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Background
Polyps are slow-growing overgrowths of the
colonic mucosa that carry a small risk (<1%) of
becoming malignant.
However, because polyps are highly prevalent in
the general population (especially with
increasing age), they confer an important
predisposition to colon cancer and are therefore
removed when detected.
Patients with isolated polyps are usually
asymptomatic.
Polyps can occur as part of inherited polyposis
syndromes in which their number is greater and
the risk for malignant progression is much
greater compared to the risk with isolated
polyps.
Pathophysiology
Colonic polyps, or adenomas, are benign
epithelial neoplasms that arise from the
epithelial cells lining the colon.
Polyps are traditionally divided into 4
groups.
Hyperplastic polyps.
Adenomas.
Polyposis syndromes.
Miscellaneous.
Hyperplastic polyps
Hyperplastic polyps comprise about 90%
of all polyps and are totally benign
protrusions.
They are usually less than 0.5 cm in
diameter.
They most commonly occur in the
rectosigmoid region during adulthood.
The lesions tend to be smaller than
adenomas and do not appear to be related
to the adenoma-carcinoma sequence.
Small polypoid nodule Hyperplastic polyp
indistinguishable from a
small sessile adenoma.
Radiograph of a mandible
demonstrating mandibular
osteoma.
Peutz-Jeghers syndrome.
Inherited in an autosomal dominant manner,
PJS is characterized by the association of
gastrointestinal polyposis and mucocutaneous
pigmentation.
Peutz-Jeghers type hamartomatous polyps are
most prevalent in the small intestine (jejenum,
ileum, and duodenum, respectively), but can
occur elsewhere in the GI tract.
Mucocutaneous hyperpigmentation presents in
children under the age of five years as dark blue
to dark brown mucocutaneous macules around
the mouth, eyes, and nostrils, in the perianal
area, on the buccal mucosa, and on the fingers.
Females are at risk for sex cord tumors
with annular tubules (SCTAT), a benign
neoplasm of the ovaries.
Males occasionally develop calcifying
Sertoli cell tumors of the testes, which
secrete estrogen and can lead to
gynecomastia.
Individuals with Peutz-Jeghers syndrome
are at increased risk for intestinal and
extraintestinal malignancies, including
colorectal, esophageal, gastric, breast,
ovarian, and pancreatic cancers.
Mucocutaneous pigmentation in a patient
with Peutz-Jeghers syndrome.
Low-power (A) and
high-power (B)
photomicrograph of a
Peutz-Jeghers polyp.
In this type of polyp, the
glandular epithelium is
supported by an
arborizing framework of
well-developed smooth
muscle that is
contiguous with the
muscularis mucosae.
Juvenile polyposis syndrome
(JPS)
Juvenile polyposis syndrome (JPS) is
characterized by predisposition for
hamartomatous polyps in the gastrointestinal
(GI) tract, specifically in the stomach, small
intestine, colon, and rectum.
JPS is diagnosed if any one of the following is
present:
More than five juvenile polyps of the colorectum.
OR
Multiple juvenile polyps throughout the GI tract.
OR
Any number of juvenile polyps.
and a
Family history of juvenile polyps.
The term "juvenile" refers to the type of
polyp, not the age of onset of polyps.
Most individuals with JPS have some
polyps by 20 years of age.
Some individuals may only have four or
five polyps over their lifetimes, whereas
others in the same family may have over a
hundred.
Most juvenile polyps are benign; however,
malignant transformation can occur.
Estimates of developing GI cancers in
families with JPS range from 9-50%.
Juvenile Polyp
Pedunculated polyp in the sigmoid
colon of a 15 year-old undergoing
colonoscopy for evaluation of
hematochezia (rectal bleeding). No
additional polyps were found.
Histology confirmed this to be a
benign juvenile (retention) polyp.
Numerous cystically dilated glands
can be seen in this low-power view
of a juvenile polyp. In addition, the
surface is ulcerated and the lamina
propria is chronically inflamed.
These polyps share many features
with inflammatory polyps, however,
the degree of cystic dilatation in
juvenile polyps is usually not seen
in inflammatory polyps.
Other hereditary syndromes
Hereditary mixed polyposis syndrome
Mode of inheritance is unknown.
The syndrome is characterized by atypical
juvenile polyps, polyps containing mixed
histology, or multiple polyps of more than one
histologic type in an individual.
Neurofibromatosis type 1 (NF1)
Individuals with NF1 may exhibit multiple
intestinal polypoid neurofibromas or
ganglioneuromas in the small bowel, stomach,
and colon.
Ganglioneuromatosis. A proliferation of neural tissue
within the mucosa. A ganglion cell is also present
(arrow). This finding may be seen as an isolated polyp
(eg, ganglioneuroma) or as a diffuse process throughout
the gastrointestinal tract (eg, ganglioneuromatosis).
Hereditary non-polyposis colon
cancer (HNPCC)
It is an autosomal dominant colon cancer
syndrome with proximal colonic predominance.
Few colonic adenomas are present.
Other malignancies include cancer of the
endometrium, ovary, stomach, small intestine,
and urinary tract.
It may be difficult to distinguish between HNPCC
and attenuated FAP in individuals and families
who have few adenomatous colonic polyps.
Acquired syndrome
Cronkite-Canada syndrome
Generalized gastrointestinal hamartomatous
polyposis, cutaneous hyperpigmentation, hair
loss, and nail atrophy.
Miscellaneous
A large, benign-appearing
submucosal polypoid lesion
in the transverse colon.
A large area of pink whirling spindle cells is observed
directly beneath the mucosa.
The lesion has the typical appearance of a leiomyoma,
complete with a well-circumscribed smooth border.
Colonic Lipoma
Colon is the most common gastrointestinal site for
lipomas: about 60-70% of all lipomas of the
gastrointestinal tract originate in the colon.
Ninety percent of colonic lipomas arise in the submucosa
and 10% in the subserosa (appendices epiploicae).
The size of colonic lipomas ranges between 1 and 10 cm
in diameter, but most are smaller than 3 cm.
They are usually solitary but can be multiple.
The right side of the colon is involved more frequently
than the left.
The majority of noncomplicated colonic lipomas will not
cause clinical complaints. However, recurrent
intussusception of the tumour may cause intermittent
abdominal pain whereas ulceration of the mucosa
overlying the tumour may lead to intestinal blood loss.
Smooth, soft polypoid lesion
in the ascending colon.
Removal of a portion of
overlying mucosa with a
biopsy forceps revealed the
underlying fatty tissue.
Pedunculated lipoma.
The stalk, which was very
thin, is visible behind the
head of the polyp at the 2
o'clock position.
Resected specimen
demonstrating fatty
consistency and
submucosal origin of
mass typical of colonic
lipoma.
Microscopic picture.
Colonic Hamartoma
Solitary diminutive polyp.
Histology revealed a benign
intestinal smooth muscle
hamartoma, confirmed with
immuno stains.