Colon Polyps

CT colonography
Two main morphological types of polyps

• Sessile polyps

• Pedunculated polyps
Two types

Neoplastic: Adenomatous :- Tubular, Tubulovillous and Villous.

• Tubular:
Small size; pedunculated polyps. Minor degree of villous change.
• Tubulovillous adenomatous polyps:
Medium size; sessile polyps. Fine nodular or reticular surface pattern.
Filling of barium within interstices of adenoma.
• Villous adenomatous polyps:
Large size; sessile polyps. Barium trapped between frond like projections
polypoid lesion with granular or reticular pattern.

Non-neoplastic: Hyperplastic, Hamartomatous and Inflammatory.

• The most clinically significant polyps are Adenomas.
• Adenomas contain dysplasia i.e. intraepithelial neoplasia.
• Colorectal cancer (CRC) represent extension of this neoplasia beyond
the muscularis mucosae into the submucosa.
• Two thirds of the CRCs originate from an adenomatous precursors.
Hence their detection is clinically important, particularly as their
removal substantially reduces subsequent carcinoma risk.
 10 %
• Rare in age < 30.
• Seen in 30% of individuals > 50 years.
• M>F 25 %
• 1st degree relative with CRC confers
additional risk of about 50 %. 15 %

50 %
Features of true polyps

• 1. Smooth surface

Exception: Lobular or slightly irregular still acceptable if lesion is big.

• 2. Non mobile

• Supine/prone/decubitus – still remains fixed to the same place.

• Fixed to the wall.
• Exception:
1. Pedunculated polyps with a long stalk.

2. Polyps in mobile part of colon: e.g. sigmoid colon, transverse colon

Here use of fixed landmarks such as a diverticula or a haustral fold may be useful.
True polyp or not?

• Irregular borders. Contrast between structure and bowel wall.

Fecal material.
3D CT colonogram shows a polypoid However 2D view of the same lesion
lesion that might be mistaken for a shows a tiny locule of gas – demonstrating
sessile polyp. that this is infact retained fecal residue.
Fecal tagging: use of oral contrast to label or ‘tag’ residual colonic contents,
improves both sensitivity and specificity. Lesions which might be obscured by
retained liquid residue can be seen within the higher density fluid and tagged
stool will not be mistaken for a polyp due to its high attenuation.

2D axial CT colonogram shows a Axial CT colonogram image with fecal tagging

pedunculated rectal polyp bathed shows a smooth, lobulated fat-density
by tagged fluid. polypoid lesion diagnostic of a lipoma.
Ilieocecal valve

At endoscopy, the ICV may be classified into three main categories on the basis of its morphologic
appearance: labial, papillary, or lipomatous.

But watch out for

Polyps on the ICV.
• Opening of Appendix
• Appendix can be seen as :
• 1- Closed
• 2- Open
• 3- Protruding into lumen.
Certain factors increase the
chance of invasive malignancy
in an adenoma.
1. Size.
2. Morphology.
3. Pathological subtype.
SIZE
• Colon carcinoma prevalence by polyp size:
• Polyps < 1 cm (1%), 1-2 cm (10-20%), > 2 cm (40-50%).

< 1 cm 1-2 cm > 2 cm

Tubular adenoma 1% 10 % 35 %
Tubulovillous adenoma 4% 7% 46 %
Villous adenoma 10 % 10 % 53 %

• Do not report a polyp if it is less than 5 mm in size as the risk of

invasion is almost negligible.
• Additionally findings of < 5 mm will lead to higher false positives and
colonoscopy miss over than 25% of them.
How do you measure a polyp.
Shortest or longest diameter?

• Sessile polyp • Pedunculated polyp?

• Longest diameter. • Measure the head of the polyp only

~ longest.
• Measure on 2D or 3D?
Preferably on 3D.
• 2D: under-estimates the longest diameter.
• 3D: More accurate and faster.
1. Size.
2. Morphology.
3. Pathological subtype.
MORPHOL
OGY
Pedunculated
In pedunculated polyps, the stalk separates the
dysplastic epithelium from the deeper submucosa and are
often considered cured once resected, if the neoplasia is
confined to the polyps stalk.

Sessile: Broad attachment: hard to evaluate!

Sessile polyps have similar diameter at
the base and near the top, roughly hemispheric.
They have a intermediate risk of invasive malignancy for
a given size.
Mexican hat sign

• Formed by pedunculated colonic polyps by the appearance of two concentric rings.

• The outer ring represents the ‘en face’ visualization of barium coating the surface of
the head of a pedunculated polyp.
• The inner ring represents a meniscus of barium surrounding the stalk of the polyp
visualized through the head.
Bowler hat sign

• Formed by a ring of barium adjacent to the base of the polyp surrounding a domed
layer of barium coating the surface of the polyp.
• The orientation of the dome can help differentiate a polyp from a diverticulum where
a polyp will point inward towards the lumen, while a diverticulum will produce the
same sign directed outward.
Flat polyps
Are not truly polypoid and hence better termed flat
lesions.
• < 2.5 mm in height above the colonic mucosal
surface at endoscopy or 3 mm in radiology.
• Height < ½ width.
Flat lesions may be depressed rather than elevated relative to the
colonic mucosa. Such depressed flat lesions carry a higher risk of
invasive cancer for a given size.
Evaluation of a flat lesions is one of the downside of CT colonography.
Sometimes: elevated margins and depressed center like volcano crater!

Better seen on Soft tissue window and use of IV contrast

1. Size.
2. Morphology.
3. Pathological subtype.
Pathological subtype
• High risk lesions: Villous adenoma.
• Relatively lower risk: Tubular and tubulo-villous lesions.
Differentials
Diverticula will be seen as extraluminal pockets of gas. “Bowler hat”
sign but dome of hat points away from lumen.
An inverted diverticulum may simulate a polyp on 3D but on 2D the
gas content indicates its true nature.
Colon carcinoma: Sessile or pedunculated polyps seen in early cancer.
Intramural mass: Usually single; polyps are often multiple.
• Lipomas: may be polypoid on 3D but fat density on 2D is diagnostic.
• Leiomyoma: Filling defect mimics villous adenoma (en face view).
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