Nonneoplastic polyps

3,598 views

Published on

0 Comments
4 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
3,598
On SlideShare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
138
Comments
0
Likes
4
Embeds 0
No embeds

No notes for slide

Nonneoplastic polyps

  1. 1. Nonneoplastic polyps Dr MJ Ehsani Gastroenterologist April 16 2009
  2. 2. Nonneoplastic polyps <ul><li>Hyperplastic </li></ul><ul><li>Mucosal </li></ul><ul><li>Inflammatory pseudopolyps </li></ul><ul><li>Submucosal </li></ul>
  3. 3. Hyperplastic polyps <ul><li>The most common nonneoplastic polyp in the colon </li></ul><ul><li>Small nodules or polypoid lesions </li></ul><ul><li>Normal cellular components </li></ul><ul><li>Indistinguishable grossly from adenomatous polyps </li></ul>
  4. 4. Hyperplastic polyps <ul><li>No dysplasia </li></ul><ul><li>Serrated (&quot;saw tooth&quot;) pattern </li></ul><ul><li>Proliferation :in the basal portion of the crypt of hyperplastic polyps. </li></ul><ul><li>Rectosigmoid ,sessile </li></ul><ul><li>less than 5 mm in size </li></ul><ul><li>Rarely, if ever, develop into colorectal cancers. </li></ul>
  5. 5. Hyperplastic/Adenomatous polyps
  6. 6. Hyperplastic colonic polyp
  7. 7. Hyperplastic polyps/ prevalence <ul><li>Common </li></ul><ul><li>Increased with age </li></ul><ul><li>In 9-10 % of asymptomatic,>50 y (up to 31 %) </li></ul><ul><li>Autopsy data: 20-35 % </li></ul><ul><li>Hyperplastic > adenomatus in diminutive polyps of rectum and sigmoid. </li></ul>
  8. 8. Hyperplastic polyps/ Significance <ul><li>Proximal neoplasm :in 21-25 % of patients with distal polyp (systematic review) </li></ul><ul><li>Relative risk of any proximal neoplasia :1.3 (95 percent CI 0.9 to 1.8). </li></ul><ul><li>Risk elevation: not clear </li></ul><ul><li>Magnitude of risk :small. </li></ul>
  9. 9. Hyperplastic polyps/ Management <ul><li>Left-sided hyperplastic polyps :not a significant marker of colon cancer risk </li></ul><ul><li>Finding them on a screening sigmoidoscopy is not a routine indication for colonoscopy. </li></ul>
  10. 10. Hyperplastic polyposis syndrome Definition <ul><li>Multiple (> 20) , large polyps (> 1 cm) </li></ul><ul><li>Proximal hyperplastic polyps </li></ul><ul><li>Serrated adenomas ,adenomas </li></ul><ul><li>Mixed hyperplastic/adenomatous polyps </li></ul>
  11. 11. WHO Criteria <ul><li>At least five hyperplastic polyps proximal to the sigmoid colon(two are greater than 1 cm in diameter). </li></ul><ul><li>Any number of hyperplastic polyps occurring proximal to the sigmoid colon in an individual who has a first degree relative with hyperplastic polyposis, </li></ul><ul><li>Greater than 30 hyperplastic polyps distributed throughout the colon. </li></ul>
  12. 12. HPS/ Course <ul><li>Risk of colorectal cancer: increased </li></ul><ul><li>Natural history :unclear </li></ul><ul><li>Careful surveillance, surgery </li></ul><ul><li>Germline mutation :not known </li></ul>
  13. 13. Management strategies <ul><li>Not been well-defined. </li></ul><ul><li>Proximal polyps: should be resected </li></ul><ul><li>Increased colonoscopic surveillance : has been proposed </li></ul><ul><li>Frequency of surveillance: no consensus </li></ul>
  14. 14. HPS/ Screening <ul><li>First-degree relatives of affected individuals : Screening colonoscopy </li></ul><ul><li>Beginning at age 40 (or 10 years earlier than the earliest age at diagnosis in the family) </li></ul><ul><li>A surveillance interval : five years for relatives (if no polyps are found). </li></ul>
  15. 15. Mucosal polyps <ul><li>Small (usually <5 mm) excrescences of tissue </li></ul><ul><li>Endoscopically resemble the adjacent flat mucosa </li></ul><ul><li>Histology: normal mucosa. </li></ul><ul><li>No clinical significance. </li></ul>
  16. 16. Inflammatory pseudopolyps <ul><li>Irregularly shaped islands of residual intact colonic mucosa </li></ul><ul><li>Mucosal ulceration and regeneration </li></ul><ul><li>Multiple, often filiform and scattered throughout the colitic region of the colon. </li></ul><ul><li>Risk factor for colon cancer? </li></ul><ul><li>Associated with surrounding dysplasia </li></ul>
  17. 17. Pseudopolyps in inflammatory bowel disease
  18. 18. Submucosal polyps <ul><li>Lymphoid aggregates </li></ul><ul><li>Lipomas, leiomyomas </li></ul><ul><li>Pneumatosis cystoid intestinalis </li></ul><ul><li>Colitis cystica profunda/solitary/< 3 cm </li></ul><ul><li>Hemangiomas </li></ul><ul><li>Fibromas </li></ul><ul><li>Carcinoids </li></ul><ul><li>Metastatic lesions </li></ul>
  19. 19. Lipoma <ul><li>Colon:the most common GI site </li></ul><ul><li>Yellow color </li></ul><ul><li>Softness </li></ul><ul><li>Pillow sign(indentation on gentle pressure) </li></ul><ul><li>Endoscopic ultrasound </li></ul>
  20. 20. Lymphoid polyps <ul><li>Hypertrophied follicles </li></ul><ul><li>Pain,bleeding </li></ul><ul><li>Pedunculate </li></ul><ul><li>Distinction from malignant lymphoid lesions </li></ul>
  21. 21. lymphoid polyps <ul><li>Lymphoid polyps of the colon in a child. </li></ul>
  22. 22. Hamartomatous polyps Juvenile polyps <ul><li>Hamartomatous lesions </li></ul><ul><li>Consist of a lamina propria and dilated cystic glands rather than increased numbers of epithelial cells </li></ul><ul><li>Retention polyp (distended,mucus filled glands,inflammatory cells) </li></ul><ul><li>Any age, more common in childhood(1-2 %). </li></ul>
  23. 23. Juvenile polyps <ul><li>Acquired </li></ul><ul><li>Single </li></ul><ul><li>3 mm-2 cm </li></ul><ul><li>Bleeding,prolapse </li></ul><ul><li>Malignancy risk: not increased </li></ul><ul><li>Removal is suggested </li></ul>
  24. 24. Juvenile polyps
  25. 25. Multiple juvenile polyps <ul><li>Rare(< 1 out of 100,000 live births) </li></ul><ul><li>Autosomal dominant inheritance (familial juvenile polyposis (FJP) </li></ul><ul><li>Germ-line mutations : SMAD4 gene on chromosome 18q21.1, or in the gene BMPR1A. </li></ul><ul><li>Increased risk for colorectal cancer, and in some families, gastric cancer, especially </li></ul>
  26. 26. Multiple juvenile polyps/FJP <ul><li>Symptoms: 4 – 14 y </li></ul><ul><li>10 or more juvenile polyps </li></ul><ul><li>Rectal bleeding/anemia(75 %),prolapse,… </li></ul><ul><li>Adenomatous changes: 8 - 47 % </li></ul><ul><li>Colon cancer risk : up to 20 % ? </li></ul><ul><li>Cancer risk: greatest if > 3 polyps or FH of juvenile polyps. </li></ul>
  27. 27. FJP/ Screening <ul><li>No consensus. </li></ul><ul><li>Asymptomatic first degree relatives : should be screened </li></ul><ul><li>Annual FOB and flexible sigmoidoscopy or colonoscopy every three to five years beginning at age 12 and continuing until approximately age 40. </li></ul><ul><li>Symptomatic patients :evaluation regardless of age. </li></ul><ul><li>Colonoscopy every one to two years beginning at age 15 to 18 (or earlier in patients who presented with symptoms) . { British Society of Gastroenterology } </li></ul>
  28. 28. FJP/ Surveillance <ul><li>Gene carriers or affected cases : surveillance until age 70. </li></ul><ul><li>Colonoscopic polypectomy with regular surveillance : if only a small number of polyps are present . </li></ul><ul><li>Prophylactic surgery :With a large number of polyps ,multiple polyps with adenomatous change and high-grade dysplasia, polyps cannot be removed endoscopically , complications (such as bleeding) are not easily controlled, colorectal cancer is a feature of the family history </li></ul>
  29. 29. FJP/ Surveillance, cont.. <ul><li>UGI surveillance has been recommended every one to two years beginning at age 25 by upper endoscopy/enteroscopy or UGI with SBFT </li></ul>
  30. 30. Peutz-Jeghers polyps  <ul><li>Hamartomatous lesion </li></ul><ul><li>Almost always with the Peutz-Jeghers syndrome. </li></ul><ul><li>Gastrointestinal (gastric, small bowel, colon, pancreas) cancer risk: increasedand </li></ul><ul><li>Nongastrointestinal cancers risk : increased </li></ul><ul><li>Cumulative cancer risk :50 % by age 60. </li></ul>
  31. 31. Colonic Peutz-Jeghers polyp
  32. 32. PJS <ul><li>Autosomal dominant. </li></ul><ul><li>Males /females :equal. </li></ul><ul><li>Rare (prevalence between 1:25,000 and 1:280,000). </li></ul><ul><li>The PJ gene :chromosomal 19p13.3 </li></ul>
  33. 33. Clinical manifestations <ul><li>Pigmented mucocutaneous macules </li></ul><ul><li>Multiple gastrointestinal polyps </li></ul><ul><li>Polyps : benign, grow progressively ,then symptoms ,malignant transformation. </li></ul>
  34. 34. Pigmented spots <ul><li>Mucocutaneous pigmentations :> 95 % </li></ul><ul><li>Flat, blue-gray to brown spots 1 to 5 mm in size </li></ul><ul><li>Freckles /onset and location. </li></ul><ul><li>PJS lesions on the lips and perioral region (94%), hands (74%), buccal mucosa (66%) and feet (62%) </li></ul>
  35. 35. Pigmented spots <ul><li>Nose, perianal area, and genitals </li></ul><ul><li>Intestines:rare </li></ul><ul><li>Occur during the first one to two years of life, increase in size and number over the ensuing years, and finally fade after puberty with the exception of those on the buccal mucosa. </li></ul><ul><li>Freckles:sparse near the nostrils and mouth, are absent at birth, and never appear on the buccal mucosa. </li></ul><ul><li>Malignant degeneration :extremely rare. </li></ul>
  36. 36. Oral lesions in Peutz-Jeghers syndrome
  37. 37. Gastrointestinal polyps <ul><li>Present in most patients with PJS </li></ul><ul><li>Proliferation of smooth muscle extending into the lamina propria in an arborization-like fashion; the overlying epithelium is normal </li></ul><ul><li>Sessile, pedunculated, lobulated </li></ul><ul><li>Small intestine — 64 percent </li></ul><ul><li>Colon — 64 percent </li></ul><ul><li>Stomach — 49 percent </li></ul><ul><li>Rectum — 32 percent </li></ul>
  38. 38. Polyps in PJS <ul><li>Number : 1 to >20 per segment of bowel </li></ul><ul><li>Size : variable (0.1 > 5 cm) </li></ul><ul><li>Grow in the first decade of life </li></ul><ul><li>Symptoms : between the age of 10 and 30 </li></ul>
  39. 39. PJS/ Presenting gastrointestinal symptoms <ul><li>Obstruction :43% (intussusception ,occlusion of the lumen) </li></ul><ul><li>Abdominal pain :23% (infarction) </li></ul><ul><li>Acute or chronic rectal bleeding :14%(ulceration) </li></ul><ul><li>Extrusion of the polyp through the rectum :7 % </li></ul><ul><li>Intussusception: Nearly one-half of the patients </li></ul>
  40. 40. Duodenal peutz-Jeghers polyp
  41. 41. Peutz-Jeghers polyp
  42. 42. Diagnosis / Clinical Criteria <ul><li>For individuals with a histopathologically confirmed hamartoma, a definite diagnosis of PJS requires two of the following three findings: </li></ul><ul><li>1. Family history consistent with autosomal dominant inheritance </li></ul><ul><li>2. Mucocutaneous hyperpigmentation </li></ul><ul><li>3. Small-bowel polyposis </li></ul>
  43. 43. Diagnosis / Clinical Criteria <ul><li>For individuals without histopathologic verification of hamartomatous polyps, a probable diagnosis of PJS can be made based on the presence of two of the three clinical criteria above. </li></ul><ul><li>For individuals without a family history of PJS, diagnosis depends upon the presence of two or more histologically verified Peutz-Jeghers-type hamartomatous polyps. </li></ul><ul><li>For individuals with a first-degree relative with PJS, presence of mucocutaneous hyperpigmentation is sufficient for presumptive diagnosis. </li></ul>
  44. 44. Risk of malignancy <ul><li>The overall risk of developing cancer at ages 20, 30, 40, 50, 60, and 70 was 1, 3, 19, 32, 63, and 81 percent, respectively. </li></ul><ul><li>The most common cancers :gastrointestinal in origin </li></ul><ul><li>The risk for these cancers at ages 30, 40, 50 and 60 was estimated to be 1, 10, 18, and 42 percent, respectively. </li></ul><ul><li>Breast cancer : increased (32 percent by age 60). </li></ul>
  45. 45. Non-gastrointestinal cancers <ul><li>lung </li></ul><ul><li>breast </li></ul><ul><li>uterus </li></ul><ul><li>ovary </li></ul><ul><li>cervix </li></ul><ul><li>testies </li></ul>
  46. 46. Chemoprophylaxis <ul><li>Not established </li></ul><ul><li>COX-2 inhibitors </li></ul><ul><li>Rapamycin(Sirolimus) </li></ul>
  47. 47. PJS/ Screening <ul><li>All GI cancers 2-13% </li></ul><ul><li>Colonoscopy at symptom onset, or in late teenage years if the individual is asymptomatic </li></ul><ul><li>Interval is determined by the number of polyps but at least q 3 yr </li></ul><ul><li>Upper GI endoscopy q 2 yr; start at age 10 yr </li></ul><ul><li>Small intestinal cancer RR, 13 Annual Hgb; small bowel series or capsule endoscopy q 2 yr; start at age 10 yr </li></ul>
  48. 48. PJS/Screening <ul><li>Pancreatic cancer RR, 100 Endoscopic or abdominal ultrasound q 1-2 yr; start at age 30 yr </li></ul><ul><li>Breast cancer RR, 8.8 Annual breast examination; mammogram q 1-3 yr; start at age 25 yr </li></ul><ul><li>Uterine; ovarian cancer RR, 8.0; 13 Annual pelvic examination; Pap smear and pelvic ultrasound; start at age 20 yr </li></ul><ul><li>Sertoli cell tumor (testis)Uncommon Annual testicular examination beginning at age 10 yr; testis ultrasound if the patient has feminizing features </li></ul>
  49. 49. Screening and surveillance <ul><li>Genetic testing :not yet widely available </li></ul><ul><li>For asymptomatic first degree relatives of patients with known PJS : screening is recommended </li></ul><ul><li>Have not been validated in clinical trials </li></ul><ul><li>Beginning at birth with an annual history, physical examination, and evaluation for melanotic spots, precocious puberty, and testicular tumors. </li></ul><ul><li>Predictive genetic testing can be offered at age eight years (in at-risk individuals in whom the diagnosis is not already apparent clinically). </li></ul>
  50. 50. Screening and surveillance <ul><li>What type of screening :unsettled. </li></ul><ul><li>upper gastrointestinal series every two years until age 25 ? </li></ul><ul><li>upper endoscopy, colonoscopy, and small bowel series at ages 12, 18, and 24 years ? </li></ul><ul><li>Endoscopic polypectomy :for polyps >1 cm </li></ul><ul><li>Surgery for large polyps </li></ul><ul><li>Clearing the small bowel of polyps at laparotomy </li></ul>
  51. 51. Surveillance of affected individuals <ul><li>Regular surveillance : recommended. </li></ul><ul><li>Surveillance :detecting cancers of the breast, colon, pancreas, stomach and small bowel, ovaries, uterus and cervix, and testicles. </li></ul><ul><li>From birth to age 12. In male patients: history and physical examination with attention to the testicles. </li></ul><ul><li>Routine blood tests annually (ultrasound of the testicles every two years until age 12 offered as an option). </li></ul>
  52. 52. Surveillance of affected individuals <ul><li>For female patients(at age 8): History and physical examination with routine blood tests annually. </li></ul><ul><li>For males and females: upper endoscopy and small bowel series; if positive, continue every two to three years(From age 18) </li></ul><ul><li>In male patients: colonoscopy, upper endoscopy, and small bowel series every two to three years. </li></ul><ul><li>In female patients: Colonoscopy, upper endoscopy, and small bowel series every two to three years; breast self-exam monthly. </li></ul>
  53. 53. Surveillance of affected individuals <ul><li>From age 21 on. For female patients: pelvic examination with a Papanicolaou smear annually. </li></ul><ul><li>From age 25 on. For male patients: endoscopic ultrasound of the pancreas every one to two years (CT scan and/or CA19-9 offered as options). </li></ul><ul><li>For female patients: endoscopic ultrasound of the pancreas every one to two years (CT scan and/or CA 19-9 offered as options); clinical breast exam semiannually; mammography annually (MRI offered as an alternative); transvaginal ultrasound and serum CA-125 annually. </li></ul>
  54. 54. Cronkhite-Canada syndrome  <ul><li>Rare, nonfamilial /Unknown etiology </li></ul><ul><li>Alopecia, cutaneous hyperpigmentation, GI polyposis(hamartomas), onychodystrophy, diarrhea, weight loss and abdominal pain. </li></ul><ul><li>Do not appear neoplastic pathologically. </li></ul><ul><li>Characteristic features :myxoid expansion of the lamina propria and increased eosinophils in the polyps </li></ul><ul><li>Five-year mortality rates up to 55 % </li></ul><ul><li>Deaths due to GIB, sepsis, and CHF </li></ul><ul><li>Treatment :nutritional support, corticosteroids, acid suppression, and antibiotics? </li></ul>
  55. 55. Thanks for your attention

×