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Colonic polyps

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.

These polyp grossly


appeared to be a
pedunculated
adenoma on a broad
stalk, or even a lipoma,
but histologically proved
to be hyperplastic (and Erythematous
therefore not a "true" polypoid lesions
polyp). which proved to
A 1cm nearly flat polyp be inflamed
on a very short stalk hyperplastic
polyps.
This high-power view shows
a gland with a serrated
lumen (open arrow) and a
thickened subepithelial
collagen table (closed arrow).
Adenomas
 Adenomas comprise approximately 10% of
polyps.
 Most (~90%) are small, usually less than 1.5 cm
in diameter, and have a very small potential for
malignancy.
 The remaining 10% of adenomas are larger than
1.5 cm and have about a 10% chance of
containing invasive cancer.
 Adenomas are traditionally divided into 3 types:
tubular, tubulovillous, and villous.
 Tubular adenomas are the most common of the
3 types and can be found anywhere in the colon.
 Those with a distinct stalk are termed
pedunculated; those without a stalk are
termed sessile.
 The risk of progression to carcinoma is
related to the size of the adenoma.
 Tubulovillous adenomas are most
commonly found in the rectal area.
 The degree of villous component of these
adenomas is correlated with the risk of
progression to carcinoma.
 Villous adenomas most commonly occur in
the rectal area.
 They tend to be larger than the other two
types; and tend to be nonpedunculated,
velvety, or cauliflower-like in appearance.
 Villous adenomas are associated with the
highest morbidity and mortality rates of all
polyps.
 They can cause hypersecretory syndromes
characterized by hypokalemia and profuse
mucous discharge and can harbor
carcinoma in situ or invasive carcinoma
more frequently than other adenomas.
Sessile Tubular Adenoma
A small, sessile,
multilobulated lesion
which proved to be a
benign tubular
adenoma.
A smooth sessile polyp
on a broad base.
Pedunculated Tubular Adenoma
Benign tubular adenoma
on a long stalk .
The stalk is several
times larger than the
polyp itself.
 Photomicrograph of tubular adenoma of the colon cut in
cross section to demonstrate stalk.
 Tubular adenomas are characterized by a complex
network of branching adenomatous glands.
Sessile Villous Adenoma
3-4 cm carpet-like
tubulovillous adenoma of the
cecum.
The orifice of the appendix is
visible in the image on the
left.
1 cm sessile tubulovillous
adenoma of the sigmoid
colon.
 Villous adenoma.
 This lesion has a sessile configuration with a
villi-form frond-like surface.
Photomicrograph of a tubulovillous adenoma. This polyp
has the characteristics of a tubular adenoma as well as
adenomatous glands that extend straight down from the
surface to the center of the polyp.
Serrated Adenoma

 Histologically this lesion was a mixture of


hyperplastic and adenomatous elements, hence
the designation of serrated adenoma.
Polyposis syndromes
 Polyposis syndromes are hereditary conditions
that include:
 Familial adenomatous polyposis (FAP).
 Gardner syndrome.
 Turcot syndrome.
 Peutz-Jeghers syndrome.
 Cowden disease.
 Familial juvenile polyposis.
 Some of the syndromes have extraintestinal
features that help differentiate one syndrome
from the other.
Familial adenomatous polyposis
(FAP)
Hundreds of benign
tubular adenomas
throughout the colon.

Small and large benign


polyps throughout the
colon.
A portion of a colectomy
specimen that shows
complete carpeting of the
mucosal surface by
adenomatous polyps.

A single adenomatous crypt


(arrow) is present in this
section of nonpolypoid
mucosa from a patient with
familial polyposis. The
presence of "unicryptal
adenomas" in nonpolypoid
mucosa is a diagnostic
feature of familial
adenomatous polyposis.
 Gardner syndrome (GS)
 Is the association of colonic adenomatous polyposis,
osteomas, and soft tissue tumors (epidermoid cysts,
fibromas, desmoid tumors).
 Turcot syndrome
 Includes polyps, medulloblastoma, congenital
hypertrophy of the retinal pigmented epithelium
[CHRPE], and glioblastoma multiforme).
 Cowden syndrome
 Includes polyps, fibrocystic disease, breast cancer,
and thyroid cancer).
Mandibular osteoma in a
patient with Gardner's
syndrome.

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

 Inflammatory polyps/ pseudopolyps


 These lesions develop as by-products of the
ulcers that penetrate into the submucosa,
leaving islands of adjacent regenerative
mucosa.
 Although most common in ulcerative colitis,
inflammatory polyps may also be seen in
Crohn's disease, ischemia, and other
ulcerative conditions of the colon.
The colonic mucosa The pseudopolyp has an Severe ulcerative
shows numerous ulcerated surface lined with
granulation tissue. The colitis with
inflammatory polyps
with intervening underlying crypts are pseudopolyps.
distorted and contain
areas of ulceration. regenerative epithelium.
The deep lamina propria
often contains increased
numbers of plasma cells
and lymphocytes.
Colonic Leiomyoma (Stromal
Tumor)
Smooth polyp with a shallow
cleft or furrow, in the distal
rectum.
The lesion was submucosal.

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.

Pedunculated polyp, quite


lobulated, on a very thin
stalk, which histologically
proved to be a hamartoma.
 This low-power photomicrograph demonstrates a
hamartomatous polyp with dilated mucus-filled glands
and extensive edema and inflammation in the lamina
propria. Hamartomas of the colon, small intestine, and
stomach characterize familial juvenile polyposis. The risk
of colon cancer is increased in this syndrome because of
the presence of synchronous adenomatous polyps.
Lymphoid Hyperplasia
Mucosal nodularity in the
distal ileum, representing
lymphoid hyperplasia, which
is a normal finding.
Right: Sessile polypoid
lesions with central
umbilications in the cecum.
Left: Lymphoid hyperplasia found
in the proximal colon.
Right: The lymphoid hyperplasia
extended into the cecum; a
portion of the cecal mass can be
seen at the right.
Fibroepithelial Polyp
During colonoscopy, retroflexion of
the instrument in the rectum
revealed a pale, tan polypoid
lesion which appeared to be
attached at its base to an internal
hemorrhoid. The lesion was
surgically excised, and
histologically proved to be a
benign fibroepithelial polyp arising
from anorectal musoca.
A benign-appearing, bland
polypoid lesion seen at
retroflexion. Histology of the
surgically-excised specimen
revealed fibroepithelial papilloma.
Filiform polyps

A numerous fingerlike projections A biopsy specimen shows a finger


rising above the mucosa is shown. like portion of colonic mucosa
These mucosal lesions are often surrounding a fibrovascular core.
grouped and are typically found in The epithelium is intact and shows
patients with chronic inflammatory relatively normal architecture.
bowel disease. These lesions are
thought to represent healed
inflammatory polyps.
Granular Cell Tumor
A smooth polypoid
lesion.
On microscopic exam, the lesion
contained cytologically bland cells
with abundant granular cytoplasm,
small regular nuclei involving
musosa and apparently associated
with, or arising from, the
muscularis mucosa, consistent
with granular cell tumor. Granular
cell tumors may occur elsewhere
in the GI tract, including the
esophagus.
Diminutive Polyp
3-4 mm polyp (left) excised
with a forceps (center), to
which cautery is applied,
leaving a small polypectomy
site (right). Grossly this
lesion cannot be reliably
distinguished from a
hyperplastic pseudopolyp vs.
a small true polyp
(adenoma), and all such
lesions should be removed
for microscopic analysis.
Rectal Condyloma
Two small, hypopigmented
polypoid lesions seen at
retroflexion in the rectum.
Histologically the lesions were
squamous papillomas, with mild to
moderate dysplasia, and features
consistent with Human Papilloma
Virus (HPV) infection.
Sessile bland polypoid lesion
seen at retroflexion in the
rectum.
Lymphomatous polyposis
 Occurrence of primary extranodal
lymphomas in the gastrointestinal tract.
 Two types include:
 Multiple lymphomatous polyposis.
 Mediterranean-type lymphoma.
Colonoscopy revealing
multiple polyploid lesions
in the colon.

Colonoscopy showing a 4-cm


polyp at the caecum.
 Figure 2.
Colonoscopy with
multiple polypoid
lesions ranging
from 0.2 to 0.5 mm
in diameter.
Mucosa between
polyps appears to
be normal. Figure
3. Colonoscopy
with a sprayed dye
technique (indigo
carmine) showing
multiple polypoid
lesions of various
sizes. Figure 4.
Colonic biopsy
specimen showing
a dense lymphoid
infiltrate with well-
defined borders
(hematoxylin-eosin,
original
magnification
×100).
 Diagrammatic representation of carcinoma within a
polyp. Black wedges represent foci of carcinoma. A
wedges indicate carcinoma in situ; malignant cells do not
traverse the muscularis mucosae. B wedges indicate
invasive carcinoma; malignant cells have breached the
muscularis mucosae.
 Metastasis cascade. Metastasis of colorectal cancer cells from the primary
site in the colon to the liver involves a complex series of events, all of which
are necessary to result in distant metastatic disease.
 Tumors must become vascularized to grow at the primary site.
 Cells must then be able to invade basement membranes, avoid immune
surveillance, adhere to vascular endothelia, and interact with the
microenvironment to set up metastatic foci.
Thank you

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