Imaging Evaluation of Polyps. CT Colonography: Sessile Adenoma. Polyps, DALMs & Megacolon Objectives
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1 Polyps, DALMs & Megacolon: Pathology and Imaging of the Colon and Rectum Angela D. Levy and Leslie H. Sobin Washington, DC Drs. Levy and Sobin have indicated that they have no relationships which, in the context of their presentation, could be perceived as a potential conflict of interest. Polyps, DALMs & Megacolon Objectives 1- to present the imaging, classification, and morphology of colorectal polyps 2- to describe DALMs and their significance 3- to present the morphology and imaging of megacolon Imaging Evaluation of Polyps CT Colonography: Sessile Adenoma Epithelial Sessile Pedunculated Filiform Subepthelial 1
2 CT Colonography: Sessile Adenoma CT Colonography: Flat Adenoma Courtesy of J.R. Choi, Sc.D., M.D. Courtesy of J.R. Choi, Sc.D., M.D. CT Colonography: Pedunculated Adenoma Villous Adenoma CT Colonography: Flat Adenoma Villous Adenoma Courtesy of J.R. Choi, Sc.D., M.D. 2
3 CT Colonography: Adenocarcinoma Courtesy of J.R. Choi, Sc.D., M.D. CT Colonography: Adenocarcinoma Annular Adenocarcinoma Courtesy of J.R. Choi, Sc.D., M.D. 3
4 Lipoma Ulcerative Colitis: Pseudopolyps Rectal Carcinoid Lipoma Rectal GIST 4
5 Intestinal Polyps Tubular adenoma Adenomas Hyperplastic polyps Peutz-Jeghers polyps Juvenile polyps Inflammatory polyps Others Dysplasia starts at the lumen Colon: Normal mucosa Tubular adenoma Adenoma - subtypes Villous adenoma >20% 5
6 Villous and tubular adenomas Adenoma, high-grade (severe) dysplasia Sessile Pedunculated Nuclei reach gland surface Adenoma, high-grade dysplasia (CIS) Villous 5.5% Tubulovillous 22.5% Tubular 71.9% Colorectal adenomas - frequency Cribriform glands; no invasion beyond mucosa Tubular adenoma, low-grade dysplasia Colorectal Carcinoma Arising in an Adenoma In situ Intraepithelial High-grade dysplasia Intramucosal Invasive = submucosal invasion Good nuclear polarity, little mucin reduction, orderly glands [Prevents over-treatment] 6
7 Flat tubular adenoma Intestinal Polyps Adenomas Hyperplastic polyps Serrated polyps Peutz-Jeghers polyps Juvenile polyps Inflammatory polyps No higher than 2x the mucosal thickness Adenocarcinoma arising in a flat adenoma Hyperplastic polyp, colon Invasive carcinoma goes to deep margin Elongated, straight tubules Tubular adenoma with pseudoinvasion Serrated adenoma (traditional). Mucin-filled cystic mass in submucosa of polyp s stalk Nuclear stratification of adenoma & serrated profiles of hyp polyp 7
8 Sessile serrated polyp/adenoma Genetic Pathways Dilated, horizontal deep glands Tumor suppressor = 85%; Microsatellite = 15% of sporadic adenomas/carcinomas Sessile serrated polyp/adenoma Serrated Polyps Hyperplastic polyp Serrated adenoma (traditional) localized lesion; eosinophilic cytoplasm Sessile serrated adenoma large, sessile; disorganized architecture Sessile adenoma rather than sessile polyp ensures follow-up Long >1 cm sessile flat lesion (low power of previous slide) Sessile Serrated Adenomas High risk precursors of microsatellite unstable colon carcinomas right sided, usually large, sessile (> 1 cm) architectural disorder decreased expression of mismatch repair proteins: MLH1, MSH2, etc up to 15% risk of subsequent carcinoma or high grade dysplasia, esp in rt colon Intestinal Polyps Adenomas Hyperplastic polyps Peutz-Jeghers polyps Juvenile polyps Inflammatory polyps 8
9 Peutz-Jeghers polyps Peutz-Jeghers polyp, pseudoinvasion, jejunum Upright due to muscular infrastructure Mucosal penetration into muscularis propria Peutz-Jeghers polyp, colon, Intestinal Polyps Adenomas Hyperplastic polyps Peutz-Jeghers polyps Juvenile polyps Inflammatory polyps Arborizing muscle, little lamina propria, overactive glands Peutz-Jeghers Colon: polyp, Peutz-Jeghers colon polyp Juvenile polyp, colon Arborizing muscle, little lamina propria, overactive glands Round, eroded, expanded lamina propria, cystic dilatation, no muscle, inflamed 9
10 Juvenile polyp (polyposis) - colon Post-inflammatory polyps (Crohn) - colon Unusual forms occur in juvenile polyposis, as does dysplasia Up-ended mucosa due to ulceration and irregular repair Intestinal Polyps Post- inflammatory polyps, colon Adenomas Hyperplastic polyps Peutz-Jeghers polyps Juvenile polyps Inflammatory polyps Result of ulcer healing and repair of up-ended pieces Inflammatory polyp, colon Post- inflammatory polyps, colon Granulation tissue polyp Mucosa looks healed. Rigidity can cause obstruction 10
11 Post- inflammatory polyps (Crohn) Inflammatory cloacogenic polyp (Prolapse polyp) Rigidity caused obstruction Squamous collar, glandular core, eroded surface Ulcerative colitis - pseudopolyps Inflammatory cloacogenic polyp Pseudomembrane: mucin and polys Ulcerative colitis, pseudopolyps Rectum: Mucosal prolapse syndrome Colitis cystica profunda Mucosal remnants adjacent to ulcers 11
12 Intestinal Polyps GIST Adenomas Hyperplastic polyps Peutz-Jeghers polyps Juvenile polyps Inflammatory polyps Others CD117+ Cronkhite-Canada polyp, colon Leiomyoma, colon Gastrointestinal stromal tumor (GIST) Colon: Lymphomatoid polyposis Mantle cell lymphoma 12
13 Endometriosis, descending colon polyp: Adenocarcinoma arising in DALM Low grade dysplasia at surface, invasive carcinoma below Adenocarcinoma arising in DALM Ulcerative Colitis - Crohn Dysplasia Associated Lesion/Mass (DALM) vs Adenoma Low grade dysplasia overlies invasive carcinoma; raised due to invasion Ulcerative Colitis Dysplasia Pedunculated adenoma in colitic area + dysplasia-free stalk = adenoma Sessile adenoma in colitic area = DALM Sessile adenoma proximal to colitis = adenoma Resectable by polypectomy = adenoma DALM: Low-grade surface dysplasia Invasive carcinoma Adenocarcinoma, Crohn colitis Low-grade tubuloglandular adenocarcinoma 13
14 Megacolon Hirschsprung s s Disease Acute Common Transient, secondary to another disease process Chronic Chronic intestinal pseudoobstruction Chronic intestinal dilatation without obstruction Megacolon Hirschsprung s s Disease Congenital Hirschsprung s disease Acquired Idopathic T. cruzi (Chaga s disease) Diabetes Myexdema Chronic intestinal pseudoobstruction Toxic megacolon Megacolon Chaga s s Disease Imaging evaluation Typical colonic diameters for diagnosis Cecum > 12 cm Ascending and transverse > 8 cm Descending and sigmoid > 6 cm Radiography Exclude obstruction CT Wall thickening Extraintestinal disease 14
15 Chronic Idiopathic Intestinal Pseudoobstruction Toxic Megacolon-Ulcerative Colitis Hereditary Visceral Myopathy Toxic Megacolon-Ulcerative Colitis Megacolon 15
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