This small polyp was removed from the transverse colon. H&E histology is attached
WHAT IS THE DIAGNOSIS?
■ Serrated polyp
Crypt pattern looks more adenomatous!
■ Adenomatous polyp
Slit-like crypts but that thick capillary doesn't fit!
■ Leiomyoma
You're good at histology!
■ Neuroendocrine tumour
That was my guess too but I was wrong!
■ Small CRC
This lesion is submucosal!
explanation
I was quite sure that this was a small NET. It's that vessel crawling up it's side which convinced me. The reason that I enclose the histology is because it's not a neuroendocrine tumour! Histology shows interlacing bundles of spindle-shaped, smooth muscle cells. with bland-looking nuclei probably arising from the muscularis mucosa just below the epithelium.
It's a leiomyoma, which are very uncommon in the colon but of course very common in the oesophagus. Endoscopically, it's usually not difficult to tell the two apart. NET's often have a dip in the centre and/or sizeable vessels crawling up their sides. Colonic leiomyomas are usually covered with entirely normal looking epithelium. With immunohistochemistry it's easy to tell the two apart. A GIST (thought to arise from the 'interstitial cells of Cajar') usually stain with c-kit (CD117) while a leiomyoma is (thought to originate from smooth muscle cells) stain positive for smooth muscle actin or desmin, but not for c-kit. Of course leiomyomas are subepithelial lesions, covered with a normal mucosa. The differential diagnosis of submucosal swellings in the colon include:
This sessile polyp was found in the caecum, close to the appendiceal orrifice WHAT IS YOUR DIAGNOSIS?
■ Mixed adenomatous & serrated polyp
I don't see a mixture of crypt patterns!
■ SSL
Absolutely!
■ TSA
No, TSA's look like a cross between TVA & VA!
■ Adenomatous polyp
Perhaps the crypts look a little slit-like but it's covered with mucus...
explanation
Well, perhaps the crypt openings look a little slit-like but the lesion is partially covered with that mucus typical of an SSL. By the way, couldn't it be a hyperplastic polyp? I think that pathologists have given up even attempting to tell the two apart! My own rule of thumb is that anything which is ≥10mm, I call an SSL and remove. By the way, SSL's usually lift very well. In this particular case, the lift is a little sub-standard for an SSL, presumably because it's situated very close to the appendix orifice which anchors it down. A word of caution! I've had several 'post polypectomy syndrome' cases after removing large SSL's. In these cases, the lift was excellent and I asked for the LARGE snare to remove the lesion en-bloc. However, in both cases, I found that the snare was taking quite a long time to cut through. Perhaps because of that fatty reaction in the stroma below which Neil Shepherd talked about in the Podcast. To avoid any risk of the 'post polypectomy syndrome', you should ask your assistant to close the snare as quickly and hard as possible. Don't worry about bleeding. These lesions are never supplied by any significant vessels. Oh yes! And place clips !!! These polyps were found in the stomach of a 40 year old man on a Barrett's surveillance programme WHAT WOULD YOU ADVICE?
■ We should eradicate your Hp
This patient is VERY unlikely to have H.pylori
■ We should remove these endoscopically
An unnecessary job unless one look wonky, like perhaps that single red one!
■ We should stop you PPI
But the patient has Barrett's ?!
■ We should stop you PPI
That's what I would do !
explanation
Of course, this is a Fundic Gland Polyps/Cystic Gland Polyps . They are usually multiple, somewhat transparent sessile polyps, usually in the 1-5mm in diameter and located in the body and fundus.
Histologically there are cystically dilated glands lined by gastric body type mucosa. Of course, there is no need to sample these. A study patients with FGPs reported that they can be diagnosed with a high degree of accuracy based on endoscopic appearance alone (J Clin Gastroenterol 2003;36:399-402). The sporadic polyps are caused by activating mutations of the beta-catenin gene. Not sure how an APC gene mutation (you may remember are involved in FAP), could give rise to FGP’s though! Furthermore, I don't know how the use of PPI's can be linked to the development of FGP's. Presumably its something to do with the prolonged hypergastrinaemia and enterochromaffin cell-like (ECL) hyperplasia? I have seen a couple of cases of cancer developing within a FGP. In both cases the patient had FAP and the polyps were markedly larger than all the surrounding cystic fundic polyps. There have been case reports of dysplasia arising within sporadic fundic gland polyps. A few series have reported a <1% risk of sporadic FGPs harbouring dysplasia (Am J Surg Pathol 1998;22:293-298, Eur J Gastroenterol Hepatol 2003;15:1153-6, Endoscopy 1995;27;32-37). I must admit that I don't believe the figure of <1% risk of dysplasia in a sporadic FGP. I suspect that these series consist of rather selected cases. Of course by only selecting polyps 10mm or larger, you would be filtering away 99% of the FGP's, leaving only the 'far above average risk lesions' behind. Nevertheless, the BSG recommend sampling some of them to confirm the diagnosis but not to set out on any attempt to remove them. Of course, this advice is different to the advice for Hyperplastic polyps which ARE usually linked with H.pylori and also a greater risk of developing cancer. The BSG advice is summarised in the algorithm below. Sporadic FGPs are not associated with either H.pylori gastritis or atrophic gastritis. In fact, it has been proposed that H. pylori infection may have an inhibitory effect on the development of FGPs. Of course, you wouldn't stop the PPI in a patient with Barrett's. Actually there is no evidence that patients with unstable Barrett's are any more or less likely to progress to cancer if they stop their PPI. However, there must be a point (I presume) when the use of PPI is beneficial in the 'evolution' of Barrett's. Are patients on a PPI less likely to develop Barrett's or to develop damage the stem cell DNA? Not sure! The BSG do recommend a colonoscopy in patients below the age of 40 yrs. to rule out the possiblity of FAP. However, as the average age of colorectal cancer in patients with 'attenuated FAP' is 55 yrs, I would personally recommend a colonoscopy in patients above the age of 40 yrs. This polyp just distally to the caecum has been referred after an initial set of samples have indicated that it's a benign TVA harbouring no more than LGD. An unfortunate, fixed loop at the hepatic flexure means that I can't retrovert behind this polyp. In fact, it's difficult to get much closer to the lesion than this. WHAT STATEMENT DO YOU AGREE WITH?
■ The resection may be difficult but it can be done
I agree with that!
■ The location of the lesion and difficult colonic configuration probably makes a resection impossible
Of course the patient may have to travel to a nearby centre with the neccessary expertise!
■ All this is irrelevant as the polyp looks suspicious and would be best removed surgically
I disagree, it does look benign! But will of course have a 15% risk of harbouring cancer...
explanation
Actually, the lesion does look very benign. It wobbles about freely perched on top of the first fold distally to the caecum. Furthermore, it has a reassuring gyrate crypt pattern of a TVA. Naturally, any polyp of this size will have a 15% risk of actually containing an unexpected focus of cancer within. Because our therapeutic waiting list is in mess in the aftermath of Covid, I do encourage everyone to sample the sessile lesion even though you are planning to refer it for resection. Such sampling on the surface of large sessile lesions doesn't induce any fibrosis and provides some (limited of course) reassurance that the lesion isn't malignant. In this case, the position is very challenging but you can get close enough to stand a good chance of removing the lesion. That's actually what I did and I've just uploaded a video of the resection together with my face-to-camera annotation to highlight the main points. Ultimately, histology confirmed a TVA harbouring no more than LGD This is the GOJ of a 60 yr old woman with dyspepsia. WHAT IS YOUR DIAGNOSIS?
■ Reflux oesophagitis
No this is a nodule not an ulcer!
■ Hyperplastic/reactive nodule
Hyperplastic nodules have villous surface!
■ Unremarkable Barrett's
A nodule within Barrett's is always suspicious!
■ Adenocarcinoma
Absolutely!
■ Squamous cell carcinoma
No abnormal vessel pattern within nearby squamous mucosa!
Explanation
Actually, this patient was on a Barrett's surveillance programme. Five years earlier a small IMca had been removed following which annual surveillance had been reassuring. However, then this lesion was found and referred for removal.
Histological assessment of the resection fragment reported early invasion into the submucosa (which is 'allowed' provided that the depth of invasion is less than 500 microns (0.5mm). There was no LVI but unfortunately, there was poor differentiation. Of course, the 'worst' feature to find is probably LVI. Poor differentiation is worrying but less worrying than LVI. The reason for this is that 'poor differentiation' is a rather poorly defined entity. For example, how many crypts should be involved to call something 'poor differentiation' rather than 'focally poor differentiation'? Anyway, the patient was young and ultimately underwent an Ivor-Lewis which confirmed that the EMR had been curative with only some HGD remaining within the residual short stretch of Barrett's. We urgently need a prospective study following this type of Barrett's patient closely over time with regular EUS and CT to see if we can detect the small number of patients who subsequently turn out to have lymphnode involvement This subcentimetere polyp was discovered in the rectum of a 60 year old woman undergoing a bowel cancer screening colonoscopy following a positive FIT. Considering the endoscopic appearance and the degree of lifting, WHAT WOULD YOU DO?
■ This is a benign adenoma but it's too close to a large vein for removal
Don't worry about the vein!
■ This is a benign adenoma which I would remove
Doesn't look benign!!
■ This is a likely early cancer which I would remove
Yes it looks evil but should you attack?
■ This is an invasive cancer which I would only sample
Can't argue with that!
explanation
That vein looks intimidating but don't be intimidated! It's not a 'show stopper'. it will move out of the way. However, that polyp does look nasty as there is no definite crypt pattern in the centre, just a swirly surface. However, the lifting is good, suggestive that we stand a good chance of clearing the lesion endoscopically ...
And at this point you can either go ahead and remove the likely early cancer. The advantage is that you get the correct diagnosis whilst biopsies are often inconclusive. The reason why surface biopsies are often unable to confirm invasive cancer is because your pathologists rely on seeing invasion of malignant tissue below the muscular mucosa. The underlying muscularis mucosa is usually NOT included in surface biopsies. However, this is a good example of the potential disadvantages of going ahead to resect the lesion. As you'll see in the video below, I removed it. Histology reported that the lesion was indeed an early rectal carcinoma, 6mm in diameter and with clear margins. However, the deep margin was 'only' clear by 200 microns which of course our pathologists would call a 'positive deep margin'. A 1mm (that is 1000 micron) is the 'accepted' definition of a 'clear surgical margin'. Secondly, there was of course a small focus of LVI. There is usually something to keep you awake at night after removing an early cancer. The disadvantage is obviously that you don't know what to tell the patient!!! - Is my cancer gone or not? - I'm sorry but I'm not sure! - Couldn't you keep a close eye on me with regular colonoscopies and CT's? Well, we could but there is absolutely no evidence that this will save your life IF you still have cancer cells inside of you... Fortunately, there is a study under way in the Netherlands to answer this very question! At the moment, we know that LVI is 'bad' and that the normal next step would be to offer the patient surgery. This 75 year old man underwent a CTC because of a change in bowel habit which has confirmed a large caecal polyp. The patient has been referred for a snare polypectomy. WHAT WOULD YOU DO NEXT?
■ Abort the procedure and reassure the patient
Absolutely!
■ Take a full set of samples
Uneccessary and they will only show normal mucosa
■ Remove the polyp by EMR
Foolish!
■ Remove the polyp by ESD
Idiotic!!!
explanation
The location and the 'pillow sign' tells you that this lesion is a lipoma. We know from Shrisha Hebbar's Podcast that the ICV is a high risk location for any attempt at removing lipomas. He mentions a patient of his who presented with acute small bowel obstruction due to engorgement of an ICV lipoma after the placement of an Olympus ligation.
Furthermore, you wouldn't of course go ahead with an attempt at resecting a lipoma without due consideration of indications. How long has the patient had symptoms? Are they getting better? Are symptoms likely to arise because of this soft and floppy lesion. Probably unlikely and statistically speaking, this elderly patient is probably far more likely to have a change in bowel habit due to constipation. By the way, please take notice of the odd looking mucosal crypt pattern which is reminiscent of a TVA! This is the normal crypt pattern at the ICV at the transition to the villous surface in the terminal ileum!
Here is a circumferential duodenal polyp situated in the second part of the duodenum. The patient is somewhat uncomfortable and your 'window of opportunity' is closing.
WHERE SHOULD YOU TARGET YOUR BIOPSY?
■ 12 O'clock
Looks amourphous and worrying but not the right answer
■ 3 O'clock
Wouldn't be my priority site
■ 6 O'clock
This is the least worrying spot!
■ 9 O'clock
Absolutely - for two reasons!
explanation
In general ampullary or peri-ampullary adenomas are far more likely to turn malignant than adenomas situated elsewhere in the duodenum. This is the first reason, why you should target your biopsy at 9 O'clock. There is a second reason and that is that the most 'chunky' polyp is at 9 O'clock. In my experience, the larger the 'polyp volume', the greater is the risk of malignant conversion.
So should we offer an ampullectomy? I would offer this to anyone with a life-expectancy of 10 years or more, I would consider (no promises) anyone with a life-expectancy of 5 years or more IF there is HGD on biopsies and there is no evidence of ductal obstruction (pt never had jaundice and there is no ductal dilatation or MRI or on EUS). Of course, an ampullectomy (probably better called a 'papillectomy') is dangerous but less dangerous than surgery. In Leeds we quote the following risks of a papillectomy: 1:10 risk of acute pancreatitis for up to a few months after the procedure, 1:10 risk of late bleeding for up to 2 weeks after the procedure, 1:50 risk of a perforation, a 1:10 risk of late papillary stenosis, 1:20 risk of acute cholangitis and a 1:200 risk of death Tiger country!!! Just a bit of fun! Above are four types of benign polyps which can be found in the stomach, duodenum and colon respectively. I've used a 'plugin' which will hopefully make it easier to see the polyps on a small screen. BUT WHAT ARE THESE FOUR POLYPS ? A = B = C = D = You'll have to make up your mind and then click 'Explanation' below to reveal the correct answers ! EXPLANATION
The 3 polyps in column A are all adenomatous polyps. Flat and plaque-like in the stomach, pale in the duodenum and a sessile TVA in the colon. Column B shows NET's with the prominent vessels along it's side in the stomach and colon whilst the duodenal NET has the typical central depression. Column C shows 'hamartomatous' polyps seen in Peutz-Jeghers syndrome. There is hardly ever any dysplasia within these polyp and it's uncertain what the 'precursor lesion' is for these patients GI cancers Column D show inflammatory polyps which are typically angry red and sometimes with pretty white spots !
A rather beautiful polyp found in the duodenum of a patient undergoing upper GI surveillance
WHAT IS THE LIKELY HISTOLOGY?
■ Inflammatory/reactive polyp
Looks too pretty to be inflammatory
■ Serrated polyp
Surprisingly, you don't get SSL's in the UGI tract
■ Hamartomatous polyp
Well done! These are usually pretty polyps!
■ Adenomatous polyp
If patient had FAP, there should be more small polyps about
■ Neuroendocrine tumour
Should have an indentation and no crypt pattern
explanation
This polyp doesn't look adenomatous. Remember that in the duodenum, the adenomatous polyp are usually flat, often with white white edges and with a slit-like or gyrate crypt pattern. Of course, in this case the crypt pattern is gyrate, almost exaggerated gyrate! The rather beautiful surface rules out an inflammatory polyp and an NET, both of which don't have this pretty surface structure. Even the histology is rather beautiful, see example below!
In addition, as you probably know, most duodenal NET's will have a central indentation and will not have a distinct crypt pattern. Cutting to the chase, this patient has Peutz-Jeghers syndrome ! This is a good example of the hamartomatous polyps these patients develop throughout their GI tract. Similar hamartomatous polyps also develop in the 'Cronkhite-Canada syndrome and Juvenile polyposis. Hamartomatous polyps are characterized by 'disorganized overgrowth' of the normal tissue but without visible cellular instability (dysplasia). Of course, these patient have an appalling lifetime risk of developing cancer which can be as high as 90%, including gastric, colorectal, breast, colorectal, and pancreatic malignancies. Unfortunately, there is no no evidence that removing hamartomatous polyp will reduce the subsequent risk of cancer. For this reason the only justification for attempting the somewhat hazardous endeavour to remove PJS polyps deep within the small bowel is to reduce the risk of subsequent intussusception. Rather surprisingly, a quick medline search has not revealed any RCT evidence that this actually is worthwhile !
A very odd looking polyp at the anal verge. I removed it but still couldn't really make out what it was!?
WHAT IS YOUR BEST GUESS AT THE MOST LIKELY DIAGNOSIS?
■ Inflammatory polyp
Good guess as there is no crypt pattern!
■ Adenomatous polyp
It has the colour of an adenomatous polyp but no crypt pattern...
■ Small adenocarcinoma
Certainly ugly enough but small carcinomas are usually more button-shaped
■ Small SCC
Arising from close to the anal margin but nearby squamous mucosa is unremarkable...
explanation
This is rare stuff! I was clueless although reassured that the thing was soft and didn't feel malignant when squeezed between my fingers.
It proved to be a (rare) 'cloacogenic polyp'! You'd be excused if you have never heard of this (I hadn't). Apparently these were first described as recently as 1981! The same year that I was born ☺! Essentially they are inflammatory polyps arising from the transitional zone of the anorectal junction. They can be much larger than this and even be multiple and can occur at any age. Patients are usually asymptomatic but could (naturally) present with some blood on the toilet paper (this patients complaint). Histology is similar to that of solitary rectal ulcers with inflammation and fibromuscular hypertrophy. For this reason it is perhaps not surprising that they are linked with constipation and straining. Rare associations include small nearby cancers and human papillomavirus infection. This lesion was found in the ascending colon. WHAT IS THE MOST LIKELY DIAGNOSIS?
■ Lipoma
Hmm looks too translucent
■ Lymphangioectatic cyst
Well it looks cystic doesn't it!!!
■ GIST
I predict that the pillow sign will be positive
■ Serrated polyp
Doesn't look like a polyp
■ Adenomatous polyp
But the crypt pattern is normal !!!
explanation
The apparent lesion is covered with a normal layer of mucosa. In addition, it seems very soft. However, the lesion looks more translucent than yellow! Of course, it's another lymphangioectatic cyst ! Naturally, you confirm this by giving it a prod with your biopsy forceps. If soft, its either a lipoma or a cyst. If firm, it's either a GIST, leiomyoma or a metastasis (I guess).
This patient was referred for an OGD after complaining of dyspepsia improving with PPI. This nodule is noted at the GOJ
WHAT IS THE MOST LIKELY DIAGNOSIS?
■ Hyperplastic/Inflammatory polyp
A shrewd guess!
■ Adenomatous polyp
Never seen one at the GOJ!
■ Dysplastic polyp
That villous surface is reassuring and makes it more likely to be inflammatory!
■ Superficial SCC
SCC's never have a villous surface like this!
■ Superficial adenocarcinoma
Villous surface and nearby reflux ulcer makes it unlikely
explanation
At first, that 'villous' surface may look disconcerting. However, you should know that in the oesophagus and stomach, polyps arising due to inflammation and oedema, (so called 'reactive or 'inflammatory' or 'hyperplastic' polyps) usually have a villous or gyrate surface pattern. In the stomach, these polyps often have an angrily red appearance and some white blobs making them look a little like pretty mushrooms (see example below).
OK, if this polyp is 'inflammatory', why is there inflammation? You can see a linear reflux ulcer in the 3 O'clock position. THIS is the reason for the inflammatory polyp. Of course, you'll take a couple of biopsies but as always, make an Endoscopic Diagnosis! You ARE a Professional and NOT a simple technitian unthinkingly feeding biopsies to the guys with brains!
This was polyp found on the greater gastric curve.
WHAT IS THE LIKELY DIAGNOSIS?
■ Hyperplastic polyp
No! Those look like mushrooms usually
■ Fundic gland polyp
No, those look like frogspawn when you look closely
■ Adenomatous polyp
Absolutely, to be specific an 'intestinal type adenoma'!
■ Early gastric cancer
It still has a crypt pattern!
■ Invasive gastric cancer
Impossible as it still has a crypt pattern!
explanation
Clearly there is a discrete nodule containing some small round crypt openings. If a dysplastic (mutated and genetically unstable) lesion produces a visible lesion, the pathologist calls it an 'adenoma'. Dysplasia in a flat mucosa is just called 'gastric dysplasia'. Of course in the colon there is a long established 'adenoma → carcinoma' sequence first proposed by Basil Morson a famous British pathologist. He estimated that about 2/3 colorectal cancer must be arising from an adenomatous precursor. What gives rise to the rest remained a disputed mystery until Jeremy Jass, another famous pathologists (and I really nice guy as I found, meeting him at a conference) proposed that serrated polyps may also give rise to cancer [Histopathology 2006;49:121-31]. His suggestion and data to support it, didn't really go anywhere for some 10 years but after he died in 2008 of glioma, the 'serrated pathway' to bowel cancer has become accepted.
Anyway, in the stomach things are even more complicated! There are at least 4 types of adenomas:
Of course, not every gastric polyp is adenomatous. Most are hyperplastic and look angrily red (because they have lots of capillaries) and often with white fibrin caps, making them look a little like mushrooms and may have a villiform surface reminisient of TVA's in the colon. Another common type are the 'Fundic gland polyps' which are full of cystic spaces and therefore look a little like frog-spawn. These usually develop in patients on PPI's but also in FAP. Polyps may also be hamartomatous as in 'Peutz-Jeghers syndrome', 'Cronkhite-Canada syndrome' and 'Juvenile polyposis'. By the way, the word 'Hamartomatous' implies that the polyp has arisen from overgrowth of multiple aberrant cell lineages rather than from a single, mutated precursor cell as in an adenoma. And then of course there are neuroendocrine tumours (NET's). A whole different thing which has a complete podcast dedicated to it. You can tell that a gastric polyp is a likely NET as they usually have little vessels crawling up it's sides. Finally, the lesion may be a gastric metastasis most commonly from breast, kidney, melanoma or HCC. By the way, there is a pitfall here as 'lobular breast cancer' mimics diffuse type gastric cancer. For this reason you should inform the pathologist if the patient has a history of breast cancer and you suspect a metastasis!
This polyp was found at the apex of the caecum. With some trepidation, a sample was obtained following which I requested the above CT
WHAT IS THE FINAL DIAGNOSIS ?
■ Hyperplastic polyp
Seems unlikely?
■ Inverted appendix
Was my very first thought too!
■ Adenoma
But I can't see a crypt pattern?!
■ Lymphoma
Why do you say that?
■ Mucocoele of the appendix
Was my diagnosis too and why I requested the CT!
explanation
I feel that I should apologise because it's almost impossible to make a diagnosis from the appearance of that appendix. The only abnormality, apart from it being there in the first place, is a subtle nodularity with a normal overlying mucosa. perhaps this rings a faint bell ???
Actually, it turns out that the submucosa is full of small lymphoid cells clusters, forming balls. This is the classical histological appearance of a Mantle Cell Lymphoma? Mantle cell lymphoma has a predilection for the GI tract as the most common extra-nodal site. Indeed, one study found lymphoma in mucosal biopsies in 56/60 patients (both in UGI and Lower GI tract). This has given rise to a theory that mantle cell lymphoma actually originate from gut B-lymphocytes within the mantle zones of mucosal lymphoid follicles [Cancer 2003;97(3):586–91]. Endoscopic findings includes nodules, polyps, ulcers, and masses. I try to remember Mantle Cell Lymphoma if the mucosa appears markedly bumpy - as if the lymphoid follicles have gone crazy! In this case, the CT shows lots of enlarged lymphnodes, both above and below the diaphragm and the patient was started on 'Ibrutinib'. It's not a 'good lymphoma' as median life expectancy is only 6-7 yrs. This was an incidental finding in the pharynx WHAT IS THE DIAGNOSIS?
■ Papilloma
Too large probably
■ Retention cyst
Absolutely right!
■ Small SCC
Smooth, round and without dilated IPCL's !?!
explanation
This is a 'Pharyngeal retention cyst'. It was an incidental finding and the patient had no symptoms relating to this. These are the most common benign lesions in the pharynx, usually arising behind the epiglottis (the area is called the valleculae) or more to the side as here. The cysts are thought to result from dilatation of mucus glands secondary to retained secretions and chronic inflammation. They are usually incidental findings although larger cysts (>1 cm) may cause dysphagia, coughing or dysphonia. Complications include ulceration and secondary infections.
Two EMR sites. The top in the duodenum and the bottom in the rectum
ARE THE SCARS 'CLEAN'?
■ Both sites look OK
No they don't!
■ Local recurrence in duodenum
You are half correct!
■ Local recurrence in duodenum
You are half right !
explanation
The teaching point behind these two images is the simple message that it's impossible to see a local recurrence with just 'white light'. You must assess the scars with NBI or dye sprye or both (I do)! In addition, remember that most local recurrences are to be find at the most 'difficult to see edge'. Perhaps you can only see a local recurrence in retrovertion?
In these particular cases both have a local recurrence (see below).
This polyp was found in the caecum.
WHAT'S THE LIKELY DIAGNOSIS?
■ Inverted appendix
The right shape but the wrong crypt pattern!
■ SSL
Absolutely, those crypts don't lie!
■ Adenomatous polyp
Wrong crypt pattern!
■ Likely underlying appendiceal tumour
Now, that's a wild guess!
explanation
I did hesitate for a moment as the lesion did, at first sight seem to arise from the caecal pole and was reminiscient of an inverted appendix (see below). However, on closer scrutiny, it has the typical wide-open crypts of a 'sessile serrated polyp' and wasn't actually that close the the caecal pole. It was removed without incidence after injecting some saline below.
Monz found this lesion in the terminal ileum. WHAT IS THE MOST LIKELY DIAGNOSIS?
■ Hyperplastic polyp
Nope, those are very rare in TI
■ Adenomatous polyp
Uncommon in TI and there are no adenomatous crypts!
■ Neuroendocrine tumour
Perhaps the most common lesion in TI with those typical little vessels!
■ Small leiomyoma
Could be but those little vessels say otherwise
■ Small GIST
Must exist but I've never seen one!
explanation
At diagnostic colonoscopies, I do try to intubate the terminal ileum. Not to 'practise' but to detect pathology such as this rare lesion at an early stage! These do have a real malignant potential and in fact usually present late with bowel obstruction.
The tell-tale sign are those tiny vessels climbing up around the edges of the polyp and the pale appearance. Of course, this is a terminal ileal NET! The lesion was removed by Monz Ahmed and histology confirmed that it was an NET. Of course, the MOST IMPORTANT issue is the WHO Grade of the lesion. This is because small bowel NET's (excluding the duodenum) are often malignant. The lesion was WHO Grade I (i.e. 1-2% mitotic figures only) which is reassuring but a CT is probably still warranted to look at those nearby lymphnodes. By the way, in the histology below, you can see how close the lesion is on the abutting deep edge. This is the common finding after your endoscopic removal and can be disconcerting. Studies have reported that if you resect lesions using a 'banding device' you can usually get a confirmed (but shallow) clear deep margin. However, neither Monz or I would use a banding device in the terminal ileum. The muscle propria layer is too thin and you are likely to end up with a full thickness resection if you tried. 'Banding resections' are probably best reserved for the oesophagus, stomach or colorectum! This lesion was found in the antrum. The histology is also attached. WHAT IS THE LIKELY DIAGNOSIS?
■ Hyperplastic polyp
Would be red with white caps!
■ Adenomatous polyp
Yes and histology confirms HGD only
■ Superficial gastric cancer
Could be but histology is benign...
explanation
Most EGC's look a little like basal cell carcinomas with an elevated rim surrounding a central depression. This is a good example of what an EGC could look like. As it happens though, it only harbours HGD. Because you can't really tell endoscopically (the pathologists struggled as well to make a distinction sometimes) There are more than one type of 'gastric adenoma':
This was reported as an intestinal type adenoma harbouring HGD !
This duodenal lesion was an incidental finding in a 55 year old patient with dyspepsia.
WHAT IS THE LIKELY DIAGNOSIS?
■ GIST
Could be but something else is more likely
■ Leiomyoma
These are rare in the duodenum!
■ NET
Yes, most duodenal NET's are umbilicated!
■ Adenoma
Duodenal adenomas are often IIc lesion but not like this!
■ Carcinoma
Too pretty to be malignant!
explanation
Umbilicated lesions in the duodenum are usually NET's. Even when the NET is as small as 7-8mm they will usually start to develop a central dimple as in the example below !
Ampullary NET's have a far worse prognosis than NET's situated elsewhere in the duodenum and are therefore first considered for a surgical resection. However, a small non-functioning, non-ampullary NET's may be considered for endoscopic resection.
I don't think that I was thinking entirely clearly when I accepted the referral from the Neuroendocrine 'multi-disciplinary team' for an attempt at endoscopic resection. The lesion is about 2cm and I quoted a 1:10 risk of requiring an emergency surgery in case of a perforation. This was probably an underestimate because NET's develop in the submucosa and you almost have to scrape them off the muscle propria layer which is VERY thin in the duodenum. Furthermore, I think that a small unrecognised 'micro-perforation' in the stomach is probably often 'sorted out' by a timely intervention by our great friend - the omentum! The duodenum on the other hand is retro-peritoneal and bathing in pancreatic juices. After 12 hours, that 1mm perforation will be 1 inch across and the patient will be in a desperate state. For this reason, if you do undertake duodenal resections you should be backed up with a 24-hour/day 364 day/year specialised pancreatic emergency surgery service. It's no good having an breast surgeon trying to patch things up! Now being an older and more experienced endoscopist, I believe that a far more sensible cut-off for endoscopic resection of a duodenal NET is probably 10-15mm. Personally, in an old person with comorbidities, who are unlikely to survive an emergency laparotomy, I would decline if I thought that the risk of emergency surgery was <1:100. Of course the NET could grow but is unlikely to turn malignant and kill an 85 year old patient with a previous myocardial infarction and dodgy kidney function. Particularly if the lesion is 'WHO grade is 1' only ! Of course Rembackens Resection Rule #15 applies: "A good endoscopist knows when to resect and a great endoscopist when to reassure! Also known as "Disengage if there is Disease".
This red patch was noted in the transverse colon. You take samples and after the examination, the patient asks you what will happen next?
WHAT WILL YOU REPLY?
■ It's probably nothing
This is SOMETHING!
■ It will probably need to be resected endoscopically
Its a TA+HGD which had to be removed by ESD
■ It will probably need to be resected surgically
Now, that would be 'overkill' !
explanation
Just found another colonic lesion demonstrating the pillow sign.
WHAT IS THE DIAGNOSIS?
■ Lipoma
Doesn't it look translucent?
■ Lymphangioectactic cyst
Yes! Pillow sign + semi-translucent = cyst
■ Phlebectasia
A dilated vein? Nope!
■ Blue rubber naevus syndrome
The naevi are dark and firm!
■ Lymphangiosarcoma
Should then have a large solid component
explanation
Just when I'd say that all lesions exhibiting the 'pillow sign', I realised that the exception are 'lymphangioectatic cysts' (lymphangiomas) !
These are thought to be developmental malformations which can be found anywhere in or on the body. Of course they are entirely harmless. In fact the only harm they cause is by being poked about! There has been a reported case of peri-colic abscess formation following biopsy [Krishna SG, Endoscopy. 2012;44(Suppl 2 UCTN):E104–5]. Therefore, either biopsy or a 'de-roofing EMR' should probably be avoided. The best way to confirm the diagnosis, if it's in doubt is by EUS. It will show several cystic spaces confined to the submucosa and without any nearby nodes. There have been reports of lesions presenting with abdominal pain, and when pedunculated endoscopic resection may be possible [Case Rep Gastroenterol. 2017 Jan-Apr; 11(1): 178–183]. Must admit that I remain a little sceptical. Each case would have to be assessed on its own merit I guess ! This 70 year old gentleman presented with PR bleeding and mucus. WHAT IS THE DIAGNOSIS?
■ Rectal prolapse
Nope, doesn't look like this!
■ Active proctitis
Seriously? How long have you been scoping?
■ Solitary rectal ulcer syndrome
SRUS can look almost like anything but not like this!
■ Rectal adenoma
Yes, to be specific it's a villous adenoma!
■ Rectal carcinoma
That polyp is big but not ugly!
explanation
Perhaps something of a 'noddy' question as any endoscopists worth his salt should recognise this as a large villous adenoma. However, many endoscopists would not see beyond the sheer size of the lesion and conclude that the lesion must be malignant SOMEWHERE! The truth is that it's precisely because the lesion is inherently innocent that it has grown to this size WITHOUT turning malignant! So how to deal with it? An endoscopic resection would include a circumferential resection for about 12cm, starting at the anal verge. There are several options; ■ Perhaps you could remove it in sections? For example, removing a quarter and then bring the patient back after a few month to do another section? I've tried it! Sadly, they grow back so quickly that by the time the patient returns, it has already re-grown to recover the previously cleared surface ! ■ Perhaps you could use APC, not to clear the lesion but to reduce the amount of blood-stained mucus it produces? I've tried that too!!! Unfortunately, APC tends to make the mucus production worse !!! ■ There is one more thing which I have learnt with large villous adenomas like this. They tend not to lift very well! As the lift is always 'shallow', you end up with a very narrow submucosal window to dissect through. Similarly, a piecemeal EMR is almost impossible unless the VA is much smaller. ■ The only thing which we haven't tried in Leeds is a joint effort whereby 2-3 endoscopists take it in turns to dissect the lesion over a 8-10 hour period, perhaps under GA. A daunting prospect and I doubt that it's actually feasible. Naturally, a TEMS procedure is similarly unlikely to succeed and the patient is probably most likely to wake up without a rectum at all. However, loosing the rectum to benign disease at the age of 75 would be a bitter pill. Perhaps that's why most choose to put up with the mucus ?
Three colonic polyps to choose between !
WHICH IS THE MOST SUSPICIOUS?
■ A
I agree! Looks like cancer!
■ B
Looks too pretty to be evil !
■ C
On size criteria, the risk is probably about 1:7
explanation
B has a lovely brain-like crypt pattern of a rather pretty TVA. Of course, C is difficult to assess as the surface crypt pattern may not reflect was is lurking deep inside. Data from the NHS Bowel Cancer Screening Programme (see table below) puts the risk of cancer in a >45 mm at 15%. For this reason, the polyp should be removed in as few fragments as possible.
However, A is the polyp which I think looks most suspicious. It has a suspicious central nodule and on the NBI image (top-right), I don't see an organised crypt pattern in parts of the polyp. This is a superficially invasive cancer which was just invading into the muscular mucosa (sm1 invasion)! it lifted well enough for a resection. Again single fragment resection would be paramount when removing this polyp. Below is a table which I received from Matt Rutter a few years ago. It links size with histology for polyps resected on the NHS Bowel Cancer Screening Programme |
Categories
All
|