Intestinal polyps

INTESTINAL POLYPS
Speaker: Dr. Diya Das
Moderator: Dr. Moumita Sengupta
IPGME&R

Objectives:
 What are the different kinds of polyps?
 What is the biological significance of
polyps?
 How to report a polyp?
 What implications does it have for the
patient and clinician?
3

G I Polyps:
Polyp: A polyp is an abnormal growth
of tissue projecting from a mucous membrane.
Presentation:
 Sporadic
 Familial (germline mutation)
Site:
 Large intestine (most common: colorectal)
 Small intestine
 Stomach
 Esophagus
4
Flat
polyp!!!

5
EsophagusFundus of
Stomach
Cardia/Pylorus of StomachDuodenumJejunumColon/RectumAppendix Anal canal

Basic Histologic Types of Polyp: Colon:
 Epithelial
 Hamartomatous
 Inflammatory
 Lymphoid
 Endocrine
 Mesenchym
al
 Miscellaneou
s
6
 Serrated lesions
 Conventional Adenoma
 Adenomatous polyposis
syndromes
 Adenomas & DALMs in IBD
 Inflammatory pseudopolyp
 Prolapse type inflammatory
polyp
Inflammatory myoglandular polyp
Juvenile polyps & juvenile
polyposis
PJ syndrome
Cowden syndrome
Cronkhite-Canada syndrome
Ganglioneuroma
Neurofi broma
Granular Cell Tumor
Intramucosal Perineurioma
Fibroblastic Polyp
Leiomyoma of the Muscularis
Mucosae
Leiomyosarcoma
Gastrointestinal Stromal Tumors
Lipomas
Lipomatous Ileocecal Valve
Infl ammatory Fibroid Polyp
Pneumatosis Coli
Mucosal Pseudolipomatosis
Endometriosis
Benign Infi ltrative Processes
Inverted Appendix
Mucosal Tag
Atheroembolus-Associated Polyps

Colonic Polyps : Epithelial :
 Premalignant lesions
◦ Adenoma
~Tubular
~ Villous
~Tubulovillous
◦ Dysplasia (intraepithelial neoplasia, low
grade)
◦ Dysplasia (intraepithelial neoplasia, high
grade)
 Serrated lesions
◦ Hyperplastic polyp
◦ Sessile serrated adenoma / polyp
◦ Traditional serrated adenoma
 Hamartomas
◦ Cowden associated polyp
◦ Juvenile polyp
◦ Peutz-Jeghers polyp
7
Conventional Adenoma
 Serrated lesions
 Adenomatous polyposis
syndromes
 Adenomas & DALMs in IBD

Colonic Polyps : Epithelial: Adenoma:
8

Adenomas:
 Dysplastic, clonal proliferation of
colonic epithelium.
 40% Lt colon, 40% Rt colon, 20%
rectum.
 Types:
1. Conventional
2. Serrated
3. Flat/depressed
 Gross:
o Polypoid
- Sessile
- Pedunculated
o Flat/Depressed 9

Tubular Adenoma:
 Small, pedunculated
 Closely packed regular/ branching
tubules
 May have cystic dilatations
10

Villous Adenoma:
 Larger, sessile
 Long slender projections (like
intestinal villi
11

Tubulo Villous Adenoma:
 Containing between 25-75% of
villi.
12

Tubular/ Villous/ Tubulovillous : Does It
Matter?
13
Size ≥10 mm
High grade
dysplasia
Villous component
Advanced
Adenoma
Surveillance interval for a patient with high risk
adenoma is different from one without a high risk :
Colonoscopy at 3 yrs instead of 5 yrs.

Low Grade Dysplasia:
 Architecture: Non-complex
 Nuclear pseudostratification/
partial stratification : nuclei reach
upto half of cytoplasm
 Atypical mitosis, significant loss of
polarity, pleomorphism : minimal to
absent
14

High Grade Dysplasia:
Primarily based on
architecture:
Associated with cytological
features:
15
• Complex architecture
• Complex glandular crowding and
irregularity, prominent budding
• Cribriforming, back to back glands
• Prominent intraluminal papillary
tufting
• Loss of cell polarity
• Nuclear stratification
• Markedly enlarged nuclei, dispersed
chromatin pattern, prominent nucleoli
• Atypical mitotic figures
• Prominent apoptosis

Dysplasia (Adenoma) vs Carcinoma:
16
Mucosa
Low Grade
Dysplasia
Cytological features
High Grade
Dysplasia
Severe dyplasia/
Carcinoma in
situ
Architectural +
Cytological
changes
Intra mucosal
carcinoma
Invasion into
lamina propria /
musc mucosae
Submucosa
Invasive
Carcinoma
Into submucosa

MalignantEpithelial Polyps:
 An adenoma containing invasive adenocarcinoma (i.e.,
cancer that extends beyond the MM into the submucosal
polyp stalk).
 Polypoid adenocarcinoma- polyp head is totally replaced by
cancer with minimal or no evidence of residual
adenomatous epithelium.
 Adenoma with focal adenocarcinoma- that invades the
submucosal stalk
17

Adenoma with epithelial
misplacement
(Pseudocarcinoma):
 Foci of misplaced
epithelium and/or
extravassated mucin within
the submucosa of an
adenoma.
 In adenomas with long stalk
 2-4% adenomas
 More commonly – Left
colon
18

Colonic Polyps : Epithelial: Serrated Lesions:
19

 Serrated architecture of epithelial compartment.
 Heterogenous group of lesions.
20

Serrated Lesions:
21
Hyperplastic polyps:
1. Microvesicular HP (MVHP)
2. Goblet Cell Rich HP (GCHP)
3. Mucin Poor HP (MPHP)
Sessile Serrated Adenoma/Polyp
(SSA/P):
With or without cytological dysplasiaTraditional Serrated Adenoma (TSA)
Serrated Polyposis Syndrome
Serrated
Polyp,
Unclassified:
•Insufficient
tissue
•Sampling
issues
•Poor
orientation

22
Ki-67

23
Ki-67

24

Hyperplastic Polyp:
 >75% of serrated lesions.
 1-5 mm
 >90% distal colon (GCHP
almost exclusively in left colon)
 May be multiple (10-20)
Endoscopy:
 Small, sessile, pearl-colored
dew drop like
25

Colonic Polyps : Epithelial: Serrated Lesions: Hyperplastic Polyps:
 No significant distortion/
horizontal branching
 Wider at surface
 Serration greater at surface
 Minimal cytologic atypia
(Regenerative)
26

Colonic Polyps : Epithelial: Serrated Lesions: Hyperplastic Polyps
MVHP Features
Crypts: Straight. Serrations
towards lumen.
Proliferatio
n:
Uniformly in basal
part of crypts.
Cytological
Dysplasia:
No.
Mucin: Microvesicular, or
mixed
microvesicular+gobl
et cell
27

28
GCHP Features
Crypts: Straight.
Serrations may
be minimal
Proliferation
:
Uniformly in
basal part of
crypts.
Cytological
Dysplasia:
No.
Mucin: Pure goblet cells

29
MPHP Features
Crypts: Straight.
Serrations
towards lumen
Proliferation
:
Uniformly in
basal part of
crypts.
Cytological
Dysplasia:
Atypia present,
but appears
reactive
Mucin: None

30
Difference lies in demographics and molecular
features.
No clinical significance between different subgroups of
HP.
Reporting subtype is optional.

Colonic Polyps : Epithelial: Serrated Lesions: SSA/P:
Sessile Serrated Adenoma/ Polyp:
 Precancerous lesion
 15-25% of serrated polyps
 Proximal colon
 Larger (50% >5mm)
31

32
SSA/P: Features
Crypts: Distorted, dilated
near base,
excess serration
near base
Proliferation: Variable from
crypt to crypt.
Proliferation
located
abnormally away
from base
Cytological
Dysplasia:
No
Mucin: Usually
microvesicular.
Sometimes with
goblet cells/
gastric foveolar
diff.

33

MVHPor SSA/P?(Overlapping
features)
 Site/ Size (>5mm, Rt colon
: Hesiatate to call it MVHP)
 Areas of SSA/P may have
staright crypts like MVHP,
but they account for <50%
of the lesion.
 If more than two or three
contiguous crypts
demonstrate features of
SSA/P, it should be called
SSA/P [WHO]
34

35
Conventional adenoma like
dysplasia:
• Elongated cells with
• Amphophilic cytoplasm
• Hyperchromatic nuclei
• Pseudostratification
• ↑Mitoses
Serrated dysplasia:
• Cuboidal cells
• Eosinophilic cytoplasm
• Vesicular nuclei with prominent
nucleoli
SSA/P with Dysplasia:

Colonic Polyps : Epithelial: TSA:
Traditional Serrated Adenoma
(TSA)
 Precancerous
 Least commom, least
understood
 Distal colon
 More protruberant (not
sessile)
36

Colonic Polyps : Epithelial:TSA
37
TSA: Features
Crypts: Hyperserrated,
owing in part to
ectopic crypts
Proliferatio
n:
Proliferation
located at base of
ectopic crypts
Cytological
Dysplasia:
May be present,
specially in cells
with eosinophilic
cytoplasm
Mucin: None or goblet
cells
Complex villi, rigid serrations
Ectopic budding crypts
Tall columnar cells with
penicillate nuclei and
eosinophilic cytoplasm

Colonic Polyps : Epithelial: TSA:
Dysplasia in TSA:
 The “dysplastic” cells of TSA - not proliferative
but senescent cells
– Do not mark with Ki67
– Not “dysplastic” in the same sense a
conventional adenoma and hence named
“eosinophilic cells with pencillate nuclei”
 Both conventional/ serrated dysplasia can be
seen in TSA !!
38

Colonic Polyps : Epithelial: Management:
39

Colonic Polyps : Epithelial: Recommended Terminology:
Recommended Terminology:
40
Reporting of
subtype is NOT
recommended

Colonic Polyps : Epithelial: Serrated Polyposis Syndrome
Serrated Polyposis Syndrome
WHO criteria:
 ≥5 serrated polyps, proximal to sigmoid colon, ≥2
being ≥10 mm
 Any number of serrated polyps, proximal to sigmoid
colon, any size, in an individual with first degree
relative with serrated polyposis syndrome
 ≥20 serrated polyps, of any size, throughout the
colon
41

Colonic Polyps : Epithelial: Serrated Polyposis Syndrome
Histopathology:
 Multiple
 Usually SSA/P, with fewer MVHP
Types:
 Type1: Multiple SSA/P, more proximal, larger,
substantially increased risk of cancer
 Type 2: Numerous small hyperplastic polyps, throughout
the colon, modestly increases cancer risk, if any at all.
42
Any definitive gene mutation is yet to be identified

Colonic Polyps : Epithelial: Carcinogenesis:
43

Colonic Polyps : Epithelial: Carcinogenesis:
44

Colonic Polyps : Epithelial:
45

Colonic Polyps : Epithelial: Familial Adenomatous Polyposis and Variants:
46

 Adenomatous Polyposis Syndromes:
 Hereditary Non-polyposis Colorectal Cancer
Syndrome:
47
1. FAP
2. Attenuated FAP
3. Gardner’s Syndrome
4. Turcot Syndrome
5. MUTYH Associated
Polyposis
1. Lynch
Syndrome
AR

Diagnostic Criteria:
1) ≥100 Colorectal
adenomas or
2) A germline disease
causing mutation of the
APC gene or
3) Family history of FAP,
and any number of
adenomas at a young
age
48
•Lt side – more
commom
•Age: Mean age of Ca:
40 yrs, 90 % develop
Ca by 50 yrs
•Penetrance 100%

 Dysplastic aberrant crypt foci ( Single crypt adenoma)
• Oligocryptal Adenoma
• Adenomatous Polyps
• Adenocarcinoma

 Autosmal dominant.
 Later presentation than classic FAP.
 Smaller no. of adenomatous
polyps(Avg.30).
 Confirmed by genetic testing for
mutations in expected areas of the APC
gene.
 Rectal sparing – common.
50

FAP : Components:
Intestinal Extra-
intestinal
51
Colorectal adenomatous
polyps (inevitably giving rise
to Ca if not removed)
Stomach: Fundic gland
polyps
Duodeum & small gut:
Adenomatous polyps and
carcinoma
Liver: Hepatoblastoma in
male infants
Biliary tree: Dysplasia and
adenocarcinoma
Fibromas
Osteomas,
odontomas,
supernumerary teeth
Retina: CHRPES
Desmoid tumours
Epidermal cysts
Medulloblastom
a

 Colonoscopy
beginning at 10-15 yrs
 Genetic testing
 Annual or biannual
colonoscopy
 Endoscopic
surveillance every 1-2
yrs upto 40 yrs, then
as per person with
average risk
52
 Known disease causing
mutation:
 Genetic testing unavailable:
all children of affected
parent
 Other family members:
 Adenomas detected :
 Genetic diagnosis not
possible:
Surveillance:

Suspected when:
 ≥10 synchronous
colorectal adenomas
 Late onset
 Absent APC germline
mutation
 Pedigree sugg of AR
inheritance
Confirmed by : Genetic
testing of loss of
MUTYH
Components:
--------------------------------------
-
•Colorectal adenomas
(usually low grade)
 Serrated polyps
 Hyperplastic polyps
•Colorectal Ca (may be in
absence of polyps)
--------------------------------------
-
•Duodenal adenomas &
carcinoma
•Fundic gland polyps and
adenomas
--------------------------------------

54
Genetics:
•MUTYH - Responsible for removing mismatched
residues, product of reactive oxygen species damage
•Penetrance 70%
D/D
1. Lynch syndrome
2. Attenuated FAP

Colonic Polyps : Epithelial: Adenomas and Adenoma like DALMs in IBD:
55

56

57

Colonic Polyps : Hamartomatous:
1. Juvenile poyps
2. Peutz Jegher Syndrome
3. Cowden and Bannayan-Riley-Ruvalcaba
Syndromes (PTEN asoociated)
4. Cronkhite-Canada Syndrome (?Inflammatory –
resembles JPS)
58

Colonic Polyps : Hamartomatous: Juvenile polyps:
59

Colonic Polyps : Hamartomatous: Juvenile Polyposis:
60
JPS: Diagnostic criteria:
1) > 3 to 5 Juv. polyps in the
colorectum
2) Juv. Polyps throughout
the GIT
3) Any no. of juv. Polyps with
a F/H/O JPS
Extra-intestinal:
• Cong anomalies
• Ganglio-neuromatous
growth in the polyps
• Hered. Hemorrhagic
Telengiectasia
• Pulm. AV malformations
• Hypertrophic
osteoarthropathy
SMAD4 &
BMPR1A

Colonic Polyps : Hamartomatous: Juvenile polyposis:
Gross:
 3-200 polyps
 Intervening mucosa- clear
 Unilobulated head
 Atypical (20%) Multilobulated head.
H/P:
 Cystic, tortuous crypts filled with
neutrophils & inspissated mucin
(older name: mucous retention
cyst)
 Stroma: edematous, inflam. cells,
muscle fibres
 Ulceration: dysplastic epithelium
 Atypical: Less stroma, more 61

Colonic Polyps : Hamartomatous: PJ Syndrome:
62
Diagnostic criteria:
1) > 3 PJ polyps
2) Any no. of PJ polyps with
F/H of PJ Syndrome
3) Characteristic,
PROMINENT
pigmentation & F/H of PJ
syndrome
4) Characteristic,
PROMINENT
pigmentation & any no of
PJ polyps
Extra-intestinal:
•Polyps in – Gall bladder/
Urinary bladder/ Nasopharynx
Ovary – Sex cord tumour with
annular tubules
Testis – Sertoli cell tumour
Cervix – Adenoma malignum
Breast – Carcinoma (risk as
high as BRCA mutations)
Pancreas – Carcinoma
•Mucocutaneous
pigmentation – oral. Palmo-
plantar, anal (may fade with
time/ may be absent)
LKB1/ STK11 gene

Colonic Polyps : Hamartomatous: PJ Syndrome:
Gross:
 3-20 polyps
 coarsely lobulated surface
H/P:
 Central core of smooth
muscle
 Arborising pattern
 Heaped up epithelium, no
dysplasia
 Intussusception and
epithelial misplacement -
common
63

Colonic Polyps : Hamartomatous: PTEN Syndromes:
64
•PTEN
•SDH B & SDH
D
Intestinal:
•Hamartomatous polyp – similar
to Juvenile Polyps
•Lipomas
•Ganglioneuromas
•Lymphoid hyperplasia
•Esophagus – Gycogenic
acanthosis
•(Risk of malignancy –
unknown)
Extra intestinal:
•Skin – TRICHILEMMOMA,
acral keratosis, oral
papillomatosis
•Breast – Benign lesions,
Carcinoma breast (younger
age)
•Thyroid – Benign lesions,
Follicular Ca, rarely Pap Ca
•CNS – Lhermitt-Dulco’s
Disease (cerebellar
dysplastic gangliocytoma)

Colonic Polyps : Hamartomatous: PTEN Syndromes:
Part of a single spectrum at the molecular level
Still being investigated. (Example: Infantile form of Juv
Polyposis)
65
Gastro-intestinal
polyps
1. Lipomatosis
2. Hemangiomatosis
3. Macrocephaly
4. Speckled penis

Colonic Polyps : Hamartomatous:
 Non-hereditary polyposis - unknown aetiology
 Mean age: 59 yrs, infantile forms very rare
66
H/P –
•Polyps resemble
juvenile polyps
•Difference:
Intervening mucosa –
edema, dilated glands,
inflam. cells.
Other features:
•Alopecia of scalp & body
• Nail dystrophy
•Skin hyperpigmentation &
macules

Colonic Polyps : Inflammatory:
 Non-neoplastic mixture of stromal and epithelial
components and inflammatory cells.
67
1. Inflammatory
pseudopolyp
2. Prolapse type
Inflammatory polyp
3. Inflammatory
myoglandular polyp

Colonic Polyps : Inflammatory: Inflammatory Pseudopolyp:
68
2. Prolapse type Inflammatory polyp
1. Inflammatory pseudopolyp
3. INFLAMMATORY MYOGLANDULAR POLYP

Polyps arising in the Small Intestine
69

Small Intestinal Polyps :
70
Hyperplasias and
Heterotopias
 Brunner’s gland
hyperplasia
 Gastric heterotopia
 Pancreatic heterotopia
Inflammatory Lesions
 Crohn’s disease–
associated inflammatory
“pseudopolyp”
 Mucosal prolapse polyp
 Xanthoma
 Inflammatory polyp NOS
 Inflammatory fibroid
polyp
Hamartomas
 Peutz-Jeghers polyp
 Juvenile polyp
 Polyp of Cronkhite-
Canada syndrome
syndrome
 Others
Benign Epithelial
Neoplasms
 Adenoma
Malignant Epithelial
Neoplasms
 Adenocarcinoma and
variants
Endocrine Tumors
 Carcinoid tumor
 Somatostatinoma
 Gangliocytic
paraganglioma
 Gastrinoma
Mesenchymal Tumors
 Gastrointestinal stromal
tumor
 Leiomyoma
 Lipoma
 Neurofi broma
 Granular cell tumor
 Ganglioneuroma
 Schwannoma
 Kaposi’s sarcoma
Lymphoid Lesions
 Nodular lymphoid
hyperplasia
 Diffuse large B-cell
lymphoma
 Mantle cell lymphoma
(lymphomatous
polyposis)
 Low-grade B-cell
lymphoma (follicular,
MALT-type,
 Mediterranean fever)
 T-cell lymphoma (gluten
sensitivity enteropathy–
associated

71
 Brunner’s Gland Hyperplasia:
Lobules of Brunner’s glands extend through
the muscularis mucosae filling the lamina
propria and are separated by delicate fibrous
septa.
Cytologically
bland neutral
mucin
containing
cells with
basal nuclei

72
 GASTRIC HETEROTOPIA
The duodenal mucosa is
filled with tightly packed
aggregates of gastric
glands
Bundles of smooth muscle
emanate from the
thickened
muscularis mucosae and
cystically dilated gastric
glands
associated with foveolar
hyperplasia
Gastric mucosa present
within Meckel’s diverticulum
adjacent to the ulcer

73
 PANCREATIC HETEROTOPIA
Lobules of
pancreatic
acini associated with
ducts and tubules

74
Carcinoid tumor of the ileum.

75
Somatostatinoma:

76
Gangliocytic
Paraganglioma

77
Gastrinoma

79
Recommendations:
• Polyps from different locations in the colon - should be
submitted in separate containers, and labelled as to their
site of origin
• Multiple small polyps from the same location can be
submitted in the same container
• Endoscopist should indicate, whether the submitted
specimen represents a biopsy of a polyp, or a
polypectomy specimen

80
Recommendations:
•Number of polyps / pieces of
tissue
•Size of polyps / pieces of tissue
•For intact polyps - whether a
stalk is present or absent
•If stalk is present
o Measure length and diameter
of stalk
o Apply ink to base of stalk
•If stalk is not present
oLook for pale tissue at base of
polyp and apply ink to this area
•If polyp not properly fixed, submit
the following day

83
38 yrs, female, duodenal polyp:
Lipoma of the duodenum.

84
26 yrs, male, duodenal polyp:
P J polyp

85
32 yrs, female, multiple erythematous duodenal polypoid lesions:
Endometriosis

86
Large bowel. What id the structure?
Tinea coli

87
Jejunal biopsy.
Plica circulares

88
46 yrs, female, colonic mass:
Schwannoma

89
52yrs, male, alcoholic cirrhosis, multiple duodenal polyps:
Portal Hypertensive duodenopathy associated
polyp

Intestinal polyps

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