Difference between revisions of "Traditional adenoma"

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{{ Infobox diagnosis
{{ Infobox diagnosis
| Name      = Tubular adenoma, tubulovillous adenoma, villous adenoma
| Name      = {{PAGENAME}}
| Image      = Tubular adenoma 4 high mag.jpg
| Image      = Tubular adenoma 4 high mag.jpg
| Width      =  
| Width      =  
| Caption    = Tubular adenoma. [[H&E stain]].
| Caption    = Tubular adenoma. [[H&E stain]].
| Micro      = nuclear changes - esp. at the surface (hyperchromatic elongated nuclei or round cleared nuclei), nuclear crowding/pseudostratification, +/- loss of nuclear polarity, loss/decrease of goblet cells, cytoplasmic hyperchromasia
| Micro      = nuclear changes - esp. at the surface (hyperchromatic elongated nuclei or round cleared nuclei), nuclear crowding/pseudostratification, +/- loss of nuclear polarity, loss/decrease of goblet cells, cytoplasmic hyperchromasia
| Subtypes  =
| Subtypes  = [[tubular adenoma]], [[villous adenoma]], [[tubulovillous adenoma]]
| LMDDx      = [[tubular adenoma]], [[villous adenoma]], [[tubulovillous adenoma]], [[sessile serrated adenoma]] with dysplasia
| LMDDx      = [[sessile serrated adenoma]] with dysplasia, reactive changes in other [[gastrointestinal polyps]], invasive adenocarcinoma, adenoma-like adenocarcinoma
| Stains    =
| Stains    =
| IHC        =
| IHC        =
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| Assdx      = [[colorectal adenocarcinoma]]
| Assdx      = [[colorectal adenocarcinoma]]
| Syndromes  = [[Familial adenomatous polyposis]]
| Syndromes  = [[Familial adenomatous polyposis]]
| Clinicalhx =
| Signs      = usually asymptomatic, may present with rectal bleeding
| Signs      = usually asymptomatic, may present with rectal bleeding
| Symptoms  = uncommon, usually asymptomatic
| Symptoms  = uncommon, usually asymptomatic
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| Prognosis  = good
| Prognosis  = good
| Other      =
| Other      =
| ClinDDx    = invasive [[colorectal adenocarcinoma]], benign colorectal mucosa, [[hyperplastic polyp]]
| ClinDDx    = invasive [[colorectal adenocarcinoma]], [[Normal_colorectal_mucosa|benign colorectal mucosa]], [[hyperplastic polyp]], other [[gastrointestinal tract polyps]]
| Tx  = usually endoscopic resection ([[polypectomy]])
}}
{{ Infobox external links
| Name          = {{PAGENAME}}
| EHVSC          =
| EHVSC_mult    = {{EHVSC3|10192|Ki-67 IHC}}
| pathprotocols  =
| wikipedia      =
| pathoutlines  =
}}
}}
'''Traditional adenoma''' refers to a group of pre-[[cancer|cancerous]] lesions of the [[gastrointestinal pathology|gastrointestinal tract]].  
'''Traditional adenoma''' refers to a group of pre-[[cancer|cancerous]] lesions of the [[gastrointestinal pathology|gastrointestinal tract]].  


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*Usually arise in the context of an ''APC'' mutation.
*Usually arise in the context of an ''APC'' mutation.
*Many are seen in the context of [[familial adenomatous polyposis]].
*Many are seen in the context of [[familial adenomatous polyposis]].
*Size matters: small (<=5 mm) polyps (known as ''diminutive polyps'') are much less likely to be associated with malignancy.<ref name=pmid23735908>{{Cite journal  | last1 = Gellad | first1 = ZF. | last2 = Voils | first2 = CI. | last3 = Lin | first3 = L. | last4 = Provenzale | first4 = D. | title = Clinical practice variation in the management of diminutive colorectal polyps: results of a national survey of gastroenterologists. | journal = Am J Gastroenterol | volume = 108 | issue = 6 | pages = 873-8 | month = Jun | year = 2013 | doi = 10.1038/ajg.2012.316 | PMID = 23735908 }}</ref><ref>URL: [http://www.internalmedicinenews.com/specialty-focus/gastroenterology/single-article-page/diminutive-polyps-not-likely-to-become-cancerous.html http://www.internalmedicinenews.com/specialty-focus/gastroenterology/single-article-page/diminutive-polyps-not-likely-to-become-cancerous.html]. Accessed on: 5 August 2013.</ref>


==Gross==
==Gross==
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#*Size and shape ''or'' size change:
#*Size and shape ''or'' size change:
#**Cigar-shaped (elongated) nucleus (usu. length:width > 3:1) with nuclear hyperchromasia (more blue).
#**Cigar-shaped (elongated) nucleus (usu. length:width > 3:1) with nuclear hyperchromasia (more blue).
#**Large round nuclei +/- vesicular appearance (clearing) -- nuclei have white space.
#**Large round nuclei +/- [[vesicular nuclei|vesicular]] appearance (clearing) -- nuclei have white space.
#*Nuclear crowding/pseudostratification - '''important'''.
#*Nuclear crowding/pseudostratification - '''important'''.
#*+/-Loss of nuclear polarity (nuclei no longer on basement membrane).
#*+/-Loss of nuclear polarity (nuclei no longer on basement membrane).
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***The base is more mature (more globlet cells, no nuclear changes -- less 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.
*[[Ampullary adenoma]]s often have less prominent pseudostratification and fine chromatin.
DDx:
*Reactive changes due to inflammation.
*Invasive adenocarcinoma.
**Adenoma-like adenocarcinoma.<ref name=pmid25913616>{{Cite journal  | last1 = Gonzalez | first1 = RS. | last2 = Cates | first2 = JM. | last3 = Washington | first3 = MK. | last4 = Beauchamp | first4 = RD. | last5 = Coffey | first5 = RJ. | last6 = Shi | first6 = C. | title = Adenoma-like adenocarcinoma: a subtype of colorectal carcinoma with good prognosis, deceptive appearance on biopsy and frequent KRAS mutation. | journal = Histopathology | volume = 68 | issue = 2 | pages = 183-90 | month = Jan | year = 2016 | doi = 10.1111/his.12725 | PMID = 25913616 }}</ref>


===Images===
===Images===
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Image:Tubular_adenoma_2_intermed_mag.jpg| Tubular adenoma - intermed. mag. (WC/Nephron).
Image:Tubular_adenoma_2_intermed_mag.jpg| Tubular adenoma - intermed. mag. (WC/Nephron).
Image:Tubulovillous_adenoma.jpg| Tubulovillous adenoma (WC/Nephron).
Image:Tubulovillous_adenoma.jpg| Tubulovillous adenoma (WC/Nephron).
Image: Tubular adenoma - ase -- low mag.jpg | TA - low mag. (WC/Nephron)
Image: Tubular adenoma - ase -- intermed mag.jpg | TA - intermed. mag. (WC/Nephron)
</gallery>
</gallery>


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*[http://www.flickr.com/photos/jian-hua_qiao_md/3985116686/ TA with HGD (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>
*[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>
*[http://www.diagnosticpathology.org/content/2/1/29/figure/f1?highres=y TA with HGD (diagnosticpathology.org)].<ref name=pmid17697327>{{Cite journal  | last1 = Armah | first1 = HB. | last2 = Krasinskas | first2 = AM. | last3 = Parwani | first3 = AV. | title = Tubular adenoma with high-grade dysplasia in the ileal segment 34 years after augmentation ileocystoplasty: report of a first case. | journal = Diagn Pathol | volume = 2 | issue =  | pages = 29 | month =  | year = 2007 | doi = 10.1186/1746-1596-2-29 | PMID = 17697327 }}</ref>


====Typing====
====Typing====
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Note 2:
Note 2:
*There is no formal definition of "villous" architecture.<ref>R. Riddell. 12 August 2011.</ref>
*There is no formal definition of "villous" architecture.<ref>R. Riddell. 12 August 2011.</ref>
**''[[Onlinepathology]]'' suggests: slender finger-like projections with length-to-width ratio greater than 4.
**''[[Libre Pathology]]'' suggests: slender finger-like projections with length-to-width ratio greater than 4.


Note 3:
Note 3:
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===Haggitt classification===
===Haggitt classification===
The ''Haggitt classification'' is a [[staging]] scheme. 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.
The ''Haggitt classification'' is a [[staging]] scheme. Surgeons may ask about it 'cause it appears in a widely read surgery textbook and is prognostic.
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>
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.
*0 - high-grade dysplasia. †
*1 - in submucosa but in head of polyp.
*1 - in submucosa but in head of polyp.
*2 - neck of polyp.
*2 - neck of polyp.
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It is mostly useless; most polyps do not have a discernible neck or stalk.  
It is mostly useless; most polyps do not have a discernible neck or stalk.  


Note:  
Notes:  
*† Some refer to this as "intramucosal carcinoma". This term is confusing in the context of colorectal lesions, as cancer is defined by submucosal invasion; it is probably best to avoid using this term.
*Dr. Haggitt is known for GI pathology and his tragic demise.<ref>Rodger C. Haggitt Endowed Chair in Gastroenterology. URL: [http://depts.washington.edu/givemed/prof-chair/endowments/rodger-haggitt/ http://depts.washington.edu/givemed/prof-chair/endowments/rodger-haggitt/]. Accessed on: February 2, 2013.</ref> He was shot by a resident that was about to be fired.<ref>Two die in UW medical school shooting. seattlepi.com. URL: [http://community.seattletimes.nwsource.com/archive/?date=20000629&slug=4029355 http://community.seattletimes.nwsource.com/archive/?date=20000629&slug=4029355]. Accessed on: 4 February 2013.</ref><ref>URL: [http://www.washington.edu/alumni/columns/sept00/choices.html http://www.washington.edu/alumni/columns/sept00/choices.html]. Accessed on: 4 February 2013.</ref>
*Dr. Haggitt is known for GI pathology and his tragic demise.<ref>Rodger C. Haggitt Endowed Chair in Gastroenterology. URL: [http://depts.washington.edu/givemed/prof-chair/endowments/rodger-haggitt/ http://depts.washington.edu/givemed/prof-chair/endowments/rodger-haggitt/]. Accessed on: February 2, 2013.</ref> He was shot by a resident that was about to be fired.<ref>Two die in UW medical school shooting. seattlepi.com. URL: [http://community.seattletimes.nwsource.com/archive/?date=20000629&slug=4029355 http://community.seattletimes.nwsource.com/archive/?date=20000629&slug=4029355]. Accessed on: 4 February 2013.</ref><ref>URL: [http://www.washington.edu/alumni/columns/sept00/choices.html http://www.washington.edu/alumni/columns/sept00/choices.html]. Accessed on: 4 February 2013.</ref>
==IHC==
*Ki-67 +ve - surface epithelium and upper portion of crypts.<ref name=pmid17616996>{{Cite journal  | last1 = Groisman | first1 = GM. | last2 = Amar | first2 = M. | last3 = Meir | first3 = A. | title = Utility of MIB-1 (Ki-67) in evaluating diminutive colorectal polyps with cautery artifact. | journal = Arch Pathol Lab Med | volume = 131 | issue = 7 | pages = 1089-93 | month = Jul | year = 2007 | doi = 10.1043/1543-2165(2007)131[1089:UOMKIE]2.0.CO;2 | PMID = 17616996 }}</ref>
**Absent/minimal staining in [[cautery artifact]].


==Sign out==
==Sign out==
===Tubular adenoma - negative for high-grade===
===Tubular adenoma - negative for high-grade===
<pre>
<pre>
COLONIC POLYP, SIGMOID COLON, BIOPSY:  
A. Colonic Polyp, Transverse Colon, Polypectomy:
- Tubular adenoma.
- NEGATIVE for high grade dysplasia.
 
B. Colonic Polyp, Transverse Colon, Polypectomy:
-Tubular adenoma.
-NEGATIVE for high grade dysplasia.
</pre>
 
<pre>
Polyp, Rectum, Polypectomy:
- Tubular adenoma.
-- NEGATIVE for high-grade dysplasia.
</pre>
 
====Block letters====
<pre>
POLYP, RECTUM, POLYPECTOMY:
- TUBULAR ADENOMA.
-- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
</pre>
 
<pre>
POLYP, SIGMOID COLON, POLYPECTOMY:
- TUBULAR ADENOMA.
-- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
</pre>
 
<pre>
POLYP, DESCENDING COLON, POLYPECTOMY:
- TUBULAR ADENOMA.
-- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
</pre>
 
<pre>
POLYP, SPLENIC FLEXURE OF COLON, POLYPECTOMY:
- TUBULAR ADENOMA.
-- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
</pre>
 
<pre>
POLYP, TRANSVERSE COLON, POLYPECTOMY:
- TUBULAR ADENOMA.
-- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
</pre>
 
<pre>
POLYP, HEPATIC FLEXURE OF COLON, POLYPECTOMY:
- TUBULAR ADENOMA.
-- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
</pre>
 
<pre>
POLYP, ASCENDING COLON, POLYPECTOMY:
- TUBULAR ADENOMA.
-- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
</pre>
 
<pre>
POLYP, CECUM, EXCISION:
- TUBULAR ADENOMA.
-- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
</pre>
 
<pre>
POLYP, LARGE BOWEL AT 30 CM, POLYPECTOMY:
- TUBULAR ADENOMA.
- TUBULAR ADENOMA.
- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
-- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
</pre>
</pre>


===Tubulovillous adenoma - negative for high-grade===
===Tubulovillous adenoma - negative for high-grade===
<pre>
Polyp, Sigmoid Colon at 30 cm, Biopsy:
- Fragments of tubulovillous adenoma.
-- NEGATIVE for high-grade dysplasia.
Comment:
This biopsy may not be representative of the lesion as a whole.
Clinical correlation is required.
</pre>
====Block letters====
<pre>
<pre>
COLONIC POLYP, SIGMOID COLON, BIOPSY:  
COLONIC POLYP, SIGMOID COLON, BIOPSY:  
- TUBULOVILLOUS ADENOMA.
- TUBULOVILLOUS ADENOMA.
- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
-- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
</pre>
</pre>


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COLONIC POLYP, DESCENDING COLON, BIOPSY:  
COLONIC POLYP, DESCENDING COLON, BIOPSY:  
- VILLOUS ADENOMA.
- VILLOUS ADENOMA.
- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
-- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
</pre>
</pre>


===Tubular adenoma with focal high-grade dysplasia===
===Tubular adenoma with focal high-grade dysplasia===
<pre>
<pre>
COLONIC POLYP, TRANSVERSE COLON, BIOPSY:
POLYP, TRANSVERSE COLON, BIOPSY:
- TUBULAR ADENOMA WITH FOCAL HIGH-GRADE DYSPLASIA.
- TUBULAR ADENOMA WITH FOCAL HIGH-GRADE DYSPLASIA, MARGINS CLEAR, SEE COMMENT.
 
COMMENT:
The case was partially reviewed internally by Dr. Pathology and there is agreement high-grade dysplasia is focally present.
</pre>
</pre>
Note:
*"Focal" is something that should prompt review; the management decision often turns on high grade versus low grade.


===Tubular adenoma with high-grade dysplasia===
===Tubular adenoma with high-grade dysplasia===
<pre>
<pre>
COLONIC POLYP, SIGMOID COLON, BIOPSY:  
POLYP, SIGMOID COLON, BIOPSY:  
- TUBULAR ADENOMA WITH HIGH-GRADE DYSPLASIA.
- TUBULAR ADENOMA WITH HIGH-GRADE DYSPLASIA, MARGINS CLEAR.
</pre>
</pre>


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COMMENT:  
COMMENT:  
No stromal desmoplasia is identified. No definite submucosa is present; thus, the presence or absence of definite invasion cannot be assessed.
No stromal desmoplasia is identified. No definite submucosa is  
present; thus, the presence or absence of definite invasion  
cannot be assessed.
</pre>
 
===Biopsy of lesion clinically suspicious for cancer===
<pre>
FLAT LESION, HEPATIC FLEXURE OF COLON, BIOPSY:
- TUBULAR ADENOMA.
-- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
 
COMMENT:
The provided clinical history is noted. The sampled tissue may
not be representative of the lesion seen. As it is at least
an adenoma, it should be completely excised.
</pre>
</pre>


===Fragment counting===
===Fragment counting===
<pre>
<pre>
COLONIC POLYP, TRANSVERSE COLON, BIOPSY:
POLYP, TRANSVERSE COLON, BIOPSY:
- TUBULAR ADENOMA (IN 1/3 TISSUE FRAGMENTS).
- TUBULAR ADENOMA (IN 1/3 TISSUE FRAGMENTS).
- NEGATIVE FOR HIGH-GRADE DYSPLASIA.  
- NEGATIVE FOR HIGH-GRADE DYSPLASIA.  
</pre>
===Surgical resection===
<pre>
RECTOSIGMOID, RESECTION:
- LARGE TUBULOVILLOUS ADENOMA WITH A SMALL FOCUS OF HIGH-GRADE DYSPLASIA.
-- SURGICAL MARGINS NEGATIVE FOR DYSPLASIA.
- FOURTEEN LYMPH NODES NEGATIVE FOR MALIGNANCY ( 0 POSITIVE / 14 ).
- NEGATIVE FOR MALIGNANCY.
</pre>
</pre>


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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.
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.
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 or lower due to sampling.
 
=====Abbreviated version 1=====
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).
 
A small number of finger-like epithelial projections (villi) are noted; however, these
appear to comprise less than 20% of the sampled tissue.
 
=====Abbreviated version 2=====
A number of finger-like epithelial projections (villi) are noted; however, these appear to comprise less than 25% of the adenomatous tissue seen in section.
 
=====More abbreviated=====
A small number of villous structures are noted; however, these is still in keeping with a tubular adenoma.
 
=====Barely villous=====
The sections shows colorectal-type mucosa with 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.
 
Finger-like epithelial projections (villi) are present and comprise approximately 55% of
the dysplastic tissue.  The remainder of the lesion has a tubular morphology.
 
A large morphologically benign lymphoid aggregate is present. No submucosal invasion is
identified.


====Tubulovillous adenoma====
====Tubulovillous adenoma====
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The villous component is over 25% of the lesion but less than 50% of the lesion.
The villous component is over 25% of the lesion but less than 50% of the lesion.
====Low-grade versus high-grade====
The sections shows colorectal-type mucosa with an epithelium that has cellular pseudostratification and enlarged hyperchromatic nuclei at the the luminal aspect (dysplasia).
The architecture is tubular and villous. The tubular component is predominant.
Focally, the nuclei are round and vesicular, and the glands do not have appreciable numbers of goblet cells. Occasionally, glands are fused and show moderate complexity. No desmoplastic response is evident. Benign fragments of submucosa are present.
====Very small adenoma====
The sections show colorectal-type mucosa with one dysplastic appearing gland with nuclear hyperchromasia, enlargement and pseudostratification at the surface. It has an abrupt transition to the surrounding normal appearing mucosa. A histomorphologically benign lymphoid aggregate is present.


==See also==
==See also==
*[[Gastrointestinal polyps]].
*[[Gastrointestinal polyps]].
*[[Gastrointestinal pathology]].
*[[Gastrointestinal pathology]].
*"[[Intramucosal colorectal carcinoma]]".


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
==External links==
*[http://www.virtualpathology.leeds.ac.uk/nbcs/guidelines.php Adenomas - villous versus not, high-grade versus not (leeds.ac.uk)].


[[Category:Gastrointestinal pathology]]
[[Category:Gastrointestinal pathology]]
Michael
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