Difference between revisions of "Gastrointestinal tract polyps"

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Gastrointestinal tract polyps (view source)

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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]]
| [http://commons.wikimedia.org/wiki/File:Hyperplastic_polyp2.jpg HP (WC)]
| [[Image:Hyperplastic polyp -- intermed mag.jpg |thumb|center|150px| HP (WC)]]
|-
|-
| [[Traditional adenoma]]
| [[Traditional adenoma]]
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| [[tubular adenoma of the gastrointestinal tract|tubular adenoma]], [[tubulovillous adenoma]], [[villous adenoma]]
| [[tubular adenoma of the gastrointestinal tract|tubular adenoma]], [[tubulovillous adenoma]], [[villous adenoma]]
| [[traditional serrated adenoma]], reactive changes (inflammation)
| [[traditional serrated adenoma]], reactive changes (inflammation)
| [http://commons.wikimedia.org/wiki/File:Tubular_adenoma_2_high_mag.jpg TA - high mag. (WC)], [http://commons.wikimedia.org/wiki/File:Tubular_adenoma_4_low_mag.jpg TA - low mag. (WC)]
| [[Image:Tubular_adenoma_4_low_mag.jpg|thumb|center|150px| TA (WC)]]
|}
|}


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| AKA sessile serrated polyp
| AKA sessile serrated polyp
| hyperplastic polyp
| hyperplastic polyp
| [http://commons.wikimedia.org/wiki/File:Sessile_serrated_adenoma_2_low_mag.jpg SSA - low mag. (WC)]
| [[Image:Sessile_serrated_adenoma_2_low_mag.jpg|thumb|center|150px|SSA (WC)]]
|-
|-
| [[Traditional serrated adenoma]] (TSA)
| [[Traditional serrated adenoma]] (TSA)
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| called "traditional" to differentiate from SSA
| called "traditional" to differentiate from SSA
| traditional serrated adenoma (esp. villous adenoma)
| traditional serrated adenoma (esp. villous adenoma)
| [http://commons.wikimedia.org/wiki/File:Traditional_serrated_adenoma_low_mag.jpg TSA - low mag. (WC)], [http://commons.wikimedia.org/wiki/File:Traditional_serrated_adenoma_very_high_mag.jpg TSA - high mag. (WC)]  
| [[Image:Traditional_serrated_adenoma_low_mag.jpg|thumb|center|150px|TSA (WC)]]
|-
|-
| [[Juvenile polyp]] (retention polyp)
| [[Juvenile polyp]] (retention polyp)
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| may be part of [[juvenile polyposis syndrome]]
| may be part of [[juvenile polyposis syndrome]]
| inflammatory pseudopolyp
| inflammatory pseudopolyp
| [http://commons.wikimedia.org/wiki/File:Gastric_juvenile_polyp_-_very_low_mag.jpg Gastric JP - low mag. (WC)]
| [[Image:Gastric_juvenile_polyp_-_very_low_mag.jpg|thumb|center|150px|Gastric JP (WC)]]
|-
|-
| [[Inflammatory pseudopolyp]]
| [[Inflammatory pseudopolyp]]
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| only seen in [[IBD]]; Dx implies IBD
| only seen in [[IBD]]; Dx implies IBD
| juvenile polyp
| juvenile polyp
| Image
| [[Image:Inflammatory polyp -- low mag.jpg|thumb|center|120px|IP (WC)]]
|-
|-
| [[Peutz-Jeghers polyp]] (PJP)
| [[Peutz-Jeghers polyp]] (PJP)
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| PJP not pre-malignant lesion in itself; see ''[[Peutz-Jeghers syndrome]]''
| PJP not pre-malignant lesion in itself; see ''[[Peutz-Jeghers syndrome]]''
| normal, classically in the small bowel
| normal, classically in the small bowel
| [http://commons.wikimedia.org/wiki/File:Peutz-Jeghers_syndrome_polyp.jpg PJP - low mag. (WC)]
| [[Image:Peutz-Jeghers_syndrome_polyp.jpg|thumb|center|120px|PJP (WC)]]
|}
|}


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===Adenomatous vs. hyperplastic===
===Adenomatous vs. hyperplastic===
Adenomatous polyps & hyperplastic polyps - a comparison (adapted from Li and Burgart<ref>{{cite journal |author=Li SC, Burgart L |title=Histopathology of serrated adenoma, its variants, and differentiation from conventional adenomatous and hyperplastic polyps |journal=Arch. Pathol. Lab. Med. |volume=131 |issue=3 |pages=440-5 |year=2007 |month=March |pmid=17516746 |doi= |url=http://journals.allenpress.com/jrnlserv/?request=get-abstract&issn=0003-9985&volume=131&page=440}}</ref>):  
Adenomatous polyps & hyperplastic polyps - a comparison (adapted from Li and Burgart<ref name=pmid17516746>{{cite journal |author=Li SC, Burgart L |title=Histopathology of serrated adenoma, its variants, and differentiation from conventional adenomatous and hyperplastic polyps |journal=Arch. Pathol. Lab. Med. |volume=131 |issue=3 |pages=440-5 |year=2007 |month=March |pmid=17516746 |doi= |url=http://journals.allenpress.com/jrnlserv/?request=get-abstract&issn=0003-9985&volume=131&page=440}}</ref>):  
{| class="wikitable"
{| class="wikitable"
! Attribute
! Attribute
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|-
|-
|Image(s)
|Image(s)
| [http://commons.wikimedia.org/wiki/File:Hyperplastic_polyp2.jpg low mag.]
| [[Image:Hyperplastic polyp -- intermed mag.jpg |thumb|center|150px|HP (WC)]]
| [http://commons.wikimedia.org/wiki/File:Sessile_serrated_adenoma_2_low_mag.jpg low mag], [http://commons.wikimedia.org/wiki/File:Sessile_serrated_adenoma.jpg low mag.]
| [[Image:Sessile_serrated_adenoma_2_low_mag.jpg|thumb|center|150px|SSA (WC)]]
| [http://commons.wikimedia.org/wiki/File:Traditional_serrated_adenoma_low_mag.jpg low mag], [http://commons.wikimedia.org/wiki/File:Traditional_serrated_adenoma_very_high_mag.jpg very high mag.]
| [[Image:Traditional_serrated_adenoma_low_mag.jpg|thumb|center|150px|TSA (WC)]]
|[http://commons.wikimedia.org/wiki/File:Tubular_adenoma_2_low_mag.jpg low mag.], [http://commons.wikimedia.org/wiki/File:Tubular_adenoma_2_high_mag.jpg high mag.]
|[[Image:Tubular_adenoma_2_low_mag.jpg|thumb|center|150px|TA (WC)]]
|}
|}
Normal colonic mucosa:  
Normal colonic mucosa:  
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*Abundant goblet cells.
*Abundant goblet cells.
*Moderate inflammation.
*Moderate inflammation.
*Paneth cells - present in right colon.
*[[Paneth cell]]s - present in right colon.
*Glands - straight, no branching; "test tube" shape.
*Glands - straight, no branching; "test tube" shape.


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*[[Collagenous colitis]].
*[[Collagenous colitis]].


Images:
====Images====
<gallery>
Image:Rectum - low mag.jpg | Rectum - low mag. (WC)
Image:Rectum - intermed mag.jpg | Rectum - intermed. mag. (WC)
Image:Rectum - alt - intermed mag.jpg | Rectum - intermed. mag. (WC)
Image:Rectum - high mag.jpg | Rectum - high mag. (WC)
</gallery>
www:
*[http://www.lab.anhb.uwa.edu.au/mb140/CorePages/GIT/images/col10he.jpg Normal colorectal mucosa (uwa.edu.au)].<ref>URL: [http://www.lab.anhb.uwa.edu.au/mb140/CorePages/GIT/git.htm http://www.lab.anhb.uwa.edu.au/mb140/CorePages/GIT/git.htm]. Accessed on: 18 October 2012.</ref>
*[http://www.lab.anhb.uwa.edu.au/mb140/CorePages/GIT/images/col10he.jpg Normal colorectal mucosa (uwa.edu.au)].<ref>URL: [http://www.lab.anhb.uwa.edu.au/mb140/CorePages/GIT/git.htm http://www.lab.anhb.uwa.edu.au/mb140/CorePages/GIT/git.htm]. Accessed on: 18 October 2012.</ref>
*[http://www.siumed.edu/~dking2/erg/GI027b.htm Colon (siumed.edu)].
*[http://www.siumed.edu/~dking2/erg/GI027b.htm Colon (siumed.edu)].
*[http://commons.wikimedia.org/wiki/File:Tubular_adenoma_2_intermed_mag.jpg Normal colon adjacent to a tubular adenoma (WC)].
*[http://www.gwc.maricopa.edu/class/bio202/Digestive/DigestHisto/ColonA.htm Normal colorectal mucosa (maricopa.edu)].
*[http://www.gwc.maricopa.edu/class/bio202/Digestive/DigestHisto/ColonA.htm Normal colorectal mucosa (maricopa.edu)].


===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:
*[[WC]]:
**[http://commons.wikimedia.org/wiki/File:Hyperplastic_polyp1.jpg HP - high mag. (WC)].
**[http://commons.wikimedia.org/wiki/File:Hyperplastic_polyp2.jpg HP - lower mag. (WC)].
*www:
**[http://www.flickr.com/photos/jthetzel/4317282727/ Microvesicular HP (flickr.com/jhetzel)].
**[http://www.flickr.com/photos/jian-hua_qiao_md/3984355417/ HP of colon (flickr.com/jian-hua_qiao_md)].
 
====Subclassification====
*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]].


==High-risk features in (colorectal) adenomatous polyps with carcinoma==
==High-risk features in (colorectal) adenomatous polyps with carcinoma==
Line 523: Line 405:
#[[Lymphovascular invasion]].
#[[Lymphovascular invasion]].
#High-grade [[tumour budding]].
#High-grade [[tumour budding]].
#*Tumour bud = 1-4 cell(s); "high-grade budding" is >=10 tumour buds in a field of 0.385 mm<sup>2</sup>.<ref name=pmid11952856>{{Cite journal  | last1 = Ueno | first1 = H. | last2 = Murphy | first2 = J. | last3 = Jass | first3 = JR. | last4 = Mochizuki | first4 = H. | last5 = Talbot | first5 = IC. | title = Tumour 'budding' as an index to estimate the potential of aggressiveness in rectal cancer. | journal = Histopathology | volume = 40 | issue = 2 | pages = 127-32 | month = Feb | year = 2002 | doi =  | PMID = 11952856 }}</ref>
#*Tumour bud = 1-4 cell(s); "high-grade budding" is >=10 tumour buds in a field of 0.385 mm<sup>2</sup>.<ref name=pmid11952856>{{Cite journal  | last1 = Ueno | first1 = H. | last2 = Murphy | first2 = J. | last3 = Jass | first3 = JR. | last4 = Mochizuki | first4 = H. | last5 = Talbot | first5 = IC. | title = Tumour 'budding' as an index to estimate the potential of aggressiveness in rectal cancer. | journal = Histopathology | volume = 40 | issue = 2 | pages = 127-32 | month = Feb | year = 2002 | doi =  | PMID = 11952856 }}</ref>‡
#**If the microscope has a 22 mm eye piece and...  
#**If the microscope has a 22 mm eye piece and...  
#***A 20x objective, the field is approximately 0.950 mm<sup>2</sup> -- to match the area/bud -- it would be 24.68 buds/0.950 mm<sup>2</sup>.
#***A 20x objective, the field is approximately 0.950 mm<sup>2</sup> -- to match the buds/area -- it would be 24.68 buds/0.950 mm<sup>2</sup>.
#***A 40x objective, the field is approximately 0.238 mm<sup>2</sup> -- to match the area/bud -- it would be 6.17 buds/0.238 mm<sup>2</sup>.
#***A 40x objective, the field is approximately 0.238 mm<sup>2</sup> -- to match the buds/area -- it would be 6.17 buds/0.238 mm<sup>2</sup>.
#Extensive submucosal invasion.
#Extensive submucosal invasion.
#*>= 4 mm width ''or'' >= 2 mm depth.
#*>= 4 mm width ''or'' >= 2 mm depth.


If none of the above factors is present the risk of [[lymph node]] metastasis is < 1%.  The presence of one risk factor increases the risk to ~20%. If multiple risk factors are present the chance of [[lymph node metastases]] is greater than 35%.<ref name=pmid15300569/>
If none of the above factors is present the risk of [[lymph node]] metastasis is < 1%.  The presence of one risk factor increases the risk to ~20%. If multiple risk factors are present the chance of [[lymph node metastases]] is greater than 35%.<ref name=pmid15300569/>
Note:
*‡Tumour budding as per international consensus is now assessed in field area of 0.785 mm<sup>2</sup>.<ref name=pmid28548122>{{Cite journal  | last1 = Lugli | first1 = A. | last2 = Kirsch | first2 = R. | last3 = Ajioka | first3 = Y. | last4 = Bosman | first4 = F. | last5 = Cathomas | first5 = G. | last6 = Dawson | first6 = H. | last7 = El Zimaity | first7 = H. | last8 = Fléjou | first8 = JF. | last9 = Hansen | first9 = TP. | title = Recommendations for reporting tumor budding in colorectal cancer based on the International Tumor Budding Consensus Conference (ITBCC) 2016. | journal = Mod Pathol | volume = 30 | issue = 9 | pages = 1299-1311 | month = Sep | year = 2017 | doi = 10.1038/modpathol.2017.46 | PMID = 28548122 }}</ref>


==Traditional adenoma==
==Traditional adenoma==
:''Includes '''tubular adenoma''', '''tubulovillous adenoma''', and '''villous adenoma'''.''
:''Includes '''tubular adenoma''', '''tubulovillous adenoma''', and '''villous adenoma'''.''
 
{{Main|Traditional adenoma}}
===General===
*Most common group of ''adenomas'' in gastrointestinal tract.
*Usually arise in the context of an ''APC'' mutation.
*Many are seen in the context of [[familial adenomatous polyposis]].
 
===Microscopic===
#Nuclear changes at the surface of the mucosa - '''key feature'''.
#*Size and shape ''or'' size change:
#**Cigar-shaped (elongated) nucleus (usu. length:width > 3:1) with nuclear hyperchromasia (more blue).
#**Large round nuclei +/- vesicular appearance (clearing) -- nuclei have white space.
#*Nuclear crowding/pseudostratification - '''important'''.
#*+/-Loss of nuclear polarity (nuclei no longer on basement membrane).
#Loss/decrease of goblet cells (common).
#Cytoplasmic hyperchromasia.
 
Notes:
*Nuclear changes deep to the surface are non-neoplastic if normal appearing mucosa (with small round nuclei) is superficial to it; mucosa that is more blue and atypical deep ''and'' less blue without nuclear atypia at the surface is said to be "maturing".
**Classically, adenomatous polyps have "reverse maturation":
***The surface is more hyperchromatic (more blue).
***The base is more mature (more globlet cells, no nuclear changes -- less blue).
*[[Ampullary adenoma]]s often have less prominent pseudostratification and fine chromatin.
 
====Images====
<gallery>
Image:Tubular_adenoma_high_mag.jpg| Small tubular adenoma - high mag. (WC/Nephron).
Image:Tubular_adenoma_2_intermed_mag.jpg| Tubular adenoma - intermed. mag. (WC/Nephron).
Image:Tubulovillous_adenoma.jpg| Tubulovillous adenoma (WC/Nephron).
</gallery>
 
www:
*[http://www.flickr.com/photos/jian-hua_qiao_md/3984353527/in/photostream/ TA (flickr.com)].
*[http://www.flickr.com/photos/jian-hua_qiao_md/3985116686/ TA with HGD (flickr.com)].
*[http://media.daveproject.org/media/images/pathology_img/fullsize/gsraju-flat_lession_emr-path.jpeg TA with HGD (daveproject.org)].<ref>URL: [http://daveproject.org/colon-cancer-prevention-flat-lesion-and-endoscopic-mucosal-resection/2011-06-10/ http://daveproject.org/colon-cancer-prevention-flat-lesion-and-endoscopic-mucosal-resection/2011-06-10/]. Accessed on: 24 August 2012.</ref>
 
====Typing====
Subclassified as:<ref name=pbod860>{{Ref PBoD|860}}</ref>
*''Tubular adenoma'' (most common), tubular component >75%.
*''Villous adenoma'' (least common ~= 1% of (traditional) adenomas), villous component >50%.
*''Tubulovillous adenoma'' (uncommon ~5-10% of (traditional) adenomas), villous component >=25% & <=50%.
 
In other words:
*Tubular T/V >75% / <25%; Tubulovillous T/V <=75%-50% / 25%-<50%; Villous T/V <=50% / >50%.
 
Note 1:<ref name=pbod860/>
*Most villous adenomas are sessile, i.e. flat.<ref name=emed_va>URL: [http://emedicine.medscape.com/article/170283-overview http://emedicine.medscape.com/article/170283-overview].</ref>
*Tubular adenomas tend to be pedunculated, i.e. have a stalk.
*Villous adenomas have a worse prognosis and warrant closer follow-up.
*One needs only to remember the criteria for ''tubular adenomas'' and ''villous adenomas'', as tubulovillous adenomas are what is left over.
**Tubular adenomas >75% tubular, Villous adenoma >=50% villous.
*Historically, there were different definitions for tubular adenoma, tubulovillous adenoma, and villous adenomas.<ref name=emed_va/>
**Health Organization (WHO) criteria: villous adenomas >80% villous architecture.
 
Note 2:
*There is no formal definition of "villous" architecture.<ref>R. Riddell. 12 August 2011.</ref>
**''[[Onlinepathology]]'' suggests: slender finger-like projections with length-to-width ratio greater than 4.
 
Note 3:
*The term ''tubular adenoma'' is used in different contexts; it should not be confused with [[Sertoli cell nodule]] ([[AKA]] ''testicular tubular adenoma'').
 
====Grading====
Adenomas are usually graded with a two-tier system:<ref name=driman>{{cite journal | last1 = Driman | first1 = DK. | last2 = Marcus | first2 = VA. | last3 = Hilsden | first3 = RJ | last4 = Owen | first4 = DA |title=Pathologic reporting of colorectal polyps: pan-Canadian consensus guidelines |journal=Canadian Journal of Pathology |volume=4 |issue=3 |pages=81-90 |year=2012 |month= |pmid= |doi= |url= }}</ref>
 
{| class="wikitable sortable"
!Feature
!Low grade dysplasia (LGD)
!High grade dysplasia (HGD)
!Importance
|-
|Architecture
|tubular, minimal focal gland fusion acceptable
|any of the following: (gland) cribriforming, glandular budding, intraluminal papillary tufting, sheeting (of epithelium), lamina propria invasion †
|'''key feature'''
|-
|Cytology
|usu. no features of HGD
|any of the following: loss of nuclear stratification, enlarged nuclei, loss of cell polarity, prominent nucleoli, open (clear) chromatin
|supportive feature, not sufficient alone for HGD
|}
 
Low power colour can be suggestive of HGD:
{| class="wikitable sortable"
!Feature
!Low grade
!High grade
|-
| Colour
| light blue
| dark blue
|}
 
Note:
*† In the colon, unlike other areas of the GI tract, invasive carcinoma is defined by neoplastic cells through the muscularis mucosae.  In all other places, e.g. small bowel, invasive carcinoma is defined by neoplastic cells through the basement membrane.
 
====Margins====
{{Main|Surgical margins}}
*Some pathologists believe it is impossible to determine margins in polypectomies.
*Others comment on what they see and then disclaim based on limitations with something like "... margin clear in plane of section."
 
====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.
In short:<ref>URL: [http://www.ganfyd.org/index.php?title=Haggitt_classification http://www.ganfyd.org/index.php?title=Haggitt_classification]. Accessed on: 19 March 2011.</ref><ref name=pmid4007423>{{Cite journal  | last1 = Haggitt | first1 = RC. | last2 = Glotzbach | first2 = RE. | last3 = Soffer | first3 = EE. | last4 = Wruble | first4 = LD. | title = Prognostic factors in colorectal carcinomas arising in adenomas: implications for lesions removed by endoscopic polypectomy. | journal = Gastroenterology | volume = 89 | issue = 2 | pages = 328-36 | month = Aug | year = 1985 | doi =  | PMID = 4007423 }}</ref>
*0 - intramucosal carcinoma.
*1 - in submucosa but in head of polyp.
*2 - neck of polyp.
*3 - stalk of polyp.
*4 - submucosa of the bowel wall but above muscularis propria.
It is mostly useless; most polyps do not have a discernible neck or stalk.
 
Note:
*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>
 
===Sign out===
====Tubular adenoma - negative for high-grade====
<pre>
COLONIC POLYP, SIGMOID COLON, BIOPSY:
- TUBULAR ADENOMA.
- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
</pre>
 
====Tubulovillous adenoma - negative for high-grade====
<pre>
COLONIC POLYP, SIGMOID COLON, BIOPSY:
- TUBULOVILLOUS ADENOMA.
- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
</pre>
 
====Villous adenoma - negative for high-grade====
<pre>
COLONIC POLYP, DESCENDING COLON, BIOPSY:
- VILLOUS ADENOMA.
- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
</pre>
 
====Tubular adenoma with focal high-grade dysplasia====
<pre>
COLONIC POLYP, TRANSVERSE COLON, BIOPSY:
- TUBULAR ADENOMA WITH FOCAL HIGH-GRADE DYSPLASIA.
</pre>
 
====Tubular adenoma with high-grade dysplasia====
<pre>
COLONIC POLYP, SIGMOID COLON, BIOPSY:
- TUBULAR ADENOMA WITH HIGH-GRADE DYSPLASIA.
</pre>
 
====Invasion cannot be assessed====
<pre>
SIGMOID LESION, 25 CM, BIOPSY:
- TUBULAR ADENOMA.
- NEGATIVE FOR HIGH-GRADE DYSPLASIA, SEE COMMENT. 
 
COMMENT:
No stromal desmoplasia is identified. No definite submucosa is present; thus, the presence or absence of definite invasion cannot be assessed.
</pre>
 
====Fragment counting====
<pre>
COLONIC POLYP, TRANSVERSE COLON, BIOPSY:
- TUBULAR ADENOMA (IN 1/3 TISSUE FRAGMENTS).
- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
</pre>
 
====Notes====
#"Negative for high-grade dysplasia and malignancy" is recommended in the Canadian consensus.<ref name=driman>{{cite journal | last1 = Driman | first1 = DK. | last2 = Marcus | first2 = VA. | last3 = Hilsden | first3 = RJ | last4 = Owen | first4 = DA |title=Pathologic reporting of colorectal polyps: pan-Canadian consensus guidelines |journal=Canadian Journal of Pathology |volume=4 |issue=3 |pages=81-90 |year=2012 |month= |pmid= |doi= |url= }}</ref> The reasoning for the first part is: "with low-grade dysplasia" may lead to over treatment by physicians that are not aware that all (traditional) adenomas have low-grade dysplasia.
#The phrase "negative for [...] malignancy" is also recommended in the Canadian consensus. This is not endorsed by [[onlinepathology]], as one very frequently does not get submucosa.  It is like reporting "negative for muscularis propria invasion" on a urinary bladder biopsy without muscularis propria. Further, the guidelines are inconsistent in that they do not advise "negative for dysplasia and malignancy" for [[SSA]]s.  If there is clinical suspicion of an invasive malignancy, it is useful to comment that no submucosa is present.
 
====Micro====
=====Tubular-tubulovillous interface=====
The sections shows colorectal-type mucosa with a tubule-forming epithelium that has cellular pseudostratification and enlarged hyperchromatic nuclei, from the crypt base to the luminal aspect (dysplasia). 
 
No cribriforming of glands, epithelial budding or intraluminal papillary tufting is identified.  Goblet cells are present in the dysplastic epithelium.  Dysplastic nuclei have an ellipsoid-shape and basally stratified.
 
A small number of rare finger-like epithelial projections (villi) are noted; however these appear to comprise less than 20% of the sampled tissue.  It is possible that the villous component is higher, due to sampling error; thus, this could represent a tubulovillous adenoma.
 
=====Tubulovillous adenoma=====
The sections shows colorectal-type mucosa with a tubule-forming and villous-forming epithelium that has cellular pseudostratification and enlarged hyperchromatic nuclei, from the crypt base to the luminal aspect (dysplasia).
 
No cribriforming of glands, epithelial budding or intraluminal papillary tufting is identified. Goblet cells are rare in the dysplastic epithelium. Dysplastic nuclei have an ellipsoid-shape and basally stratified.
 
The villous component is over 25% of the lesion but less than 50% of the lesion.


==Traditional serrated adenoma==
==Traditional serrated adenoma==
===General===
{{Main|Traditional serrated adenoma}}
*Very rare.
 
===Microscopic===
Features:
*Serrated.
*Nuclear atypia (as in tubular adenoma).
*Villous architecture.
 
DDx:
*[[Villous adenoma]].
 
Images:
*[http://commons.wikimedia.org/wiki/File:Traditional_serrated_adenoma_low_mag.jpg TSA - low mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Traditional_serrated_adenoma_intermed_mag.jpg TSA - intermed. mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Traditional_serrated_adenoma_very_high_mag.jpg TSA - very high mag. (WC)].


==Sessile serrated adenoma==
==Sessile serrated adenoma==
*Often abbreviated ''SSA''.
{{Main|Sessile serrated adenoma}}
*[[AKA]] ''sessile serrated polyp'', abbreviated ''SSP''.
*[[AKA]] ''sessile serrated lesion''.
*[[AKA]] ''sessile serrated adenoma/polyp'', abbreviated ''SSA/P''.
 
===General===
*Colonic lesion.
*May be seen in the context of ''[[serrated polyposis syndrome]]''.
 
Epidemiology:
*Thought to lead to colorectal cancer through a different pathway that most tumours in the left colon/rectum.
*''Microvesicular [[hyperplastic polyp]]s'' are hypothesized to be the the precursor of SSAs.<ref name=pmid21045813>{{Cite journal  | last1 = Huang | first1 = CS. | last2 = Farraye | first2 = FA. | last3 = Yang | first3 = S. | last4 = O'Brien | first4 = MJ. | title = The clinical significance of serrated polyps. | journal = Am J Gastroenterol | volume = 106 | issue = 2 | pages = 229-40; quiz 241 | month = Feb | year = 2011 | doi = 10.1038/ajg.2010.429 | PMID = 21045813 }}</ref>
 
===Gross===
Features:<ref name=pmid22710576/>
*Flat lesions, usually > 5 mm.
*Typically have a "mucous cap" - present ~65% of the time; useful for identification.
*Border not well-demarcated.
*More common in the proximal colon.
 
Note:
*Sessile lesions over 1 cm are usually SSAs.<ref name=pmid22710576/>
 
Image:
*[http://www.nature.com/ajg/journal/v105/n12/fig_tab/ajg2010330f1.html SSA - endoscopy (nature.com)].<ref name=pmid21131934>{{cite journal |author=Rex DK, Hewett DG, Snover DC |title=Editorial: Detection targets for colonoscopy: from variable detection to validation |journal=Am. J. Gastroenterol. |volume=105 |issue=12 |pages=2665–9 |year=2010 |month=December |pmid=21131934 |doi=10.1038/ajg.2010.330 |url=}}</ref>
 
===Microscopic===
Features:
*Serrated epithelium at the surface and deep in the crypts.
**Saw-tooth appearance, epithelium has jagged appearing edge.
*Crypt dilation at base with serrations - '''key feature'''.
**Very common -- anecdotally the most sensitive feature.
*"Boot"-shape or "L"-shaped glands.
**Shape may be similar to a hockey stick.
*Horizontal crypts = crypt long axis parallel to the muscularis mucosae.
*Crypt branching.
 
Minimal extent criteria - number of abnormal crypts with the above features:
*''German Society of Pathology'' proposal: at least two abnormal crypts -- crypts do not have to be adjacent.<ref name=pmid23052370>{{Cite journal  | last1 = Ensari | first1 = A. | last2 = Bilezikçi | first2 = B. | last3 = Carneiro | first3 = F. | last4 = Doğusoy | first4 = GB. | last5 = Driessen | first5 = A. | last6 = Dursun | first6 = A. | last7 = Flejou | first7 = JF. | last8 = Geboes | first8 = K. | last9 = de Hertogh | first9 = G. | title = Serrated polyps of the colon: how reproducible is their classification? | journal = Virchows Arch | volume = 461 | issue = 5 | pages = 495-504 | month = Nov | year = 2012 | doi = 10.1007/s00428-012-1319-7 | PMID = 23052370 }}</ref><ref name=pmid20617338>{{Cite journal  | last1 = Aust | first1 = DE. | last2 = Baretton | first2 = GB. | title = Serrated polyps of the colon and rectum (hyperplastic polyps, sessile serrated adenomas, traditional serrated adenomas, and mixed polyps)-proposal for diagnostic criteria. | journal = Virchows Arch | volume = 457 | issue = 3 | pages = 291-7 | month = Sep | year = 2010 | doi = 10.1007/s00428-010-0945-1 | PMID = 20617338 }}</ref>
**[[Onlinepathology]] prefers this definition.
*An expert panel lead by ''Rex'' states that one unequivocally altered crypt should prompt calling SSA.<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>
*The WHO requires - depending on what you read:
**Three adjacent crypts to be abnormal.<ref>URL: [http://surgpathcriteria.stanford.edu/gitumors/sessile-serrated-polyp-adenoma/ http://surgpathcriteria.stanford.edu/gitumors/sessile-serrated-polyp-adenoma/]. Accessed on: 26 September 2012.</ref>
**Two or three adjacent crypts to be abnormal.<ref name=pmid23052370/>
 
Notes:
*Typically do not have nuclear atypia, i.e. no nuclear crowding, no nuclear hyperchromasia, no cigar-shaped nuclei.
**SSAs with nuclear atypia may be referred to as ''advanced sessile serrated adenomas''.
 
DDx:
*[[Hyperplastic polyp]].
*[[Tubular adenoma of the gastrointestinal tract|Tubular adenoma]] - for ''SSA with dysplasia'', TAs often less than 1 cm (uncommon for SSAs).
 
Images:
*[http://commons.wikimedia.org/wiki/File:Sessile_serrated_adenoma.jpg SSA - low mag. (WC/Nephron)].
*[http://commons.wikimedia.org/wiki/File:Sessile_serrated_adenoma2.jpg SSA - intermed. mag. (WC/Nephron)].
*[http://commons.wikimedia.org/wiki/File:Sessile_serrated_adenoma3.jpg SSA - high mag. (WC/Nephron)].
*[http://commons.wikimedia.org/wiki/File:Sessile_serrated_adenoma_3_low_mag.jpg SSA - low mag. (WC/Nephron)].
 
===Sign out===
<pre>
COLONIC POLYP, ASCENDING COLON, BIOPSY:
- SESSILE SERRATED ADENOMA.
- NEGATIVE FOR DYSPLASIA.
</pre>
 
<pre>
COLONIC POLYP, ASCENDING COLON, BIOPSY:
- SESSILE SERRATED ADENOMA WITH DYSPLASIA.
</pre>
 
Note:
*The above exactly mirrors the Canadian consensus.<ref name=driman>{{cite journal | last1 = Driman | first1 = DK. | last2 = Marcus | first2 = VA. | last3 = Hilsden | first3 = RJ | last4 = Owen | first4 = DA |title=Pathologic reporting of colorectal polyps: pan-Canadian consensus guidelines |journal=Canadian Journal of Pathology |volume=4 |issue=3 |pages=81-90 |year=2012 |month= |pmid= |doi= |url= }}</ref>


=Malignant polyps=
=Malignant polyps=
Line 824: Line 442:
===Microscopic===
===Microscopic===
One of the two following:
One of the two following:
#Usual morphology - features:<ref name=pmid22827760>{{Cite journal  | last1 = Kimura | first1 = R. | last2 = Fujimori | first2 = T. | last3 = Ichikawa | first3 = K. | last4 = Ajioka | first4 = Y. | last5 = Ueno | first5 = H. | last6 = Ohkura | first6 = Y. | last7 = Kashida | first7 = H. | last8 = Togashi | first8 = K. | last9 = Yao | first9 = T. | title = Desmoplastic reaction in biopsy specimens of early colorectal cancer: a Japanese prospective multicenter study. | journal = Pathol Int | volume = 62 | issue = 8 | pages = 525-31 | month = Aug | year = 2012 | doi = 10.1111/j.1440-1827.2012.02840.x | PMID = 22827760 }}</ref>
#Dysplasia and evidence of invasion - features:<ref name=pmid22827760>{{Cite journal  | last1 = Kimura | first1 = R. | last2 = Fujimori | first2 = T. | last3 = Ichikawa | first3 = K. | last4 = Ajioka | first4 = Y. | last5 = Ueno | first5 = H. | last6 = Ohkura | first6 = Y. | last7 = Kashida | first7 = H. | last8 = Togashi | first8 = K. | last9 = Yao | first9 = T. | title = Desmoplastic reaction in biopsy specimens of early colorectal cancer: a Japanese prospective multicenter study. | journal = Pathol Int | volume = 62 | issue = 8 | pages = 525-31 | month = Aug | year = 2012 | doi = 10.1111/j.1440-1827.2012.02840.x | PMID = 22827760 }}</ref>
#*Nuclear changes seen in adenomatous polyps - malignant-appearing cells.
#*Nuclear changes seen in adenomatous polyps - malignant-appearing cells.
#**Enlarged nuclei.
#**Enlarged nuclei.
Line 830: Line 448:
#**Round-shape ''or'' cigar-shaped and pseudostratified.
#**Round-shape ''or'' cigar-shaped and pseudostratified.
#*Architectural changes - usually those of high-grade dysplasia:
#*Architectural changes - usually those of high-grade dysplasia:
#**Cribriforming.
#**Cribriforming - most common.
#**Papillary tufting.
#**Papillary tufting.
#**Budding.
#**Budding.
Line 837: Line 455:
#*#Malignant-appearing cells in the submucosa.
#*#Malignant-appearing cells in the submucosa.
#*#*Pseudoinvasion must be excluded.  
#*#*Pseudoinvasion must be excluded.  
#*#[[Desmoplastic response]].  
#*#[[Desmoplastic stromal response]].  
#*#*Spindle cells with:
#*#*Spindle cells with:
#*#**Large nuclei (nucleus ~ size of a plasma cell).
#*#**Large nuclei (nucleus ~ size of a plasma cell).
Line 851: Line 469:
</ref>
</ref>


Image:
====Image====
*[http://commons.wikimedia.org/wiki/File:Cecal_adenocarcinoma.jpg Colorectal carcinoma (WC)].
<gallery>
Image:Cecal_adenocarcinoma.jpg | Colorectal carcinoma. (WC/Nephron)
</gallery>


===Sign out===
===Sign out===
Line 858: Line 478:
RECTOSIGMOID TUMOUR, BIOPSY:
RECTOSIGMOID TUMOUR, BIOPSY:
- INVASIVE ADENOCARCINOMA, MODERATELY DIFFERENTIATED.
- INVASIVE ADENOCARCINOMA, MODERATELY DIFFERENTIATED.
</pre>
<pre>
RECTUM, BIOPSY:
- INVASIVE ADENOCARCINOMA, MODERATELY DIFFERENTIATED.
</pre>
<pre>
RECTUM, BIOPSY:
- HIGHLY SUSPICIOUS FOR INVASIVE ADENOCARCINOMA, SEE MICROSCOPIC.
- TUBULOVILLOUS ADENOMA WITH HIGH-GRADE DYSPLASIA.
</pre>
</pre>


Line 864: 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 881: 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:
*[http://www.nature.com/modpathol/journal/v16/n4/fig_tab/3880773f4.html Juvenile polyp (nature.com)].
*[http://commons.wikimedia.org/wiki/File:Gastric_juvenile_polyp_-_very_low_mag.jpg Juvenile polyp of the stomach - very low mag. (WC)]
*[http://commons.wikimedia.org/wiki/File:Gastric_juvenile_polyp_-_2_-_very_low_mag.jpg Juvenile polyp of the stomach - very low mag. (WC)].
 
===IHC===
*Usually none.
 
Notes:
*IHC can be used if it is suspected to have dysplasia (p53, Ki-67).
**p53 mutations in dysplastic epithelium -- negative stain (normal).
 
===Sign out===
<pre>
RECTOSIGMOID POLYP, BIOPSY:
- RETENTION POLYP.
</pre>


==Peutz-Jeghers polyp==
==Peutz-Jeghers polyp==
===General===
{{Main|Peutz-Jeghers polyp}}
====Epidemiology====
Features:<ref name=Ref_PBoD859/><ref name=pmid12692201>{{Cite journal  | last1 = Bronner | first1 = MP. | title = Gastrointestinal inherited polyposis syndromes. | journal = Mod Pathol | volume = 16 | issue = 4 | pages = 359-65 | month = Apr | year = 2003 | doi = 10.1097/01.MP.0000062992.54036.E4 | PMID = 12692201 | url = http://www.nature.com/modpathol/journal/v16/n4/full/3880773a.html }}</ref>
*[[Peutz-Jeghers syndrome]] is autosomal dominant.
*Altered gene: STK11.
 
====Clinical====
Features:<ref>URL: [http://www.ncbi.nlm.nih.gov/omim/175200 http://www.ncbi.nlm.nih.gov/omim/175200]. Accessed on: 13 July 2010.</ref>
*Melanocytic macules.
**Lips, buccal mucosa, and digits.
**Multiple Peutz-Jeghers polyps.
 
Increased risk of various neoplasms - primarily:
*Breast and gastrointestinal cancer.<ref name=pmid20581245>{{cite journal |author=Beggs AD, Latchford AR, Vasen HF, ''et al.'' |title=Peutz-Jeghers syndrome: a systematic review and recommendations for management |journal=Gut |volume=59 |issue=7 |pages=975–86 |year=2010 |month=July |pmid=20581245 |doi=10.1136/gut.2009.198499 |url=}}</ref>
*Others tumours:<ref>URL: [http://www.ncbi.nlm.nih.gov/omim/175200 http://www.ncbi.nlm.nih.gov/omim/175200]. Accessed on: 22 December 2010.</ref>
**[[Granulosa cell tumour]].
**[[Sertoli cell tumour]] - esp. with calcification.
 
===Microscopic===
Features:<ref name=Ref_PBoD859/><ref name=pmid12692201>{{Cite journal  | last1 = Bronner | first1 = MP. | title = Gastrointestinal inherited polyposis syndromes. | journal = Mod Pathol | volume = 16 | issue = 4 | pages = 359-65 | month = Apr | year = 2003 | doi = 10.1097/01.MP.0000062992.54036.E4 | PMID = 12692201 | url = http://www.nature.com/modpathol/journal/v16/n4/full/3880773a.html }}</ref>
*Frond-like polyp with all three components of mucosa:
*# Muscosal epithelium (melanotic mucosa, goblet cells).
*# Lamina propria.
*# M. mucosae.
 
Notes:
*''Frond'' = leaflike expansion.<ref>URL: [http://dictionary.reference.com/browse/frond http://dictionary.reference.com/browse/frond]. Accessed on: 26 July 2011.</ref>
**The '''key''' is "thick" smooth muscle bundles - if one is lucky one sees branching.<ref>C. Streutker. 26 July 2011.</ref>
***"Thick" ~= thickness of muscularis mucosae.
 
Images:
*[http://commons.wikimedia.org/wiki/File:Peutz-Jeghers_syndrome_polyp.jpg Peutz-Jeghers polyp - intestine (WC)].
*[http://commons.wikimedia.org/wiki/File:Gastric_Peutz-Jeghers_polyp_-_very_low_mag.jpg Peutz-Jeghers polyp - stomach (WC)].
*[http://www.nature.com/modpathol/journal/v16/n4/fig_tab/3880773f3.html Peutz-Jeghers polyp (nature.com)].
 
===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 1,001: 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 1,027: Line 560:
**Large cells with a round nucleus and a prominent nucleolus.
**Large cells with a round nucleus and a prominent nucleolus.


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


==Inflammatory myoglandular polyp==
==Inflammatory myoglandular polyp==
Line 1,050: 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 1,060: Line 621:
*[[Small bowel]].
*[[Small bowel]].
*[[Colon]].
*[[Colon]].
*[[Polypectomy]].


=References=
=References=
Michael
48,466

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