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Neoplasm of colon Dr. Amitabha Basu MD

Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

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Page 1: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

Neoplasm of colon

Dr. Amitabha Basu MD

Page 2: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

Topic

• Terms

• Classification of neoplasm

• Classification of non-neoplastic polyps

• Discussion on polyps

• Polyps and syndrome

• Discussion on carcinomas

Page 3: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

Terms

• Polyp: Mass protruded in lumen– Pedunculated– Sessile

Adenomatous polyps:

a polyp formed by an adenoma.

Page 4: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

Classification of neoplasm of colon

1. Non neoplastic polyp

2. Neoplastic lesions

3. Adenomatous polyp

4. Carcinoma

5. Mesenchymal neoplasms

6. Lymphoma

Page 5: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

Important Non-neoplastic polyp

Hyperplastic polyps Common, no malignant potential

Hamartomatous polyps

•Juvenile polyps

•Peutz-Jeghers polyps

Page 6: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

Hyperplastic polyp

• small star shaped (usually <5 mm in diameter) epithelial polyps like due drop.

• Location: recto sigmoid colon

• No malignant potential

Page 7: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

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.

Page 8: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

Peutz-Jeghers polyps

• Hamartomatous polyps that involve the mucosal epithelium, lamina propria, and muscularis mucosa.

• Location: mainly small intestine

• Associated with Peutz-Jeghers syndrome.

Page 9: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and
Page 10: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

Neoplastic lesionsAdenomatous polypCarcinomaCarcinoid

Page 11: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

Adenomas (adenomatous polyps)

• Tubular adenoma

• Villous adenoma

Page 12: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

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

Page 13: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

Tubular adenoma (a Pedunculated

adenoma showing a fibro vascular stalk)

Adenomatous epithelium in an otherwise normal (mucin-secreting, clear) colonic mucosa

Page 14: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

diagnosis?

Page 15: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

Villous adenoma: sessile adenoma with villous

architecture

Dysplasia present: locate it

Page 16: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

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.

Page 17: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

Treatment

• Single pedunculated polyp: polypectomy

• Polyposis: complete resection

• Sessile adenoma: recestion

Page 18: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

Polyps and syndrome

• Various syndromes are associate with the polyps of the intestine

Page 19: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

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 )

Page 20: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

Familial Polyposis syndrome

Study other similar picture

Page 21: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

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

Page 22: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

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

Page 23: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

Malignant Epithelial Lesions

Adenocarcinoma*

Carcinoid tumor

Page 24: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

Colorectal carcinoma: topic

• Features

• Colorectal Carcinogenesis;– Multistep carcinogenesis

• Morphology

Page 25: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

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 )

Page 26: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

Adenoma carcinoma sequence: Multistep carcinogenesis

Page 27: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

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.

Page 28: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

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

Page 29: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

Carcinoma of the cecum. The fungating carcinoma

projects into the lumen but has not caused obstruction

Page 30: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

Carcinoma of the descending colon.

Circumferential tumor has heaped-up edges and an ulcerated central portion.

The arrows identify separate mucosal polyps

Page 31: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

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

Page 32: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

Invasive adenocarcinoma of colon, showing malignant glands infiltrating the muscle wall.

Page 33: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

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.

Page 34: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

Staging of colon carcinoma

• Depends on: size, node involvement and metastasis.

• The Astler-Coller Staging System

• TNM

Page 35: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and
Page 36: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

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

Page 37: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

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

Page 38: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

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

Page 39: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

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.

Page 40: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

Carcinomas arising in the anorectal canal

• Dominated by squamous cell carcinoma.

• Below the ano-rectal junction

• Due to chronic HPV infection

Page 41: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

Carcinoid tumors

• Origin: Neuroendocrine cells

• Age: sixth decade

• Appendiceal (commonest) and rectal carcinoids.

• Other sites: Ileal , gastric, and colonic carcinoids.

Page 42: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

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

Page 43: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

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

Page 44: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

Multiple protruding tumors are present at the ileocecal junction

Page 45: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

Tumor cells exhibit a monotonous morphology (salt and pepper)

Page 46: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

Electron micrograph showing dense core bodies in the cytoplasm

Study other similar picture

Page 47: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

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)

Page 48: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

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%

Page 49: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

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)

Page 50: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

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.

Page 51: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

Classification: GASTROINTESTINAL

LYMPHOMA

B-cell lymphoma

MALT lymphoma ; small tumor [t(11;18): translocation common]

Starry sky: bulky tumor

Burkitt lymphoma (t8;14 )

Page 52: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

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.

Page 53: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

Melanosis coli

• DEF: Black (brown –black) pigmentation of colon.

• Deposit: Lipofuscin ( “wear and tear”)

• Etiology: laxative use

• Can mimic a tumor/ colitis

• Clinical: constipation.

Page 54: Neoplasm of colon Dr. Amitabha Basu MD. Topic Terms Classification of neoplasm Classification of non-neoplastic polyps Discussion on polyps Polyps and

Thank you