Sm.all Colon Polyps: The Prbnary J Am Board Fam Pract: first published as 10.3122/jabfm.2.3.204 on 1 July 1989. Downloaded from Physician's DilelllIna Jaydev R. Varma, M.D., and Richard E. Melcher, M.D.

Abstract: This case report and literature review is with a significant malignant potential, there is no presented to alert primary care physicians perform­ way to distinguish them visually; hence, all need to ing flexible sigmoidoscopy and limited colonoscopy . be biopsied. The following case report shows the ne­ to the malignant potential of even diminutive polyps. cessity of identifying neoplastic lesions within di­ The term "polyp" refers to any circumscribed mass minutive polyps « 1 em). Standard biopsy tech­ of tissue that arises from mucosa and protrudes into nique usually removes these lesions; nevertheless, the lumen of the gastrointestinal tract. The signifi­ when histology confirms the presence of adenoma or cance of this lesion in the rectum and colon is its carcinoma, the patient requires additional evaluation propensity for malignant change. Although small of the entire large intestine and more frequent fol­ polyps in the region of the rectum tend to be hyper­ low-up examinations. (1 Am Bd Fam Pract 1989; plastic and those more proximal tend to be adenomas 2:204-7.)

A 44-year-old white man came for a routine phys­ and was identified as an adenomatous polyp with ical examination at the Family Practice Center of atypical hyperplasia and mitotic activity consis­ the Medical College of Georgia. The patient had tent with early adenocarcinoma (Figure 3). The been treated for essential hypertension for 7 years patient was treated definitively with segmental and currently was well controlled with a single surgical resection of the colon. The following are agent. He was asymptomatic, and his family history his surgical and pathology reports: was negative for cancer. His physical examination showed him to be well-developed and well-nourished. Although Surgery fundoscopic examination revealed early vascular The patient had previous removal of an adenoma­ changes consistent with hypertension, no other tous polyp with carcinoma within the polyp at manifestations of disease were found. Complete 23-27 cm. The sigmoid was initially taken out blood count, SMA -18 TM, and electrocardiogram

and submitted to pathology in a fresh state. The http://www.jabfm.org/ were all unremarkable, and the stool was guaiac polypectomy site was not found. Further explora­ negative. Screening flexible sigmoidoscopy was tion distally down to below the peritoneal reflec­ suggested and performed 6 days later at the Cen­ tion to the midrectum was accomplished, and this ter. Following routine preparation, the rectum segment was resected, revealing a small area of and colon were examined to a distance of 60 cm ulceration, which appeared to be the biopsy site. without difficulty. A single sessile lesion estimated No other abnormalities were noted; the peritoneal at 5 to 6 mm was located at 25 cm. Although the cavity was smooth and glistening; the liver was on 30 September 2021 by guest. Protected copyright. lesion was less than 1 cm in size, it exhibited a free of palpable abnormality, and there was no "thin red zone" at its base, an abnormality not evidence of any mesenteric adenopathy or per­ usually found with hyperplastic polyps (Figures 1, iaortic adenopathy. Discharge diagnosis was ade­ 2). This finding should alert one to the presence of nomatous polyp with carcinoma in the polyp and an adenoma, even before biopsy, in circumstances colon, probable Duke's stage-A carcinoma of the like this. The patient was referred for colonoscopy. colon. Complete colonoscopy confirmed the presence of the single lesion, and a biopsy was performed. The tan mucoid lesion was 0.6 x 0.5 x 0.4 cm Pathology Biopsy of Small Polyp during Colonoscopy From the Department of Family Medicine. Medical College A tan mucoid lesion: 0.6 x 0.5 x 0.4 cm with of Georgia. Augusta. GA. Address reprint requests to Jaydev R. Varma. M.D .• Department of family Medicine. EG 226. Medi­ atypical hyperplasia and mitotic activity consis­ cal College of Georgia. Augusta. GA 30912-3520. tent with early adenocarcinoma.

204 The Journal of the American Board of Family Practice-Vol. 2 No. 3 / July - September 1989 1 I

~-- J. J Am Board Fam Pract: first published as 10.3122/jabfm.2.3.204 on 1 July 1989. Downloaded from

Figure 1. Small polyp surrounded by a red zone at the Figure 2. Black arrow: small polyp with red zone at base. the base; clear arrow: normal mucosa.

Specimen: Segments of Sigmoid Colon, Part A these crypts. The cells then migrate upward to the and Part B surface and differentiate into mature goblet and Part A. Representative sections are examined mi­ absorptive cells. croscopically. This includes a section of the small Under normal circumstances, cell divi ion and hyperplastic polyp noted grossly. A random sec­ exfoliation occur as well-balanced phenomena. tion of colonic mucosa is unremarkable. A protrusion or polyp results when factors dis­ Part B. Multiple representative sections are ex­ turbing this balance in favor of cell division oc­ amined microscopically. This consists of sections cur. 5,6 Most of these polyps are minute hyper­ of colon showing an intact mucosal surface. There plastic dewdrop-like elevations ranging from 1 http://www.jabfm.org/ is underlying vascular congestion and hyperemia. to 5 mm. Ninety percent of these polyps are said This is probably related to the surgical procedure. to be hyperplastic and 10 percent adenoma­ No definite previous excision site is identified mi­ toUS. 2 ,5-B The frequency of polyps (nonjuvenile) croscopically or grossly. is variable, and they are estimated to occur in 25

Discussion on 30 September 2021 by guest. Protected copyright. Although the adenomatous polyp in this case was • less than 0.7 cm, early adenocarcinoma was iden­ tified histologically, showing the need for defini­ tive treatment. While individual polyp size and the degree of dysplasia are important determi­ nants of the potential for malignant change, even the smallest lesions may have neoplastic potential. Understanding the differences between hyper­ plastic polyps and adenomatous polyps is essen­ tial to this discussion. Microscopically, the mucosal surface of the nor­ mal colon is flat and consists of simple, test-tube­ shaped glands called crypts of Lieberkuhn. 1- 5 Cell Figure 3. Arrow showing area of severe dysplasia sug­ division occurs mainly in the deepest one-third of gestive of intra mucosal carcinoma.

Small Colon Polyps 205 J Am Board Fam Pract: first published as 10.3122/jabfm.2.3.204 on 1 July 1989. Downloaded from to 50 percent of adults, with the frequency in­ and he suggested a relationship between the creasing with age.6 •7 epithelia of the two types of polypS.16 He cited These adenomas range from a few millimeters properties common to hyperplastic and villous ad­ to several centimeters, occur in all shapes, and are enomas, including reduced cytoplasmic enzymes, either pedunculated or sessile. The lesions are reduced secretion of O-acetylated sialomucin, ab­ usually noninvasive and considered to be benign. sence of IgA secretion, and increased CEA activ­ However, they are neoplastic; hence, there is a ity. 3 He proposed two sets of phenomena affecting serious disturbance in cellular proliferation that is alteration of colonic epithelium: one set leading to unrestricted. Therefore, cell differentiation is in­ hyperplasia, the other set to neoplasia. However, complete, and malignant potential exists.4,8·1o In both sets contribute to malignancy. These phe­ removing adenomas at colonoscopy, strict criteria nomena might explain the occurrence of mixed ll l3 need to be followed. · hyperplastic-neoplastic polyps. 17 To the naked eye, there is no distinction be­ Waye and associates reported on 1048 polyps tween the hyperplastic and neoplastic polyp.l0 less than 6 mm that were removed during colon­ Without biopsy, the diagnostic and treatment di­ oscopy.18 Of these, 61 percent (638) were neo­ lemma is self evident. Improvements in the tech­ plastic, 38.9 percent (407) were nonneoplastic, nology of endoscopy have generated greater inter­ and 212 were hyperplastic, with 188 mucosal est in flexible sigmoidoscopy screening by primary excrescences. They recommended removal of all care physicians. The detection and identification small colonic polyps encountered during colonos­ of larger adenomas (greater than 1 em) present copy in view of their potential for malignant less difficulty in management because their malig­ change. nant potential is directly related to increasing Tedesco reported on 329 diminutive polyps. 1 In size.8.)4 The dilemma arises when lesions are this study, 49.2 percent were neoplastic, while smaller than 1 em, because the actual frequency of 49.9 percent were nonneoplastic and 0.9 percent neoplasia in small colonic polyps is much higher were of a mixed type. Lane found 90 percent of than previously acknowledged.8 Small lesions polyps to be hyperplastic and 10 percent to be with any color changes should alert the physician adenomatous.2 Lane and Fenoglio published a re­ that neoplastic vascularity often warrants the pre­ port wherein they stated, "The common hyper­ sumptive diagnosis of adenoma. plastic polyp is not a neoplasm and is unrelated to Feczko and others have reported on 222 polyps either adenoma or carcinoma," and foci of carci­ of which 144 (65 percent) were 1 cm or less.8 noma or adenoma are (almost) never found in Eighty percent of these were adenomatous. these lesions. 19 Eighty-two polyps ranged from 6 to 10 mm, and Morson and Konishi also indicated that there is http://www.jabfm.org/ 68 (83 percent) of them were adenomas, includ­ no acceptable evidence that hyperplastic polyps ing one adenocarcinoma and five villous ade­ have any malignant potential.20 nomas. Forty-seven of the diminutive polyps Maskens, after a detailed histologic study, (~5 mm) were adenomatous, including two with concluded that the hyperplastic polyp was a sepa­ atypia.8 Church and others have reported on the rate pathologic entity and has no malignant histology of small colonic polyps, less than 0.5 cm, potentiaL 21 on 30 September 2021 by guest. Protected copyright. in a series of 303 patients. 15 Seven hundred sixty­ In Gottlieb's study of 1124 diminutive polyps six polyps were removed, and 458 (60 percent) (0;;;5 mm), there were 572 (51 percent) adenomas, were adenomas, and 308 (22 percent) were hyper­ 179 (16 percent) that were hyperplastic, and 373 plastic. They suggested that lesions of this size are (33 percent) either lipomas, normal mucosa, or rarely symptomatic and are often followed too con­ other. He indicated that the diminutive polyp servatively after discovery. The report further stated should be considered part ofthe adenoma-dyspla­ that small colorectal polyps comprise approximately sia -adenocarcinoma continuum.22 50 percent of all polyps. Although small rectal pol­ yps tend to be hyperplastic, correct diagnosis cannot be made on gross inspection,1O and biopsy of these Conclusion smaller lesions is, therefore, important to identify In the midst of conflicting findings, the primary neoplastic potential histologically. care physician, who is increasingly performing Jass recently questioned whether hyperplastic sigmoidoscopies and limited colonoscopies, en­ polyps should ever be considered insignificant, counters these diminutive lesions and is faced

206 The Journal of the American Board of Family Practice-Vol. 2 No. 3 / July - September 1989 J Am Board Fam Pract: first published as 10.3122/jabfm.2.3.204 on 1 July 1989. Downloaded from with the decision of proper management. It is pru­ 9. Cooper HS. Patchefsky AS. Marks G. Adenoma­ dent to observe the view that although diminutive tous and carcinomatous changes within hyper­ plastic colonic epithelium. Dis Colon Rectum polyps in the region of the rectum tend to be 1979; 22: 152-6. hyperplastic and those more proximal tend to be 10. Neale AV. Demers RY. Budev H. Scott RO. Physi­ adenomas, there is no way to differentiate them cian accuracy in diagnosing colorectal polyps. Dis visually.6.9,IB Lesions up to 1.0 cm, formerly Colon Rectum 1987; 30:247-50. thought to be "safe," should be considered for II. Decosse JJ. Malignant colorectal polyp. Gut 1984; 25:433-6. biopsy. When pathology reports neoplastic tissue, 12. Morson BC. Whiteway JE, Jones EA. Macrae FA, further evaluation of the entire colon is indicated. Williams CB. Histopathology and prognosis of rna­ The patient is then identified as being high risk for lignant colorectal polyps treated by endoscopic colorectal cancer. Evaluation for complete poly­ polypectomy. Gut 1984; 25:437-44. pectomy and detection of recurrence are indicated. 13. Winawer SF, Sherlock P. Surveillance for colorec­ tal cancer in average-risk patients, familial high­ risk groups. and patients with adenomas. Cancer 1982; 50(Suppl):2609-14. References 14. Lotfi AM. Spencer RJ. Ilstrup DM, Melton W, 3d. I. Tedesco FJ, Hendrix JC, Pickens CA, Brady PG. Colorectal polyps and the risk of subsequent carci­ Mills LR. Diminutive polyps: histopathology. spa­ noma. Mayo Clin Proc 1986; 61:337-43. tial distribution, and clinical significance. Gas­ 15. Church JM. Fazio VW. Jones IT. Small colorectal trointest Endosc 1982; 28: 1- 5. polyps. Are they worth treating? Dis Colon Rec­ 2. Lane N. Kaplan H. Pascal RR. Minute adenoma­ tum 1988; 31:50-3. tous and hyperplastic polyps of the colon: diver­ 16. Jass JR. Relation between metaplastic polyp and gent patterns of epithelial growth with specific as­ carcinoma of the colorectum. Lancet }983; 1: sociated mesenchymal changes. Contrasting roles 28-30. in the pathogenesis of carcinoma. Gastroenterol­ 17. Fenoglio-Preiser CM. Hutter RV. Colorectal pol­ ogy 1971; 60:537-51. yps: a pathologic diagnosis and clinical signifi­ 3. Dawson PM. Habib NA. Rees HC. Wood CB. Mu­ cance. CA 1985; 35:322-44. cosal field change in colorectal cancer. Am J Surg 18. Waye JD. Lewis BS. Frankel A. Geller SA. Small 1987; 153:281-4. colon polyps. Am J Gastroenterol 1988; 83: 120-2. 4. Matthews JL, Glynn M. Parkins A. Cooke T. Alter­ 19. Lane N. Fenoglio CM. Observations on the adeno­ ation in colonic epithelia cell DNA associated with ma as precursor to ordinary large bowel carcino­ intestinal neoplasia: selection of high risk patients. ma.. Gastrointest Radiol 1976; 1: 111-9. BrJ Surg 1987; 74:23-5. 20. Morson BC, Konishi F. Contribution of the 5. Fenoglio CM. Pascal RR. Colorectal adenomas and pathologist to the radiology and management of cancer: pathologic relationships. Cancer 1982; colorectal polyps. Gastrointest Radiol 1982; 7: 50(Suppl):2601-8. 275-81. 6. Fenoglio CM. Lane N. The anatomical precursor of 21. Maskens AP. Histogenesis of adenomatous polyps http://www.jabfm.org/ colorectal carcinoma. Cancer 1974; 34:819-23. in the human large intestine. Gastroenterology 7. Fedotin MS, Ginsberg DW. Practical consider­ 1979; 77: 1245-51. ations in screening for colorectal cancer. Mod Med 22. Gottlieb LS, Winawer SJ. Sternberg S. et al. Na­ 1988; 56:127-35. tional polyp study (NPS): the diminutive colonic 8. Feczko PJ. Bernstein MA. Halpert RD, Ackerman polyp. Mallory Institute ofPatho!ogy. Boston: Me­ LV. Small colonic polyps: a reappraisal of their morial Sloan-Kettering Cancer Center 1984; significance. Radiology 1984; 152:301-3. 30(2). abstract. on 30 September 2021 by guest. Protected copyright.

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