4TH YEAR MBBS,

JINNAH MEDICAL COLLEGE, PESHAWAR

COLONIC POLYPS

Lecture By:
Dr. Shahid Hasnain Siddiqui
Assistant Professor Pathology
COLONIC POLYPS
• Polyp is a projecting growth of tissue from a surface in the body,
usually a mucous membrane.

• Polyps are most common in the colon and may also occur in the
esophagus, stomach, or small intestine.

• Those without stalks are referred to as sessile. As sessile polyps enlarge,

traction on the luminal protrusion may create a stalk.

• Polyps with stalks are termed pedunculated.

COLONIC POLYPS
• In general, intestinal polyps can be classified as non-neoplastic or
neoplastic.

• The most common neoplastic polyp is the adenoma, which has the
potential to progress to cancer.

• Non-neoplastic colonic polyps can be further classified as

inflammatory, hamartomatous, or hyperplastic.
INFLAMMATORY POLYPS
• Inflammatory polyps are associated with the solitary rectal ulcer
syndrome (single or multiple ulcerated or polypoid lesions).

• Patients present with the triad of rectal bleeding, mucus discharge, and
an inflammatory polyp on the anterior rectal wall.

• Impaired relaxation of the anorectal sphincter can result in difficulty

with the passage of stool, leading to increased straining during bowel
movements.
INFLAMMATORY POLYPS
• Chronic straining can create excessive pressure on the rectal wall. This
increased pressure can give rise to mucosal injury and inflammation.

• This leads to recurrent abrasion and ulceration of the overlying rectal

mucosa.

• With repeated cycles of injury and healing, a polypoid mass forms that is
composed of inflamed and reactive mucosal tissue.
INFLAMMATORY POLYPS
• These polyps are typically inflammatory in nature, with features such as
distorted glandular architecture and an influx of inflammatory cells.
Dense inflammation in
lamina propria
Surface mucosal ulceration
Surface erosion with
granulation tissue
HAMARTOMATOUS POLYPS
• Hamartomatous polyps is characterized by papillary architecture with
arborizing compact bundles of smooth muscle.

• Hamartomatous polyps occur sporadically and are associated with

genetic conditions that predispose individuals to polyp formation.

• These polyps are disorganized, tumor like growths composed of

mature cell types normally present at the site where the polyp develops.

• Some examples of hemartomatous polyps are Juvenile polyps and Peutz-

Jeghers polyps.
JUVENILE POLYPS
• Juvenile polyps are the most common type of hamartomatous polyp.
They may be sporadic or syndromic.

• Sporadic juvenile polyps are usually solitary with minimal malignant

potential, while juvenile polyposis, > 3-5 polyps in colorectum, and are
associated with a positive family history.

• Most juvenile polyps occur in children younger than 5 years.

• Characteristically located in rectum and usually manifest with rectal

bleeding.
JUVENILE POLYPS
• Juvenile polyposis is linked with inherited mutations in genes that code
for elements of the TGFb/BMP signaling pathway, like SMAD4.

• Typically pedunculated, smooth-surfaced, reddish lesions less than 3

cm in diameter that display characteristic cystic spaces on cut sections.

• These spaces are dilated glands filled with mucin and inflammatory
debris.

• Dysplasia occurs in a small proportion of juvenile polyps, and juvenile

polyposis is associated with an increased risk for adenocarcinoma.
Multiple polyps, mainly in
the colon & rectum of an
11 year old boy, in a case
of juvenile polyposis
syndrome
Juvenile polyp from 04
months old with surface
ulceration, dilated colonic
glands.
Juvenile polyp from
02 years old with
cystically dilated
colonic glands &
inflammation.
(Low Power)
Juvenile polyp from 02
years old with cystically
dilated colonic glands
& inflammation. (High
Power)
PEUTZ-JEGHERS SYNDROME
• Multiple gastrointestinal hamartomatous polyps

• Mucocutaneous hyperpigmentation

• Increased susceptibility to various types of cancers due to the genetic

mutation (lifetime cumulative risk for all cancer types >90%)

• Malignancies associated with Peutz-Jeghers syndrome include cancers of

the colorectum, stomach, small intestine, pancreas, breast, ovaries,
uterus, and testes.
PEUTZ-JEGHERS SYNDROME
• About half of patients with familial form of Peutz-Jeghers syndrome
have germline loss-of-function mutations in LKB1/STK11 gene.

• LKB1/STK11 gene encodes a tumor suppressive protein kinase that

controls cellular metabolism, cell cycle arrest and Wnt signaling.

• Loss of LKB1/STK11 leads to immortalization and hyperproliferation

of melanocytes leading to increased mucocutaneous pigmentation.
PEUTZ-JEGHERS SYNDROME
• On gross evaluation, the polyps are large and pedunculated with a
lobulated contour.

• Histologic examination demonstrates a characteristic branching

network of connective tissue, smooth muscle, lamina propria, and
glands lined by normal-appearing intestinal epithelium.
A-
A- Duodenal dilatation
with multiple
arborizing polyps

B- Polyps necrosis in
the proximal jejunum
A- Small sessile
polyps

B- Multiple
arborizing polyps,
pedunculated or
sessile in the small
intestinal mucosa.
Peutz-Jeghers polyps
shows papillary
architecture with
compact bundles of
smooth muscle.
Peutz-Jeghers polyps with
a tree-like arborization
of smooth muscle with a
central core branching
outwards.
Arborizing bundles
of smooth muscle
surrounded by small
intestinal glandular
epithelium.
HYPERPLASTIC POLYPS
• Colonic hyperplastic polyps are common epithelial proliferations that
typically occur in the sixth and seventh decades of life.

• Thought to result from decreased epithelial cell turnover and delayed

shedding of surface epithelial cells, leading to a “pileup” of goblet cells.

• Although these lesions have no malignant potential, they are difficult to

distinguish endoscopically from sessile serrated adenomas.
HYPERPLASTIC POLYPS
• Hyperplastic polyps are most commonly found in the left colon and are
typically less than 5 mm in diameter.

• They may occur singly but more frequently are multiple and most
common in the sigmoid colon and rectum.

• Histologically, composed of an expanded population of mature goblet

and absorptive cells.
HYPERPLASTIC POLYPS
• This epithelial overcrowding creates a serrated architecture, which is
the morphologic hallmark of these lesions.

• Sawtooth appearance (nodular protrusions of mucosa), with serrations

generally limited to the upper half of the crypts.

• No dilated, branched or horizontally spreading crypts

• No evidence of conventional dysplasia, e.g. as is seen in colorectal

adenomas.
(A) Polyp surface with irregular tufting of
epithelial cells.

(B) Tufting results from epithelial

overcrowding.

(C) Epithelial crowding produces a serrated

architecture when glands are cut in cross-
section.
Epithelial tufting
leading to a sawtooth
appearance in a
hyperplastic polyp.
Hyperplastic polyp
showing characteristic
sawtooth glands.
ADENOMA
• The most common and clinically important neoplastic polyps are colonic
adenomas, which are precursor lesions of colorectal adenocarcinomas.

• No sex predilection, found in about 50% adults in western world >50

yrs.

• Current recommendations are that all adults in the US undergo screening

colonoscopy starting at 45 years of age.

• Since individuals with a family history are at risk for developing colon
cancer earlier in life, they are typically screened at least 10 years before
the youngest age at which a relative was diagnosed.
ADENOMA
• Size is the most important characteristic that correlates with risk for
malignancy.

• Cancer is extremely rare in adenomas less than 1 cm in diameter

• Some studies suggest that nearly 40% of lesions larger than 4 cm in

diameter contain foci of invasive cancer.

• High-grade dysplasia is a second, less important risk factor for the

presence of cancer in a polyp.
MORPHOLOGY
GROSS
• Typical adenomas range from 0.3 to 10 cm in diameter

• Typically dark red compared with mucosa

• May be pedunculated or sessile

• Both types having a velvety texture and bumpy surface due to the
abnormal epithelial growth pattern.
(A) Pedunculated adenoma
(endoscopic view).

(B) Adenoma with a velvety

surface.
MICROSCOPY
• Histologically, the cytologic hallmark is epithelial dysplasia, marked by
nuclear hyperchromasia, elongation, and stratification.

• These changes are most easily appreciated at the surface of the

adenoma because the epithelium fails to mature as cells migrate from the
crypt.

• Pedunculated adenomas have slender fibromuscular stalks containing

prominent blood vessels derived from the submucosa.
MORPHOLOGY
• The stalk is usually covered by non-neoplastic epithelium, but
dysplastic epithelium is sometimes present.

• Adenomas may be classified as tubular, tubulovillous, or villous based

on their architecture.

• Tubular adenomas tend to be small, pedunculated polyps composed of

small, rounded, or tubular glands.
Low-magnification
photomicrograph of a pedunculated
tubular adenoma.
 Pencillate, dark nuclei with pseudostratification is
Hyperchromasia and nuclear crowding
the hallmark of tubular adenomas
MORPHOLOGY
• Villous adenoma may be pedunculated or sessile, with macroscopic
finger-like projections, often larger than tubular adenomas.

• Averages several centimeters in diameter, and may be up to 10 cm.

• Villous adenoma: > 80% villosity

• Although foci of invasion are more frequent in villous adenomas than

in tubular adenomas, villous architecture alone does not increase cancer
risk which is related to size.
Sessile villous adenoma, larger
than a tubular adenoma.

A villous adenoma averages

several centimeters in diameter
and may be up to 10 cm.
Cross section of the
rectal wall shows giant
villous adenoma
occupying 100% of the
circumference.
Sigmoid polyp showing
epithelial finger-like
projections formed by
fibrovascular cores lined by
dysplastic epithelium.
MORPHOLOGY
• Tubulovillous adenomas have a mixture of tubular and villous
elements.

• Tubulovillous adenoma: 20 - 80% villosity

• Tubulovillous adenoma shows nuclear pseudostratification and elongated

nuclei occupying the basal half of the cytoplasm.
Tubulovillous Adenoma,
colon:

A large pedunculated
polyp with predominant
tubular and minor
villous growth pattern.
SESSILE SERRATED ADENOMA (SSA)

• SSA is a type of precancerous colonic polyp that has specific histological

characteristics and poses an increased risk for colorectal cancer.

• The histologic features of sessile serrated adenomas overlap with those

of hyperplastic polyps.

• Hyperplastic polyps typically lack dysplasia while sessile serrated

adenomas have a malignant potential similar to conventional
adenomas.
 SESSILE SERRATED ADENOMA (SSA)
• The most useful feature distinguishing sessile serrated adenoma from
hyperplastic polyp is the:

• Presence of serrated architecture throughout the full length of the

glands, including the crypt base, in association with crypt dilation and
lateral growth.

• By contrast, serrated architecture is typically confined to the surface of

hyperplastic polyps.
- Basal crypt dilation with mucous retention
- Bases of the crypts are more serrated compared to the surface and have mature goblet
cells and mucinous cells
Thank You!
Any Questions?