Post on 06-Apr-2018
transcript
8/2/2019 Colonic Pathology GSF 2011(1)
1/55
ColonicPathology
8/2/2019 Colonic Pathology GSF 2011(1)
2/55
Inflammatory
&
Neoplastic
8/2/2019 Colonic Pathology GSF 2011(1)
3/55
IDIOPATHIC CHRONIC
INFLAMMATORY BOWEL DISEASE
Crohns Disease&
Ulcerative Colitis
8/2/2019 Colonic Pathology GSF 2011(1)
4/55
CROHNS DISEASE
Common in North America and Northern
Europe
Prevalence from 30 to 100 per 100000
Family history common, relative risk for
a sibling is 13-36
Maximal incidence in young adults 15-30
yrs
8/2/2019 Colonic Pathology GSF 2011(1)
5/55
CROHNS DISEASE
Any portion of the GI tract can be affected but
pattern of anatomical involvement is important
Involvement of both terminal ileum and
caecum in 40-50%
In 20% of patients disease confined to the
colon
Discontinuous or skip lesions on
colonoscopy or barium studies are characteristic
8/2/2019 Colonic Pathology GSF 2011(1)
6/55
CROHNS DISEASE
Pathology (Macroscopic examination)
Involved bowel portions and associated
mesentery thickened and oedematousMucosal lesion typically begins as a
superficial ulcer
As disease advances ulcers enlarge, deepen
and eventually coalesce to form transverse and
longitudinal ulcers, giving cobblestone
appearance.
8/2/2019 Colonic Pathology GSF 2011(1)
7/55
CROHNS DISEASE
8/2/2019 Colonic Pathology GSF 2011(1)
8/55
CROHNS DISEASE
8/2/2019 Colonic Pathology GSF 2011(1)
9/55
CROHNS DISEASE
Histopathology
Transmural inflammation
Non-necrotising granulomas (40-60%)
Crypt abscesses
Ulcers may penetrate deeply forming fissures in
the muscularis propria leading to abscess and
fistula formationHealing of these penetrating lesions is
responsible for fibrosis and stricture formations
8/2/2019 Colonic Pathology GSF 2011(1)
10/55
CROHNS DISEASE
8/2/2019 Colonic Pathology GSF 2011(1)
11/55
CROHNS DISEASE
ComplicationsInflammatory adhesions, perforation, perirectal
disease (perianal fistulas and abscesses),
malabsorption, small bowel adenocarcinoma
Treatment
5-Aminosalycilic acid, steroids,
immunosuppressive drugs, monoclonalantibodies against TNF- (Infliximab), surgery
8/2/2019 Colonic Pathology GSF 2011(1)
12/55
ULCERATIVE COLITIS
Common in North America and Northern Europe.
Prevalence from 35 to 50 per 100000
Family history common, relative risk for a sibling
is 7-17. Maximal incidence in young adults 20-50
yrs., second peak 60-70 yrs
8/2/2019 Colonic Pathology GSF 2011(1)
13/55
ULCERATIVE COLITIS
HistologicallyCrypt abscesses with neutrophils within the
crypt, in the crypt wall and in the lamina
propriaCrypt architectural distortion, with gland
branching, shortening and loss of the normal
parallel arrangement of glands
8/2/2019 Colonic Pathology GSF 2011(1)
14/55
LAYERS OF THE LOWER GI TRACT
8/2/2019 Colonic Pathology GSF 2011(1)
15/55
Large Bowel
8/2/2019 Colonic Pathology GSF 2011(1)
16/55
ULCERATIVE COLITIS
8/2/2019 Colonic Pathology GSF 2011(1)
17/55
ULCERATIVE COLITIS
8/2/2019 Colonic Pathology GSF 2011(1)
18/55
ULCERATIVE COLITIS
8/2/2019 Colonic Pathology GSF 2011(1)
19/55
TOXIC MEGACOLON
High feverTachycardia
Diarrhoea
Paralysis of the motorfunction of the
transverse colon
Mortality up to 30%
8/2/2019 Colonic Pathology GSF 2011(1)
20/55
ULCERATIVE COLITIS
Complications
Toxic megacolon, perforation, massive haemorrhage,
colon cancer (correlation with colonic involvement and
duration of disease)
Treatment
5-ASA, steroids, immunosuppressive drugs, surgery
8/2/2019 Colonic Pathology GSF 2011(1)
21/55
Neoplastic
8/2/2019 Colonic Pathology GSF 2011(1)
22/55
Benign and Malignant
Intestinal polyps
Colorectal Polyps: definition, classificationand behaviour
Colorectal Cancer: location, risk factors,
screening, spread, staging, survival,complications
8/2/2019 Colonic Pathology GSF 2011(1)
23/55
INTRODUCTION
Terminology
Hyperplasia: increase in cell number bymitosis
Hypertrophy: increase in cell size without
cell division
8/2/2019 Colonic Pathology GSF 2011(1)
24/55
Terminology
Differentiation: cells develop specialised
function
Metaplasia: acquired form of altered
differentiation
Dysplasia: abnormal growth anddifferentiation of a
tissue often premalignant
8/2/2019 Colonic Pathology GSF 2011(1)
25/55
COLORECTAL POLYPS
Definition
Protruberant growthEpithelial (very common)
Mesenchymal (uncommon)
Benign or Malignant
8/2/2019 Colonic Pathology GSF 2011(1)
26/55
COLORECTAL POLYPS
Classification
1. INFLAMMATORY: pseudopolyps,
benign lymphoid polyps
2. HAMARTOMATOUS: juvenile polyp,
Peutz-Jegher
3. NEOPLASTIC: adenoma, adenocarcinoma
4. OTHERS: hyperplastic,
lipoma, leiomyoma
8/2/2019 Colonic Pathology GSF 2011(1)
27/55
INFLAMMATORY PSEUDOPOLYPS
Seen in ulcerative colitis and Crohns
diseaseMacroscopically: can look like
adenomas
Microscopically: inflammatory tissue,hyperplastic mucosa
8/2/2019 Colonic Pathology GSF 2011(1)
28/55
HAMARTOMATOUS POLYPS
Hamartoma:
Benign tumour-like lesion
Two or more differentiated tissue elements,
normally present in the organ
8/2/2019 Colonic Pathology GSF 2011(1)
29/55
HAMARTOMATOUS POLYPS
Juvenile Polyps: most common paediatric
GI polyps
Peutz-Jegher: GI polyps
pigmentations of oral
mucosa, lips, palms,
genitalia
8/2/2019 Colonic Pathology GSF 2011(1)
30/55
Juvenile polyp
Cystic glands with normal orinflamed epithelium
Germ line SMAD4 mutation
(18q21-22) (25-30%)Children mean age 8
80% in the rectum
Clinical manifestations: bleeding(up to 95%), prolapse
8/2/2019 Colonic Pathology GSF 2011(1)
31/55
Peutz-Jeghers Polyps (PJP)
Autosomal dominantOccur throughout the GI tract
Small bowel more common than
large bowel
Intussusception and partial or
complete obstruction
Adenoma/Carcinoma in PJP
Carcinoma develops from
dysplastic foci (73% GI tract)
8/2/2019 Colonic Pathology GSF 2011(1)
32/55
NEOPLASTIC POLYPS
Definition
All are dysplastic
Disregulated proliferation
Failure to fully differentiate
Premalignant
Adenoma
8/2/2019 Colonic Pathology GSF 2011(1)
33/55
NEOPLASTIC POLYPS
Adenoma Classification
Tubular
Tubulovillous
Villous
8/2/2019 Colonic Pathology GSF 2011(1)
34/55
Tubular adenoma
Tubular growth
8/2/2019 Colonic Pathology GSF 2011(1)
35/55
Tubulo-villous adenomaMuscularis mucosa
Stalk
Villielongated crypts
8/2/2019 Colonic Pathology GSF 2011(1)
36/55
Villous adenoma
More than 75% villous
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/med/images/Large/37073707villous-1.jpg&template=izoom28/2/2019 Colonic Pathology GSF 2011(1)
37/55
Flat/Depressed adenoma
High malignant potential
(even if small)
High incidence of severedysplasia
Associated with familial
colon cancer syndromes,HNPCC (50%) or FAP
8/2/2019 Colonic Pathology GSF 2011(1)
38/55
NEOPLASTIC POLYPS
Villosity (25-85%) of villous
adenomas may contain cancer
Size (30% of villous adenomas > 5cm
may contain cancer
Degree of dysplasia (severe)
Malignant potentialof adenomas is
proportional to:
8/2/2019 Colonic Pathology GSF 2011(1)
39/55
HYPERPLASTIC POLYP
Commonest in adults
Asymptomatic, any age but
increase in 60s and 70s, mostly
rectosigmoid< 5 mm, sessile nodule
Benign, no malignant potential
unless they are mixed (hyperplastic-adenomatous polyps, Serrated
Adenomas)
8/2/2019 Colonic Pathology GSF 2011(1)
40/55
Leiomyoma
Ileocaecal valve
8/2/2019 Colonic Pathology GSF 2011(1)
41/55
Leiomyomatous polyp
Rectum, as well as jejunum, ileum
Muscularis mucosa
Symptoms : anaemia, bleeding due to
ulceration, epigastric pain
8/2/2019 Colonic Pathology GSF 2011(1)
42/55
Colorectal Cancer
8/2/2019 Colonic Pathology GSF 2011(1)
43/55
Colorectal Cancer
Peaks at 75-80 years
Carcinoma colon F>M
Carcinoma rectum M>F
Location
Right colon 25%
Left colon 15%
Rectosigmoid 50%
i h i i
8/2/2019 Colonic Pathology GSF 2011(1)
44/55
Site Characteristics
Left ColonRight ColonPolypoid
Mass
Discomfort/anaemia
Anular,obstructing
Bleeding/mucus
Colicky painChange of bowel habit
8/2/2019 Colonic Pathology GSF 2011(1)
45/55
Screening
Colonoscopy: UC
FAP/HNPCC
Adenomatous Polyps
Faecal occult bloods (false positives)
Flexible sigmoidoscopy
Genetic testing
8/2/2019 Colonic Pathology GSF 2011(1)
46/55
Spread
Direct
Lymphatic
Vascular (liver, lungs, bones)
8/2/2019 Colonic Pathology GSF 2011(1)
47/55
Complications
Obstruction
PerforationBleeding
Pericolic abscess
Fistulae
Intussusception
8/2/2019 Colonic Pathology GSF 2011(1)
48/55
8/2/2019 Colonic Pathology GSF 2011(1)
49/55
Survival
DUKEs staging 5 year survival
A
B
C (C1 and C2)
99%
75%
35%
8/2/2019 Colonic Pathology GSF 2011(1)
50/55
Tumour
T1:Tumour invades submucosa
T2:Tumour invades muscularis propria
T3:Tumour invades through the muscularis propria into the
subserosa, or into the pericolic or perirectal tissues
T4:Tumour directly invades other organs or structures,and/or perforates
Node
N0:No regional lymph node metastasis
N1:Metastasis in 1 to 3 regional lymph nodesN2:Metastasis in 4 or more regional lymph nodes
Metastasis
M0:No distant metastasis
M1:Distant metastasis present
TNM Staging System (Tumour, Node, Metastasis)
8/2/2019 Colonic Pathology GSF 2011(1)
51/55
Stage Groupings
Stage I:T1 N0 M0; T2 N0 M0
Cancer has begun to spread, but is still in the inner lining
Stage II:T3 N0 M0; T4 N0 M0
Cancer has spread to other organs near the colon or rectum. It has
not reached lymph nodes
Stage III:any T, N1-2, M0
Cancer has spread to lymph nodes, but has not been carried to
distant parts of the body
Stage IV:any T, any N, M1Cancer has been carried through the lymph system to distant parts
of the body. This is known as metastasis. The most likely organs to
experience metastasis from colorectal cancer are the lungs and liver
8/2/2019 Colonic Pathology GSF 2011(1)
52/55
CRC Survival
Stage grouping 5 year survivalI (Dukes A)
II (Dukes B)
III (Dukes C)
IV (Dukes D)
99%
75%
35%
5%
F ili l C l l C S d
8/2/2019 Colonic Pathology GSF 2011(1)
53/55
Familial Colorectal Cancer Syndrome
Dominant
Carcinoma developes younger
Right sided
Multiple
about 5% of casesabnormalities in 4 mismatch repair
genes (microsatellite instability)
HNPCC
8/2/2019 Colonic Pathology GSF 2011(1)
54/55
Identifying HNPCC
Amsterdam Criteria(all criteria must be met)
Three or more family members with colorectal cancer, at
least two of which must be first-degree relatives (e.g.
parent, sibling or child)
The disease affects family members from at least two
successive generations
One of the colorectal cancers must occur prior to age 50Familial Adenomatous Polyposis excluded
F ili l Ad P l i (FAP)
8/2/2019 Colonic Pathology GSF 2011(1)
55/55
Familial Adenomatous Polyposis (FAP)
Relatively rare condition
(approximately 1 in 8000 individuals)
Without intervention virtually all
people with this condition will
develop colon cancer
Characterised by multiple polyps
throughout the entire colon (up to
thousands) The polyps are not present at birth
but develop over time