neoplasm of colon dr. amitabha basu md. topic terms classification of neoplasm classification of...
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Neoplasm of colon
Dr. Amitabha Basu MD
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Topic
• Terms
• Classification of neoplasm
• Classification of non-neoplastic polyps
• Discussion on polyps
• Polyps and syndrome
• Discussion on carcinomas
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Terms
• Polyp: Mass protruded in lumen– Pedunculated– Sessile
Adenomatous polyps:
a polyp formed by an adenoma.
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Classification of neoplasm of colon
1. Non neoplastic polyp
2. Neoplastic lesions
3. Adenomatous polyp
4. Carcinoma
5. Mesenchymal neoplasms
6. Lymphoma
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Important Non-neoplastic polyp
Hyperplastic polyps Common, no malignant potential
Hamartomatous polyps
•Juvenile polyps
•Peutz-Jeghers polyps
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Hyperplastic polyp
• small star shaped (usually <5 mm in diameter) epithelial polyps like due drop.
• Location: recto sigmoid colon
• No malignant potential
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Hamartomatous Polyps
• Juvenile polyps : Focal hamartomatous malformations of mucosa.
• Also called as retention polyps=1 to 3 cm in diameter.
• Tumor composed of Cystically dilated glands.
• Location: colon and rectum • Clinical: spontaneous removal with stool and
blood.
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Peutz-Jeghers polyps
• Hamartomatous polyps that involve the mucosal epithelium, lamina propria, and muscularis mucosa.
• Location: mainly small intestine
• Associated with Peutz-Jeghers syndrome.
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Neoplastic lesionsAdenomatous polypCarcinomaCarcinoid
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Adenomas (adenomatous polyps)
• Tubular adenoma
• Villous adenoma
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AdenomaTubular adenoma Villous adenoma
Pedunculated
Colon, Stomach, and small intestine, ampulla of Vater
Large and sessile
Rectum and recto sigmoid colon
75% tubular architecture Villus projection
Cancer is rare More chance of cancer(40%)
Dysplasia:+ Dysplasia ; +++++++++
Presentation: asymptomatic, rectal occult bleeding (+ve guaiac test), Iron deficiency anemia
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Tubular adenoma (a Pedunculated
adenoma showing a fibro vascular stalk)
Adenomatous epithelium in an otherwise normal (mucin-secreting, clear) colonic mucosa
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diagnosis?
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Villous adenoma: sessile adenoma with villous
architecture
Dysplasia present: locate it
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Malignant risk with an adenomatous polyp
• Cancer is rare in tubular adenomas < 1 cm in diameter.
• The risk of cancer is high (approaching 40%) in sessile villous adenomas > 4 cm in diameter.
• Severe dysplasia, when present, is often found in villous areas.
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Treatment
• Single pedunculated polyp: polypectomy
• Polyposis: complete resection
• Sessile adenoma: recestion
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Polyps and syndrome
• Various syndromes are associate with the polyps of the intestine
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Familial Polyposis syndrome
• Autosomal dominant.• Number: > 100.• Two syndromes:
– Classic FAP syndrome, patients typically develop 500 to 2500 colonic adenomas.
– Variant of FAP=Gardner syndrome exhibit intestinal polyps identical to those in classic FAP ( + osteoma , epidermal cysts, fibromatosis, CA breast )
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Familial Polyposis syndrome
Study other similar picture
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Syndromes Altered Gene
Pathology in GI Tract
Familial adenomatous Polyposis
APC ( 5q21) Multiple adenomatous polyps
Hereditary nonpolyposis colorectal carcinoma
AKA: lynch syndrome
Autosomal dominant familial syndrome
Defects in mismatch DNA repair genes → leading to micro satellite instability
Colon cancer, endometrial cancer and fewer/no polyps.
Syndromes
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Syndromes Pathology in GI Tract
Peutz-Jeghers syndrome
Hamartomatous polyps+ multiple carcinomas + pigment in mouth, lips
Juvenile polyposis syndrome
Numerous Juvenile polyps
Turcot syndrome Multiple adenomatous polyps, Gliomas.
Cowden disease Hamartomatous polyps + carcinoma breast
Syndromes
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Malignant Epithelial Lesions
Adenocarcinoma*
Carcinoid tumor
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Colorectal carcinoma: topic
• Features
• Colorectal Carcinogenesis;– Multistep carcinogenesis
• Morphology
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Features
• Age: Ages 60 and 79
• Dietary factors:– (1) Excess dietary caloric intake. – (2) A low content of unabsorbable
vegetable fiber, – (3) High content of refined carbohydrates, – (4) Intake of red meat, and – (5) Decreased intake of protective
micronutrients (vitamins A, C, and E )
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Adenoma carcinoma sequence: Multistep carcinogenesis
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Adenoma carcinoma sequence
1. Loss of Adenomatous Polyposis Coli (APC) Gene(5q21 ) : first hit & second hit: 2 hit theory
2. Mutation of K-RAS + Loss of SMADs + Loss of p53 = adenoma formation.
3. Activation of Telomerase: invasive tumor.
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Gross of colon cancer
Proximal colon (right) Distal colon (left)
Polypoid Exophytic masses
Annular, encircling lesions (napkin-ring constrictions )
Obstruction is uncommon.
Obstruction is common.
Develop iron deficiency anemia
No anemia
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Carcinoma of the cecum. The fungating carcinoma
projects into the lumen but has not caused obstruction
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Carcinoma of the descending colon.
Circumferential tumor has heaped-up edges and an ulcerated central portion.
The arrows identify separate mucosal polyps
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Microscopic morphology
• Features of right- and left-sided colonic adenocarcinoma are similar.
• Shows desmoplastic reaction.
• Many tumors produce mucin- PAS positive
• Some cancers the cells take on a signet-ring appearance
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Invasive adenocarcinoma of colon, showing malignant glands infiltrating the muscle wall.
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Marker and clinical
• CEA ( carcino embryonic antigen)
– Useful for following the course of the disease.
– Stool : occult blood positive ( non specific)
– Alternate Constipation and diarrhea.
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Staging of colon carcinoma
• Depends on: size, node involvement and metastasis.
• The Astler-Coller Staging System
• TNM
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T
• Tis=Carcinoma in situ (high-grade dysplasia) or intramucosal carcinoma (lamina propria invasion)
• T1=Tumor invades sub mucosa• T2=Extending into the muscularis propria but
not penetrating through it• T3=Penetrating through the muscularis
propria into subserosa• T4=Tumor directly invades other organs or
structures
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NM
• Nx= Regional lymph nodes cannot be assessed
• N0=No regional lymph node metastasis• N1=Metastasis in 1 to 3 lymph nodes• N2=Metastasis in 4 or more lymph nodes• Mx=Distant metastasis cannot be assessed• M0=No distant metastasis• M1=Distant metastasis
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Grading
• Grade depends on: # of mitosis and differentiation.
• Well differentiated tumor (WD) : good prognosis.
• Small tumor (usually < 2 cm) : usually good prognosis
• Low mitosis (WD): good prognosis• More/ atypical mitosis: bad prognosis
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Prognosis depends on Grading and staging – 2 of 2
• Tumor with high mitosis: poor prognosis.• Lymph node involvement : bad prognosis
– (more the number worse is the prognosis)
• Distant metastasis: bad prognosis always.• Poorly differentiated < undifferentiated tumor
< anaplasia : poor prognosis.
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Carcinomas arising in the anorectal canal
• Dominated by squamous cell carcinoma.
• Below the ano-rectal junction
• Due to chronic HPV infection
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Carcinoid tumors
• Origin: Neuroendocrine cells
• Age: sixth decade
• Appendiceal (commonest) and rectal carcinoids.
• Other sites: Ileal , gastric, and colonic carcinoids.
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Morphology The appendix is the most common site.
• Appendicular tumor: Appear as bulbous swellings of the tip, which frequently obliterate the lumen.
• Other place: Bronchus= Intramural masses that create small, polypoid or plateau-like elevations(<3cm)
Remember the size
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Colour
• Characteristic feature is a solid, yellow-tan appearance on transection.
• Micro:
– form discrete islands, trabeculae, stands, glands.
– a scant, pink granular cytoplasm and a round to oval stippled nucleus
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Multiple protruding tumors are present at the ileocecal junction
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Tumor cells exhibit a monotonous morphology (salt and pepper)
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Electron micrograph showing dense core bodies in the cytoplasm
Study other similar picture
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Clinical Features: many are asymptomatic Malignant carcinoid: mets. to liver
Skin Flushing & diarrhea
Carcinoid syndrome:
By Serotonin
Gastric and pancreatic carcinoids Produce.
Multiple non healing peptic ulcers.
Zollinger-Ellison syndrome
by Gastrin
Cushing syndrome ; hypertension, weight gain, moonfaced.
ACTH
Appendix carcinoid → Obstruction Appendicitis (RUQ pain and neutrophilia)
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Diagnosis and prognosis
• Elevated levels of 5-HT and its metabolite, 5-hydroxyindoleacetic acid (5-HIAA), are present in the blood and urine .
• Overall five-year survival rate for carcinoids (excluding appendiceal) is approximately 90%
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GASTROINTESTINAL LYMPHOMA
• Definition ::- Primary gastrointestinal lymphomas exhibit no evidence of liver, spleen, mediastinal lymph node, or bone marrow involvement at the time of diagnosis.
• They are nonHodgkins lymphoma(NHL)
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Etiology/Risk factors
(1) Chronic gastritis caused by H. pylori
(2) Chronic sprue like syndromes
(3) Natives of the Mediterranean region
(4) Infection with human immunodeficiency virus.
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Classification: GASTROINTESTINAL
LYMPHOMA
B-cell lymphoma
MALT lymphoma ; small tumor [t(11;18): translocation common]
Starry sky: bulky tumor
Burkitt lymphoma (t8;14 )
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Morphology
• Location:– Stomach, Small intestine, colon
• Gross: plaque-like, with effacement of the overlying mucosal folds and focal ulceration.
• Micro:• Small/Large blue round cell with scanty
cytoplasm.
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Melanosis coli
• DEF: Black (brown –black) pigmentation of colon.
• Deposit: Lipofuscin ( “wear and tear”)
• Etiology: laxative use
• Can mimic a tumor/ colitis
• Clinical: constipation.
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Thank you