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8/14/2019 Differential Diagnosis of Adenomas
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Group 2Section BMHAM College of Medicine
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Case:
A 45 Year old Man with a FamilyHistory of Colon CA undergoes ascreening colonoscopy. No
Invasive Ca, but 2 smallpedunculated tubular adenomas& 1 villous adenomas 5 mm.
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Adenocarcinoma is a canceroriginating in glandular tissue. Thistissue is also part of a larger tissuecategory known as epithelial.Epithelial tissue includes, but is notlimited to, skin, glands and a variety
of other tissue that lines the cavitiesand organs of the body
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Morphology
one will see a mass thatlooks of a different color thanthe surrounding tissue.
Histologically, a glandularstructure, similar to thehealthy normal surroundingglands may be seen.
If they look very similar, thisis a low grade, well
differentiated tumor. Often these glands will be
disorganized and they will beseen growing back to back.
However, if the tumordoes not look like a gland
anymore, it is a highgrade tumor with poordifferentiation.
Regardless of the grade,malignant tumors tend tohave a large nucleus with
prominent nucleoli. There will also be a
noticeable increase inthe incidence of mitoses,or cell divisions
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GROSS MICROSCOPIC
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Benign adenomas (NeoplasticPolyps)
• Polyps arise from dysplastic epithelium• 50% after age 60
• 90% : in the colon; maybe single or multiple
• divided by histology into 4 types – Tubular adenoma: small, but become pendunculated as they
grow – Villous adenoma: large, frondlike projection, sessile
– Tubulovillous adenoma: intermediate in size, stalk& mixedarchitecture
– Serrated adenoma: mixture of hyperplastic polyp and adenoma
•
greater than 1 cm, (>25%) villous component, or havehigh-grade dysplasia are commonly referred to asadvanced neoplasms and carry an increased cancer risk.
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• All patients will develop colorectalcancer from the colon polyps usuallyby age 40.
• Patients with FAP must have the colon,and sometimes the rectum, removedto prevent colon cancer.
• In over 80 percent of patients with FAP,
polyps form in the stomach and smallintestine. The polyps found in theupper portion of the stomach are calledfundic gland polyps.
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• The polyps found in the bottom of thestomach (the antrum) most often areprecancerous polyps called adenomas.
• Polyps in the duodenum (the first part of the small intestine) are adenomas and canturn into cancer .
• Duodenal polyps can be very subtle and
hard to detect, or they may be obvious andcover a large segment of the duodenum.
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polyps duodenum
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They are often found at the openingof the bile duct and the duodenum,called the papilla. Because of thegreat number of polyps, they areusually not removed.
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Gross MorphologyFamilial polyposis of the
colon Familial adenomatous polyposis: theentire colonic mucosa is carpeted with aclose crop of polyps.
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Microscopic Morphology
Familial polyposis of thecolonThe changes are subtle .This slide shows the subtle changes in thebowel mucosa that can lead to big troubleslater. BENIGN
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MORPHOLOGY OF CARCINOID
TUMOR Appendix is the most commonsite followed by a smallintestine (primarily ileum),rectum, stomach, and colon.
In the appendix, it appearsbulbous swelling of the tip,which frequently obliteratethe lumen.
Elsewhere in the gut, theyappear as intramural orsubmucosal masses thatcreate small, polypoid orplateau-like elevations rarelymore than 3 cm.
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Morphology
Solid, yellow-tan appearance, firmdue to desmoplasia.
Rectal and appendiceal carcinoidsalmost never metastasize
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Microscopic
The neoplastics cells formdiscrete islands, trabeculae,strands, glands orundifferentiated sheets.
Monotonous appearance withscanty pinkish granularcytoplasm, round to ovalstippled nucleus.
In most tumors, there is
minimal variation in cell andnuclear size and mitoses areinfrequent or absent.
DIAGNOSISOCCURENC FAMILISize/ Morphology/ impression
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DIAGNOSISOCCURENCE
FAMILIALPRED.
Size/multiplicity
Morphology/invasiveness
impression
AdenoCa 40-70 yo+
3 cmsingle
Exophylic -sessileinvasive
Rule in
Adenoma(benign)
40-60 yo+
< 5cmsingle
Small,pedunculatedNon invasive
Rule in
Hyperplasticpolyps
60 andabove
- < 5 cmsingle
Nipple-likeNon-invasive
Rule out
Harmatoma(Peutz Jehger)
9 yo andabove +
Smallmultiple
PolypoidsNon-invasive
Rule out
Gastro-
Intestinaltumors
- - < 4cm
multiple
Fugating/
ulceratinginvasive
Rule out
FamilialAdenomatous polyps
Children+
multiple PolypoidRisk to AdenoCa
Rule out
InflammatoryPolyps all + Multiple Inflammed mucosaUlcerating; Non invsv.Rule out
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Laboratory test
Stool Examination: Fecal Occult Blood Testing
Hemoccult is composed of guaiacimpregnated paper enclosed in acardboard frame which permits sampleapplication to one side, and developmentand interpretation on the reverse side.
The process involves placing twospecimens, collected from each of threesuccessive evacuations, onto the guaiacpaper.
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Hemoccult is based on the oxidation of guaiac by hydrogen peroxide to a bluecolored compound.
The heme portion of hemoglobin, if presentin the fecal specimen, has peroxide activitywhich catalyzes the oxidation of alphaguaiaconic acid (active component of theguaiac paper) by hydrogen peroxide (activecomponent of the developer) to form ahighly conjugated blue quinone compound.
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Hemoccult test willshow hidden blood inthe stool in early
curable stages of colon cancer. Evenbetter, as in thiscase, the Hemocculttest may be positive
even before cancercells have developed.
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Blood Testing
Reticulocytosis Abnormal Lab Findings - Decreased
MCH (Lab)
MCHC (Lab) MCV/Mean Corpuscular Volume (Lab)
Abnormal Lab Findings - Increased Hemoglobin (Lab)
Polychrome RBCs (Lab) Reticulocytes (Lab) TIBC/Total Iron Binding capacity (Lab)
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Barium Enema
The doctor puts a liquid calledbarium into your rectum beforetaking x rays of your large intestine.Barium makes your intestine lookwhite in the pictures. Polyps aredark, so they’re easy to see.
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Sigmoidoscopy
With this test, the doctor puts a thin,flexible tube into your rectum. Thetube is called a sigmoidoscope, andit has a light in it. The doctor usesthe sigmoidoscope to look at the lastthird of your large intestine.
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Colonoscopy
The doctor will give you medicine tosedate you during the colonoscopy.
This test is like the sigmoidoscopy,but the doctor looks at the entirelarge intestine with a long, flexibletube with a camera that shows
images on a TV screen. The tube hasa tool that can remove polyps. Thedoctor usually removes polyps duringcolonoscopy.
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Computerized Tomography
Scan• With this test, also called virtual
colonoscopy. A machine using x rays andcomputers creates pictures of the large
intestine that can be seen on a screen.• The CT scan takes less time than a
colonoscopy because polyps are notremoved during the test. If the CT scan
shows polyps, you will need a colonoscopyso they can be removed.
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Biopsy
Once a polyp is found, it is removed,either by colonoscopy, flexiblesigmoidoscopy, or as part of asurgery. A pathologist closelyexamines the polyp cells - known asa biopsy sample -- under a
microscope in the laboratory todetermine whether the growth isbenign or malignant.
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This small adenomatous polyp(tubular adenoma) on a small
stalk is seen microscopicallyto have more crowded,disorganized glands than thenormal underlying colonicmucosa. Goblet cells are less
numerous and the cells liningthe glands of the polyp havehyperchromatic nuclei.However, it is still well-differentiated andcircumscribed, without
invasion of the stalk, and isbenign
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Prognosis
Adenomatous polyps: Can all potentially become malignant,
but actual risk per polyp is small.
Up to 50% of over 60 year olds havemore than one adenomatous polyp,but only 6 % of people develop bowel
cancer.
Risk of recurrence is great however if original polyps were >1cm, or morethan 4 polyps, or if dysplasia is shown.