Dr.

Marwan Qubaja / Pathology II

GIT III: Small

and

Large Intestines

Dr. Marwan Qubaja

Al-Quds University
Faculty of Medicine
Pathology Department
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Tumors of the Small

and
Large Intestines
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GIT III - Tumors of small and large intestines

Dr. Marwan Qubaja / Pathology II

Tumors of the Small and Large

Intestines
Common site: Colorectal cancer
second to bronchogenic carcinoma among the cancer
killers
5% of population will develop colorectal cancer
40% of this population will die of the disease
Common type: adenocarcinomas ~ 70% of GI
malignancies

Tumors of the Small and Large Intestines

Non-neoplastic Polyps:

Hyperplastic polyps

Hamartomatous polyps
o

Juvenile polyps

Peutz-Jeghers polyps

Inflammatory polyps

Lymphoid polyps

Neoplastic Epithelial Lesions:

Benign polyps

Malignant lesions

Adenoma*

Adenocarcinoma*

Carcinoid tumor

Anal zone carcinoma

Mesenchymal Lesions:

Gastrointestinal stromal tumors (benign or malignant)

Other benign lesions: Lipoma Neuroma Angioma

Kaposi sarcoma
Lymphoma

GIT III - Tumors of small and large intestines

Dr. Marwan Qubaja / Pathology II

Polyps

lesions arising from the epithelium of the mucosa

mass that protrudes into the lumen of the gut

Morphology:
1. Pedunculated or stalked polyp
2. Sessile
Sessile, without a definable stalk

non--neoplastic polyps:
non
due to abnormal mucosal maturation or inflammation
an example is the hyperplastic polyp

neoplastic polyps:
due epithelial proliferation and dysplasia
termed adenomatous polyps or adenomas
are precursors of carcinoma

Two forms of sessile polyp:

1. hyperplastic polyp
2. adenoma

Adenoma: neoplastic polyps

Two types of adenoma:

1. pedunculated
2. Sessile villous

GIT III - Tumors of small and large intestines

Dr. Marwan Qubaja / Pathology II

Non-neoplastic Polyps
occur particularly in the colon
increase in frequency with age
~ 90% of all epithelial polyps in the large intestine
Most are hyperplastic polyps:
< 5 mm in diameter, hemispherical, smooth protrusions
more often multiple
> 50% are found in the
rectosigmoid region

Juvenile polyps
are hamartomatous proliferations
occur mostly in children < 5 yrs
found in adults of any age (called
called retention polyps)
polyps
usually large in children (1 to 3 cm) but smaller in adults
rounded, smooth, or lobulated
have a stalk up to 2 cm long
have no malignant potential
Complications:
rectal bleeding
painful infarction if twisted on their stalks

GIT III - Tumors of small and large intestines

Dr. Marwan Qubaja / Pathology II

Peutz--Jeghers polyps
Peutz
uncommon hamartomatous polyps
Part of rare autosomal dominant Peutz
Peutz--Jeghers
syndrome
characterized by melanotic mucosal and cutaneous
pigmentation
associated with an increased risk of both intestinal and
extraintestinal malignancies.

Peutz--Jeghers
Peutz
syndrome

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GIT III - Tumors of small and large intestines

Dr. Marwan Qubaja / Pathology II

Adenomas: Neoplastic polyps

Shape: pedunculated or sessile

sessile, M = F

4 fold greater risk for adenomas among first-degree relatives

4 fold greater risk of colorectal carcinoma

result from epithelial proliferation and dysplasia

Three subtypes:
1. Tubular adenomas:
adenomas mostly tubular glands
2. Villous adenomas: villous projections
3. Tubulovillous adenomas: a mixture of the above

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Tubular adenomas:
the most common
small and pedunculated
The lowest risk for cancer

Tubulovillous adenomas:
5% to 10% of adenomas

Villous adenomas:
only 1% of adenomas
tend to be large and sessile
The highest risk for cancer

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GIT III - Tumors of small and large intestines

Dr. Marwan Qubaja / Pathology II

Tubular adenomas
arise anywhere in the colon
50% in the rectosigmoid
% increasing with age
Varies from 0.3 cm to 2.5 cm
have stalks 1 to 2 cm long
and raspberry-like heads

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A, Pedunculated tubular adenoma showing a fibrovascular stalk

covered by normal colonic mucosa and a head that contains abundant
dysplastic epithelial glands
B, A small focus of adenomatous epithelium
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GIT III - Tumors of small and large intestines

Dr. Marwan Qubaja / Pathology II

Villous adenomas:
up to 10 cm in diameter
cauliflower
cauliflower--like masses projecting 1 to 3 cm
above the surrounding normal mucosa
invasive carcinoma is found in up to 40% of
these lesions
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Villous adenoma is shown above the surface at the left, and

in cross section at the right. Note that this type of adenoma is
sessile, rather than pedunculated, and larger than a tubular
sessile
adenoma

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GIT III - Tumors of small and large intestines

Dr. Marwan Qubaja / Pathology II

A, Sessile villous adenoma: frond is lined by dysplastic epithelium

B, Portion of a villous frond with dysplastic columnar epithelium on the left
and normal colonic columnar epithelium on the right

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Adenomas: Clinical Features

small adenomas are usually asymptomatic
overt or occult rectal bleeding
hypoproteinemia or hypokalemia
Treatment:
all adenomas, regardless of their location, are to be
considered potentially malignant
Surgical excision

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GIT III - Tumors of small and large intestines

Dr. Marwan Qubaja / Pathology II

Familial Adenomatous Polyposis (FAP

(FAP))
uncommon autosomal dominant disorders
risk of colonic cancer is almost 100% by midlife
usually 500 to 2500 colonic adenomas
> 100 adenoma is required for the diagnosis
may be present anywhere in the GTI
Most polyps are tubular adenomas
Treatment: prophylactic colectomy
Gardner syndrome: osteomas and soft tissue tumor with FAP
Turcot syndrome: gliomas with FAP

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Familial adenomatous polyposis

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GIT III - Tumors of small and large intestines

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Dr. Marwan Qubaja / Pathology II

Colorectal Carcinoma
~ 98% are adenocarcinomas
peak incidence is 60 to 70 years of age
Males > females
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Colorectal Carcinoma
Risk factors:
Adenomatous polyps
FAP
Ulcerative colitis
Family history of colorectal carcinoma
low fiber and high fat diet
Protective effect by NSAIDs
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GIT III - Tumors of small and large intestines

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Dr. Marwan Qubaja / Pathology II

Morphologic and Molecular Progression in Neoplasm:

Neoplastic transformation is a progressive process involving
multiple hits or genetic changes

hyperplasia

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Molecular model for the evolution of colorectal

cancers through the adenoma-carcinoma
sequence

In colon
cancer:
APC
inactivation is
an important
first step in
oncogenesis

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GIT III - Tumors of small and large intestines

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Dr. Marwan Qubaja / Pathology II

Colorectal Carcinoma
25% are in the cecum or ascending colon
25% in the rectum and distal sigmoid
25% are in the descending colon and
proximal sigmoid
25% are scattered elsewhere
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Colorectal CarcinomaCarcinoma- Morphology

Carcinomas in the proximal colon:
tend to be polypoid, exophytic masses
obstruction is uncommon

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GIT III - Tumors of small and large intestines

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Dr. Marwan Qubaja / Pathology II

Carcinomas in the distal colon:

tend to be annular encircling
lesions
produce napkin-ring
constrictions of the bowel
cause narrowing of the lumen
The arrows identify separate
mucosal polyps

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Colorectal CarcinomaCarcinoma- Clinical Features

Asymptomatic
Cecal and right colonic cancers:
Fatigue and iron deficiency anemia

Left
Left--sided lesions:
lesions
produce occult bleeding
changes in bowel habit
left lower quadrant discomfort

Metastasis sites are:

regional lymph nodes
liver, lungs, and bones
serosal membrane of the peritoneal cavity

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GIT III - Tumors of small and large intestines

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Dr. Marwan Qubaja / Pathology II

TNM STAGING OF COLON CANCERS

Tumor (T)
0 = none evident
is = in situ (limited to mucosa)
1 = invasion of submucosa
2 = invasion of muscularis propria
3 = invasion of subserosa or pericolic fat
4 = invasion of contiguous structures
Lymph Nodes (N)
0 = none evident
1 = 1 to 3 positive pericolic nodes
2 = 4 or more positive pericolic nodes
3 = any positive node along a named blood vessel
Distant Metastasis (M)
0 = none evident
1 = any distant metastasis
5-Year Survival Rates
Tl = 97%
T2 = 90%
T3 = 78%
T4 = 63%
Any T; N1; M0 = 66%
Any T; N2; M0 = 37%
Any T; N3; M0 = data not available
Any Ml = 4%

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Colorectal CarcinomaCarcinoma- Diagnosis

Digital rectal examination
Fecal testing for occult blood loss
Barium enema
Biopsy by sigmoidoscopy, and colonoscopy
CT
Serum markers: CEA
Molecular detection of APC mutations in epithelial cells
isolated from stools

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GIT III - Tumors of small and large intestines

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Dr. Marwan Qubaja / Pathology II

Small Intestinal Neoplasms

~ 3% to 6% of gastrointestinal tumors
Mostly benign tumors:
stromal tumors of smooth muscle origin
Adenomas
Lipomas

Malignant:
Adenocarcinomas
Carcinoids (50%)
Lymphoma

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Carcinoid Tumors
develops from enterochromaffin cells
The appendix is the most common site
rectal and appendiceal carcinoids almost
never metastasize
associated with carcinoid syndrome (1%)
arise from elaboration of serotonin
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GIT III - Tumors of small and large intestines

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Dr. Marwan Qubaja / Pathology II

Carcinoid Tumors
Multiple protruding tumors are present at the ileocecal
junction

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GIT III - Tumors of small and large intestines

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Dr. Marwan Qubaja / Pathology II

Clinical Features of Carcinoid Syndrome

Vasomotor disturbances
Cutaneous flushes and apparent cyanosis (most patients)
Intestinal hypermotility
Diarrhea, cramps, nausea, vomiting (most patients)
Asthmatic bronchoconstrictive attacks
Cough, wheezing, dyspnea (about one third of patients)
Hepatomegaly
Nodular, related to hepatic metastases (some cases)
Niacin deficiency (due to shunting of niacin to serotonin synthesis)
Systemic fibrosis
Cardiac involvement
Pulmonic and tricuspid valve thickening and stenosis
Endocardial fibrosis, principally in right ventricle (bronchial carcinoids affect
the left side)
Retroperitoneal and pelvic fibrosis
Collagenous pleural and intimal aortic plaques
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GIT III - Tumors of small and large intestines

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