SlideShare a Scribd company logo
1 of 100
LARGE INTESTINAL
TUMORS
DR.Navleen kaur
3rd year Pathology resident
AIMSR, Bathinda
Lesson plan
ī‚§ Anatomy of intestine
ī‚§ Normal histology
ī‚§ Classification
ī‚§ Polyps
ī‚§ Ca colon
ī‚§ Other types
ī‚§ Appendix
NORMAL HISTOLOGY OF COLON
Epithelium-lined by absorptive colonocytes, goblet cells, endocrine
cells and paneth cells.
Goblet cells
Fetal colon
meconium
NORMAL HISTOLOGY OF RECTUM
AND ANAL CANAL
Definitions of histological
abnormalities
ī‚§ Normal colorectal crypts are straight, parallel
and extend from immediately above the
muscularis mucosae to the surface.
ī‚§ Crypt distortion: implies non-parallel,
variable diameter or cystically dilated crypts
as opposed to the normal 'test-tube rack'
appearance.
WHO CLASSIFICATION OF TUMORS
OF COLON AND RECTUM
ī‚§ EPITHELIALTUMORS
ī‚§ Adenoma
Tubular
Villous
Tubulovillous
ī‚§ Dysplasia(IEN), low grade
ī‚§ Dysplasia, high grade
ī‚§ Serrated lesions
Hyperplastic polyps
Sessile serrated polyp
Traditional serrated adenoma
ī‚§ Hamartomatous
Cowden-associated polyp
Juvenile polyp
Peutz-Jeghers polyp
CARCINOMAS
ī‚§ Adenocarcinoma
ī‚§ Other types
MESENCHYMAL TUMORS
ī‚§ Lipoma
ī‚§ Leiomyoma
ī‚§ Gastrointestinal stromal tumor
ī‚§ Leiomyosarcoma
ī‚§ Angiosarcoma
ī‚§ Kaposi sarcoma
Lymphomas
ī‚§ B-cell lymphoma,unclassifiable
ī‚§ Burkitt lymphoma
ī‚§ Diffuse large B-cell lymphoma
ī‚§ Mantle cell lymphoma
ī‚§ Marginal zone lymphoma of mucosa-
associated lymphoid tissue(MALT)
ī‚§ Secondary tumors
POLYPS
ī‚§ Definition:The term polyp refers to any
circumscribed mucosal growth either flat,
depressed, sessile or pedunculated.
adenomas
ī‚§ Tubular adenoma – distributed regularly
throughout the large bowel with 40 % in right
colon, 40 % left colon and 20 % in rectum.
ī‚§ Blacks>whites.
ī‚§ Assymptomatic, but can result in bleeding.
Gross
ī‚§ < 1cm.
ī‚§ Sessile/peduncul
ated
ī‚§ Single/multiple
ī‚§ Knob-like
projections can
be seen.
Microscopy
ī‚§ in number of
glands and cells
per unit area
confined to
normal mucosa.
ī‚§ Disorganized
glands, Cells are
crowded,
enlarged with
hyperchromatic
nuclei
Villous adenoma
ī‚§ Infrequent type
of polyp,single,
sessile, larger
than tubular.
ī‚§ Very soft in
consistency, can
be missed on
DRE.
microscopy
ī‚§ A villous adenoma is shown at its edge on the left,
and projecting above the basement membrane at
the right. The cauliflower-like appearance is due to
the elongated glandular structures covered by
dysplastic epithelium
Tubulovillous adenoma
ī‚§ Polyps in which adenomatous and villous
components are present in approximately
equal amounts are referred to as
Villoglandular polyps,Tubullovillous
adenomas or papillary adenomas.
ī‚§ TVAs are considered to have a higher risk of
malignant transformation than tubular
adenomas
tubular component - left of image,
villous component - right of image
HYPERPLASTIC POLYPS
ī‚§ Colonic hyperplastic polyps are benign
epithelial proliferations that are typically
discovered in 6th and 7th decades of life.
ī‚§ Site- most common in left colon and <5mm in
diameter.
ī‚§ Pathogenesis- decreased epithelial turnover
and delayed shedding of surface epithelial
cells, leading to “piling up” of goblet and
absorptive cells.
Clinical significance
ī‚§ They must be distinguished from sessile
serrated adenomas, which are histological
similar and have malignant potential.
Hyperplastic polyps
Gross- < 5 mm in diameter
left colon
small,sessile
ī‚§ Microscopy- 1)mature goblet and absorptive cells.
ī‚§ 2)irregular tufting of epithelial cells.
ī‚§ 3)epithelial overcrowding serrated
architecture.
Hyperplastic polyp
GROSS
MICROSCOPY
Sessile serrated adenomas
ī‚§ Histologically similar to hyperplastic polyp
but has malignant potential.
ī‚§ Commonly found in right colon.
ī‚§ Serrated architecture is present throughout
the full length of the glands, including crypt
base and leads to its dilatation.
Hamartomatous polyps
ī‚§ 1.juvenile polyps
ī‚§ 2.cowden associated
ī‚§ 3.peutz-jeghers polyp
ī‚§ 4.Bannyan –Riley syndrome
Hamartomas are tumor-like growth comprised
of mature tissues that are normally present at
the site in which they develop.
Juvenile polyps
ī‚§ Sporadic/syndromic
ī‚§ Site-rectum
ī‚§ Age -<5 yrs
ī‚§ C.F- Rectal bleeding
ī‚§ Pathogenesis- associated with mutations in
SMAD 4 and also in BMPR1A.
GROSS
ī‚§ <3 cm in diameter.
ī‚§ Pedunculated, smooth, reddish lesion
ī‚§ C/S –lattice like appearance
MICROSCOPIC PICTURE
ī‚§ Surface ulceration
with granulation
tissue
ī‚§ Beneath, cystically
dilated glands filled
with mucus,
inflammatory debris
ī‚§ Inflammed &
edematous stroma
Cowden syndrome
ī‚§ Autosomal dominant hamartomatous polyp
syndrome.
ī‚§ Loss of function mutation in PTEN mutation
ī‚§ Macrocephaly, intestinal hamartomatous
polyp,benign skin tumors.
Bannyan Riley Syndrome
ī‚§ Similar to cowden syndrome
ī‚§ But has mental deficiencies & development
delays
ī‚§ Less incidence of neoplasia than cowden
syndrome.
Cronkhite Canada syndrome
ī‚§ Non-hereditary sundrome
ī‚§ >50 yrs
ī‚§ Hamartomatous polyps of stomach, small
intestine & colorectum that are
histologically indistinguishable from juvenile
polyps.
ī‚§ 50 % cases are fatal
Peutz Jeghers syndrome
ī‚§ Autosomal dominant syndrome
characterized by:
1) Multiple hamartomatous polyps
in the GI tract.
2) Muco-cutaneous pigmentation .
3) Increased risk of various GI and
non GI malignancies.
Pathogenesis
ī‚§ Germline mutation in gene LKB1/STK11
ī‚§ Site- most common in small intestine but can
occur in stomach and large intestine.
ī‚§ Lobulated with dark head,absent stalk
ī‚§ Size- 5-50mm
Microscopy- central core of smooth muscle
that shows tree like branching.
Familial adenomatous polyposis
(FAP)
ī‚§ It is the most common adenomatous
polyposis syndrome.
ī‚§ An autosomal dominant disorder
characterized by the early onset of
numerous adenomatous polyps throughout
the colon.
ī‚§ Incidence- 1 per 7000 and 1 per 30,000
newborns.
ī‚§ Age group- between 10 and 20 years
ī‚§ Site- more common in sigmoid colon and
rectum
ī‚§ Clinical features- obstruction and rectal
bleeding
A.Colectomyspecimensfrompatientswithfamilialadenomatouspolyposis.A Hundredsof
polyps of differentsize covertheentiremucosalsurface.
BMultipleadenomasindifferentstagesof development.
C Lateralviewof polyps.D Numeroussmall early (sessile)adenomas.
Pathophysiology
ī‚§ 90% of cases of classic FAP are caused by
germline mutation of APC.
ī‚§ PC (adenomatous polyposis coli) is a tumor
suppressor gene involved in cell cycle control
and downregulation of beta-catenin through
theWnt signaling pathway
ī‚§ The APC protein is normally involved in
apoptosis of colonic epithelial cells
APC-β Catenin pathway
Diagnostic criteria:
īƒē 100 or more colorectal adenomatous polyps, or
īƒē Germline mutation in APC or
īƒē Family history of FAP with colorectal adenomas
(age < 30) or
īƒē Family history of FAP and presence of at least
one epidermoid cyst, osteoma or desmoid tumor
ī‚§ Patients with a history of > 10 colorectal
adenomas, a family history of adenomatous
polyposis syndromes or a history of
adenomas with FAP type extracolonic
lesions should undergo assessment for
adenomatous polyposis syndrome.
ī‚§ Histological confirmation requires
examination of several polyps.
Adenoma involving few crypts
Tubular adenoma polyp, FAP patient
ī‚§ Colorectal adenocarcinomas develops
in 100% patients of untreated FAP patients,
often before age 30 and nearly always by age
50.
COLORECTAL CARCINOMA
ī‚§ Adenocarcinoma – the most common
Gastro-intestinal malignancy
ī‚§ Incidence(as shown in next slide)
ī‚§ Age group - 60-70 years
ī‚§ Males > females
Etiology
ī‚§ Decrease in fibre diet.
ī‚§ Decrease intake of vitamins- A,C,E.
ī‚§ Increase in fat intake.
ī‚§ Drugs like NSAID’s play a protective role
pathogenesis
ī‚§ Ca Colon development = genetics!!!!
ī‚§ It can arise in 2 settings
1) Mutations as seen in FAP, leading to
Adenocarinoma via APC-β Catenin pathway
2) MSI pathway leading to HNPCC.
2) APC-β Catenin pathway
Pathogenesis
2) Microsatellite instability pathway-
seen in patients with DNA mismatch repair
gene
Normally, when there is abnormal basepairing=
DNA repair genes come & try to correct the
mismatch
But when there is no mismatch repair gene
Accumulation of abnormal DNA
Carcinogenesis
Genes affected(DNA mismatch repair
are)-
ī‚§ MLH1
ī‚§ MSH2
ī‚§ Clinical features – rectal bleeding
altered bowel habits
abdominal pain
ī‚§ Anemia of chronic blood loss
ī‚§ If a post-menopausal women or elderly
male comes with Iron deficiency anemia,
think of colorectal CA.
ī‚§ INTESTINAL OBSTRUCTION -if left side
colon is involved.
ī‚§
MORPHOLOGY
ī‚§ Common site- rectosigmoid region
ī‚§ Types of growth-
ī‚§ Right colon- polypoidal
ī‚§ Left colon- napkin ring constriction
ī‚§ c/s- grey white
MICROSCOPY
ī‚§ Usually well or moderately differentiated
gland forming carcinoma with marked
desmoplasia, particularly at edge of tumor
ī‚§ Glands often filled with necrotic debris ("dirty
necrosis"), in both primary and metastatic
sites
ī‚§ Inflammatory cells and scattered
neuroendocrine cells are common
ī‚§ Well differentiated:
īƒē 15% - 20% of all carcinomas
īƒē Well formed glands or simple tubules with uniform,
basally oriented nuclei
īƒē Somewhat resembles adenomatous epithelium
ī‚§ Moderately differentiated:
īƒē 60% - 70% of all carcinomas
īƒē Tubules may be simple, complex or slightly irregular
īƒē Nuclear polarity lost
ī‚§ Poorly differentiated:
īƒē 15% - 20% all of carcinomas
īƒē Less than 50% gland formation
īƒē Majority of tumor (excluding advancing edge) consists
of sheets of cells without gland formation
īƒē Usually right sided
Moderately differentiatd
adenocarcinoma
Other microscopic types
ī‚§ Cribriform comedo-type carcinoma
ī‚§ Medullary carcinoma
ī‚§ Micropapillary carcinoma
ī‚§ Mucinous
ī‚§ Serrated adenocarcinoma
ī‚§ Signet-ring cell carcinoma
ī‚§ Adenosquamous carcinoma
ī‚§ Spindle cell carcinoma
ī‚§ Squamous cell carcinoma
ī‚§ Undifferentiated carcinoma
ī‚§ Neuroendocrine neoplasms
ī‚§ Neuroendocrine tumor(NET)
ī‚§ Neuroendocrine Carcinoma
Large cell NEC
Small cell NEC
Mixed adenoneuroendocrine carcinoma
Immunohistochemistry
ī‚§ Positive for
ī‚§ MUC 1
ī‚§ MUC3
ī‚§ CK20
ī‚§ CEA
MUC 3 POSITIVE/MUC 1 POSITIVE
CK20 POSITIVE
Dukes staging
TNM STAGING
Astler-Coller classification (not
currently used
ī‚§ A: lesion limited to mucosa
ī‚§ B1: lesion involves muscularis propria but does
not penetrate through it
ī‚§ B2: lesion penetrates through the muscularis
propria
ī‚§ C1: metastatic tumor in lymph nodes but the
tumor is still confined to the bowel wall
ī‚§ C2: metastatic tumor in lymph nodes and tumor
has penetrated through the entire bowel wall
Prognostic factors
WORST PROGNOSIS IS SEEN IN
ī‚§ 1) young patients
ī‚§ 2) males
ī‚§ 3) Increased CEA levels
ī‚§ 4) Rectosigmoid region
ī‚§ 5) Left side colon-obstruction
ī‚§ 6) Perforation
ī‚§ 7) Infiltrating margins
ī‚§ 8)Vascular/perineural invasion
ī‚§ 9)Tumor angiogenesis
ī‚§ 10) APC>HNPCC
ī‚§ 11)Lymph nodes
ī‚§ 12) Stage C
Intestinal lymphomas
Most common site for Primary Extra Nodal
Lymphoma is GIT.
But more common in small intestine than Large
intestine
ī‚§ T cell Lymphoma
ī‚§ B cell Lymphoma
ī‚§ T cell- malignancy of intra-epithelialT cells.
ī‚§ Associated with Celiac disease.
ī‚§ Common site- small intestine
B cell lymphoma
ī‚§ MALTOMAS
ī‚§ Solitary
ī‚§ More common in small intestine(ileum)
ī‚§ Gross- garden hose appearance/bulky
tumor
Important B cell lymphomas that
affect intestine are
ī‚§ Α-HCD
ī‚§ MALTOMA
ī‚§ Follicular lymphoma
ī‚§ Mantle cell lymphoma
this photomicrograph shows MALT lymphoma
extending from mucosa (top arrow) to the
subserosa (bottom arrow).
ī‚§APPENDIX
Gross Anatomy
Extension of cecum
NORMAL HISTOLOGY OF APPENDIX
This is the appendix comprise of the mucosa
submucosa with prominent lymphoid
tissue beneath
which are the inner circular and the outer
longitudinal smooth muscle coats, all
surrounded by a serosa with
adjacent adipose tissue.
The lumen of the appendix is typically filled
with fecal material
ī‚§ Gross- grey yellow
ī‚§ Microscopy-Three histological subtypes
including classic, tubular, and goblet cell
types are recognized.
ī‚§ classic carcinoid insular growth pattern of
solid islands of uniform polygonal cells with
minimal pleomorphism, retraction of
peripheral tumor cells from stroma
M.c- Carcinoid tumor
Conclusion
ī‚§ Polyps – anywhere in the GI tract can be a
precursor to the malignancy.
ī‚§ FAP has high chances of turning into
malignancy.
ī‚§ Adenocarcinoma is the most common
malignancy of the COLON.
References
ī‚§ Rosai and Ackerman
ī‚§ Robbins & Cotran
ī‚§ Wasington manual of surgical pathology
ī‚§ Internet resources-
ī‚§ Pathology outlines
ī‚§ https://library.med.utah.edu/WebPath/GIHT
ML/GIIDX.html
THANK YOU

More Related Content

What's hot (20)

Colorectal cancer
Colorectal cancerColorectal cancer
Colorectal cancer
 
Tumours of Colon and Rectum
Tumours of Colon and RectumTumours of Colon and Rectum
Tumours of Colon and Rectum
 
Intestinal neoplasm
Intestinal neoplasmIntestinal neoplasm
Intestinal neoplasm
 
Liver abscess
Liver abscessLiver abscess
Liver abscess
 
Gastric Carcinoma
Gastric CarcinomaGastric Carcinoma
Gastric Carcinoma
 
Gastric carcinoma
Gastric carcinoma Gastric carcinoma
Gastric carcinoma
 
Intestinal polyps
Intestinal polypsIntestinal polyps
Intestinal polyps
 
Tumor of kidney and urinary tract
Tumor of kidney and urinary tractTumor of kidney and urinary tract
Tumor of kidney and urinary tract
 
Ca. Bladder.pptx
Ca. Bladder.pptxCa. Bladder.pptx
Ca. Bladder.pptx
 
Tumours of large intestine
Tumours of large intestineTumours of large intestine
Tumours of large intestine
 
Carcinoma gall bladder
Carcinoma gall bladderCarcinoma gall bladder
Carcinoma gall bladder
 
Bladder carcinoma
Bladder carcinomaBladder carcinoma
Bladder carcinoma
 
Upper GI Bleeds
Upper GI BleedsUpper GI Bleeds
Upper GI Bleeds
 
Cystic disease of the kidney
Cystic disease of the kidneyCystic disease of the kidney
Cystic disease of the kidney
 
Ulcerative colitis
Ulcerative colitisUlcerative colitis
Ulcerative colitis
 
Neoplasm of pancreas
Neoplasm of pancreasNeoplasm of pancreas
Neoplasm of pancreas
 
Gastric polyps & tumors by Dr. Karan Arora
Gastric polyps & tumors by Dr. Karan AroraGastric polyps & tumors by Dr. Karan Arora
Gastric polyps & tumors by Dr. Karan Arora
 
Carcinoma of the GI Tract
Carcinoma of the GI TractCarcinoma of the GI Tract
Carcinoma of the GI Tract
 
Gall bladder disease
Gall bladder diseaseGall bladder disease
Gall bladder disease
 
L31 cholecystitis students
L31 cholecystitis studentsL31 cholecystitis students
L31 cholecystitis students
 

Similar to Large intestinal tumors

Serrated lesions of colon and rectum
Serrated lesions of colon and rectumSerrated lesions of colon and rectum
Serrated lesions of colon and rectumDr Snehal Kosale
 
Recent advances in colorectal carcinoma
Recent advances in colorectal carcinomaRecent advances in colorectal carcinoma
Recent advances in colorectal carcinomaVikash Prasad
 
PANCREATIC NEOPLASM HISTOPATHOLOGY .pptx
PANCREATIC NEOPLASM HISTOPATHOLOGY .pptxPANCREATIC NEOPLASM HISTOPATHOLOGY .pptx
PANCREATIC NEOPLASM HISTOPATHOLOGY .pptxRami Al Amawi
 
Discuss the management of colonic polyps
Discuss the management of colonic polypsDiscuss the management of colonic polyps
Discuss the management of colonic polypsDrkabiru2012
 
Neoplastic Colonic polyps- Colonic Adenoma; Familial Syndromes
Neoplastic Colonic polyps- Colonic Adenoma; Familial SyndromesNeoplastic Colonic polyps- Colonic Adenoma; Familial Syndromes
Neoplastic Colonic polyps- Colonic Adenoma; Familial SyndromesMohammad Manzoor
 
Gastric tumours seminar.pptx
Gastric tumours seminar.pptxGastric tumours seminar.pptx
Gastric tumours seminar.pptxDr Manoj Prajapati
 
premalignant lesions new.pptx
premalignant lesions new.pptxpremalignant lesions new.pptx
premalignant lesions new.pptxsaswati14
 
Manik crc final
Manik crc finalManik crc final
Manik crc finalmanik mandal
 
Tumours of the pancreas hegazy
Tumours of the pancreas hegazyTumours of the pancreas hegazy
Tumours of the pancreas hegazymostafa hegazy
 
kidney tumors.pptx
kidney tumors.pptxkidney tumors.pptx
kidney tumors.pptxMeethuRappai1
 
Colo-rectal Carcinoma at a glance !!!
Colo-rectal Carcinoma at  a glance !!!Colo-rectal Carcinoma at  a glance !!!
Colo-rectal Carcinoma at a glance !!!Suman Baral
 
salivary gland and esophagus
 salivary gland and esophagus salivary gland and esophagus
salivary gland and esophagusimrana tanvir
 
Gallbladder and Bile ducts Ultrasound
Gallbladder and Bile ducts Ultrasound Gallbladder and Bile ducts Ultrasound
Gallbladder and Bile ducts Ultrasound Moses Hadid
 
Carcinoma colon-and-management
Carcinoma colon-and-managementCarcinoma colon-and-management
Carcinoma colon-and-managementshiv kishor
 

Similar to Large intestinal tumors (20)

Serrated lesions of colon and rectum
Serrated lesions of colon and rectumSerrated lesions of colon and rectum
Serrated lesions of colon and rectum
 
Recent advances in colorectal carcinoma
Recent advances in colorectal carcinomaRecent advances in colorectal carcinoma
Recent advances in colorectal carcinoma
 
Pancreas 2
Pancreas 2Pancreas 2
Pancreas 2
 
Small bowel neoplasms
Small bowel neoplasmsSmall bowel neoplasms
Small bowel neoplasms
 
PANCREATIC NEOPLASM HISTOPATHOLOGY .pptx
PANCREATIC NEOPLASM HISTOPATHOLOGY .pptxPANCREATIC NEOPLASM HISTOPATHOLOGY .pptx
PANCREATIC NEOPLASM HISTOPATHOLOGY .pptx
 
Discuss the management of colonic polyps
Discuss the management of colonic polypsDiscuss the management of colonic polyps
Discuss the management of colonic polyps
 
Neoplastic Colonic polyps- Colonic Adenoma; Familial Syndromes
Neoplastic Colonic polyps- Colonic Adenoma; Familial SyndromesNeoplastic Colonic polyps- Colonic Adenoma; Familial Syndromes
Neoplastic Colonic polyps- Colonic Adenoma; Familial Syndromes
 
Liver 3
Liver 3Liver 3
Liver 3
 
Gastric tumours seminar.pptx
Gastric tumours seminar.pptxGastric tumours seminar.pptx
Gastric tumours seminar.pptx
 
premalignant lesions new.pptx
premalignant lesions new.pptxpremalignant lesions new.pptx
premalignant lesions new.pptx
 
Manik crc final
Manik crc finalManik crc final
Manik crc final
 
Tumours of the pancreas hegazy
Tumours of the pancreas hegazyTumours of the pancreas hegazy
Tumours of the pancreas hegazy
 
kidney tumors.pptx
kidney tumors.pptxkidney tumors.pptx
kidney tumors.pptx
 
Colo-rectal Carcinoma at a glance !!!
Colo-rectal Carcinoma at  a glance !!!Colo-rectal Carcinoma at  a glance !!!
Colo-rectal Carcinoma at a glance !!!
 
GIT GU.ppt
GIT  GU.pptGIT  GU.ppt
GIT GU.ppt
 
salivary gland and esophagus
 salivary gland and esophagus salivary gland and esophagus
salivary gland and esophagus
 
Gallbladder and Bile ducts Ultrasound
Gallbladder and Bile ducts Ultrasound Gallbladder and Bile ducts Ultrasound
Gallbladder and Bile ducts Ultrasound
 
Pancreatic carcinoma dr mnr
Pancreatic carcinoma dr mnrPancreatic carcinoma dr mnr
Pancreatic carcinoma dr mnr
 
Carcinoma colon-and-management
Carcinoma colon-and-managementCarcinoma colon-and-management
Carcinoma colon-and-management
 
Pathology ca bladder
Pathology   ca bladderPathology   ca bladder
Pathology ca bladder
 

Recently uploaded

BASLIQ CURRENT LOOKBOOK LOOKBOOK(1) (1).pdf
BASLIQ CURRENT LOOKBOOK  LOOKBOOK(1) (1).pdfBASLIQ CURRENT LOOKBOOK  LOOKBOOK(1) (1).pdf
BASLIQ CURRENT LOOKBOOK LOOKBOOK(1) (1).pdfSoniaTolstoy
 
CARE OF CHILD IN INCUBATOR..........pptx
CARE OF CHILD IN INCUBATOR..........pptxCARE OF CHILD IN INCUBATOR..........pptx
CARE OF CHILD IN INCUBATOR..........pptxGaneshChakor2
 
Science 7 - LAND and SEA BREEZE and its Characteristics
Science 7 - LAND and SEA BREEZE and its CharacteristicsScience 7 - LAND and SEA BREEZE and its Characteristics
Science 7 - LAND and SEA BREEZE and its CharacteristicsKarinaGenton
 
MENTAL STATUS EXAMINATION format.docx
MENTAL     STATUS EXAMINATION format.docxMENTAL     STATUS EXAMINATION format.docx
MENTAL STATUS EXAMINATION format.docxPoojaSen20
 
mini mental status format.docx
mini    mental       status     format.docxmini    mental       status     format.docx
mini mental status format.docxPoojaSen20
 
Introduction to AI in Higher Education_draft.pptx
Introduction to AI in Higher Education_draft.pptxIntroduction to AI in Higher Education_draft.pptx
Introduction to AI in Higher Education_draft.pptxpboyjonauth
 
Hybridoma Technology ( Production , Purification , and Application )
Hybridoma Technology  ( Production , Purification , and Application  ) Hybridoma Technology  ( Production , Purification , and Application  )
Hybridoma Technology ( Production , Purification , and Application ) Sakshi Ghasle
 
microwave assisted reaction. General introduction
microwave assisted reaction. General introductionmicrowave assisted reaction. General introduction
microwave assisted reaction. General introductionMaksud Ahmed
 
Incoming and Outgoing Shipments in 1 STEP Using Odoo 17
Incoming and Outgoing Shipments in 1 STEP Using Odoo 17Incoming and Outgoing Shipments in 1 STEP Using Odoo 17
Incoming and Outgoing Shipments in 1 STEP Using Odoo 17Celine George
 
A Critique of the Proposed National Education Policy Reform
A Critique of the Proposed National Education Policy ReformA Critique of the Proposed National Education Policy Reform
A Critique of the Proposed National Education Policy ReformChameera Dedduwage
 
Crayon Activity Handout For the Crayon A
Crayon Activity Handout For the Crayon ACrayon Activity Handout For the Crayon A
Crayon Activity Handout For the Crayon AUnboundStockton
 
The Most Excellent Way | 1 Corinthians 13
The Most Excellent Way | 1 Corinthians 13The Most Excellent Way | 1 Corinthians 13
The Most Excellent Way | 1 Corinthians 13Steve Thomason
 
How to Make a Pirate ship Primary Education.pptx
How to Make a Pirate ship Primary Education.pptxHow to Make a Pirate ship Primary Education.pptx
How to Make a Pirate ship Primary Education.pptxmanuelaromero2013
 
SOCIAL AND HISTORICAL CONTEXT - LFTVD.pptx
SOCIAL AND HISTORICAL CONTEXT - LFTVD.pptxSOCIAL AND HISTORICAL CONTEXT - LFTVD.pptx
SOCIAL AND HISTORICAL CONTEXT - LFTVD.pptxiammrhaywood
 
The basics of sentences session 2pptx copy.pptx
The basics of sentences session 2pptx copy.pptxThe basics of sentences session 2pptx copy.pptx
The basics of sentences session 2pptx copy.pptxheathfieldcps1
 
“Oh GOSH! Reflecting on Hackteria's Collaborative Practices in a Global Do-It...
“Oh GOSH! Reflecting on Hackteria's Collaborative Practices in a Global Do-It...“Oh GOSH! Reflecting on Hackteria's Collaborative Practices in a Global Do-It...
“Oh GOSH! Reflecting on Hackteria's Collaborative Practices in a Global Do-It...Marc Dusseiller Dusjagr
 
Presentation by Andreas Schleicher Tackling the School Absenteeism Crisis 30 ...
Presentation by Andreas Schleicher Tackling the School Absenteeism Crisis 30 ...Presentation by Andreas Schleicher Tackling the School Absenteeism Crisis 30 ...
Presentation by Andreas Schleicher Tackling the School Absenteeism Crisis 30 ...EduSkills OECD
 

Recently uploaded (20)

TataKelola dan KamSiber Kecerdasan Buatan v022.pdf
TataKelola dan KamSiber Kecerdasan Buatan v022.pdfTataKelola dan KamSiber Kecerdasan Buatan v022.pdf
TataKelola dan KamSiber Kecerdasan Buatan v022.pdf
 
BASLIQ CURRENT LOOKBOOK LOOKBOOK(1) (1).pdf
BASLIQ CURRENT LOOKBOOK  LOOKBOOK(1) (1).pdfBASLIQ CURRENT LOOKBOOK  LOOKBOOK(1) (1).pdf
BASLIQ CURRENT LOOKBOOK LOOKBOOK(1) (1).pdf
 
CARE OF CHILD IN INCUBATOR..........pptx
CARE OF CHILD IN INCUBATOR..........pptxCARE OF CHILD IN INCUBATOR..........pptx
CARE OF CHILD IN INCUBATOR..........pptx
 
Science 7 - LAND and SEA BREEZE and its Characteristics
Science 7 - LAND and SEA BREEZE and its CharacteristicsScience 7 - LAND and SEA BREEZE and its Characteristics
Science 7 - LAND and SEA BREEZE and its Characteristics
 
MENTAL STATUS EXAMINATION format.docx
MENTAL     STATUS EXAMINATION format.docxMENTAL     STATUS EXAMINATION format.docx
MENTAL STATUS EXAMINATION format.docx
 
mini mental status format.docx
mini    mental       status     format.docxmini    mental       status     format.docx
mini mental status format.docx
 
Introduction to AI in Higher Education_draft.pptx
Introduction to AI in Higher Education_draft.pptxIntroduction to AI in Higher Education_draft.pptx
Introduction to AI in Higher Education_draft.pptx
 
Hybridoma Technology ( Production , Purification , and Application )
Hybridoma Technology  ( Production , Purification , and Application  ) Hybridoma Technology  ( Production , Purification , and Application  )
Hybridoma Technology ( Production , Purification , and Application )
 
microwave assisted reaction. General introduction
microwave assisted reaction. General introductionmicrowave assisted reaction. General introduction
microwave assisted reaction. General introduction
 
Incoming and Outgoing Shipments in 1 STEP Using Odoo 17
Incoming and Outgoing Shipments in 1 STEP Using Odoo 17Incoming and Outgoing Shipments in 1 STEP Using Odoo 17
Incoming and Outgoing Shipments in 1 STEP Using Odoo 17
 
A Critique of the Proposed National Education Policy Reform
A Critique of the Proposed National Education Policy ReformA Critique of the Proposed National Education Policy Reform
A Critique of the Proposed National Education Policy Reform
 
Crayon Activity Handout For the Crayon A
Crayon Activity Handout For the Crayon ACrayon Activity Handout For the Crayon A
Crayon Activity Handout For the Crayon A
 
The Most Excellent Way | 1 Corinthians 13
The Most Excellent Way | 1 Corinthians 13The Most Excellent Way | 1 Corinthians 13
The Most Excellent Way | 1 Corinthians 13
 
How to Make a Pirate ship Primary Education.pptx
How to Make a Pirate ship Primary Education.pptxHow to Make a Pirate ship Primary Education.pptx
How to Make a Pirate ship Primary Education.pptx
 
SOCIAL AND HISTORICAL CONTEXT - LFTVD.pptx
SOCIAL AND HISTORICAL CONTEXT - LFTVD.pptxSOCIAL AND HISTORICAL CONTEXT - LFTVD.pptx
SOCIAL AND HISTORICAL CONTEXT - LFTVD.pptx
 
The basics of sentences session 2pptx copy.pptx
The basics of sentences session 2pptx copy.pptxThe basics of sentences session 2pptx copy.pptx
The basics of sentences session 2pptx copy.pptx
 
Model Call Girl in Tilak Nagar Delhi reach out to us at 🔝9953056974🔝
Model Call Girl in Tilak Nagar Delhi reach out to us at 🔝9953056974🔝Model Call Girl in Tilak Nagar Delhi reach out to us at 🔝9953056974🔝
Model Call Girl in Tilak Nagar Delhi reach out to us at 🔝9953056974🔝
 
“Oh GOSH! Reflecting on Hackteria's Collaborative Practices in a Global Do-It...
“Oh GOSH! Reflecting on Hackteria's Collaborative Practices in a Global Do-It...“Oh GOSH! Reflecting on Hackteria's Collaborative Practices in a Global Do-It...
“Oh GOSH! Reflecting on Hackteria's Collaborative Practices in a Global Do-It...
 
Presentation by Andreas Schleicher Tackling the School Absenteeism Crisis 30 ...
Presentation by Andreas Schleicher Tackling the School Absenteeism Crisis 30 ...Presentation by Andreas Schleicher Tackling the School Absenteeism Crisis 30 ...
Presentation by Andreas Schleicher Tackling the School Absenteeism Crisis 30 ...
 
CÃŗdigo Creativo y Arte de Software | Unidad 1
CÃŗdigo Creativo y Arte de Software | Unidad 1CÃŗdigo Creativo y Arte de Software | Unidad 1
CÃŗdigo Creativo y Arte de Software | Unidad 1
 

Large intestinal tumors

  • 1. LARGE INTESTINAL TUMORS DR.Navleen kaur 3rd year Pathology resident AIMSR, Bathinda
  • 2. Lesson plan ī‚§ Anatomy of intestine ī‚§ Normal histology ī‚§ Classification ī‚§ Polyps ī‚§ Ca colon ī‚§ Other types ī‚§ Appendix
  • 3.
  • 4.
  • 5.
  • 6.
  • 7.
  • 8.
  • 10. Epithelium-lined by absorptive colonocytes, goblet cells, endocrine cells and paneth cells. Goblet cells
  • 12. NORMAL HISTOLOGY OF RECTUM AND ANAL CANAL
  • 13. Definitions of histological abnormalities ī‚§ Normal colorectal crypts are straight, parallel and extend from immediately above the muscularis mucosae to the surface. ī‚§ Crypt distortion: implies non-parallel, variable diameter or cystically dilated crypts as opposed to the normal 'test-tube rack' appearance.
  • 14. WHO CLASSIFICATION OF TUMORS OF COLON AND RECTUM ī‚§ EPITHELIALTUMORS ī‚§ Adenoma Tubular Villous Tubulovillous ī‚§ Dysplasia(IEN), low grade ī‚§ Dysplasia, high grade
  • 15. ī‚§ Serrated lesions Hyperplastic polyps Sessile serrated polyp Traditional serrated adenoma ī‚§ Hamartomatous Cowden-associated polyp Juvenile polyp Peutz-Jeghers polyp
  • 17. MESENCHYMAL TUMORS ī‚§ Lipoma ī‚§ Leiomyoma ī‚§ Gastrointestinal stromal tumor ī‚§ Leiomyosarcoma ī‚§ Angiosarcoma ī‚§ Kaposi sarcoma
  • 18. Lymphomas ī‚§ B-cell lymphoma,unclassifiable ī‚§ Burkitt lymphoma ī‚§ Diffuse large B-cell lymphoma ī‚§ Mantle cell lymphoma ī‚§ Marginal zone lymphoma of mucosa- associated lymphoid tissue(MALT) ī‚§ Secondary tumors
  • 19. POLYPS ī‚§ Definition:The term polyp refers to any circumscribed mucosal growth either flat, depressed, sessile or pedunculated.
  • 20. adenomas ī‚§ Tubular adenoma – distributed regularly throughout the large bowel with 40 % in right colon, 40 % left colon and 20 % in rectum. ī‚§ Blacks>whites. ī‚§ Assymptomatic, but can result in bleeding.
  • 21. Gross ī‚§ < 1cm. ī‚§ Sessile/peduncul ated ī‚§ Single/multiple ī‚§ Knob-like projections can be seen.
  • 22. Microscopy ī‚§ in number of glands and cells per unit area confined to normal mucosa. ī‚§ Disorganized glands, Cells are crowded, enlarged with hyperchromatic nuclei
  • 23. Villous adenoma ī‚§ Infrequent type of polyp,single, sessile, larger than tubular. ī‚§ Very soft in consistency, can be missed on DRE.
  • 24. microscopy ī‚§ A villous adenoma is shown at its edge on the left, and projecting above the basement membrane at the right. The cauliflower-like appearance is due to the elongated glandular structures covered by dysplastic epithelium
  • 25. Tubulovillous adenoma ī‚§ Polyps in which adenomatous and villous components are present in approximately equal amounts are referred to as Villoglandular polyps,Tubullovillous adenomas or papillary adenomas. ī‚§ TVAs are considered to have a higher risk of malignant transformation than tubular adenomas
  • 26.
  • 27. tubular component - left of image, villous component - right of image
  • 28. HYPERPLASTIC POLYPS ī‚§ Colonic hyperplastic polyps are benign epithelial proliferations that are typically discovered in 6th and 7th decades of life. ī‚§ Site- most common in left colon and <5mm in diameter. ī‚§ Pathogenesis- decreased epithelial turnover and delayed shedding of surface epithelial cells, leading to “piling up” of goblet and absorptive cells.
  • 29. Clinical significance ī‚§ They must be distinguished from sessile serrated adenomas, which are histological similar and have malignant potential.
  • 30. Hyperplastic polyps Gross- < 5 mm in diameter left colon small,sessile ī‚§ Microscopy- 1)mature goblet and absorptive cells. ī‚§ 2)irregular tufting of epithelial cells. ī‚§ 3)epithelial overcrowding serrated architecture.
  • 32. Sessile serrated adenomas ī‚§ Histologically similar to hyperplastic polyp but has malignant potential. ī‚§ Commonly found in right colon. ī‚§ Serrated architecture is present throughout the full length of the glands, including crypt base and leads to its dilatation.
  • 33.
  • 34. Hamartomatous polyps ī‚§ 1.juvenile polyps ī‚§ 2.cowden associated ī‚§ 3.peutz-jeghers polyp ī‚§ 4.Bannyan –Riley syndrome Hamartomas are tumor-like growth comprised of mature tissues that are normally present at the site in which they develop.
  • 35. Juvenile polyps ī‚§ Sporadic/syndromic ī‚§ Site-rectum ī‚§ Age -<5 yrs ī‚§ C.F- Rectal bleeding ī‚§ Pathogenesis- associated with mutations in SMAD 4 and also in BMPR1A.
  • 36. GROSS ī‚§ <3 cm in diameter. ī‚§ Pedunculated, smooth, reddish lesion ī‚§ C/S –lattice like appearance
  • 37. MICROSCOPIC PICTURE ī‚§ Surface ulceration with granulation tissue ī‚§ Beneath, cystically dilated glands filled with mucus, inflammatory debris ī‚§ Inflammed & edematous stroma
  • 38. Cowden syndrome ī‚§ Autosomal dominant hamartomatous polyp syndrome. ī‚§ Loss of function mutation in PTEN mutation ī‚§ Macrocephaly, intestinal hamartomatous polyp,benign skin tumors.
  • 39. Bannyan Riley Syndrome ī‚§ Similar to cowden syndrome ī‚§ But has mental deficiencies & development delays ī‚§ Less incidence of neoplasia than cowden syndrome.
  • 40. Cronkhite Canada syndrome ī‚§ Non-hereditary sundrome ī‚§ >50 yrs ī‚§ Hamartomatous polyps of stomach, small intestine & colorectum that are histologically indistinguishable from juvenile polyps. ī‚§ 50 % cases are fatal
  • 41. Peutz Jeghers syndrome ī‚§ Autosomal dominant syndrome characterized by: 1) Multiple hamartomatous polyps in the GI tract. 2) Muco-cutaneous pigmentation . 3) Increased risk of various GI and non GI malignancies.
  • 42. Pathogenesis ī‚§ Germline mutation in gene LKB1/STK11 ī‚§ Site- most common in small intestine but can occur in stomach and large intestine. ī‚§ Lobulated with dark head,absent stalk ī‚§ Size- 5-50mm
  • 43. Microscopy- central core of smooth muscle that shows tree like branching.
  • 44. Familial adenomatous polyposis (FAP) ī‚§ It is the most common adenomatous polyposis syndrome. ī‚§ An autosomal dominant disorder characterized by the early onset of numerous adenomatous polyps throughout the colon.
  • 45. ī‚§ Incidence- 1 per 7000 and 1 per 30,000 newborns. ī‚§ Age group- between 10 and 20 years ī‚§ Site- more common in sigmoid colon and rectum ī‚§ Clinical features- obstruction and rectal bleeding
  • 46.
  • 47.
  • 48. A.Colectomyspecimensfrompatientswithfamilialadenomatouspolyposis.A Hundredsof polyps of differentsize covertheentiremucosalsurface. BMultipleadenomasindifferentstagesof development. C Lateralviewof polyps.D Numeroussmall early (sessile)adenomas.
  • 49. Pathophysiology ī‚§ 90% of cases of classic FAP are caused by germline mutation of APC. ī‚§ PC (adenomatous polyposis coli) is a tumor suppressor gene involved in cell cycle control and downregulation of beta-catenin through theWnt signaling pathway ī‚§ The APC protein is normally involved in apoptosis of colonic epithelial cells
  • 51. Diagnostic criteria: īƒē 100 or more colorectal adenomatous polyps, or īƒē Germline mutation in APC or īƒē Family history of FAP with colorectal adenomas (age < 30) or īƒē Family history of FAP and presence of at least one epidermoid cyst, osteoma or desmoid tumor
  • 52. ī‚§ Patients with a history of > 10 colorectal adenomas, a family history of adenomatous polyposis syndromes or a history of adenomas with FAP type extracolonic lesions should undergo assessment for adenomatous polyposis syndrome. ī‚§ Histological confirmation requires examination of several polyps.
  • 54. Tubular adenoma polyp, FAP patient
  • 55. ī‚§ Colorectal adenocarcinomas develops in 100% patients of untreated FAP patients, often before age 30 and nearly always by age 50.
  • 56.
  • 57. COLORECTAL CARCINOMA ī‚§ Adenocarcinoma – the most common Gastro-intestinal malignancy ī‚§ Incidence(as shown in next slide) ī‚§ Age group - 60-70 years ī‚§ Males > females
  • 58.
  • 59. Etiology ī‚§ Decrease in fibre diet. ī‚§ Decrease intake of vitamins- A,C,E. ī‚§ Increase in fat intake. ī‚§ Drugs like NSAID’s play a protective role
  • 60. pathogenesis ī‚§ Ca Colon development = genetics!!!! ī‚§ It can arise in 2 settings 1) Mutations as seen in FAP, leading to Adenocarinoma via APC-β Catenin pathway 2) MSI pathway leading to HNPCC.
  • 63. 2) Microsatellite instability pathway- seen in patients with DNA mismatch repair gene Normally, when there is abnormal basepairing= DNA repair genes come & try to correct the mismatch But when there is no mismatch repair gene Accumulation of abnormal DNA Carcinogenesis
  • 64. Genes affected(DNA mismatch repair are)- ī‚§ MLH1 ī‚§ MSH2
  • 65. ī‚§ Clinical features – rectal bleeding altered bowel habits abdominal pain
  • 66. ī‚§ Anemia of chronic blood loss ī‚§ If a post-menopausal women or elderly male comes with Iron deficiency anemia, think of colorectal CA. ī‚§ INTESTINAL OBSTRUCTION -if left side colon is involved. ī‚§
  • 67.
  • 68. MORPHOLOGY ī‚§ Common site- rectosigmoid region ī‚§ Types of growth- ī‚§ Right colon- polypoidal ī‚§ Left colon- napkin ring constriction ī‚§ c/s- grey white
  • 69.
  • 70.
  • 71. MICROSCOPY ī‚§ Usually well or moderately differentiated gland forming carcinoma with marked desmoplasia, particularly at edge of tumor ī‚§ Glands often filled with necrotic debris ("dirty necrosis"), in both primary and metastatic sites ī‚§ Inflammatory cells and scattered neuroendocrine cells are common
  • 72. ī‚§ Well differentiated: īƒē 15% - 20% of all carcinomas īƒē Well formed glands or simple tubules with uniform, basally oriented nuclei īƒē Somewhat resembles adenomatous epithelium ī‚§ Moderately differentiated: īƒē 60% - 70% of all carcinomas īƒē Tubules may be simple, complex or slightly irregular īƒē Nuclear polarity lost ī‚§ Poorly differentiated: īƒē 15% - 20% all of carcinomas īƒē Less than 50% gland formation īƒē Majority of tumor (excluding advancing edge) consists of sheets of cells without gland formation īƒē Usually right sided
  • 73.
  • 75.
  • 76. Other microscopic types ī‚§ Cribriform comedo-type carcinoma ī‚§ Medullary carcinoma ī‚§ Micropapillary carcinoma ī‚§ Mucinous ī‚§ Serrated adenocarcinoma ī‚§ Signet-ring cell carcinoma ī‚§ Adenosquamous carcinoma
  • 77. ī‚§ Spindle cell carcinoma ī‚§ Squamous cell carcinoma ī‚§ Undifferentiated carcinoma ī‚§ Neuroendocrine neoplasms ī‚§ Neuroendocrine tumor(NET) ī‚§ Neuroendocrine Carcinoma Large cell NEC Small cell NEC Mixed adenoneuroendocrine carcinoma
  • 79. ī‚§ Positive for ī‚§ MUC 1 ī‚§ MUC3 ī‚§ CK20 ī‚§ CEA
  • 80. MUC 3 POSITIVE/MUC 1 POSITIVE
  • 84. Astler-Coller classification (not currently used ī‚§ A: lesion limited to mucosa ī‚§ B1: lesion involves muscularis propria but does not penetrate through it ī‚§ B2: lesion penetrates through the muscularis propria ī‚§ C1: metastatic tumor in lymph nodes but the tumor is still confined to the bowel wall ī‚§ C2: metastatic tumor in lymph nodes and tumor has penetrated through the entire bowel wall
  • 85. Prognostic factors WORST PROGNOSIS IS SEEN IN ī‚§ 1) young patients ī‚§ 2) males ī‚§ 3) Increased CEA levels ī‚§ 4) Rectosigmoid region ī‚§ 5) Left side colon-obstruction ī‚§ 6) Perforation ī‚§ 7) Infiltrating margins
  • 86. ī‚§ 8)Vascular/perineural invasion ī‚§ 9)Tumor angiogenesis ī‚§ 10) APC>HNPCC ī‚§ 11)Lymph nodes ī‚§ 12) Stage C
  • 87. Intestinal lymphomas Most common site for Primary Extra Nodal Lymphoma is GIT. But more common in small intestine than Large intestine ī‚§ T cell Lymphoma ī‚§ B cell Lymphoma
  • 88. ī‚§ T cell- malignancy of intra-epithelialT cells. ī‚§ Associated with Celiac disease. ī‚§ Common site- small intestine
  • 89. B cell lymphoma ī‚§ MALTOMAS ī‚§ Solitary ī‚§ More common in small intestine(ileum) ī‚§ Gross- garden hose appearance/bulky tumor
  • 90. Important B cell lymphomas that affect intestine are ī‚§ Α-HCD ī‚§ MALTOMA ī‚§ Follicular lymphoma ī‚§ Mantle cell lymphoma
  • 91. this photomicrograph shows MALT lymphoma extending from mucosa (top arrow) to the subserosa (bottom arrow).
  • 95. This is the appendix comprise of the mucosa submucosa with prominent lymphoid tissue beneath which are the inner circular and the outer longitudinal smooth muscle coats, all surrounded by a serosa with adjacent adipose tissue. The lumen of the appendix is typically filled with fecal material
  • 96. ī‚§ Gross- grey yellow ī‚§ Microscopy-Three histological subtypes including classic, tubular, and goblet cell types are recognized. ī‚§ classic carcinoid insular growth pattern of solid islands of uniform polygonal cells with minimal pleomorphism, retraction of peripheral tumor cells from stroma
  • 98. Conclusion ī‚§ Polyps – anywhere in the GI tract can be a precursor to the malignancy. ī‚§ FAP has high chances of turning into malignancy. ī‚§ Adenocarcinoma is the most common malignancy of the COLON.
  • 99. References ī‚§ Rosai and Ackerman ī‚§ Robbins & Cotran ī‚§ Wasington manual of surgical pathology ī‚§ Internet resources- ī‚§ Pathology outlines ī‚§ https://library.med.utah.edu/WebPath/GIHT ML/GIIDX.html