Special polyp types Professor Neil A Shepherd Gloucester, UK NHSBCSP Pathology Day, London, November...
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Transcript of Special polyp types Professor Neil A Shepherd Gloucester, UK NHSBCSP Pathology Day, London, November...
Special polyp types
Professor Neil A ShepherdGloucester, UK
NHSBCSP Pathology Day,London, November 21, 2007
Pathology and the NHSBCSP
• a polyp is any lesion raised above the level of an epithelial surface
• suddenly, with BCSP, there are lots more colonoscopies
• all done by experts with dye-spray of small lesions and EMR
• we might expect to see the occasional funny and we need to be alert
A classification of polyps of the colorectum
• adenomas• hyperplastic polyps• mixed polyps• inflammatory polyps• juvenile polyps• Peutz-Jeghers polyps • stromal polyps
• syndromic polyps – the triumvirate of polyposes, Cowden’s, Cronkhite-Canada, etc
Morson & Dawson, 2003
A classification of polyps of the colorectum
• adenomas• hyperplastic polyps• mixed polyps• inflammatory polyps• juvenile polyps• Peutz-Jeghers polyps • stromal polyps
• syndromic polyps – polyposes, Cowden’s, Cronkhite-Canada, etc
• but some ‘polyps’ likely to be excised in BCSP are not in the list…..
normal 30 19.87%
cancer 24 15.89%
low risk polyps 20 13.25%
intermediate risk polyps
38 25.17%
high risk polyps 22 14.57%
abnormal result, not polyps
6 3.97%
refer for surgery (polyp)
5 3.31%
miscellaneous 6 3.97%
TOTAL 151 100%
Gloucestershire BCSP, January-October 2007
A classification of polyps of the colorectum
• adenomas• hyperplastic polyps• mixed polyps• inflammatory polyps• juvenile polyps• Peutz-Jeghers polyps • stromal polyps
• syndromic polyps – polyposes, Cowden’s, Cronkhite-Canada, etc
Morson & Dawson, 2003
Hyperplastic polyps
• about 25% of all polyps
Issues:
• differentiating them from mixed polyps & serrated adenoma
• when they are large and right-sided and show SSP features
• when they show epithelial misplacement – inverted hyperplastic polyps
A classification of polyps of the colorectum
• adenomas• hyperplastic polyps• mixed polyps• inflammatory polyps• juvenile polyps• Peutz-Jeghers polyps • stromal polyps
• syndromic polyps – polyposes, Cowden’s, Cronkhite-Canada, etc
Morson & Dawson, 2003
Inflammatory polyps
• the most common ‘other’ entity in BCSP
• most are single/scanty and not related to CIBD (UC, CD, chronic infection such as schisto)
• in the age group of the BSCP population, diverticulosis-associated polyps, polypoid mucosal prolapse, post-interventional polyps more common
Polypoid mucosal prolapse
• in the BCSP age group, lower rectal/anal most common: inflammatory cloacogenic polyp
• epithelial (villous) hyperplasia traps the unwary into calling them large villous adenomas
• may be seen in association with diverticulosis, at stomas, in SUMPS, etc
Polypoid mucosal prolapse at the anorectal junction
• a word of warning with inflammatory cloacogenic polyp
• 4 cases of adenomas of the lower rectum causing secondary polypoid mucosal prolapse
Parfitt & Shepherd, 2008
A classification of polyps of the colorectum
• adenomas• hyperplastic polyps• mixed polyps• inflammatory polyps• juvenile polyps• Peutz-Jeghers polyps • stromal polyps
• syndromic polyps – polyposes, Cowden’s, Cronkhite-Canada, etc
Morson & Dawson, 2003
Juvenile polyps• commonest polyp in childhood
• sporadic juvenile polyps do occur in adulthood but very rare in BCSP age group
• inflammatory polyps can look similar
• pretty unlikely to see juvenile polyposis….
Juvenile polyposis
• 1 in 80,000
• genetics becoming clearer but polymorphic: SMAD4 implicated in 25%
• high rates of colorectal cancer: life time risk - ? up to 30%
• dysplasia in atypical juvenile polyps
• ? surveillance ? prophylactic colectomy
Jass et al 1988,Woodford-Richens et al, 2000
Quick quiz question
SMAD 4 mutation is implicated in about a quarter of cases of this condition. What does SMAD stand for? Is it:
1. somatic mutation in Arctic drosophila
2. serine-methionine-arginine deletion
3. small mothers against decapentaplegia
Quick quiz question
SMAD 4 mutation is implicated in about a quarter of cases of this condition. What does SMAD stand for? Is it:
1. somatic mutation in Arctic drosophila
2. serine-methionine-arginine deletion
3. small mothers against decapentaplegia
A classification of polyps of the colorectum
• adenomas• hyperplastic polyps• mixed polyps• inflammatory polyps• juvenile polyps• Peutz-Jeghers polyps • stromal polyps
• syndromic polyps – polyposes, Cowden’s, Cronkhite-Canada, etc
Morson & Dawson, 2003
Peutz-Jeghers polyps
• syndrome about 1 in 100,000
• sporadic PJ-like polyps described but very rare
• ? relationship to ‘inflammatory myoglandular polyp’
• aren’t sporadic PJPs most likely to be post-inflammatory or post-mucosal prolapse?
Do sporadic Peutz-Jeghers polyps exist?
• 119 polyps in 38 patients
• most patients with PJ-like polyps were actually shown to have PJS (scanty colonic polyps in the syndrome)
• 8 left: three small bowel ones with PJ features; 5 colonic with suggestive features of PJPs (top GI pathologists could not tell for certain: mucosal prolapse could not be excluded). 40% in BCSP screening age group
• if they exist, sporadic colorectal PJ polyps are very rare
Burkhart et al. Do sporadic Peutz-Jeghers polyps exist? Experience from a large teaching hospital. AJSP, August
2007
A classification of polyps of the colorectum
• adenomas• hyperplastic polyps• mixed polyps• inflammatory polyps• juvenile polyps• Peutz-Jeghers polyps • stromal polyps
• syndromic polyps – polyposes, Cowden’s, Cronkhite-Canada, etc
Morson & Dawson, 2003
Stromal polyps
• GIST• leiomyoma of muscularis mucosae• gastrointestinal schwannoma• neurofibroma• ganglioneuroma• epithelioid mucosal nerve sheath tumour• intestinal perineurioma• fibroblastic polyp• inflammatory fibroid polyp• that’s enough stromal polyps (Ed)
Gastrointestinal schwannoma• 33 cases: 4 oesophagus, 24 stomach, 2 colon and 3 rectum
• mainly within muscularis propria and/or subserosa
• none encapsulated but all well circumscribed
• 32/33 cuff of lymphocytes
• only 12 originally called schwannoma
• S100 and vimentin +ve
• CD117, CD34, ASMA, desmin –ve
• nestin 80% positive; GFAP 64% positive
• all showed some nuclear pleomorphism: ? longevity: no mitoses
• all benign
Hou et al, 2006 (Histopathology)
Colonic polypoid mucosal lesions with mucosal entrapment and epithelial serration
A feature only rarely seen in GISTs
Colorectal intramucosal tumours with epithelial ‘entrapment’
Name First recognise
d
S100 CD 34 EMA Epithelial serration
Clinical features
neuro-fibroma
The year dot
+ ve -ve - ve occasionally
Most solitary
but @ NF
ganglio-neuroma
probably down to Carney…
+ve -ve -ve notdescribed
sporadicor NF-1, MEN 2b
benign fibroblastic
polyp of colon
2004 - ve +ve - ve 3/13 none
intestinalperi-
neurioma
2005 - ve -ve + ve 5/9 none
epithelioid NS tumour
2005 +ve +/-ve -ve 0/6 none
Benign fibroblastic polyp of colon:Eslami-Varzaneh F, Washington K, Robert ME, Kashgarian M,
Goldblum JR, Jain D. AJSP 2004; 28: 374-378.
CD34 positive: ‘neural’ markers negative
Intestinal perineurioma:Hornick JL, Fletcher CDM. AJSP 2005; 29: 859-865.
EMA positive: CD 117, CD 34, S100 negative
Mucosal epithelioid nerve sheath tumour: Lewin MR, Dilworth HP, Alfa AK, Epstein JI, Montgomery E.
AJSP 2005; 29: 1310-1315.
S100 & CD 34 positive: EMA & CD 117 negative
S 100 CD 34
Colorectal intramucosal tumours with epithelial ‘entrapment’ and surface
serration• extraordinary ‘new’ descriptions of three entities – smallish spindle
cell polypoid tumours with epithelial entrapment and surface epithelial serration
• ? recent recognition due to legislation to allow Medicare customers to undergo screening colonoscopy (2001)
• lesions are mainly of schwann cell/perineural cell origin
• differentiation by immunohistochemistry although specificity of these entities is a little doubtful..
Zamecnik & Chlumska, 2006 Groisman et al, 2006
• all are benign and should not be confused with more sinister lesions such as GISTs and others
Take home messages: special polyp types
• inflammatory polyp/polypoid mucosal prolapse most common after adenomas and HPs
• remember other lesions can be polypoid – leiomyoma of mm and rectal carcinoid – clinical, endoscopic and imaging correlation important
• the ‘hamartomatous’ polyps and syndromes are very rare (but not unheard of) in the BCSP age group
• serrated change can be a secondary phenomenon (polypoid mucosal prolapse, fibroblastic polyps, etc)