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Clinicopathologic Features and Diagnostic Implications of Pyloric Gland Metaplasia in Intestinal Specimens. Am J Surg Pathol 2021; 45:365-373. [PMID: 33105158 DOI: 10.1097/pas.0000000000001608] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Pyloric gland metaplasia (PGM) is a histopathologic change usually seen after inflammatory injury and, although described in association with inflammatory bowel disease (IBD) and particularly Crohn disease (CD), its significance is still debated. We evaluated long-term correlates of PGM in a large cohort of 601 intestinal specimens, 227 (37.8%) biopsies, and 374 (62.2%) resections, from 567 different patients, 328 (57.8%) male and 239 (42.2%) female, with a mean age of 43.4±15.8 years. During mean clinical follow-up of 83.5±48.1 months, 511 (90.1%) patients were diagnosed with IBD, 457 (89.4%) with CD, and 53 (10.4%) with ulcerative colitis. In multivariate analysis, IBD patients with PGM were younger (P<0.001) and more often had severely active inflammation (P=0.002) compared with non-IBD patients, whereas, among IBD patients, those with ulcerative colitis were more likely to have PGM in a biopsy (P<0.001) or in the colorectum (P=0.009), compared with CD patients. Kaplan-Meier analyses showed that incidental PGM in a biopsy was more likely to predict IBD in patients younger than 50 years (P<0.001) and those without a history of bowel surgery (P<0.001) and also more likely to signify CD in patients younger than 50 years (P=0.004), those without a history of bowel surgery (P=0.020), and when identified in the small intestine (P=0.032). In conclusion, intestinal PGM warrants a high suspicion for IBD and specifically CD, however, it should be interpreted with caution, especially in older patients or those with a history of prior intestinal surgery and in colorectal biopsies or specimens lacking severely active inflammation.
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Sekine S, Yamashita S, Yamada M, Hashimoto T, Ogawa R, Yoshida H, Taniguchi H, Kojima M, Ushijima T, Saito Y. Clinicopathological and molecular correlations in traditional serrated adenoma. J Gastroenterol 2020; 55:418-427. [PMID: 32052185 DOI: 10.1007/s00535-020-01673-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 01/22/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Traditional serrated adenoma (TSA) is the least common type of colorectal serrated polyp, which exhibits considerable morphological and molecular diversity. METHODS We examined the spectra of alterations in MAPK and WNT pathway genes and their relationship with clinicopathological features in 128 TSAs. RESULTS Sequencing analyses identified BRAF V600E, BRAF non-V600E, KRAS, and NRAS mutations in 77, 3, 45, and 1 lesion, respectively. Collectively, 124 lesions (97%) had mutations in MAPK pathway genes. Alterations in WNT pathway genes were identified in 107 lesions (84%), including RSPO fusions/overexpression, RNF43 mutations, ZNRF3 mutations, APC mutations, and CTNNB1 mutations in 47, 45, 2, 13, and 2 lesions, respectively. Ten lesions (8%) harbored GNAS mutations. There was significant interdependence between the altered MAPK and WNT pathway genes. RSPO fusions/overexpression was significantly associated with KRAS mutations (31/47, 66%), whereas most RNF43 mutations coexisted with the BRAF V600E mutation (40/45, 89%). Histologically, extensive slit-like serration was more common in lesions with the BRAF V600E mutation (71%) and those with RNF43 mutations (87%). Prominent ectopic crypt formation was more prevalent in lesions with RSPO fusions/overexpression (58%) and those with GNAS mutations (100%). CONCLUSIONS Our observations indicate that TSAs mostly harbor various combinations of concurrent WNT and MAPK gene alterations. The associations between genetic and morphological features suggest that the histological diversity of TSA reflects the underlying molecular heterogeneity.
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Affiliation(s)
- Shigeki Sekine
- Division of Pathology and Clinical Laboratories, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan.
- Division of Molecular Pathology, National Cancer Center Research Institute, Tokyo, Japan.
| | - Satoshi Yamashita
- Division of Epigenomics, National Cancer Center Research Institute, Tokyo, Japan
| | - Masayoshi Yamada
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Taiki Hashimoto
- Division of Pathology and Clinical Laboratories, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Reiko Ogawa
- Division of Molecular Pathology, National Cancer Center Research Institute, Tokyo, Japan
| | - Hiroshi Yoshida
- Division of Pathology and Clinical Laboratories, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Hirokazu Taniguchi
- Division of Pathology and Clinical Laboratories, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Motohiro Kojima
- Division of Pathology, Research Center for Innovative Oncology, National Cancer Center, Kashiwa, Chiba, Japan
| | - Toshikazu Ushijima
- Division of Epigenomics, National Cancer Center Research Institute, Tokyo, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
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Okuno T, Kanazawa T, Kishi H, Anzai H, Yasuda K, Ishihara S. Filiform polyposis with sigmoid colon adenocarcinoma: a case report. Surg Case Rep 2019; 5:184. [PMID: 31782007 PMCID: PMC6883011 DOI: 10.1186/s40792-019-0747-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 11/11/2019] [Indexed: 11/30/2022] Open
Abstract
Background Filiform polyposis is a rare form of inflammatory polyposis, which is occasionally formed in the colon of patients with history of inflammatory bowel disease (IBD). It is characterized by presence of several to hundreds of slender, worm-like polyps in the colon lined by histologically normal colonic mucosa and often coalesce, resulting in a tumor-like mass. Filiform polyposis is most frequently associated with a post-inflammatory reparative process in patients with IBD history, and only cases of filiform polyposis occurring in patients without IBD history have been reported. Filiform polyposis has been considered as a benign inflammatory polyposis without any risk of dysplasia, while the possibility of carcinogenesis of inflammatory polyps is not fully excluded. To date, only three cases of filiform polyposis coexisting with dysplasia have been reported. Case presentation A 59-year-old male patient with no past medical history of IBD underwent laparoscopic sigmoidectomy for obstructive filiform polyposis, which was associated with sigmoid colon adenocarcinoma. Based on the histological findings of the resected specimen, invasive sigmoid colon adenocarcinoma was surrounded by filiform polyposis, and adenocarcinoma also scattered uniformly on the surface of filiform polyposis. In immunohistochemistry, abnormal p53 expression was observed in adenocarcinoma, while it was not shown in mucosa on filiform polyposis. Conclusions This is the fourth case of filiform polyposis that is closely associated with colon dysplasia or adenocarcinoma based on histological findings. However, immunohistochemical findings did not support the theory that inflammation initiates adenocarcinoma in filiform polyposis like IBD. Hence, further immunohistochemical and genetic analyses are needed to clarify the association between filiform polyposis and carcinogenesis.
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Affiliation(s)
- Takayuki Okuno
- Department of Surgery, Douai Memorial Hospital, 2-1-11 Yokoami, Sumida-ku, Tokyo, 130-8587, Japan.
| | - Takamitsu Kanazawa
- Department of Surgery, Douai Memorial Hospital, 2-1-11 Yokoami, Sumida-ku, Tokyo, 130-8587, Japan
| | - Hirohisa Kishi
- Department of Pathology, Douai Memorial Hospital, 2-1-11 Yokoami, Sumida-ku, Tokyo, 130-8587, Japan
| | - Hiroyuki Anzai
- Department of Surgery, Douai Memorial Hospital, 2-1-11 Yokoami, Sumida-ku, Tokyo, 130-8587, Japan
| | - Koji Yasuda
- Department of Surgery, Douai Memorial Hospital, 2-1-11 Yokoami, Sumida-ku, Tokyo, 130-8587, Japan
| | - Soichiro Ishihara
- Department of Surgical Oncology, The University of Tokyo, 7-3-1, Tokyo, Japan
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Acquisition of WNT Pathway Gene Alterations Coincides With the Transition From Precursor Polyps to Traditional Serrated Adenomas. Am J Surg Pathol 2019; 43:132-139. [PMID: 30179900 DOI: 10.1097/pas.0000000000001149] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Colorectal traditional serrated adenomas (TSAs) are often associated with precursor polyps, including hyperplastic polyps and sessile serrated adenoma/polyps. To elucidate the molecular mechanisms involved in the progression from precursor polyps to TSAs, the present study analyzed 15 precursor polyp-associated TSAs harboring WNT pathway gene mutations. Laser microdissection-based sequencing analysis showed that BRAF or KRAS mutations were shared between TSA and precursor polyps in all lesions. In contrast, the statuses of WNT pathway gene mutations were different between the 2 components. In 8 lesions, RNF43, APC, or CTNNB1 mutations, were exclusively present in TSA. RNF43 mutations were shared between the TSA and precursor components in 3 lesions; however, they were heterozygous in the precursor polyps whereas homozygous in the TSA. In 4 lesions with PTPRK-RSPO3 fusions, RNA in situ hybridization demonstrated that overexpression of RSPO3, reflecting PTPRK-RSPO3 fusion transcripts, was restricted to TSA components. Consistent with the results of the genetic and in situ hybridization analyses, nuclear β-catenin accumulation and MYC overexpression were restricted to the TSA component in 13 and 12 lesions, respectively. These findings indicate that the WNT pathway gene alterations are acquired during the progression from the precursor polyps to TSAs and that the activation of the WNT pathway plays a critical role in the development of TSA rather than their progression to high-grade lesions.
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McCarthy AJ, Serra S, Chetty R. Traditional serrated adenoma: an overview of pathology and emphasis on molecular pathogenesis. BMJ Open Gastroenterol 2019; 6:e000317. [PMID: 31413858 PMCID: PMC6673762 DOI: 10.1136/bmjgast-2019-000317] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/02/2019] [Accepted: 07/08/2019] [Indexed: 12/21/2022] Open
Abstract
Objective To provide an overview of the pathology and molecular pathogenesis of traditional serrated adenomas (TSA). Design Describe the morphology and molecules that play a role in their pathogenesis. Results These exuberant polypoid lesions are typified by tall cells with deeply eosinophilic cytoplasm, elongated nuclei bearing delicate chromatin, ectopic crypt foci, deep clefting of the lining mucosa and an overall resemblance to small bowel mucosa. Broadly, TSAs arise via three mechanisms. They may be BRAF mutated and CpG island methylator phenotype (CIMP)-high: right sided, mediated through a microvesicular hyperplastic polyp or a sessile serrated adenoma, may also have RNF43 mutations and result in microsatellite stable (MSS) colorectal cancers (CRC). The second pathway that is mutually exclusive of the first is mediated through KRAS mutation with CIMP-low TSAs. These are left-sided TSAs, are not associated with another serrated polyp and result in MSS CRC. These TSAs also have RSPO3, RNF43 and p53 mutations together with aberrant nuclear localisation of β-catenin. Third, there is a smaller group of TSAs that are BRAF and KRAS wild type and arise by as yet unknown molecular events. All TSAs show retention of mismatch repair proteins. Conclusion These are characteristic unusual polyps with a complex molecular landscape.
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Affiliation(s)
- Aoife J McCarthy
- Division of Anatomical Pathology, Laboratory Medicine Program, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Stefano Serra
- Division of Anatomical Pathology, Laboratory Medicine Program, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Runjan Chetty
- Division of Anatomical Pathology, Laboratory Medicine Program, University Health Network and University of Toronto, Toronto, Ontario, Canada
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The Molecular Hallmarks of the Serrated Pathway in Colorectal Cancer. Cancers (Basel) 2019; 11:cancers11071017. [PMID: 31330830 PMCID: PMC6678087 DOI: 10.3390/cancers11071017] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 07/15/2019] [Accepted: 07/19/2019] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancer (CRC) is a leading cause of cancer death worldwide. It includes different subtypes that differ in their clinical and prognostic features. In the past decade, in addition to the conventional adenoma-carcinoma model, an alternative multistep mechanism of carcinogenesis, namely the “serrated pathway”, has been described. Approximately, 15 to 30% of all CRCs arise from neoplastic serrated polyps, a heterogeneous group of lesions that are histologically classified into three morphologic categories: hyperplastic polyps, sessile serrated adenomas/polyps, and the traditional serrated adenomas/polyps. Serrated polyps are characterized by genetic (BRAF or KRAS mutations) and epigenetic (CpG island methylator phenotype (CIMP)) alterations that cooperate to initiate and drive malignant transformation from normal colon mucosa to polyps, and then to CRC. The high heterogeneity of the serrated lesions renders their diagnostic and pathological interpretation difficult. Hence, novel genetic and epigenetic biomarkers are required for better classification and management of CRCs. To date, several molecular alterations have been associated with the serrated polyp-CRC sequence. In addition, the gut microbiota is emerging as a contributor to/modulator of the serrated pathway. This review summarizes the state of the art of the genetic, epigenetic and microbiota signatures associated with serrated CRCs, together with their clinical implications.
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Villanacci V, Baronchelli C, Manenti S, Bassotti G, Salviato T. Serrated lesions of the colon A window on a more clear classification. Ann Diagn Pathol 2019; 41:8-13. [PMID: 31112900 DOI: 10.1016/j.anndiagpath.2019.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 05/11/2019] [Indexed: 01/26/2023]
Abstract
Serrated polyps evaluation represents a challenge for pathologists for lacking of univocal criteria that leads to different inter -individual interpretation. The aim of our review is to offer an alternative simpler histologic and endoscopic approach to these lesions for a more correct relationship between endoscopists and pathologists.
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Affiliation(s)
| | | | | | - Gabrio Bassotti
- Gastroenterology and Hepatology Section, Department of Medicine, University of Perugia, Italy
| | - Tiziana Salviato
- Pathology Institute, Azienda Ospedaliera Universitaria, Ospedali Riuniti di Trieste, Trieste, Italy.
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Akabane S, Oonishi T, Takenoue T, Kawamoto T, Kunimura T. A rare trigger for acute appendicitis leading to small bowel obstruction: traditional serrated adenoma of the appendiceal foramen. J Surg Case Rep 2019; 2019:rjz047. [PMID: 30834108 PMCID: PMC6391586 DOI: 10.1093/jscr/rjz047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 01/31/2019] [Indexed: 12/05/2022] Open
Abstract
This is the first documented case of traditional serrated adenoma (TSA) of the appendiceal foramen that triggered acute appendicitis resulting in small bowel obstruction (SBO). An 88-year-old Japanese man presented with abdominal pain, distension, and appetite loss. Computed tomography demonstrated distended ileum adherent to cecum with thickened walls. He was diagnosed with SBO, and open ileoceal resection was eventually performed. Pathological examination revealed that a pedunculated polyp had obstructed the appendiceal foramen and triggered acute appendicitis, thus leading to SBO. Histopathological examination of the polyp revealed that the long fronds of the adenoma were lined by dysplastic epithelial cells, which is a characteristic feature of TSA. This case report illustrates that a tiny TSA can trigger the obstruction of the appendiceal foramen and lead to acute appendicitis and SBO. We underline the need for the resection of the polyps in this region regardless of their size.
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Affiliation(s)
- Shota Akabane
- Department of General Surgery, Yamato Tokushukai Hospital, Chuo 4-4-12, Yamato, Kanagawa, Japan
- Correspondence address. Bessho 1-65-2, Hachioji, Tokyo, Japan. Tel: +81-80-3464-1295; Fax: +81-42-674-5266; E-mail:
| | - Takahisa Oonishi
- Department of General Surgery, Yamato Tokushukai Hospital, Chuo 4-4-12, Yamato, Kanagawa, Japan
| | - Tomohiro Takenoue
- Department of General Surgery, Yamato Tokushukai Hospital, Chuo 4-4-12, Yamato, Kanagawa, Japan
| | - Tatsunari Kawamoto
- Department of General Surgery, Yamato Tokushukai Hospital, Chuo 4-4-12, Yamato, Kanagawa, Japan
| | - Toshiaki Kunimura
- Department of Clinical Pathology, Yamato Tokushukai Hospital, Chuo 4-4-12, Yamato, Kanagawa, Japan
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Kim SY, Kim TI. Serrated neoplasia pathway as an alternative route of colorectal cancer carcinogenesis. Intest Res 2018; 16:358-365. [PMID: 30090034 PMCID: PMC6077295 DOI: 10.5217/ir.2018.16.3.358] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 05/28/2018] [Accepted: 05/29/2018] [Indexed: 01/10/2023] Open
Abstract
In the past two decades, besides conventional adenoma pathway, a subset of colonic lesions, including hyperplastic polyps, sessile serrated adenoma/polyps, and traditional serrated adenomas have been suggested as precancerous lesions via the alternative serrated neoplasia pathway. Major molecular alterations of sessile serrated neoplasia include BRAF mutation, high CpG island methylator phenotype, and escape of cellular senescence and progression via methylation of tumor suppressor genes or mismatch repair genes. With increasing information of the morphologic and molecular features of serrated lesions, one major challenge is how to reflect this knowledge in clinical practice, such as pathologic and endoscopic diagnosis, and guidelines for treatment and surveillance.
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Affiliation(s)
- Soon Young Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Il Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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10
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N Kalimuthu S, Serra S, Hafezi-Bakhtiari S, Colling R, Wang LM, Chetty R. Mucin-rich variant of traditional serrated adenoma: a distinct morphological variant. Histopathology 2017; 71:208-216. [PMID: 28295534 DOI: 10.1111/his.13212] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 03/08/2017] [Indexed: 12/28/2022]
Abstract
AIMS Traditional serrated adenomas (TSAs) account for 5% of serrated polyps, and have a villiform architecture, eosinophilic cells with a brush border, and indented, flat-topped luminal serrations. However, some are composed of mucin-filled goblet cells (GCs): mucin-rich TSA (MrTSA). The aim of this study was to determine whether this variant has unique features as compared with classic TSA (cTSA). METHODS AND RESULTS One hundred and fifty-six TSAs were retrieved from the period 2010-2016. Patient demographics, site of polyps and 16 microscopic variables were evaluated. TSAs containing ≥50% GCs were classified as MrTSAs. Ectopic crypt foci (ECFs) were quantified as low (1-10) or high (>10), counted at ×200 magnification, and the average was taken for 10 fields. Twenty-four fulfilled the criteria for MrTSA. In males, MrTSAs (65%) were more prevalent than cTSAs (55%). There was no age difference, and both variants had a predilection for the left colon, although, in the right colon, MrTSAs were more frequent (39%) than cTSAs (10%) (P = 0.012). Adenomatous dysplasia was present in four of 24 MrTSAs (low grade, 3; high grade, 1). The most distinctive features of MrTSAs were: a variable growth pattern [endophytic (9%), mixed (30%), or villiform/exophytic (61%)], and a lower frequency of ECFs (P = 0.001) and more intraepithelial lymphocytes (P < 0.05) than in cTSAs. MrTSAs retain characteristic luminal serrations, at least focally. Inflamed MrTSAs can mimic inflammatory polyps and hamartomatous polyps (when there are >95% GCs). CONCLUSIONS MrTSA is characterized by >50% GCs, and fewer ECFs than cTSA, but with preservation of archetypal luminal serrations. Awareness of this variant will prevent misdiagnosis, given the association of TSA with the accelerated pathway to colorectal cancer.
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Affiliation(s)
- Sangeetha N Kalimuthu
- Department of Pathology, Laboratory Medicine Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Stefano Serra
- Department of Pathology, Laboratory Medicine Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Sara Hafezi-Bakhtiari
- Department of Pathology, Laboratory Medicine Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Richard Colling
- Department of Cellular Pathology, Oxford University Hospitals, Oxford, UK
| | - Lai Mun Wang
- Department of Cellular Pathology, Oxford University Hospitals, Oxford, UK
| | - Runjan Chetty
- Department of Pathology, Laboratory Medicine Program, University Health Network, University of Toronto, Toronto, ON, Canada
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Rashtak S, Rego R, Sweetser SR, Sinicrope FA. Sessile Serrated Polyps and Colon Cancer Prevention. Cancer Prev Res (Phila) 2017; 10:270-278. [PMID: 28325827 DOI: 10.1158/1940-6207.capr-16-0264] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 11/21/2016] [Accepted: 03/15/2017] [Indexed: 11/16/2022]
Abstract
Evidence suggests that up to one fifth of colorectal carcinomas develop from serrated polyps, named for their pattern of colonic crypts, and include the sessile serrated adenoma/polyp (SSA/P) that has malignant potential. SSA/Ps are typically located in the proximal colon and have molecular features of hypermethylation of CpG islands in gene promoters and activating point mutations (V600E) in the BRAF oncogene. Both of these features are seen in sporadic colorectal carcinomas with microsatellite instability (MSI) which is potentially consistent with an origin of these cancers from precursor SSA/Ps. Dysplasia is detected in a subset of SSA/Ps with a high risk of progression to carcinoma. An uncommon serrated polyp is the traditional serrated adenoma that is typically found in the left colon, has a tubulovillous architecture, and frequently harbors mutant KRAS To date, the epidemiology of these serrated lesions is poorly understood, and limited observational data suggest a potential chemopreventive benefit of nonsteroidal anti-inflammatory drugs. The current primary strategy to reduce the risk of colorectal carcinoma from serrated polyps is to enhance their detection at colonoscopy and to ensure their complete removal. This review provides insight into the epidemiologic, clinical, histopathologic, and molecular features of serrated polyps and includes data on their endoscopic detection and chemoprevention. Cancer Prev Res; 10(5); 270-8. ©2017 AACR.
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Affiliation(s)
- Shahrooz Rashtak
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Rafaela Rego
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota.,Department of Pathology, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal
| | - Seth R Sweetser
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Frank A Sinicrope
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota. .,Department of Oncology, Mayo Clinic, Rochester, Minnesota
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Choi EYK, Appelman HD. A Historical Perspective and Exposé on Serrated Polyps of the Colorectum. Arch Pathol Lab Med 2017; 140:1079-84. [PMID: 27684980 DOI: 10.5858/arpa.2016-0278-ra] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This article offers a historical perspective on the discovery of 3 types of serrated colorectal polyps recognized in the past 60 years. The first to be discovered was the hyperplastic polyp, which is still the most commonly encountered serrated polyp. In the past 20 years, the carcinoma-associated sessile serrated adenoma/polyp has been recognized, but its diagnosis can be difficult owing to overlapping histologic features with hyperplastic polyps. Less is known about the third type, the traditional serrated adenoma, because it is far less common than the other 2 types, and its association with cancer is currently under investigation.
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Abstract
Serrated polyps (SPs) of the colorectum pose a novel challenge to practicing gastroenterologists. Previously thought benign and unimportant, there is now compelling evidence that SPs are responsible for a significant percentage of incident colorectal cancer worldwide. In contrast to conventional adenomas, which tend to be slow growing and polypoid, SPs have unique features that undermine current screening and surveillance practices. For example, sessile serrated polyps (SSPs) are flat, predominately right-sided, and thought to have the potential for rapid growth. Moreover, SSPs are subject to wide variations in endoscopic detection and pathologic interpretation. Unfortunately, little is known about the natural history of SPs, and current guidelines are based largely on expert opinion. In this review, we outline the current taxonomy, epidemiology, and management of SPs with an emphasis on the clinical and public health impact of these lesions.
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Affiliation(s)
| | - Seth D Crockett
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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14
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Prevalence and Anatomic Distribution of Serrated and Adenomatous Lesions in Patients with Inflammatory Bowel Disease. Can J Gastroenterol Hepatol 2017; 2017:5490803. [PMID: 28182112 PMCID: PMC5274674 DOI: 10.1155/2017/5490803] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 06/01/2016] [Accepted: 08/18/2016] [Indexed: 12/29/2022] Open
Abstract
Background. Sessile serrated adenomas/polyps (SSA/Ps) and traditional serrated adenomas (TSAs) have not been well characterized in patients with inflammatory bowel disease (IBD). This study assesses the prevalence and anatomic distribution of SSA/Ps, TSAs, and conventional adenomas/dysplasia (Ad/Ds) in IBD patients. Methods. IBD patients with serrated, adenomatous, or hyperplastic lesions between 2005 and 2009 were identified in the regional tertiary-care hospital database. Clinicopathological information was reviewed and the histology of biopsies was reevaluated. Results. Ninety-six Ad/Ds, 25 SSA/Ps, and 4 TSAs were identified in 83 patients. Compared to Ad/Ds, serrated lesions were more prevalent in females (p = 0.046). The prevalence of Ad/Ds was 4.95%, SSA/Ps was 1.39%, and TSAs was 0.31%. No relationship was identified between lesion type and IBD type. Comparing all IBD patients, the distribution of lesion types was significantly different (p = 0.02) with Ad/Ds more common distally, SSA/Ps more common proximally, and TSAs evenly distributed. Among Crohn's disease (CD) patients, a similar distribution difference was noted (p < 0.001). However, ulcerative colitis (UC) patients had a uniform distribution of lesion types (p = 0.320). Conclusions. IBD patients have a lower prevalence of premalignant lesions compared to the general population, and the anatomic distribution of lesions differed between CD and UC patients. These findings may indicate an interaction between lesion and IBD pathogenesis with potential clinical implications.
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15
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Gibson JA, Odze RD. Pathology of premalignant colorectal neoplasia. Dig Endosc 2016; 28:312-23. [PMID: 26861656 DOI: 10.1111/den.12633] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 01/29/2016] [Accepted: 02/05/2016] [Indexed: 02/08/2023]
Abstract
Colorectal cancer is a heterogeneous oncological disease that develops through several molecular pathways. Each pathway is associated with specific neoplastic precursor lesions. Classification of colorectal polyps and the molecular features of associated colorectal cancers have undergone significant changes. An understanding of colorectal carcinogenesis and the molecular features of colorectal carcinomas is now regarded as necessary for personalized treatment and management of patients with colon cancer, and even for patients undergoing screening colonoscopy for early detection and prevention of colorectal cancer. In the present review, we describe the pathological and molecular features of epithelial precursor lesions involved in the early phases of colorectal carcinogenesis.
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Affiliation(s)
- Joanna A Gibson
- Department of Pathology, Yale University School of Medicine, New Haven, USA
| | - Robert D Odze
- Department of Pathology, Brigham and Women's Hospital, Boston, USA
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16
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Chetty R. Traditional serrated adenoma (TSA): morphological questions, queries and quandaries. J Clin Pathol 2015; 69:6-11. [PMID: 26553935 DOI: 10.1136/jclinpath-2015-203452] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Accepted: 10/17/2015] [Indexed: 12/31/2022]
Abstract
AIM Traditional serrated adenoma (TSA) is an uncommon type of serrated adenoma that can be a precursor to biologically aggressive colorectal cancer that invokes the serrated (accelerated) pathway. The purpose of this review is to address some of the more contentious issues around nomenclature, diagnostic criteria, histological variants, coexistence with other polyp types, the occurrence of dysplasia and the differential diagnosis. RESULTS While the vast majority of TSAs are exophytic villiform polyps composed of deeply eosinophilic cells, flat top luminal serrations and numerous ectopic crypt foci, histological variants include flat TSA, filiform TSA and one composed of large numbers of mucin-containing cells. It is unlikely that there is any biological difference between the histological variants. There is a contention that TSAs are not dysplastic ab initio and that the majority do not show cytological atypia. Two types of dysplasia are associated with TSA. Serrated dysplasia is less well recognised and less commonly encountered than adenomatous dysplasia. TSA with dysplasia must be separated from TSA with coexisting conventional adenoma. CONCLUSIONS TSA is a characteristic polyp that may be extremely exophytic, flat or composed of mucin-rich cells and is typified by numerous ectopic crypt foci. They may coexist with other serrated polyps and conventional adenomas. Approximately 20-25% will be accompanied by adenomatous dysplasia.
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Affiliation(s)
- Runjan Chetty
- Laboratory Medicine Program, Department of Pathology, University Health Network and University of Toronto, Toronto, Canada
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Yang HM, Mitchell JM, Sepulveda JL, Sepulveda AR. Molecular and histologic considerations in the assessment of serrated polyps. Arch Pathol Lab Med 2015; 139:730-41. [PMID: 26030242 DOI: 10.5858/arpa.2014-0424-ra] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
UNLABELLED CONTEXT : Colorectal cancer is a heterogeneous disease resulting from different molecular pathways of carcinogenesis. Recent data evaluating the histologic features and molecular basis of the serrated polyp-carcinoma pathway have significantly contributed to more comprehensive classifications of and treatment recommendations for these tumors. OBJECTIVE To integrate the most recent molecular findings in the context of histologic classifications of serrated lesions and their implications in diagnostic pathology and colorectal cancer surveillance. DATA SOURCES Published literature focused on serrated polyps and their association with colorectal cancer. CONCLUSIONS Three types of serrated polyps are currently recognized: hyperplastic polyps, sessile serrated adenomas/polyps, and traditional serrated adenomas. The BRAF V600E mutation is one of the most frequent molecular abnormalities identified in hyperplastic polyps and sessile serrated adenomas. In contrast, in traditional serrated adenomas, either BRAF V600E or KRAS mutations can be frequently identified. CpG methylation has emerged as a critical molecular mechanism in the sessile serrated pathway. CpG methylation of MLH1 often leads to reduced or lost expression in dysplastic foci and carcinomas arising in sessile serrated adenomas/polyps.
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Affiliation(s)
- Hui-Min Yang
- From the Department of Pathology and Cell Biology, Columbia University, New York, New York
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Bateman AC, Shepherd NA. UK guidance for the pathological reporting of serrated lesions of the colorectum. J Clin Pathol 2015; 68:585-91. [PMID: 25934843 DOI: 10.1136/jclinpath-2015-203016] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 04/13/2015] [Indexed: 11/04/2022]
Abstract
Bowel cancer screening programmes have highlighted to endoscopists and clinicians the spectrum of serrated colorectal lesions. One of the most significant developments has been the recognition that sessile serrated lesions (SSLs), while bearing histological resemblance to hyperplastic polyps (HPs), may be associated with the enhanced development of epithelial dysplasia and colorectal adenocarcinoma. Different minimum criteria exist for the diagnosis of SSLs and their differentiation from HPs. Furthermore, the spectrum of terminology used to describe the entire range of serrated lesions is wide. This variability has impaired interobserver agreement during their histopathological assessment. Here, we provide guidance for the histopathological reporting of serrated lesions, including a simplified nomenclature system. Essentially, we recommend use of the following terms: HP, SSL, SSL with dysplasia, traditional serrated adenoma (TSA) and mixed polyp. It is hoped that this standardisation of nomenclature will facilitate studies of the biological significance of serrated lesions in terms of the relative risk of disease progression.
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Affiliation(s)
- Adrian C Bateman
- Department of Cellular Pathology, Southampton General Hospital, Southampton, UK
| | - Neil A Shepherd
- Gloucestershire Cellular Pathology Laboratory, Cheltenham General Hospital, Cheltenham, UK
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Bettington ML, Chetty R. Traditional serrated adenoma: an update. Hum Pathol 2015; 46:933-8. [PMID: 26001333 DOI: 10.1016/j.humpath.2015.04.002] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 03/29/2015] [Accepted: 04/03/2015] [Indexed: 02/06/2023]
Abstract
Although recognized 25 years ago, the traditional serrated adenoma (TSA) remains an ongoing source of diagnostic and biologic debate. Recent research has greatly improved our understanding of the morphological and molecular aspects of these polyps. In particular, the recognition of ectopic crypt foci (ECFs) in combination with typical cytology and slitlike serrations improves diagnostic reproducibility. Awareness that many TSAs, particularly BRAF-mutated TSAs, arise in precursor microvesicular hyperplastic polyps and sessile serrated adenomas can aid in making this diagnosis and should not be confused with a sessile serrated adenoma with dysplasia. At a molecular level, TSAs can be divided into 2 groups based on their BRAF or KRAS mutation status. The development of overt cytologic dysplasia is accompanied by TP53 mutation, Wnt pathway activation, and, in some cases, silencing of CDKN2A. Importantly, however, mismatch repair enzyme function is retained. Thus, the TSA is an important precursor of aggressive molecular subtypes of colorectal carcinoma.
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Affiliation(s)
- Mark L Bettington
- The Conjoint Gastroenterology Laboratory, QIMR Berghofer Medical Research Institute, School of Medicine, University of Queensland, Envoi Specialist Pathologists, Brisbane 4072, Queensland, Australia
| | - Runjan Chetty
- Department of Pathology, Laboratory Medicine Program, University Health Network, University of Toronto, Toronto, Ontario M5G 2C4, Canada.
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20
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Serrated polyps and their alternative pathway to the colorectal cancer: a systematic review. Gastroenterol Res Pract 2015; 2015:573814. [PMID: 25945086 PMCID: PMC4405010 DOI: 10.1155/2015/573814] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 03/20/2015] [Accepted: 03/22/2015] [Indexed: 12/15/2022] Open
Abstract
Colorectal cancer (CRC) is the third most frequently diagnosed cancer in the world. For a long time, only one pathway of colorectal carcinogenesis was known. In recent years, a new “alternative” pathway through serrated adenoma was described. Recent meta-analysis estimated these cancers as about 10% to 30% of all CRCs. Serrated polyps are the second most popular groups of polyps (after conventional adenomas) found during colonoscopy. Serrated polyps of the colon are clinically and molecularly diverse changes that have common feature as crypt luminal morphology characterized by glandular serration. Evidence suggests that subtypes of serrated polyps, particularly TSA and SSA/P, can lead to adenocarcinoma through the serrated pathway. Moreover, the data indicate that the SSA/P are the precursors of colorectal carcinoma by MSI and may be subject to rapid progression to malignancy. An important step to reduce the incidence of CRC initiated by the serrated pathway is to improve the detection of serrated polyps and to ensure their complete removal during endoscopy. Understanding of the so-called serrated carcinogenesis pathway is an important step forward in expanding possibilities in the prevention of CRC.
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21
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Bettington ML, Walker NI, Rosty C, Brown IS, Clouston AD, McKeone DM, Pearson SA, Klein K, Leggett BA, Whitehall VLJ. A clinicopathological and molecular analysis of 200 traditional serrated adenomas. Mod Pathol 2015; 28:414-27. [PMID: 25216220 DOI: 10.1038/modpathol.2014.122] [Citation(s) in RCA: 122] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 06/13/2014] [Accepted: 06/15/2014] [Indexed: 12/12/2022]
Abstract
The traditional serrated adenoma is the least common colorectal serrated polyp. The clinicopathological features and molecular drivers of these polyps require further investigation. We have prospectively collected a cohort of 200 ordinary and advanced traditional serrated adenomas and performed BRAF and KRAS mutational profiling, CpG island methylator phenotype analysis, and immunohistochemistry for a panel of 7 antibodies (MLH1, β-catenin, p53, p16, Ki67, CK7, and CK20) on all cases. The mean age of the patients was 64 years and 50% were female. Of the polyps, 71% were distal. Advanced histology (overt dysplasia or carcinoma) was present in 19% of cases. BRAF mutation was present in 67% and KRAS mutation in 22%. BRAF mutant traditional serrated adenomas were more frequently proximal (39% versus 2%; P≤0.0001), were exclusively associated with a precursor polyp (57% versus 0%; P≤0.0001), and were more frequently CpG island methylator phenotype high (60% versus 16%; P≤0.0001) than KRAS mutant traditional serrated adenomas. Advanced traditional serrated adenomas retained MLH1 expression in 97%, showed strong p53 staining in 55%, and nuclear β-catenin staining in 40%. P16 staining was lost in the advanced areas of 55% of BRAF mutant traditional serrated adenomas compared with 10% of the advanced areas of KRAS mutant or BRAF/KRAS wild-type traditional serrated adenomas. BRAF and KRAS mutant traditional serrated adenomas are morphologically related but biologically disparate polyps with distinctive clinicopathological and molecular features. The overwhelming majority of traditional serrated adenomas retain mismatch repair enzyme function indicating a microsatellite-stable phenotype. Malignant progression occurs via TP53 mutation and Wnt pathway activation regardless of mutation status. However, CDKN2A (encoding the p16 protein) is silenced nearly exclusively in the advanced areas of the BRAF mutant traditional serrated adenomas. Thus, the BRAF mutant traditional serrated adenoma represents an important precursor of the aggressive BRAF mutant, microsatellite-stable subtype of colorectal carcinoma.
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Affiliation(s)
- Mark L Bettington
- 1] The Conjoint Gastroenterology Laboratory, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia [2] The School of Medicine, The University of Queensland, Brisbane, QLD, Australia [3] Envoi Specialist Pathologists, Brisbane, QLD, Australia
| | - Neal I Walker
- 1] The School of Medicine, The University of Queensland, Brisbane, QLD, Australia [2] Envoi Specialist Pathologists, Brisbane, QLD, Australia
| | - Christophe Rosty
- 1] The School of Medicine, The University of Queensland, Brisbane, QLD, Australia [2] Envoi Specialist Pathologists, Brisbane, QLD, Australia [3] Genetic Epidemiology Laboratory, Department of Pathology, The University of Melbourne, Carlton, VIC, Australia
| | - Ian S Brown
- 1] Envoi Specialist Pathologists, Brisbane, QLD, Australia [2] Department of Anatomical Pathology, Pathology Queensland, Brisbane, QLD, Australia
| | - Andrew D Clouston
- 1] The School of Medicine, The University of Queensland, Brisbane, QLD, Australia [2] Envoi Specialist Pathologists, Brisbane, QLD, Australia [3] Department of Anatomical Pathology, Pathology Queensland, Brisbane, QLD, Australia
| | - Diane M McKeone
- The Conjoint Gastroenterology Laboratory, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Sally-Ann Pearson
- The Conjoint Gastroenterology Laboratory, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Kerenaftali Klein
- Statistics Unit, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Barbara A Leggett
- 1] The Conjoint Gastroenterology Laboratory, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia [2] The School of Medicine, The University of Queensland, Brisbane, QLD, Australia [3] The Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Vicki L J Whitehall
- 1] The Conjoint Gastroenterology Laboratory, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia [2] The School of Medicine, The University of Queensland, Brisbane, QLD, Australia [3] Department of Chemical Pathology, Pathology Queensland, Brisbane, QLD, Australia
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Rosty C, Campbell C, Clendenning M, Bettington M, Buchanan DD, Brown IS. Do serrated neoplasms of the small intestine represent a distinct entity? Pathological findings and molecular alterations in a series of 13 cases. Histopathology 2015; 66:333-42. [PMID: 24894811 DOI: 10.1111/his.12469] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 05/30/2014] [Indexed: 12/28/2022]
Abstract
AIMS To characterize pathological, immunohistochemical and molecular features of small intestinal serrated neoplasms. METHODS AND RESULTS We report 13 serrated neoplasms located predominantly in the duodenum (median age, 71 years; male to female ratio, 7:6). The serrated adenomas demonstrated prominent serration, ectopic crypt formations and cytological features reminiscent of colorectal traditional serrated adenomas. Almost half the serrated adenomas demonstrated high-grade dysplasia or were associated with an adenocarcinoma. Immunohistochemical and molecular analysis showed an intestinal (CDX2-positive) phenotype in all tumours, abnormal β-catenin staining in three cases (23%), abnormal p53 expression in four cases (31%), focal loss of MGMT expression in one case (8%), KRAS mutation in five cases (38%) and CpG island methylator phenotype in six cases (50%). A diffuse pattern of Ki67 expression was present in eight adenomas (62%) and was associated with high-grade dysplasia (P = 0.02). No BRAF(V600E) mutation or loss of MLH1 expression was observed. CONCLUSIONS To our knowledge, this is the first series reporting serrated adenoma in the small intestine, a rare subtype of adenomas resembling traditional serrated adenoma with aggressive morphological features. The absence of the BRAF(V600E) mutation does not support a role for the serrated neoplasia pathway in the development of these lesions, as in colorectal serrated polyps.
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Affiliation(s)
- Christophe Rosty
- Envoi Pathology, Brisbane, Qld, Australia; School of Medicine, University of Queensland, Brisbane, Qld, Australia; Genetic Epidemiology Laboratory, Department of Pathology, The University of Melbourne, Carlton, Vic., Australia
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23
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Kharlova OA, Danilova NV, Malkov PG, Ageikina NV, Knyazev MV. [Serrated lesions of the large bowel]. Arkh Patol 2015; 77:60-68. [PMID: 25868371 DOI: 10.17116/patol201577160-] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The 2010 WHO classification identifies a new group of pretumor lesions of the large bowel--serrated masses, which includes hyperplastic polyps (HPs), sessile serrated adenomas/polyps (SSA/P), and traditional serrated adenomas (TSA). Serrated masses are a heterogeneous group characterized by serrated gland lumens and, in most cases, without dysplasia. An enlarged proliferative zone, elongated crypts, and no cytological atypia in addition to a serrated lumen are typical of HPs. SSA/P is characterized by the migration of the proliferative zone to the crypt walls, giving rise to specific architectural disorders, such as expanded and horizontally growing basal gland segments along the lamina muscularis mucosae. TSA is typified by short ectopic crypts that cannot reach the lamina muscularis and by epithelial eosinophilic changes. SSA/P and TSA have peculiar molecular genetic profiles and proven malignant potential.
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Affiliation(s)
- O A Kharlova
- Russian Medical Academy of Postgraduate Education, Moscow
| | - N V Danilova
- Russian Medical Academy of Postgraduate Education, Moscow; Faculty of Fundamental Medicine, M.V. Lomonosov Moscow State University, Moscow
| | - P G Malkov
- Russian Medical Academy of Postgraduate Education, Moscow; Faculty of Fundamental Medicine, M.V. Lomonosov Moscow State University, Moscow
| | - N V Ageikina
- Polyclinic Two, Ministry of Economic Development of Russia, Moscow
| | - M V Knyazev
- Polyclinic Two, Ministry of Economic Development of Russia, Moscow
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Abstract
The concept of serrated colorectal neoplasia has become recognised as a key process in the development of colorectal cancer (CRC) and an important alternative pathway to malignancy compared with the long established ‘adenoma-carcinoma’ sequence. Increasing recognition of the morphological spectrum of serrated lesions has occurred in parallel with elucidation of the distinct molecular genetic characteristics of progression from normal mucosa, via the ‘serrated pathway’, to CRC. Some of these lesions can be difficult to identify at colonoscopy. Challenges for pathologists include the requirement for accurate recognition of the forms of serrated lesions that are associated with a significant risk of malignant progression and therefore the need for widely disseminated reproducible criteria for their diagnosis. Alongside this process, pathologists and endoscopists need to formulate clear guidelines for the management of patients with these lesions, particularly with respect to the optimal follow-up intervals. This review provides practical guidance for the recognition of these lesions by pathologists, a discussion of ‘serrated adenocarcinoma’ and an insight into the distinct molecular genetic alterations that are seen in this spectrum of lesions in comparison to those that characterise the classic ‘adenoma-carcinoma’ sequence.
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25
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Abstract
The serrated pathway (SP) can be viewed as two parallel, but partially overlapping, arrays of colorectal precursor lesions, and their respective endpoint carcinomas, that are distinct from those of the conventional adenoma-carcinoma sequence (APC-pathway). In this review we focus at the outset on the clinical impact, pathological features, molecular genetics and biological behaviours of the various SP cancers. Then we summarize the clinicopathological features, classification and molecular profiles of the two main precursor lesions that anchor the respective pathways: (i) sessile serrated adenoma/polyp (SSA/P), also called sessile serrated lesion (SSL), and (ii) traditional serrated adenoma (TSA). Activating mutations of the RAS-RAF-MAPK pathway initiate and sustain the lesions of the SP, and CpG island methylation of the promoter regions of tumour suppressor and DNA repair genes play the major role in their neoplastic progression. The SP includes microsatellite stable (MSS) carcinomas that are among the most biologically aggressive colorectal carcinomas (CRC), and also accounts for the great preponderance of sporadic hypermutated, mismatch repair (MMR)-deficient or microsatellite instable (MSI) CRC. The identification, removal and appropriate classification of at-risk SP precursors and surveillance of individuals who harbour these lesions present a challenge and opportunity for CRC prevention and mortality reduction.
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Affiliation(s)
- Michael J O'Brien
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
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26
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Abstract
Colonoscopy offers incomplete protection from colorectal cancer, particularly in the right colon. Part of this inadequacy may be related to serrated neoplasia. Serrated polyps of the colorectum are now understood to be a heterogeneous group of polyps, some of which are cancer precursors, such as the sessile serrated adenoma (SSA) and the traditional serrated adenoma (TSA). In contrast to conventional adenomas, there is limited published literature on the epidemiology and natural history of these lesions. Furthermore, existing guidelines regarding screening and surveillance practices for these polyps are based largely on expert opinion without firm evidence. In this review, we describe the current understanding of the molecular biology, histopathology, and endoscopic features of serrated neoplasia of the colorectum, with an emphasis on aspects relevant to the practicing gastroenterologist.
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Droy-Dupré L, Küry S, Coron E, Bézieau S, Laboisse CL, Mosnier JF. Reappraisal of the so-called 'villous tumours' of the rectosigmoid, based on histological, immunohistochemical and genotypic features. United European Gastroenterol J 2014; 2:307-14. [PMID: 25083289 DOI: 10.1177/2050640614541258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 05/06/2014] [Accepted: 06/02/2014] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Villous tumours of the rectosigmoid are historically defined as broad-based lesions associated with secretory diarrhoea. OBJECTIVE This study aimed to perform a reappraisal of these tumours, on the basis of newly introduced histological, immunohistochemical and molecular parameters. METHODS For this study, 22 villous tumours, diagnosed by endoscopic criteria (19 Paris 0-IIa, three Paris 0-Is), were evaluated according to WHO classification. Microsatellite instability status, KRAS and BRAF mutations, MGMT status of villous tumours and associated invasive carcinoma were determined. RESULTS The 22 villous tumours fell into four groups: 1) nine villous adenomas, 2) six tubulovillous adenomas, 3) three filiform traditional serrated adenomas, and 4) four traditional serrated adenomas with conventional dysplasia. Filiform serrated adenomas displayed a distinctive endoscopic protruding pattern (Paris 0-Is). Villous adenomas were strongly associated with secretory diarrhoea. All the villous tumours were microsatellite stable. Five tumours exhibited MGMT abnormalities. KRAS mutations were frequent in villous adenomas, whereas BRAF mutations were essentially detected in serrated lesions. Invasive carcinomas (n = 7) maintained the histopathological and molecular imprint of the prior villous tumour. CONCLUSION The rectosigmoid villous tumours are histologically and molecularly heterogeneous, including serrated neoplasias. Endoscopic and clinical findings are predictive of the histopathological diagnosis of some of these distinct entities.
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Affiliation(s)
- Laure Droy-Dupré
- CHU Nantes, Service d'Anatomie et Cytologie Pathologiques, Nantes, France
| | - Sébastien Küry
- CHU Nantes, Service de Génétique Médicale, Nantes, France
| | - Emmanuel Coron
- CHU Nantes, Service de Gastroentérologie, Nantes, France
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Boulagnon C, Jazeron JF, Diaz-Cives A, Ehrhard F, Bouché O, Diebold MD. Filiform polyposis: A benign entity? Case report and literature review. Pathol Res Pract 2014; 210:189-93. [PMID: 24315830 DOI: 10.1016/j.prp.2013.11.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2013] [Revised: 08/23/2013] [Accepted: 11/06/2013] [Indexed: 12/29/2022]
Abstract
Filiform polyposis (FP) is a distinctive and unusual form of benign non syndromic polyposis that is occasionally encountered in the colon of patients with inflammatory bowel disease (IBD) history. FP is characterized by one to hundreds, slender, arborizing, vermiform projections in the colon lined by normal or inflammatory colonic mucosa. Only rare cases without history or evidence of IBD have been reported. In those cases, the sigmoid colon was the most common location and none of them showed dysplasia or malignancy neither at first evaluation nor during follow-up. In this report, we present the first case of FP associated with six adenomas developed on filiform polyps and invasive adenocarcinoma in the right colon of a 54 year-old man without a past medical history of IBD.
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Affiliation(s)
| | | | - Ana Diaz-Cives
- Digestive Surgery Department, Academic Hospital, Reims, France
| | - Florent Ehrhard
- Gastroenterology Department, Robert Debré Academic Hospital, Reims, France
| | - Olivier Bouché
- Gastroenterology Department, Robert Debré Academic Hospital, Reims, France
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30
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Sweetser S, Smyrk TC, Sinicrope FA. Serrated colon polyps as precursors to colorectal cancer. Clin Gastroenterol Hepatol 2013; 11:760-7; quiz e54-5. [PMID: 23267866 PMCID: PMC3628288 DOI: 10.1016/j.cgh.2012.12.004] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Revised: 11/27/2012] [Accepted: 12/07/2012] [Indexed: 02/07/2023]
Abstract
Identification of the serrated neoplasia pathway has improved our understanding of the pathogenesis of colorectal cancer (CRC). Insights include an increased recognition of the malignant potential of different types of serrated polyps such as sessile and traditional serrated adenomas. Sessile serrated adenomas share molecular features with colon tumors that have microsatellite instability and a methylator phenotype, indicating that these lesions are precursors that progress via the serrated neoplasia pathway. These data have important implications for clinical practice and CRC prevention, because hyperplastic polyps were previously regarded as having no malignant potential. There is also evidence that the serrated pathway contributes to interval or missed cancers. Endoscopic detection of serrated polyps is a challenge because they are often inconspicuous with indistinct margins and are frequently covered by adherent mucus. It is important for gastroenterologists to recognize the subtle endoscopic features of serrated polyps to facilitate their detection and removal, and thereby ensure a high-quality colonoscopic examination. Recognition of the role of serrated polyps in colon carcinogenesis has led to the inclusion of these lesions in postpolypectomy surveillance guidelines. However, an enhanced effort is needed to identify and completely remove serrated adenomas, with the goal of increasing the effectiveness of colonoscopy to reduce CRC incidence.
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Affiliation(s)
- Seth Sweetser
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
| | - Thomas C. Smyrk
- Division of Anatomic Pathology, Mayo Clinic College of Medicine, Rochester, MN
| | - Frank A. Sinicrope
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
- Division of Oncology, Mayo Clinic College of Medicine, Rochester, MN
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31
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Serrated lesions and hyperplastic (serrated) polyposis relationship with colorectal cancer: classification and surveillance recommendations. Gastrointest Endosc 2013; 77:858-71. [PMID: 23684091 DOI: 10.1016/j.gie.2013.02.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Accepted: 02/11/2013] [Indexed: 02/08/2023]
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Naini BV, Odze RD. Advanced precancerous lesions (APL) in the colonic mucosa. Best Pract Res Clin Gastroenterol 2013; 27:235-56. [PMID: 23809243 DOI: 10.1016/j.bpg.2013.03.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 03/08/2013] [Indexed: 01/31/2023]
Abstract
Colorectal cancer is a leading cause of cancer death worldwide. Most colorectal cancers are preventable. Surveillance colonoscopy is used to detect and remove precancerous lesions. Although the majority of precancerous lesions develop sporadically, some have an inherited component. In this review, we summarize the clinical, pathologic, and molecular features of advanced precancerous lesions of the colon. The most common and clinically important intestinal polyposis syndromes, and their genetics, are also discussed. Finally, current recommendations regarding the treatment and surveillance of precancerous lesions, both in the sporadic and in inherited setting, are reviewed.
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Affiliation(s)
- Bita V Naini
- David Geffen School of Medicine at UCLA, Department of Pathology & Lab Medicine, Box 951732, 1P-172 CHS, 10833 Le Conte Ave, Los Angeles, CA 90095-1732, USA.
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Limketkai BN, Lam-Himlin D, Arnold MA, Arnold CA. The cutting edge of serrated polyps: a practical guide to approaching and managing serrated colon polyps. Gastrointest Endosc 2013; 77:360-75. [PMID: 23410696 DOI: 10.1016/j.gie.2012.11.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Accepted: 11/06/2012] [Indexed: 12/13/2022]
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Patai AV, Molnár B, Tulassay Z, Sipos F. Serrated pathway: alternative route to colorectal cancer. World J Gastroenterol 2013; 19:607-15. [PMID: 23431044 PMCID: PMC3574586 DOI: 10.3748/wjg.v19.i5.607] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Revised: 09/03/2012] [Accepted: 09/12/2012] [Indexed: 02/06/2023] Open
Abstract
Serrated polyps have been an area of intense focus for gastroenterologists over the past several years. Contrary to what was thought before, a growing body of literature indicates that these polyps can be precursors of colorectal cancer (CRC). Most of these lesions, particularly those in the proximal colon, have so far been under-recognized and missed during colonoscopy, qualifying these lesions to be the main cause of interval cancers. It is estimated that 10%-20% of CRCs evolve through this alternative, serrated pathway, with a distinct genetic and epigenetic profile. Aberrant DNA methylation plays a central role in the development of this CRC subtype. This characteristic molecular background is reflected in a unique pathological and clinical manifestation different from cancers arising via the traditional pathway. In this review we would like to highlight morphological, molecular and clinical features of this emerging pathway that are essential for gastroenterologists and may influence their everyday practice.
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Bettington M, Walker N, Clouston A, Brown I, Leggett B, Whitehall V. The serrated pathway to colorectal carcinoma: current concepts and challenges. Histopathology 2013; 62:367-86. [DOI: 10.1111/his.12055] [Citation(s) in RCA: 328] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Fu B, Yachida S, Morgan R, Zhong Y, Montgomery EA, Iacobuzio-Donahue CA. Clinicopathologic and genetic characterization of traditional serrated adenomas of the colon. Am J Clin Pathol 2012; 138:356-66. [PMID: 22912351 DOI: 10.1309/ajcpvt7lc4crpzsk] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Traditional serrated adenomas (TSAs) are a type of colorectal polyp with neoplastic potential. Immunohistochemical analysis and sequencing were performed on 24 TSAs from 23 patients to characterize the molecular genetics of TSAs. Abnormal Ki-67 and p53 labeling were observed in 7 (29%) of 24 and 6 (25%) of 24 TSAs, respectively; both types were significantly associated with the presence of conventional epithelial dysplasia (P = .0005 and P = .0001, respectively). Activating KRAS mutation was identified in 11 TSAs (46%) and was mutually exclusive with activating BRAF mutations, which were seen in 7 TSAs (29%). Abnormal p53 nuclear labeling in a TSA was significantly associated with BRAF mutation status (P = .04), whereas no relationship was found for β-catenin labeling patterns. The overall morphologic features of TSA do not correlate with the genetic status of the KRAS and BRAF genes. However, conventional epithelial dysplasia and abnormal p53 labeling in a TSA are seen more often in the setting of BRAF mutation.
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Rex DK, Ahnen DJ, Baron JA, Batts KP, Burke CA, Burt RW, Goldblum JR, Guillem JG, Kahi CJ, Kalady MF, O’Brien MJ, Odze RD, Ogino S, Parry S, Snover DC, Torlakovic EE, Wise PE, Young J, Church J. Serrated lesions of the colorectum: review and recommendations from an expert panel. Am J Gastroenterol 2012; 107:1315-29; quiz 1314, 1330. [PMID: 22710576 PMCID: PMC3629844 DOI: 10.1038/ajg.2012.161] [Citation(s) in RCA: 792] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Serrated lesions of the colorectum are the precursors of perhaps one-third of colorectal cancers (CRCs). Cancers arising in serrated lesions are usually in the proximal colon, and account for a disproportionate fraction of cancer identified after colonoscopy. We sought to provide guidance for the clinical management of serrated colorectal lesions based on current evidence and expert opinion regarding definitions, classification, and significance of serrated lesions. A consensus conference was held over 2 days reviewing the topic of serrated lesions from the perspectives of histology, molecular biology, epidemiology, clinical aspects, and serrated polyposis. Serrated lesions should be classified pathologically according to the World Health Organization criteria as hyperplastic polyp, sessile serrated adenoma/polyp (SSA/P) with or without cytological dysplasia, or traditional serrated adenoma (TSA). SSA/P and TSA are premalignant lesions, but SSA/P is the principal serrated precursor of CRCs. Serrated lesions have a distinct endoscopic appearance, and several lines of evidence suggest that on average they are more difficult to detect than conventional adenomatous polyps. Effective colonoscopy requires an endoscopist trained in the endoscopic appearance of serrated lesions. We recommend that all serrated lesions proximal to the sigmoid colon and all serrated lesions in the rectosigmoid > 5 mm in size, be completely removed. Recommendations are made for post-polypectomy surveillance of serrated lesions and for surveillance of serrated polyposis patients and their relatives.
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Affiliation(s)
| | - Dennis J. Ahnen
- Staff Physician Denver VA Medical Center and Professor of Medicine, University of Colorado School of Medicine
| | | | | | - Carol A. Burke
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio
| | - Randall W. Burt
- Division of Gastroenterology, Department of Internal Medicine, University of Utah School of Medicine
| | | | | | - Charles J. Kahi
- Indiana University School of Medicine; Richard L. Roudebush VA Medical Center
| | | | | | - Robert D. Odze
- Brigham and Womens Hospital, Department of Pathology, Harvard Medical School, Boston MA
| | - Shuji Ogino
- Department of Pathology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Susan Parry
- New Zealand Familial GI Cancer Registry, Auckland City Hospital, New Zealand; Department of Gastroenterology, Middlemore Hospital, Auckland, New Zealand
| | - Dale C. Snover
- Department of Pathology, Fairview Southdale Hospital, Edina, MN
| | - Emina Emilia Torlakovic
- Department of Laboratory Medicine and Pathobiology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Paul E. Wise
- Department of Surgery, Vanderbilt University Medical Center
| | - Joanne Young
- Cancer Council Queensland Senior Research Fellow, Laboratory Head, Familial Cancer Laboratory, Australia
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Filiform serrated adenoma: authors' reply. Pathology 2012; 44:386. [PMID: 28193346 DOI: 10.1097/pat.0b013e3283540012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Filiform serrated adenoma is an unusual, less aggressive variant of traditional serrated adenoma. Pathology 2012; 44:18-23. [PMID: 22157687 DOI: 10.1097/pat.0b013e32834d7bbf] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
AIMS Filiform serrated adenoma (SA) is an uncommon type of polyp that shows morphological features similar to traditional serrated adenoma (TSA). Unlike TSA, filiform SA is composed predominantly of prominent, thin, elongated filiform projections lined by neoplastic epithelium with a serrated contour. However, the molecular pathogenesis underlying filiform SA is unclear and its relationship with TSA has not been explored yet. The purpose of this study was to determine the clinicopathological and molecular characteristics of filiform SA in a cohort of Korean patients. METHODS Thirteen filiform SAs were evaluated for mutations of BRAF and KRAS genes, microsatellite instability (MSI), and promoter hypermethylation of hMLH1, MGMT, p16, MINT1, MINT2, MINT31 and the APC genes. The clinicopathological and molecular results were compared to results from previously published studies of left-sided TSAs among Koreans. RESULTS All but one filiform SAs were located in the left colon and showed low grade dysplasia. BRAF and KRAS mutations were observed in six (46.2%) and four (30.3%) filiform SAs, respectively. Hypermethylation of hMLH1 (using both Herman et al. and Park et al.), MGMT, p16, MINT1, MINT2, MINT31 and the APC gene was found in 30.3% and 7.7%, 38.5%, 15.4%, 53.8%, 46.2%, 38.5% and 15.4% of cases, respectively. Thirteen filiform SAs were MS stable and classified with a CpG island methylator phenotype (CIMP) of high in five, CIMP low in five and CIMP negative in three cases. Compared to TSAs in the left colon, methylation of hMLH1, APC, and MGMT was less frequent in cases of filiform SA, but the filiform SA sizes were larger. CONCLUSION Our findings suggest that filiform SA may grow larger without acquisition of additional genetic alterations and can be categorised as a rare, less aggressive variant of TSA with unique morphology.
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Alizart MMC, Rosty C, Brown IS. Colonic mucosubmucosal elongated polyp: a clinicopathologic study of 13 cases and review of the literature. Am J Surg Pathol 2012; 35:1818-22. [PMID: 21989340 DOI: 10.1097/pas.0b013e31822c0688] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Colonic mucosubmucosal elongated polyp (CMSEP) is a distinctive non-neoplastic colorectal polyp characterized by pedunculated, elongated shape and is composed mainly of expanded submucosa with a normal mucosal lining. Only a small number of these polyps have been reported, exclusively from Japan. We report the clinicopathologic characteristics of 13 CMSEPs occurring in 11 patients, mostly from European ancestry. Ten of these polyps were resected during colonoscopy, and 3 were diagnosed in a patient who underwent sigmoid resection for diverticular disease. Among patients who had undergone a colonoscopy, 4 had altered bowel habit, and 1 suffered from abdominal discomfort; the other 5 patients had routine screening colonoscopy. Eight polyps were located in the sigmoid colon, 3 in the right colon, 1 in the rectosigmoid junction, and 1 in the descending colon. Polyp size ranged from 10 to 150 mm. Histologically, CMSEPs were characterized by unremarkable large bowel mucosa and submucosal stalk containing dilated thick-walled veins running parallel to the long axis of the polyp. Mucosal inflammation or fibromuscular proliferation characteristic of mucosal prolapse was absent. The pathogenesis of CMSEP may involve mechanical traction of the mucosa and the superficial submucosa during peristalsis in a fragile area of the colon. Despite the occasional large size, CMSEP is a benign lesion seldom leading to clinical complications.
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Affiliation(s)
- Michelle Marie-Christine Alizart
- Anatomical Pathology, Pathology Queensland, Royal Brisbane and Women's Hospital, The University of Queensland School of Medicine, UQ Centre for Clinical Research, Herston, Australia.
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[Histopathological diagnosis and differential diagnosis of colorectal serrated polys: findings of a consensus conference of the working group "gastroenterological pathology of the German Society of Pathology"]. DER PATHOLOGE 2011; 32:76-82. [PMID: 20924763 DOI: 10.1007/s00292-010-1365-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Until recently, two major types of colorectal epithelial polyps were distinguished: the adenoma and the hyperplastic polyp. While adenomas - because of their cytological atypia - were recognized as precursor lesions for colorectal carcinoma, hyperplastic polyps were perceived as harmless lesions without any potential for malignant progression, mainly because hyperplastic polyps lack cytological atypia. Meanwhile, it is evident that the lesions formerly classified as hyperplastic represent a heterogeneous group of polyps, some of which exhibit a significant risk of neoplastic progression. These lesions show characteristic epigenetic alterations not commonly seen in colorectal adenomas and progress to colorectal carcinoma via the so-called serrated pathway (CIMP pathway). This group of polyps is comprised not only of hyperplastic polyps, but also of sessile serrated adenomas (SSA), traditional serrated adenomas (TSA) and mixed polyps, showing serrated and "classical" adenomatous features. In a consensus conference of the working group of gastroenterological pathology of the German Society of Pathology, standardization of nomenclature and diagnostic criteria as well as recommendations for clinical management of these serrated polyps were formulated and are presented herein.
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Klarskov L, Mogensen AM, Jespersen N, Ingeholm P, Holck S. Filiform serrated adenomatous polyposis arising in a diverted rectum of an inflammatory bowel disease patient. APMIS 2011; 119:393-8. [PMID: 21569098 DOI: 10.1111/j.1600-0463.2011.02717.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
A 54-year-old man, previously colectomized for inflammatory bowel disease, developed carcinoma in the inflamed rectum stump. The malignant growth was surrounded by a filiform polyposis, grossly considered as pseudopolyps. The histology disclosed, however, a morphology corresponding to the recently described filiform subset of serrated adenoma (FSA). The clustering of the FSA amounted to a filiform serrated adenomatous polyposis, a hitherto unreported observation. It is speculated that neoplastic transformation of pre-existing pseudopolyps and prolaps-related events lead to this peculiar morphology. Minor zones with a villous structure were admixed as were small areas of traditional serrated adenoma and patches of flat dysplasia. Although a combined gastric and intestinal (positivity for MUC5AC, MUC2, MUC6, CDX2) immunoprofile characterized the adenomatous component, a downregulation of the gastric mucin along with a loss of the serrated attribute accompanied the malignant transformation. An added dynamic shift during the adenoma carcinoma sequence included the acquisition of CK7 expression in the malignant portion. Gastric mucin may play a role in the initial step of the neoplastic evolution and CK7 may denote neoplastic progression. This case confirms the notion of a widely variegated morphology of precursor lesions of colorectal carcinoma arising in a chronically inflamed bowel as opposed to the generally more monotonous appearance of adenomas in a sporadic context.
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Affiliation(s)
- Louise Klarskov
- Department of Pathology, University of Copenhagen, Hvidovre Hospital, Denmark
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Abstract
Until very recently, there was general acceptance in the pathology community that all serrated lesions of the colon and rectum without overt cytologic dysplasia were hyperplastic polyps and had no malignant potential. Although there are still several unanswered questions in regard to the relationship between the various serrated lesions, there is a better understanding of the relationship of sessile serrated adenoma to carcinoma. This article discusses hyperplastic polyps, sessile serrated adenoma, traditional serrated adenoma, mixed polyps, and serrated lesions in such conditions as idiopathic inflammatory bowel disease and mechanical trauma. The major focus of the content is on diagnostic features of these lesions.
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Affiliation(s)
- Dale C Snover
- Department of Pathology, Fairview Southdale Hospital, 6401 France Avenue South, Edina, MN 55435-2199, USA; Department of Laboratory Medicine and Pathology, The University of Minnesota Medical School, Minneapolis, Mayo Mail Code 609, 420 Delaware Street SE, Minneapolis, MN 55455, USA
| | - Kenneth P Batts
- Department of Laboratory Medicine and Pathology, The University of Minnesota Medical School, Minneapolis, Mayo Mail Code 609, 420 Delaware Street SE, Minneapolis, MN 55455, USA; Department of Pathology and Laboratory Medicine, and Virginia Piper Cancer Center, Abbott Northwestern Hospital, 800 East 28th Street, Minneapolis, MN 55407, USA; Hospital Pathology Associates, PA, 2345 Rice Street, Suite 160, Saint Paul, MN 55113-3769, USA.
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Aust DE, Baretton GB. Serrated polyps of the colon and rectum (hyperplastic polyps, sessile serrated adenomas, traditional serrated adenomas, and mixed polyps)-proposal for diagnostic criteria. Virchows Arch 2010; 457:291-7. [PMID: 20617338 DOI: 10.1007/s00428-010-0945-1] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2010] [Revised: 06/20/2010] [Accepted: 06/20/2010] [Indexed: 12/17/2022]
Abstract
Until recently, two major types of colorectal epithelial polyps were distinguished: the adenoma and the hyperplastic polyp. While adenomas-because of their cytological atypia-were recognized as the precursor lesions for colorectal carcinoma, hyperplastic polyps were perceived as harmless lesions without any potential for malignant progression mainly because hyperplastic polyps are missing cytological atypia. Meanwhile, it is recognized that the lesions, formerly classified as hyperplastic, represent a heterogeneous group of polyps with characteristic serrated morphology some of which exhibit a significant risk of neoplastic progression. These serrated lesions show characteristic epigenetic alterations not commonly seen in colorectal adenomas and progress to colorectal carcinoma via the so-called serrated pathway (CpG-island-methylation-phenotype pathway). This group of polyps is comprised not only of hyperplastic polyps, but also of sessile serrated adenomas, traditional serrated adenomas and mixed polyps, showing serrated and "classical" adenomatous features. Diagnostic criteria and nomenclature for these lesions are not uniform and, therefore, somewhat confusing. In a consensus conference of the Working Group of Gastroenterological Pathology of the German Society of Pathology, standardization of nomenclature and diagnostic criteria as well as recommendations for clinical management of these serrated polyps were formulated and are presented herein.
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Affiliation(s)
- Daniela E Aust
- Institute for Pathology, University Hospital Carl Gustav Carus, TU Dresden, 01307 Dresden, Germany.
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Abstract
Filiform polyposis is a rare condition of uncertain pathogenesis that is usually found in association with Crohn’s disease, ulcerative colitis, intestinal tuberculosis or histiocytosis X. We report seven interesting cases of polyposis with various pathologic components, mainly located in the left side of the colon with no associated inflammatory bowel disease, intestinal tuberculosis or histiocytosis X. Multiple finger-like polypoid lesions with the appearance of stalactites were noted on the left side of the colon, especially in the sigmoid area, at the time of colonoscopy. The polyps had a variety of sizes and shapes and were shown to have various histopathologic components among the different patients. Although filiform polyposis localized in the sigmoid colon appears not to have high oncogenic potential, periodic follow-up seems to be needed.
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Beta-catenin nuclear labeling is a common feature of sessile serrated adenomas and correlates with early neoplastic progression after BRAF activation. Am J Surg Pathol 2009; 33:1823-32. [PMID: 19745699 DOI: 10.1097/pas.0b013e3181b6da19] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Recent observations indicate that some sessile serrated adenomas (SSAs) have aberrant beta-catenin nuclear labeling, implicating the Wnt pathway in the molecular progression of SSAs to colorectal carcinoma. We sought to expand upon this finding by characterizing beta-catenin expression in the full spectrum of serrated colorectal polyps, and correlating these findings with the genetic status of BRAF, KRAS and CTNNB1. Immunolabeling for beta-catenin confirmed the presence of abnormal nuclear accumulation in SSAs, with 35/54 (67%) SSAs showing nuclear labeling compared with 0/12 hyperplastic polyps. Abnormal nuclear labeling was also identified in 4/11 (36%) traditional serrated adenomas (TSAs) (P=0.00001). When SSAs were further analyzed with respect to the presence or absence of conventional epithelial dysplasia, nuclear beta-catenin labeling was seen in 8/27 (29%) SSAs without dysplasia (SSA) but in 27/27 (100%) of SSAs with dysplasia (P=0.000001). Sequencing of genomic DNA extracted from a subset of hyperplastic polyps, SSAs, SSAs with dysplasia, TSAs and tubular adenomas failed to identify any CTNNB1 mutations to account for abnormal beta-catenin nuclear labeling. However, abnormal nuclear labeling always occurred in the setting of a BRAF V600E mutation, indicating aberrant nuclear labeling occurs on a background of BRAF activation. Of interest, all 6 TSAs contained a KRAS mutation confirming that SSAs and TSAs are genetically distinct entities. These findings validate previous reports implicating activation of the Wnt signaling pathway in SSAs, and further indicate that Wnt pathway activation plays a role in the neoplastic progression of SSAs and TSAs to colonic carcinoma by mechanisms independent of CTNNB1 mutation.
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Bokhary R. Serrated colonic polyps in a teaching hospital in Saudi Arabia: prevalence and review of classification. Saudi J Gastroenterol 2009; 15:234-8. [PMID: 19794268 PMCID: PMC2981839 DOI: 10.4103/1319-3767.56097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND/AIM To determine the prevalence of serrated colorectal polyps in the King AbdulAziz University Hospital population and to review the current classification of colorectal serrated polyps with emphasis on morphological features. MATERIALS AND METHODS This retrospective study used cases diagnosed with serrated colorectal polyps at the histopathology laboratory of King AbdulAziz University Hospital during last five years (2004-2008). The slides were reexamined microscopically and the lesions were renamed according to the terminology discussed in this article. RESULTS Diagnosed hyperplastic polyps represented 12.3% of all colorectal polyps submitted to our laboratory during the study period. However, the false positive rate was found to be 42.5%. Of the truly diagnosed serrated polyps, the most common subtype is the microvesicular serrated polyps. The majority of the serrated colorectal polyps was found in males, with a wide age range. CONCLUSION The prevalence of serrated colorectal polyps in our geographic area seems to be similar to that in western populations.
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Affiliation(s)
- Rana Bokhary
- Department of Laboratory Medicine, Anatomical Pathology, King Abdul Aziz University Hospital, P.O. Box 80215, Jeddah 21589, Saudi Arabia.
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Abstract
Serrated polyps of the large intestine comprise a heterogeneous group of mucosal lesions that includes nondysplastic polyps, such as hyperplastic polyps and sessile serrated polyps, and polyps that show overt cytologic dysplasia, namely serrated adenomas and mixed hyperplastic/adenomatous polyps. These polyps have received increased recognition over the past 2 decades, as emerging evidence suggests that a subset may be precursors to colorectal carcinomas that lack chromosomal instability. Several investigators have proposed the concept of the "serrated neoplastic pathway" according to which nondysplastic serrated lesions develop progressively severe dysplasia culminating in the development of microsatellite unstable carcinomas that show DNA hypermethylation and BRAF mutations. A subset of hyperplastic polyps and sessile serrated polyps show mutations in the BRAF gene and abnormal DNA methylation, which can, ultimately, affect the promoter regions of key DNA-repair and tumor suppressor genes, such as MLH1 and MGMT, leading to their decreased transcription and microsatellite instability. On the basis of this hypothesis, many authors have proposed that sessile serrated polyps should be treated and surveilled similar to conventional adenomas, although prospective data are lacking. This review describes the clinicopathologic and molecular features of serrated polyps and discusses the current data regarding their biologic significance.
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