965

Colon Polyp Morphology on

Double-Contrast Barium
Enema: Its Pathologic Predictive
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Value

1
David J. Ott The morphologic appearance of 9 6 polyps seen on double-contrast barium enema
1
David W. Gelfand was reviewed t o assess t h e predictive value of various signs described t o diagnose

Wallace C. W u 2 malignancy. Size, surface contour, basal i n d e n t a t i o n , a n d p e d u n c u l a t i o n w e r e s t u d i e d .

1 3 Sessile p o l y p s h a d a n a p p r e c i a b l e i n c i d e n c e o f m a l i g n a n c y , w i t h size being t h e best
Deborah S. A b l i n -
indicator o f that risk. Pedunculation w a s f o u n d t o be a reliable sign of benignity in
predicting t h e absence of malignant invasion into t h e adjacent colonic wall. Polyps
under 1 c m a n d having a s m o o t h contour were invariably benign. Conversely, polyps
larger than 1 c m with a lobulated c o n t o u r a n d basal indentation had a significant
incidence of malignancy.

The term "polyp" is u s e d to d e s c r i b e any growth that protrudes into the

c o l o n i c l u m e n [ 1 ] . N e a r l y all c o l o n i c p o l y p s a r i s e f r o m t h e e p i t h e l i u m , w i t h t h e
t w o m o s t c o m m o n t y p e s b e i n g h y p e r p l a s t i c o r n e o p l a s t i c in o r i g i n [ 1 - 6 ] . Hyper­
plastic polyps are typically s m o o t h , sessile, and under 5 m m , and they constitute
t h e b u l k o f all c o l o n i c p o l y p s in t h i s s i z e r a n g e . N e o p l a s t i c e p i t h e l i a l p o l y p s a r e
generally larger than 5 mm and include benign a d e n o m a s , a d e n o m a s with focal
carcinoma, and polypoid adenocarcinomas. Neoplastic polyps vary in their
appearance from small, smooth, and sessile lesions simulating hyperplastic
p o l y p s to larger lesions that m a y be l o b u l a t e d or p e d u n c u l a t e d .
Several radiographic criteria have been used to estimate the malignant p o t e n ­
tial of a c o l o n i c polyp [ 7 - 1 5 ] . The most useful have included size, surface
c o n t o u r , b a s a l i n d e n t a t i o n , a n d p e d u n c u l a t i o n . W e h a v e r e a s s e s s e d t h e v a l u e of
t h e s e c r i t e r i a a s p r e d i c t o r s of m a l i g n a n c y t h r o u g h a r e v i e w o f t h e r a d i o g r a p h i c
a p p e a r a n c e of 9 6 p o l y p s p a t h o l o g i c a l l y e x a m i n e d a n d seen o n d o u b l e - c o n t r a s t
barium enema.

Materials and Methods

Received March 2 1 , 1983; accepted after re­
vision July 8, 1 9 8 3 .
'Department of Radiology, Bowman Gray
School of Medicine, Winston-Salem, NC 2 7 1 0 3 .
Address reprint requests to D. J . Ott.
d e p a r t m e n t of Medicine, Bowman Gray
School of Medicine, Winston-Salem, NC 2 7 1 0 3 .
'Present address: Department of Radiology,
Children's Orthopedic Hospital, Seattle, WA
98105.
AJR 1 4 1 : 9 6 5 - 9 7 0 , November 1 9 8 3
0361-803X/83/1415-0965
© American Roentgen Ray Society
The study extended over a 2-year period a n d included 61 patients with 9 6 colonic
p o l y p s . All lesions w e r e originally d i a g n o s e d o n d o u b l e - c o n t r a s t b a r i u m e n e m a a n d w e r e
later r e m o v e d a n d e x a m i n e d pathologically. T h e patients i n c l u d e d 2 2 w o m e n a n d 3 9 m e n
aged 2 3 - 8 1 years (mean, 57). Thirty-nine patients (64%) had single polyps; 2 2 (36%) had
multiple polyps. The radiographic diagnosis of a colonic polyp was confirmed by e n d o s c o p y
in 3 9 p a t i e n t s ( 6 4 % ) a n d b y s u r g e r y in 2 2 ( 3 6 % ) .
T o d e t e r m i n e t h e v a l u e o f p o l y p m o r p h o l o g y i n p r e d i c t i n g t h e l i k e l i h o o d of c a r c i n o m a ,
the original double-contrast barium enemas were reviewed a n d correlated with t h e histo­
logic f i n d i n g s . T h e 9 6 p o l y p s s t u d i e d w e r e s e g r e g a t e d a c c o r d i n g t o size (diameter) into
t h r e e c a t e g o r i e s : 5 - 1 0 m m , 11 - 2 0 m m , a n d g r e a t e r t h a n 2 0 m m . P o l y p s i z e w a s m e a s u r e d
directly from the films, a n d n o correction f o r magnification w a s made. T h e radiographic
m o r p h o l o g y of each polyp w a s evaluated. Surface c o n t o u r w a s categorized as s m o o t h or
i r r e g u l a r . B a s a l i n d e n t a t i o n a n d p e d u n c u l a t i o n , if p r e s e n t , w e r e a l s o n o t e d .
Polyps smaller than 5 m m were excluded from t h e study because w e d o not routinely
report these lesions radiographically [ 4 ] . Most of these minute polyps a r e probably no
 966 OTT ET AL. AJFC141, November 1983

greater than 3 - 4 m m in a c t u a l s i z e if m a g n i f i c a t i o n f a c t o r s are TABLE 1: Radiographic Morphology and Malignant Incidence

c o n s i d e r e d . T h e i n c i d e n c e of i n v a s i v e c a r c i n o m a in p o l y p s of t h i s of 71 Sessile Polyps
s i z e r a n g e r e m a i n s m i n u s c u l e [ 1 - 6 ] , w h i l e t h e d e g r e e of f a l s e -
Size (mm)
p o s i t i v e r a d i o g r a p h i c e r r o r in d i a g n o s i n g s u c h d e f e c t s is m o s t l i k e l y Total
c o n s i d e r a b l e . For t h e s e r e a s o n s , w e believe that m u c h u n n e c e s s a r y 5-10 11-20 >20
c o l o n o s c o p y w o u l d b e p e r f o r m e d in a t t e m p t i n g t o r e s o l v e every
Smooth surface:
minute defect seen on double-contrast barium enema.
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Number 34 6 2 42
Malignant 0 1 (17) 0 1 (2.4)
Lobulated surface:
Results Number 3 9 17 29
Malignant 0 1(11) 12(71) 13(44.8)
Forty-one polyps (43%) were 5-10 mm in diameter, 32
Note.—Numbers in parentheses are percentages.
(33%) were 11-20 mm, and 23 (24%) were over 20 mm.
Seventy-one polyps (74%) were sessile radiographically; 25
(26%) were pedunculated (tables 1 and 2). Pedunculation
was seen in 53% of 11 -20 mm polyps, but was infrequent T A B L E 2: R a d i o g r a p h i c M o r p h o l o g y a n d M a l i g n a n t Incidence
of 25 Pedunculated Polyps
in polyps in the other two size categories. Six (15%) of 41
polyps measuring 5-10 mm showed lobulation, compared Size (mm)
to 17 (53%) of 32 polyps of 11 -20 mm and 21 (91 %) of 23 Total
5-10 11-20 >20
polyps over 20 mm.
Smooth surface:
Benign adenomas of various histologic types accounted Number 1 9 0 10
for 63 (66%) of the 96 polyps (table 3). Twelve (86%) of the Malignant 0 1 * (11) 0 1 (10)
14 hyperplastic polyps were in the 5-10 mm range. One Lobulated surface:
(2.4%) of 41 polyps of 5-10 mm harbored invasive carci­ Number 3 8 4 15
Malignant 1f(33) 1 f (13) 0 2(13.3)
noma; three (9.4%) of 32 polyps of 11-20 mm and 12
(52.2%) of 23 polyps over 20 mm were carcinomatous. Note.—Numbers in parentheses are percentages.
* Adenoma with carcinoma in situ.
Although only one (1.9%) of 52 radiographically smooth t Adenoma with focally invasive carcinoma.
polyps contained invasive carcinoma, 15 (34%) of the 44
lobulated polyps were carcinomatous. Of the 15 lobulated
carcinomas, 13 were sessile and two were pedunculated
T A B L E 3: P a t h o l o g i c F i n d i n g s i n 9 6 P o l y p s S e e n o n D o u b l e -
adenomas with focally invasive carcinoma (fig. 1). Most Contrast Barium Enema
small (5-10 mm) hyperplastic and adenomatous polyps
were smooth and sessile radiographically and were indistin­ Size (mm)
Total
guishable from each other (fig. 2). 5-10 11-20 >20
Indentation was present radiographically at the base of
Hyperplastic 12 2 0 14
11 (15%) of 71 sessile polyps (table 4). Only one (3%) of
Lipoma 0 0 2 2
37 polyps in the 5-10 mm range showed indentation, con­ Benign adenomas:
trasted to four (27%) of 15 polyps of 11 -20 mm and six Tubular 27 22 5 54
(32%) of 19 polyps larger than 20 mm. Basal indentation Mixed 0 1 2 3
was found in both benign and malignant polyps smaller than Villous 1 3 2 0

Carcinomas:
20 mm; however, malignancy was invariably present when
In s i t u 0 1 0 1
this sign was seen in polyps larger than 20 mm (fig. 3). Invasive* 1 3 12 16
' Includes two adenomas with focally invasive carcinoma.

Discussion
The double-contrast barium enema has improved the ra­ not the subject of this investigation, it has been demon­
diologic detection of colonic polyps and also has permitted strated that polyps smaller than 5 mm are almost invariably
better evaluation of their morphology. The radiographic benign [4, 14, 17-20]. Many of these minute growths are
criteria currently used for predicting the malignant nature of hyperplastic in origin, while the adenomas of this size have
a colon polyp include size, contour, basal indentation, and less than a 0.5% incidence of invasive malignancy. How­
pedunculation. With the advent of colonoscopy, evaluation ever, polyps larger than 5 mm have an increasing chance of
of growth of a polyp between separate radiographic exami­ harboring invasive carcinoma, the average reported inci­
nations, a previously used criterion [7, 8, 11, 16], has
dence of malignancy being 1 % of 5-9 mm polyps, 6% for
generally become unnecessary.
10-20 mm polyps, and 26% for polyps greater than 20 mm
[4].
Polyp Size
As expected, our results showed a strong correlation
between polyp size and malignancy. Only 2.4% of 5-10 mm
Size is an important criterion used to judge the malignant polyps were malignant, compared with 9.4% of 11 -20 mm
potential of a sessile colonic polyp [1, 4, 5, 7, 9, 11]. While polyps and 52.2% of those over 20 mm. Since 10 mm
 PREDICTIVE VALUE OF POLYP MORPHOLOGY 967
AJR: 1 4 1 , November 1 9 8 3

Fig. 1.—A, C a r c i n o m a in situ in s m o o t h , p e ­

d u n c u l a t e d a d e n o m a (arrow), with head measur­
ing 1 2 m m . Additional 1 6 m m , lobulated, sessile
a d e n o m a (arrowhead), harboring focally invasive
c a r c i n o m a . B, P e d u n c u l a t e d a d e n o m a w i t h l o b u ­
lated 1 6 x 1 8 m m head containing focally invasive
carcinoma. Pedicle w a s 4 c m long.
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T
Fig. 2 . — A , S m o o t h , sessile, 8 m m adenoma

1
y
(arrow) in s i g m o i d c o l o n , similar in a p p e a r a n c e to
h y p e r p l a s t i c p o l y p s h o w n i n B. B, S m o o t h , s e s s i l e , s
hyperplastic polyp (arrow) in s i g m o i d colon.
Larger, lobulated adenoma (arrowhead) also

/
present.

1
f.
w
lis
\

seems to be a critical diameter, polyps larger than this TABLE 4: Basal Indentation in 71 Radiographically Sessile

s h o u l d be r e m o v e d r o u t i n e l y [ 4 , 5, 9, 1 5 ] . D e p e n d i n g o n t h e Polyps

clinical circumstances, 5-10 mm polyps should probably Size (mm)

a l s o b e r e m o v e d t o e l i m i n a t e t h e small f r a c t i o n of carcino­ Total

5-10 11-20 >20

mas already present in t h i s s i z e r a n g e a n d t h o s e t h a t may
Total 37 15 19 71
potentially develop from benign a d e n o m a s [ 4 , 5, 20-23].
No. with indentation . . . 1 (3) 4(27) 6(32) 11 ( 1 5 )
P a t h o l o g y of i n d e n t e d
polyps:
Polyp Contour
Adenoma 1 2 0 3
Carcinoma 0 2 (50) 6(100) 8 (73)
T h e s u r f a c e c o n t o u r of a p o l y p h a s p r o v e n t o b e a r e l i a b l e

but s o m e w h a t less valuable sign for d i a g n o s i n g malignancy N o t e . — N u m b e r s in parentheses are percentages.

 968 OTT
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[7, 8, 1 1 - 1 5 ] . Although surface irregularity has been re­
g a r d e d a s i n d i c a t i n g t h a t a p o l y p is i n c r e a s i n g l y l i k e l y t o be
m a l i g n a n t , it d o e s n o t a l w a y s c o r r e l a t e w i t h t h e p r e s e n c e of
c a r c i n o m a . T h i s is p a r t i c u l a r l y t r u e in s m a l l , s l i g h t l y l o b u ­
l a t e d p o l y p s w h e r e mild s u r f a c e i r r e g u l a r i t y m a y b e of little
v a l u e in f o r e c a s t i n g m a l i g n a n c y [ 1 4 , 1 5 ] .
In o u r s t u d y , a s m o o t h s u r f a c e n e a r l y a l w a y s i n d i c a t e d a
b e n i g n l e s i o n , r e g a r d l e s s of s i z e . C o n v e r s e l y , o n e - t h i r d of
t h e l o b u l a t e d p o l y p s w e r e m a l i g n a n t , w i t h t h e i n c i d e n c e of
m a l i g n a n c y d e p e n d i n g o n t h e s i z e of t h e l e s i o n . A l t h o u g h
o n l y t h r e e ( 1 3 % ) of 2 3 l o b u l a t e d p o l y p s of 2 0 m m or less
w e r e m a l i g n a n t , 1 2 ( 5 7 % ) of 21 l a r g e r t h a n 2 0 m m w e r e
c a r c i n o m a t o u s . T h u s , t h e p r e s e n c e of l o b u l a t i o n in a s m a l l
c o l o n i c p o l y p s e e m s to be a p o o r p r e d i c t o r of m a l i g n a n c y .
I n d e e d , t h e s u r f a c e m o r p h o l o g y of a s m a l l c o l o n i c p o l y p
w a s of little v a l u e in i n d i c a t i n g t h e h i s t o l o g i c o r i g i n of t h e
lesion. Hyperplastic polyps were invariably smooth and typ­
ically s e s s i l e , a s w e r e m o s t of t h e s m a l l e r b e n i g n a d e n o m a s .
In t h e 5 - 1 0 m m r a n g e , t h e s e l e s i o n s w e r e u s u a l l y i n d i s t i n ­
guishable.
Basal Indentation
I n d e n t a t i o n at t h e b a s e of a p o l y p h a s b e e n s u g g e s t e d a s
a s i g n i n d i c a t i v e of m a l i g n a n t i n f i l t r a t i o n i n t o t h e c o l o n i c wall
[ 7 - 1 5 ] . T h e f r e q u e n c y a n d r e l i a b i l i t y of t h i s f i n d i n g , p a r t i c ­
ularly f o r p o l y p s of v a r i o u s s i z e s , h a s n o t b e e n w e l l d o c u ­
mented [7]. Indeed, recent studies have suggested that
smooth basal indentation m a y be a p r o j e c t i o n a l artifact
r e l a t e d to t h e g e o m e t r y at t h e j u n c t i o n of t h e b a s e of t h e
polyp and colonic wall [ 2 4 , 2 5 ] . This w o u l d seem to be an
ET AL. AJR:141, November 1983
i m p o r t a n t c o n s i d e r a t i o n in e v a l u a t i n g s m a l l e r p o l y p s w i t h
smooth, minimal indentation.
B a s a l i n d e n t a t i o n w a s c l e a r l y e v i d e n t in 1 1 ( 1 5 % ) of t h e
7 1 s e s s i l e p o l y p s in o u r s e r i e s , a n d its p r e s e n c e w a s s i z e -
d e p e n d e n t . I n d e n t a t i o n w a s s e e n in o n l y o n e 5 - 1 0 mm
p o l y p , a b e n i g n a d e n o m a . F u r t h e r m o r e , t w o of t h e f o u r 1 1 -
2 0 mm polyps s h o w i n g basal indentation w e r e also b e n i g n .
T h e s e f i n d i n g s s u p p o r t t h e c o n c e p t t h a t t h e p r e s e n c e of
b a s a l i n d e n t a t i o n in s m a l l e r c o l o n i c p o l y p s m a y r e p r e s e n t a
g e o m e t r i c p h e n o m e n o n r a t h e r t h a n a s i g n of m a l i g n a n c y .
O n t h e o t h e r h a n d , e i g h t of t h e 1 0 p o l y p s o v e r 1 0 m m t h a t
s h o w e d basal indentation w e r e malignant. A most important
observation, however, was that among these larger malig­
nant polyps, the basal indentation seen w a s prominent and
i r r e g u l a r , a n d o n p a t h o l o g i c e x a m i n a t i o n it i n v a r i a b l y r e p ­
resented carcinomatous infiltration.
Polyp Pedunculation
P e d u n c u l a t i o n of a c o l o n p o l y p h a s b e e n u s e d a s a s i g n
of b e n i g n i t y f o r m a n y y e a r s [ 7 - 1 2 ] , a n d t h e l e n g t h of t h e
pedicle has been e m p h a s i z e d . Polyps on stalks longer than
2 c m are almost never associated with malignant invasion
into t h e a d j a c e n t c o l o n i c w a l l [ 2 6 ] . T h i s is t r u e r e g a r d l e s s of
t h e p r e s e n c e of f o c a l l y i n v a s i v e c a r c i n o m a in t h e h e a d of
the polyp [ 2 7 , 2 8 ] . As a result, p e d u n c u l a t e d polyps must
be viewed s o m e w h a t differently from sessile lesions r e g a r d ­
ing t h e i r c u r r e n t d a n g e r t o t h e p a t i e n t a n d t h e i r likely m e a n s
of r e m o v a l .
P e d u n c u l a t i o n w a s not a c o m m o n f i n d i n g in o u r i n v e s t i ­
g a t i o n . It w a s s e e n in j u s t o v e r o n e - f o u r t h of all p o l y p s , w i t h
 AJR:141, November 1983 PREDICTIVE VALUE
Fig. 4 . — A, 1.5 x 2 . 5 c m , l o b u l a t e d p o l y p n e a r
splenic flexure, thought to be sessile radiograph­
i c a l l y a n d h i g h l y s u s p e c t f o r c a r c i n o m a . B, S u r g i ­
c a l s p e c i m e n . S h o r t p e d i c l e (arrows) is e v i d e n t .
Colonoscopic polypectomy could have been done
easily. Pathologic examination revealed benign
adenoma.
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t h e h i g h e s t i n c i d e n c e in p o l y p s w h o s e h e a d s m e a s u r e d 1 1 -
2 0 m m . P r e s u m a b l y , t h e s m a l l e r p o l y p s w e r e of i n s u f f i c i e n t
size t o p r o m o t e f o r m a t i o n of a r a d i o g r a p h i c a l l y v i s i b l e p e d ­
icle, w h i l e t h e l a r g e r o n e s w e r e o f t e n m a l i g n a n t , having
infiltrated the colonic wall. Also, radiographic m e t h o d s seem
to b e less s e n s i t i v e t h a n e n d o s c o p y in d e m o n s t r a t i n g p e ­
d u n c u l a t i o n , e s p e c i a l l y if a r e l a t i v e l y s h o r t p e d i c l e e x i s t s
(fig. 4 ) . I n d e e d , in m a n y of o u r " r a d i o g r a p h i c a l l y s e s s i l e "
p o l y p s , s h o r t s t a l k s w e r e p r e s e n t e n d o s c o p i c a l l y . It is i m ­
p o r t a n t to a p p r e c i a t e this l i m i t a t i o n , s i n c e e v e n l a r g e p o l y p s
o n s h o r t s t a l k s c a n be r e a d i l y r e m o v e d e n d o s c o p i c a l l y .
A s a n t i c i p a t e d , p e d u n c u l a t i o n p r o v e d to b e a r e l i a b l e s i g n
of a b s e n c e of c a r c i n o m a t o u s i n v a s i o n into t h e c o l o n i c w a l l .
Of 2 5 p a t h o l o g i c a l l y e x a m i n e d p e d u n c u l a t e d polyps,
( 8 8 % ) were benign, including four lobulated lesions with
heads larger than 2 c m . The three "malignant" lesions
i n c l u d e d o n e c a r c i n o m a in situ a n d t w o f o c a l l y invasive
c a r c i n o m a s in o t h e r w i s e b e n i g n a d e n o m a s , w i t h t h e p e d i ­
c l e s in all t h r e e l e s i o n s b e i n g f r e e of c a r c i n o m a . T h u s , all
2 5 p e d u n c u l a t e d p o l y p s in o u r s e r i e s r e q u i r e d o n l y s i m p l e
s u r g i c a l or e n d o s c o p i c r e m o v a l .
Clinical Significance of Radiologic Signs
T h e d o u b l e - c o n t r a s t b a r i u m e n e m a is a n e f f e c t i v e m e a n s
of discovering and morphologically describing colonic
polyps. Although the method cannot make specific histo­
logic d i a g n o s e s , a g o o d e s t i m a t i o n of t h e p o t e n t i a l risk of
m a l i g n a n c y in a c o l o n i c p o l y p c a n be g i v e n .
Size and surfce contour are important criteria for estimat­
OF POLYP MORPHOLOGY 969
ing t h e risk of m a l i g n a n c y in a c o l o n i c p o l y p . S m o o t h , s e s s i l e
p o l y p s of 5 - 1 0 m m a r e a l m o s t a l w a y s b e n i g n . In t h i s size
r a n g e , t h e p r e s e n c e of s l i g h t l o b u l a t i o n a n d m i n i m a l b a s a l
i n d e n t a t i o n a r e m i s l e a d i n g a s s i g n s of m a l i g n a n c y . P o l y p s
l a r g e r t h a n 1 0 m m , h o w e v e r , h a v e a n i n c r e a s i n g c h a n c e of
invasive malignancy. Lobulation and irregular basal i n d e n ­
tation a r e v a l u a b l e a d d i t i o n a l i n d i c a t o r s of c a r c i n o m a in
these larger polyps.
R a d i o g r a p h i c p e d u n c u l a t i o n is a r e l i a b l e s i g n of b e n i g n i t y ,
virtually e x c l u d i n g malignant invasion into the a d j a c e n t c o ­
lonic w a l l . C o m p a r e d w i t h t h e s e s s i l e p o l y p , e v a l u a t i n g t h e
size a n d s u r f a c e c o n t o u r of t h e h e a d of a pedunculated
p o l y p is l e s s c r u c i a l b e c a u s e t h e s e l e s i o n s a r e e a s i l y r e ­
22 m o v e d e n d o s c o p i c a l l y , r e g a r d l e s s of t h e h i s t o l o g i c n a t u r e
of t h e p o l y p h e a d .
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