Zaman 1-7-07 Gi-5 Colonic Neoplasms

Front 1

Normal mucosa looks like test tubes in _____

Back 1

a rack

Front 2

A normal variation of colonic mucosa are what kind of "grooves"

Back 2

innominate

Front 3

A normal variation of colonic mucosa appear as ployps endoscopically

Back 3

lymphoid aggregate

Front 4

polyps that do not have malignant potential

Back 4

•hamartomatous polyps
•and hyperplastic polyps.

Front 5

Give two types of hamartomous polyps

Back 5

•Juvenile (Retention) Polyps
•Peutz-Jegher's Polyps

Front 6

what are "juvenile polyps" called in adults

Back 6

retention polyps

Front 7

Juvenile Polyps are composed of colonic mucosa
containing cystically dilated glands. lnflammation is
often seen in the ______ _______.

Back 7

Juvenile Polyps are composed of colonic mucosa
containing cystically dilated glands. lnflammation is
often seen in the lamina propria.

Front 8

Peutz-Jegher's Syndrome:.
•An autosomal ________ syndrome in which
patients develop multiple P-J polyps in small
intestine +/-colon +/-stomach.
•These patients also develop cutaneous and
mucosal p____________ (perioral, palmar, oral
mucosa & external genitalia).
•Patients with PJ syndrome are at an increased risk
of developing carcinomas of the breast, lung,
pancreas, and gynecologic tract, and may develop
GI carcinoma from concomitant intestinal
adenomas

Back 8

Peutz-Jegher's Syndrome:.
•An autosomal dominant syndrome in which
patients develop multiple P-J polyps in small
intestine +/-colon +/-stomach.
•These patients also develop cutaneous and
mucosal pigmentation (perioral, palmar, oral
mucosa & external genitalia).
•Patients with PJ syndrome are at an increased risk
of developing carcinomas of the breast, lung,
pancreas, and gynecologic tract, and may develop
GI carcinoma from concomitant intestinal
adenomas

Front 9

• P-J polyps are large and pedunculated.
•Sporadic polyps occur singly
•Pathology: composed of mucosa containing
convoluted crypts along a b________ framework
of fibrous tissue and smooth muscle.

Back 9

• P-J polyps are large and pedunculated.
•Sporadic polyps occur singly
•Pathology: composed of mucosa containing
convoluted crypts along a branching framework
of fibrous tissue and smooth muscle.

Front 10

• ____________ polyps are small, common. usually
asymptomatic polyps.
• They are most often found in patients in their 6-7th decades.
• 80% of ____________ polyps occur in the rectum or sigmoid
colon.
• They arise due to delayed shedding of surface epithelial cells,
which results in crowding and infoldings of crypt epithelium.

Back 10

• Hyperplastic polyps are small, common. usually
asymptomatic polyps.
• They are most often found in patients in their 6-7th decades.
• 80% of hyperplastic polyps occur in the rectum or sigmoid
colon.
• They arise due to delayed shedding of surface epithelial cells,
which results in crowding and infoldings of crypt epithelium.

Front 11

Hyperplastic Polyps

Pathology:

• The colonic crypts have ________ (serrated) luminal
contours.
• There is no adenomatous/ dysplastic change of the
epithelium.

Back 11

Hyperplastic Polyps

Pathology:

• The colonic crypts have sawtooth (serrated) luminal
contours.
• There is no adenomatous/ dysplastic change of the
epithelium.

Front 12

Hyperplastic polyp loses the test tube in a rack look. The test tubes instead look how?

Back 12

twisted

Front 13

Adenomas are precursors of ______________. These polyps
are very common with a prevalence of 40-50% after age 60.

Back 13

Adenomas are precursors of adenocarcinoma. These polyps
are very common with a prevalence of 40-50% after age 60.

Front 14

Patients with one ___________ polyp are at increased risk
of developing other adenomas or carcinomas of the colon.

Back 14

Patients with one adenomatous polyp are at increased risk
of developing other adenomas or carcinomas of the colon.

Front 15

________ adenomas are the most common type of
adenoma.

Back 15

•Tubular adenomas are the most common type of
adenoma.

Front 16

Tubular adenoma:

•By definition more than __% the polyp has a
tubular architecture (less than 25% villous).

Back 16

Tubular adenoma:

•By definition more than 75% the polyp has a
tubular architecture (less than 25% villous).

Front 17

Tubulovillous adenoma:
• Mucosal polyp which contains both tubular glands
and areas with villous '______like' surface
projections in same polyp.
•The epithelium shows adenomatous changes.
•By definition, these polyps have 25-50% villous
architecture, and the Tubular adenoma rest is
tubular.

Back 17

Tubulovillous adenoma:
• Mucosal polyp which contains both tubular glands
and areas with villous 'fingerlike' surface
projections in same polyp.
•The epithelium shows adenomatous changes.
•By definition, these polyps have 25-50% villous
architecture, and the Tubular adenoma rest is
tubular.

Front 18

Villous adenoma:
•Mucosal polyps containing villous '______like'
projections of mucosa lined by adenomatous
epithelium along the luminal surface.
•Villous adenomas are the _____ common type of
adenoma.
•Large polyps are often sessile.
• By definition, more than __% of the architecture is
villous.

Back 18

Villous adenoma:
•Mucosal polyps containing villous 'fingerlike'
projections of mucosa lined by adenomatous
epithelium along the luminal surface.
•Villous adenomas are the least common type of
adenoma.
•Large polyps are often sessile.
• By definition, more than 50% of the architecture is
villous.

Front 19

Adenomatous Polyposis
Syndromes
•1.C_____’s syndrome
•2. Familial Adenomatous Polyposis [FAP]
(Familial Polyposis Coli)
•3. G______'s Syndrome
•4. T_____'s Syndrome

Back 19

Adenomatous Polyposis
Syndromes
•1.Cowden’s syndrome
•2. Familial Adenomatous Polyposis [FAP]
(Familial Polyposis Coli)
•3. Gardner's Syndrome
•4. Turcot's Syndrome

Front 20

Hereditary Nonpolyposis Colorectal Cancer
(_____) Syndrome

Back 20

Hereditary Nonpolyposis Colorectal Cancer
(Lynch) Syndrome

Front 21

Polyposis syndromes – Cowden’s
•Autosomal dominant
•10q23 (same as MEN II – MEN I 11q13)
•9q22.3
•Hamartomas/Juvenile polyps/Inflammatory
•Entire GI tract (no malignant potential)
•Increased risk of breast, thyroid CA
•Multiple facial ______lemommas
•Oral mucosal papillomas
•Lipomas, hemangiomas
35

Back 21

Polyposis syndromes – Cowden’s
•Autosomal dominant
•10q23 (same as MEN II – MEN I 11q13)
•9q22.3
•Hamartomas/Juvenile polyps/Inflammatory
•Entire GI tract (no malignant potential)
•Increased risk of breast, thyroid CA
•Multiple facial trichilemommas
•Oral mucosal papillomas
•Lipomas, hemangiomas
35

Front 22

Adenomatous Polyposis
Syndromes :
•Caused by a mutation of tumor suppressor
("gate______") gene "___" (Adenomatous Polyposis
Coli )on 5q21.
•All are autosomal dominant, except ______'s
syndrome which is autosomal recessive.
•Patients with these syndromes develop
adenomatous polyps in 2-3rd decades.

Back 22

Adenomatous Polyposis
Syndromes :
•Caused by a mutation of tumor suppressor
("gatekeeper") gene "APC" (Adenomatous Polyposis
Coli )on 5q21.
•All are autosomal dominant, except Turcot's
syndrome which is autosomal recessive.
•Patients with these syndromes develop
adenomatous polyps in 2-3rd decades.

Front 23

[FAP] (F_______ P________ C___):
•Patients with classic FAP develop 100-2500
adenomatous polyps of the colon +I-polyps in the
rest of the GI tract.
•A minimum of 100 adenomas is needed for
diagnosis.
•The frequency of developing colon cancer in FAP
patients is close to 100% by age 40 if not treated
with prophylactic _________.
•Attenuated FAP patients develop fewer polyps
(average 30) usually in the right colon and have a
lower cancer risk.

Back 23

[FAP] (Familial Polyposis Coli):
•Patients with classic FAP develop 100-2500
adenomatous polyps of the colon +I-polyps in the
rest of the GI tract.
•A minimum of 100 adenomas is needed for
diagnosis.
•The frequency of developing colon cancer in FAP
patients is close to 100% by age 40 if not treated
with prophylactic colectomy.
•Attenuated FAP patients develop fewer polyps
(average 30) usually in the right colon and have a
lower cancer risk.

Front 24

A variant of FAP syndrome with osteomas,
epidermal cysts, fibromatoses, dental abnormalities,
and a high frequency of duodenal adenomas/
cancer and thyoid cancer.

Back 24

Gardner's Syndrome:

Front 25

A variant of FAP syndrome + gliomas of the CNS.

Back 25

Turcot's Syndrome:

Front 26

HNPCC (______) Syndrome:
•An autosomal dominant familial syndrome due to a
mutation in one of four DNA mismatch repair genes
(MSH2, MLHI. MSH6. PMSI, PMS2) which
'proofread' DNA during DNA replication.
•This mutation leads to microsatellite instability.
•The patients with this syndrome tend to develop
adenomas at an earlier age than general population
and tend to develop multiple colon cancers that are
often not associated with a pre-existing ____oma.
•Patients are also at increased risk for extraintestinal
cancers such as __________ carcinoma.

Back 26

HNPCC (Lynch) Syndrome:
•An autosomal dominant familial syndrome due to a
mutation in one of four DNA mismatch repair genes
(MSH2, MLHI. MSH6. PMSI, PMS2) which
'proofread' DNA during DNA replication.
•This mutation leads to microsatellite instability.
•The patients with this syndrome tend to develop
adenomas at an earlier age than general population
and tend to develop multiple colon cancers that are
often not associated with a pre-existing adenoma.
•Patients are also at increased risk for extraintestinal
cancers such as endometrial carcinoma.

Front 27

Colorectal Adenocarcinoma:
•Epidemiology:
•Most cancers of the colon are _______________.
•Colon carcinoma is the ______ most common cause
of cancer deaths in the U.S. (after ____ cancer).
• Colon cancer most commonly occurs in patients
between 60-79 years old.
•There is a very high prevalence in US., Canada,
Europe, and Australia, with much lower incidence
of colon cancer in Japan, South America and Africa.
•Environmental and dietary factors may account for
some of the geographic differences in incidence.

Back 27

Colorectal Adenocarcinoma:
•Epidemiology:
•Most cancers of the colon are adenocarcinomas.
•Colon carcinoma is the second most common cause
of cancer deaths in the U.S. (after lung cancer).
• Colon cancer most commonly occurs in patients
between 60-79 years old.
•There is a very high prevalence in US., Canada,
Europe, and Australia, with much lower incidence
of colon cancer in Japan, South America and Africa.
•Environmental and dietary factors may account for
some of the geographic differences in incidence.

Front 28

Colonic (Colorectal)
Adenocarcinoma:
•Distribution of disease in colon:
•____ colon cancers tend to be annular lesions
causing "______ ring" constrictions and causing
symptoms of obstruction.
•_____ colon cancers tend to be ______ing masses
along one wall and become symptomatic later.
• Colon carcinomas at any site often cause bleeding
& anemia.

Back 28

Colonic (Colorectal)
Adenocarcinoma:
•Distribution of disease in colon:
•Left colon cancers tend to be annular lesions
causing "napkin ring" constrictions and causing
symptoms of obstruction.
•Right colon cancers tend to be fungating masses
along one wall and become symptomatic later.
• Colon carcinomas at any site often cause bleeding
& anemia.

Front 29

moderately differentiated adenocarcinoma
"looks really ____"

Back 29

moderately differentiated adenocarcinoma
"looks really blue"

Front 30

Poorly differentiated adenocarcinoma
"looks like a ____"
"looks more like a ____oma"

Back 30

Poorly differentiated adenocarcinoma
"looks like a mass"
"looks more like a sarcoma"

Front 31

I___________ Adenocarcinoma:
• The neoplastic glands invade into the lamina
propria (but not deeper). With this lesion there is
still little or no metastatic potential.

Back 31

Intramucosal Adenocarcinoma:
• The neoplastic glands invade into the lamina
propria (but not deeper). With this lesion there is
still little or no metastatic potential.

Front 32

Severe dysplasia /Carcinoma in Situ:
•The dysplastic/adenomatous epithelium shows
marked cytologic atypia and a complex back- to-
back glandular proliferation.
•Since there is no invasion of the lamina propria,
there is no possibility of __________.

Back 32

Severe dysplasia /Carcinoma in Situ:
•The dysplastic/adenomatous epithelium shows
marked cytologic atypia and a complex back- to-
back glandular proliferation.
•Since there is no invasion of the lamina propria,
there is no possibility of metastases.

Front 33

I_______ Adenocarcinoma:
•The neoplastic glands invade into the
Adenocarcinoma in situ submucosa or beyond
and have metastatic potential.

Back 33

Invasive Adenocarcinoma:
•The neoplastic glands invade into the
Adenocarcinoma in situ submucosa or beyond
and have metastatic potential.

Front 34

_____ is the classification of extent of tumor spread at the time
of diagnosis. _____ is the most important prognostic factor in
colon carcinoma.

Back 34

Stage is the classification of extent of tumor spread at the time
of diagnosis. Stage is the most important prognostic factor in
colon carcinoma.

Front 35

• Tis Carcinoma in situ or intramucosal adenocarcinoma
• T1 Invasion into _________
• T2 Invasion into __________ propria;
• T3 Invasion through muscularis propria into _________
• T4 Invasion into other organs or perforates visceral
peritoneum
- NX = lymph nodes not identified
• N0 regional lymph nodes negative
• N1 metastases in 1-3 lymph nodes
• N2 metastases in 4 or more lymph nodes

Back 35

• Tis Carcinoma in situ or intramucosal adenocarcinoma
• T1 Invasion into submucosa
• T2 Invasion into muscularis propria;
• T3 Invasion through muscularis propria into subserosa
• T4 Invasion into other organs or perforates visceral
peritoneum
- NX = lymph nodes not identified
• N0 regional lymph nodes negative
• N1 metastases in 1-3 lymph nodes
• N2 metastases in 4 or more lymph nodes

Front 36

Treatment:
•________ _____ ________ is adequate treatment for
adenomas including those with severe glandular
dysplasia / carcinoma in situ and intramucosal
adenocarcinoma.

Back 36

Treatment:
•Complete local excision is adequate treatment for
adenomas including those with severe glandular
dysplasia / carcinoma in situ and intramucosal
adenocarcinoma.

Front 37

•Complete local excision is also adequate for
invasive adenocarcinoma confined to a polyp [only
if the carcinoma: is not at or close to the stalk
margin, is not poorly differentiated, is without
vascular invasion, and is not s______.]

Back 37

•Complete local excision is also adequate for
invasive adenocarcinoma confined to a polyp [only
if the carcinoma: is not at or close to the stalk
margin, is not poorly differentiated, is without
vascular invasion, and is not sessile.]

Front 38

•Need subsequent surgical _________ for carcinomas
not confined to a polyp.

Back 38

•Need subsequent surgical resection for carcinomas
not confined to a polyp.

Front 39

Development of cancer in the colon is felt to be
the result of a "_____-___" process in which the
accumulation of multiple mutations is needed for
the development of cancer.

Back 39

Development of cancer in the colon is felt to be
the result of a "multi-hit" process in which the
accumulation of multiple mutations is needed for
the development of cancer.

Front 40

___ mutations are present in patients with FAP and in 80%
of sporadic colon cancers.

Back 40

APC mutations are present in patients with FAP and in 80%
of sporadic colon cancers.

Front 41

Sporadic colon cancers that lack an APC mutation often
have a mutation in B-_______.

Back 41

Sporadic colon cancers that lack an APC mutation often
have a mutation in B-catenin.

Front 42

Accumulations of mutations of the following genes are
common: ___, K-___, etc.

Back 42

Accumulations of mutations of the following genes are
common: APC, K-ras, etc.

Front 43

Most important gene mutation that lifts all regulation off of the cell cycle

Back 43

17p loss (p53)

Front 44

The ______________ instability Pathway
• Explains the development of colon cancer in patients
with HNPCC syndrome.

Back 44

The Microsatellite instability Pathway
• Explains the development of colon cancer in patients
with HNPCC syndrome.

Front 45

The Microsatellite instability Pathway

Carcinomas arising from this pathway do not usually
arise in ________ and are often in the _____ colon.

Back 45

The Microsatellite instability Pathway

Carcinomas arising from this pathway do not usually
arise in adenomas and are often in the right colon.

Front 46

CARCINOID
• Neoplasms arising from ______________ cells.
• Tendency for aggressive behavior correlates with site of origin,
depth of invasion and size.
• Appendiceal and rectal carcinoids infrequently metastasize.
• 90% of ileal, gastric & colonic carcinoids that have penetrated
1/2 way through the muscle wall will have metastases.
• Carcinoid syndrome can be produced by _________ (secreting
carcinoids either metastatic to liver or in extraintestinal sites.
• _ ________________ ______ _____, can be detected in urine.
• Carcinoid syndrome produces cyanotic flushing, GI symptoms,
asthmatic attacks, intermittent HTN and palpitations.

Back 46

CARCINOID
• Neoplasms arising from neuroendocrine cells.
• Tendency for aggressive behavior correlates with site of origin,
depth of invasion and size.
• Appendiceal and rectal carcinoids infrequently metastasize.
• 90% of ileal, gastric & colonic carcinoids that have penetrated
1/2 way through the muscle wall will have metastases.
• Carcinoid syndrome can be produced by serotonin (secreting
carcinoids either metastatic to liver or in extraintestinal sites.
• 5 hydroxyindoleacetic acid (5HIAA), can be detected in urine.
• Carcinoid syndrome produces cyanotic flushing, GI symptoms,
asthmatic attacks, intermittent HTN and palpitations.