyps in a Devon family ('Devon polyposis syndrome'): an update. | journal = Gut | volume = 33 | issue = 7 | pages = 1004-5 | month = Jul | year = 1992 | doi =  | PMID = 1644320 }}</ref>

{{Main|Juvenile polyp}}

{{Main|Peutz-Jeghers polyp}}

Etiology:  

*PTEN gene mutation.

Clinical features:<ref name=Ref_PBoD858-9>{{Ref PBoD|858-9}}</ref>

 

 

 

*Rare, benign, non-neoplastic.<ref name=pmid20102635>{{Cite journal  | last1 = Meniconi | first1 = RL. | last2 = Caronna | first2 = R. | last3 = Benedetti | first3 = M. | last4 = Fanello | first4 = G. | last5 = Ciardi | first5 = A. | last6 = Schiratti | first6 = M. | last7 = Papini | first7 = F. | last8 = Farelli | first8 = F. | last9 = Dinatale | first9 = G. | title = Inflammatory myoglandular polyp of the cecum: case report and review of literature. | journal = BMC Gastroenterol | volume = 10 | issue =  | pages = 10 | month =  | year = 2010 | doi = 10.1186/1471-230X-10-10 | PMID = 20102635 | PMC = 2828397 | URL = http://www.biomedcentral.com/1471-230X/10/10 }}</ref>

 

Features:<ref name=pmid1309176>{{Cite journal  | last1 = Nakamura | first1 = S. | last2 = Kino | first2 = I. | last3 = Akagi | first3 = T. | title = Inflammatory myoglandular polyps of the colon and rectum. A clinicopathological study of 32 pedunculated polyps, distinct from other types of polyps. | journal = Am J Surg Pathol | volume = 16 | issue = 8 | pages = 772-9 | month = Aug | year = 1992 | doi =  | PMID = 1309176 }}</ref>

 

DDx:<ref name=pmid8338196/>

*[[Mucosal prolapse syndrome]].

*[[Inflammatory cloacogenic polyp]].

*[[Inflammatory cap polyp]].

 

*[http://www.biomedcentral.com/1471-230X/10/10/figure/F3 IMP (biomedcentral.com)].<ref name=pmid20102635/>

 

*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>

*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.

 

<pre>

 

</pre>