Colon Polyp Morphology on Double-Contrast Barium Enema: Its Pathologic Predictive Value

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1 965 David J. Ott 1 David W. Gelfand 1 Wallace C. Wu 2 Deborah S. Ablin 1-3 Received March 21, 1983; accepted after revision July 8, 'Department of Radiology, Bowman Gray School of Medicine, Winston-Salem, NC Address reprint requests to D. J. Ott. department of Medicine, Bowman Gray School of Medicine, Winston-Salem, NC 'Present address: Department of Radiology, Children's Orthopedic Hospital, Seattle, WA AJR 141: , November X/83/ American Roentgen Ray Society Colon Polyp Morphology on Double-Contrast Barium Enema: Its Pathologic Predictive Value was The morphologic appearance of 96 polyps seen on double-contrast barium enema reviewed to assess the predictive value of various signs described to diagnose malignancy. Size, surface contour, basal indentation, and pedunculation were studied. Sessile polyps had an appreciable incidence of malignancy, with size being the best indicator of that risk. Pedunculation was found to be a reliable sign of benignity in predicting the absence of malignant invasion into the adjacent colonic wall. Polyps under 1 cm and having a smooth contour were invariably benign. Conversely, polyps larger than 1 cm with a lobulated contour and basal indentation had a significant incidence of malignancy. The term "polyp" is used to describe any growth that protrudes into the colonic lumen [1]. Nearly all colonic polyps arise from the epithelium, with the two most common types being hyperplastic or neoplastic in origin [1-6]. Hyperplastic polyps are typically smooth, sessile, and under 5 mm, and they constitute the bulk of all colonic polyps in this size range. Neoplastic epithelial polyps are generally larger than 5 mm and include benign adenomas, adenomas with focal carcinoma, and polypoid adenocarcinomas. Neoplastic polyps vary in their appearance from small, smooth, and sessile lesions simulating polyps to larger lesions that may be lobulated or pedunculated. hyperplastic Several radiographic criteria have been used to estimate the malignant potential of a colonic polyp [7-15]. The most useful have included size, surface contour, basal indentation, and pedunculation. We have reassessed the value of these criteria as predictors of malignancy through a review of the radiographic appearance of 96 polyps pathologically examined and seen on double-contrast barium enema. Materials and Methods The study extended over a 2-year period and included 61 patients with 96 colonic polyps. All lesions were originally diagnosed on double-contrast barium enema and were later removed and examined pathologically. The patients included 22 women and 39 men aged years (mean, 57). Thirty-nine patients (64%) had single polyps; 22 (36%) had multiple polyps. The radiographic diagnosis of a colonic polyp was confirmed by endoscopy in 39 patients (64%) and by surgery in 22 (36%). To determine the value of polyp morphology in predicting the likelihood of carcinoma, the original double-contrast barium enemas were reviewed and correlated with the histologic findings. The 96 polyps studied were segregated according to size (diameter) into three categories: 5-10 mm, mm, and greater than 20 mm. Polyp size was measured directly from the films, and no correction for magnification was made. The radiographic morphology of each polyp was evaluated. Surface contour was categorized as smooth or irregular. Basal indentation and pedunculation, if present, were also noted. Polyps smaller than 5 mm were excluded from the study because we do not routinely report these lesions radiographically [4]. Most of these minute polyps are probably no

2 966 OTT ET AL. AJFC141, November 1983 greater than 3-4 mm in actual size if magnification factors are considered. The incidence of invasive carcinoma in polyps of this size range remains minuscule [1-6], while the degree of falsepositive radiographic error in diagnosing such defects is most likely considerable. For these reasons, we believe that much unnecessary colonoscopy would be performed in attempting to resolve every minute defect seen on double-contrast barium enema. Results Forty-one polyps (43%) were 5-10 mm in diameter, 32 (33%) were 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 mm polyps, but was infrequent in polyps in the other two size categories. Six (15%) of 41 polyps measuring 5-10 mm showed lobulation, compared to 17 (53%) of 32 polyps of mm and 21 (91 %) of 23 polyps over 20 mm. Benign adenomas of various histologic types accounted for 63 (66%) of the 96 polyps (table 3). Twelve (86%) of the 14 hyperplastic polyps were in the 5-10 mm range. One (2.4%) of 41 polyps of 5-10 mm harbored invasive carcinoma; three (9.4%) of 32 polyps of mm and 12 (52.2%) of 23 polyps over 20 mm were carcinomatous. Although only one (1.9%) of 52 radiographically smooth 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 adenomas with focally invasive carcinoma (fig. 1). Most small (5-10 mm) hyperplastic and adenomatous polyps were smooth and sessile radiographically and were indistinguishable from each other (fig. 2). Indentation was present radiographically at the base of 11 (15%) of 71 sessile polyps (table 4). Only one (3%) of 37 polyps in the 5-10 mm range showed indentation, contrasted to four (27%) of 15 polyps of mm and six (32%) of 19 polyps larger than 20 mm. Basal indentation was found in both benign and malignant polyps smaller than 20 mm; however, malignancy was invariably present when this sign was seen in polyps larger than 20 mm (fig. 3). Discussion The double-contrast barium enema has improved the radiologic detection of colonic polyps and also has permitted better evaluation of their morphology. The radiographic criteria currently used for predicting the malignant nature of a colon polyp include size, contour, basal indentation, and pedunculation. With the advent of colonoscopy, evaluation of growth of a polyp between separate radiographic examinations, a previously used criterion [7, 8, 11, 16], has generally become unnecessary. Polyp Size Size is an important criterion used to judge the malignant potential of a sessile colonic polyp [1, 4, 5, 7, 9, 11]. While TABLE 1: Radiographic Morphology and Malignant Incidence of 71 Sessile Polyps Smooth surface: Number Malignant 0 1 (17) 0 1 (2.4) Lobulated surface: Number Malignant 0 1(11) 12(71) 13(44.8) Note. Numbers in parentheses are percentages. TABLE 2: Radiographic Morphology and Malignant Incidence of 25 Pedunculated Polyps Smooth surface: Number Malignant 0 1* (11) 0 1 (10) Lobulated surface: Number Malignant 1f(33) 1f (13) 0 2(13.3) Note. Numbers in parentheses are percentages. * Adenoma with carcinoma in situ. t Adenoma with focally invasive carcinoma. TABLE 3: Pathologic Findings in 96 Polyps Seen on Double- Contrast Barium Enema Hyperplastic Lipoma Benign adenomas: Tubular Mixed Villous Carcinomas: In situ Invasive* ' Includes two adenomas with focally invasive carcinoma. not the subject of this investigation, it has been demonstrated that polyps smaller than 5 mm are almost invariably benign [4, 14, 17-20]. Many of these minute growths are hyperplastic in origin, while the adenomas of this size have less than a 0.5% incidence of invasive malignancy. However, polyps larger than 5 mm have an increasing chance of harboring invasive carcinoma, the average reported incidence of malignancy being 1 % of 5-9 mm polyps, 6% for mm polyps, and 26% for polyps greater than 20 mm [4]. As expected, our results showed a strong correlation between polyp size and malignancy. Only 2.4% of 5-10 mm polyps were malignant, compared with 9.4% of mm polyps and 52.2% of those over 20 mm. Since 10 mm

3 AJR: 141, November 1983 PREDICTIVE VALUE OF POLYP MORPHOLOGY 967 Fig. 1. A, Carcinoma in situ in smooth, pedunculated adenoma (arrow), with head measuring 12 mm. Additional 16 mm, lobulated, sessile adenoma (arrowhead), harboring focally invasive carcinoma. B, Pedunculated adenoma with lobulated 16 x 18 mm head containing focally invasive carcinoma. Pedicle was 4 cm long. (arrow) Fig. 2. A, Smooth, sessile, 8 mm adenoma in sigmoid colon, similar in appearance to hyperplastic polyp shown in B. B, Smooth, sessile, hyperplastic polyp (arrow) in sigmoid colon. Larger, lobulated adenoma (arrowhead) also present. seems to be a critical diameter, s y 1 f. w \ / polyps larger than this should be removed routinely [4, 5, 9, 1 5]. Depending on the clinical circumstances, 5-10 mm polyps should probably also be removed to eliminate the small fraction of carcinomas already present in this size range and those that may potentially develop from benign adenomas [4, 5, 20-23]. Polyp Contour The surface contour of a polyp has proven to be a reliable but somewhat less valuable sign for diagnosing malignancy T 1 lis TABLE 4: Basal Indentation in 71 Radiographically Sessile Polyps No. with indentation... 1 (3) 4(27) 6(32) 11 (15) Pathology of indented polyps: Adenoma Carcinoma 0 2 (50) 6(100) 8 (73) Note. Numbers in parentheses are percentages.

4 968 OTT ET AL. AJR:141, November 1983 [7, 8, 11-15]. Although surface irregularity has been regarded as indicating that a polyp is increasingly likely to be malignant, it does not always correlate with the presence of carcinoma. This is particularly true in small, slightly lobulated polyps where mild surface irregularity may be of little value in forecasting malignancy [14, 15]. In our study, a smooth surface nearly always indicated a benign lesion, regardless of size. Conversely, one-third of the lobulated polyps were malignant, with the incidence of malignancy depending on the size of the lesion. Although only three (13%) of 23 lobulated polyps of 20 mm or less were malignant, 12 (57%) of 21 larger than 20 mm were carcinomatous. Thus, the presence of lobulation in a small colonic polyp seems to be a poor predictor of malignancy. Indeed, the surface morphology of a small colonic polyp was of little value in indicating the histologic origin of the lesion. Hyperplastic polyps were invariably smooth and typically sessile, as were most of the smaller benign adenomas. In the 5-10 mm range, these lesions were usually indistinguishable. Basal Indentation Indentation at the base of a polyp has been suggested as a sign indicative of malignant infiltration into the colonic wall [7-15]. The frequency and reliability of this finding, particularly for polyps of various sizes, has not been well documented [7]. Indeed, recent studies have suggested that smooth basal indentation may be a projectional artifact related to the geometry at the junction of the base of the polyp and colonic wall [24, 25]. This would seem to be an important consideration in evaluating smaller polyps with smooth, minimal indentation. Basal indentation was clearly evident in 11 (15%) of the 71 sessile polyps in our series, and its presence was sizedependent. Indentation was seen in only one 5-10 mm polyp, a benign adenoma. Furthermore, two of the four mm polyps showing basal indentation were also benign. These findings support the concept that the presence of basal indentation in smaller colonic polyps may represent a geometric phenomenon rather than a sign of malignancy. On the other hand, eight of the 10 polyps over 10 mm that showed basal indentation were malignant. A most important observation, however, was that among these larger malignant polyps, the basal indentation seen was prominent and irregular, and on pathologic examination it invariably represented carcinomatous infiltration. Polyp Pedunculation Pedunculation of a colon polyp has been used as a sign of benignity for many years [7-12], and the length of the pedicle has been emphasized. Polyps on stalks longer than 2 cm are almost never associated with malignant invasion into the adjacent colonic wall [26]. This is true regardless of the presence of focally invasive carcinoma in the head of the polyp [27, 28]. As a result, pedunculated polyps must be viewed somewhat differently from sessile lesions regarding their current danger to the patient and their likely means of removal. Pedunculation was not a common finding in our investigation. It was seen in just over one-fourth of all polyps, with

5 AJR:141, November PREDICTIVE 1983 VALUE OF POLYP MORPHOLOGY 969 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. 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 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 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 p o l y p s of 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 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 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 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 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 infiltrated the colonic wall. Also, radiographic m e t h o d s seem 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 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 invasive malignancy. Lobulation and irregular basal i n d e n 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 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 (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 " these larger polyps. in 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 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, 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 virtually e x c l u d i n g malignant invasion into the a d j a c e n t c o 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. 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 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 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 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. 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 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 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 polyps, 22 ( 8 8 % ) were benign, including four lobulated lesions with heads larger than 2 c m. The three "malignant" 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 of t h e p o l y p h e a d. lesions 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 REFERENCES 1. M o r s o n B C, D a w s o n I M P. Gastrointestinal pathology, 2nd ed. Oxford: Blackwell Scientific, : L a n e N, F e n o g l i o C M. O b s e r v a t i o n s o n t h e a d e n o m a a s p r e c u r s o r t o o r d i n a r y l a r g e b o w e l c a r c i n o m a. Gastrointest Radiol 1976;1 : L a n e N. T h e p r e c u r s o r t i s s u e of o r d i n a r y l a r g e b o w e l c a n c e r : i m p l i c a t i o n s f o r c a n c e r p r e v e n t i o n. In: Y a r d l e y J H, M o r s o n B C, A b e l l M R, e d s. The gastrointestinal tract. B a l t i m o r e : W i l l i a m s & Wilkins, : O t t D J, G e l f a n d D W. C o l o r e c t a l t u m o r s : p a t h o l o g y a n d d e t e c t i o n. AJR ; : S h i n y a H, W o l f f W l. M o r p h o l o g y, a n a t o m i c d i s t r i b u t i o n a n d c a n c e r p o t e n t i a l o f c o l o n i c p o l y p s. Ann Surg ; :

6 970 OTT ET AL. AJR:141, November Williams GT, Arthur JF, Bussey HJR, Morson BC. Metaplastic polyps and polyposis of the colorectum. Histopathology 1980;4: Youker JE, Welin S, Main G. Computer analysis in the differentiation of benign and malignant polypoid lesions of the colon. Radiology 1968;90: Youker JE, Dodds WJ, Welin S. Colonic polyps. In: Margulis AR, Burhenne HJ, eds. Alimentary tract roentgenology, vol 2, 2d ed. St. Louis: Mosby, 1973: Marshak RH, Lindner AE, Maklansky D. Adenomatous polyps of the colon: a rational approach. JAMA 1976;235: Wiot JF, Felson B. Solitary benign colon tumors. Semin Roentgenol 1976;11: Welin S, Welin G. The double contrast examination of the colon: experiences with the Welin modification. Stuttgart: Georg Thieme, 1976: Laufer I. Double contrast gastrointestinal radiology with endoscopic correlation. Philadelphia: Saunders, 1979: Maruyama M. Radiologic diagnosis of polyps and carcinoma of the large bowel. Tokyo: Igaku-Shoin, 1978: Skucas J, Spataro R, Cannucciari DP. The radiologic appearance of small colon carcinomas. Radiographics 1981;1: Skucas J, Spataro RF, Cannucciari DP. The radiologic features of small colon cancers. Radiology 1982;143: Figiel LS, Figiel SJ, Wietersen FK. Roentgenologic observations of growth rates of colonic polyps and carcinoma. Acta Radio [Diagn] (Stockh) 1965;3: Arthur JF. Structure and significance of metaplastic nodules in the rectal mucosa. J Clin Pathol 1968;21: Lane N, Kaplan H, Pascal RR. Minute adenomatous and hyperplastic polyps of the colon: divergent patterns of epithelial growth with specific associated mesenchymal changes. Gastroenterology 1971;60: Granqvist S, Gabrielsson N, Sundelin P. Diminutive colon polyps: clinical significance and management. Endoscopy 1979; 11 : Tedesco FJ, Hendrix JC, Pickens CA, Brady PG, Mills LR. Diminutive polyps: histopathology, spatial distribution, and clinical significance. Gastrointest Endosc 1982;28: Christie JP. Which colonic polyps should be excised endoscopically? South Med J 1976;69: Parrish JF. Management of patients with polypoid lesions of the colon: current concepts and controversies. Am J Gastroenterol 1979; 71 : Colacchio TA, Forde KA, Scantlebury VP. Endoscopic polypectomy: inadequate treatment for invasive colorectal carcinoma. Ann Surg 1981;194: Ament AE, Alfidi RJ. Sessile polyps: analysis of radiographic projections with the aid of a double-contrast phantom. AJR 1982;139: Ament AE, Alfidi RJ, Rao PS. Basal indentation of sessile polypoid lesions: a function of geometry rather than a sign of malignancy. Radiology 1982; 143: Marshak RH. The pedunculated adenomatous polyp. Am J Dig Dis 1965;10: Smith TR. Pedunculated malignant colonic polyps with superficial invasion of the stalks. Radiology 1975;115: Okike N, Weiland LH, Anderson MJ Sr, Adson MA. Stromal invasion of cancer in pedunculated adenomatous colorectal polyps. Arch Surg 1977;112:

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