PEDUNCULATED INVERTED HYPERPLASTIC POLYP OF THE SIGMOID COLON TREATED WITH ENDOSCOPIC POLYPECTOMY

A case of inverted hyperplastic polyp of the sigmoid colon is reported. The patient was a 67‐year‐old woman who visited our hospital for further evaluation of constipation. Colonoscopy revealed a pedunculated polyp with linear central depression, about 12 mm in diameter, in the sigmoid colon. Excluding the polyp, there was no lesion in the colorectum. Endoscopic polypectomy was performed. Histological examination of the specimen revealed a stalked polyp that had scattered goblet cells and elongated tubules with serrated profiles in the superficial portion. The nodules of deep tubules impinged on the muscularis mucosae. Proliferation of fibromuscular tissue was not seen in the polyp. There was no evidence of malignancy. This polyp was diagnosed as an inverted hyperplastic polyp. Pedunculated‐type inverted hyperplastic polyp of the colon is rare.     

Fibrovascular polyp of the sigmoid colon

A case of a fibrovascular polyp of the sigmoid colon is reported. The patient tested positively for fecal occult blood on a mass survey for colorectal cancer, and underwent colonoscopic examination which revealed a pedunculated submucosal tumor in the sigmoid colon. The tumor, about 10 mm in diameter, had a short thin stalk and was removed endoscopically; the histological diagnosis was fibrovascular polyp. This extremely rare polyp is discussed, and particular attention is focused on the unusual endoscopic features and on the appropriate management.     

A case of pedunculated colonic adenoma with pseudocarcinomatous invasion and squamous metaplasia occurring in the sigmoid colon

A case of pedunculated colonic adenoma with pseudocarcinomatous invasion and squamous metaplasia occurring in the sigmoid colon is reported. The patient was a 65-year-old man who visited our hospital for further evaluation of a positive fecal occult blood test. Colonoscopy revealed a pedunculated polyp with a thick swollen stalk in the sigmoid colon. EUS revealed a hyperechoic lesion in the stalk. However, endosonographically, the third and fourth layers of the colonic wall were shown to be normal. It was suspected to be a colonic adenoma with pseudocarcinomatous invasion from these endoscopic findings. Endoscopic polypectomy was performed. Histological examination of the specimen revealed tubular adenoma with moderate epithelial atypia and submucosal displacement of adenomatous glands with variable cystic changes. Squamous metaplasia and hemosiderin deposition were also seen in the mucosal and submucosal layer, respectively. This polyp was diagnosed as a colonic adenoma with pseudocarcinomatous invasion with squamous metaplasia.     

A case of polypoid cavernous hemangioma of the sigmoid colon excised by colonoscopic polypectomy

A 28-year-old Japanese man was admitted to our institute because of sharp anal pain and a mass that prolapsed from the anus after defecation. After spinal anesthesia for emergency operation, the mass spontaneously withdrew into the anus and the pain disappeared. Surgery was postponed. Barium enema and colonoscopy revealed a pedunculated polyp in the sigmoid colon, which was removed by snare polypectomy with electrocautery. The resected polyp was granular and reddish, and measured 33 × 22 × 14 mm. Histological examination of the polyp revealed a cavernous hemangioma. Hemangioma of the colon is rare; only 52 cases have been reported in Japan. Of these patients, eight underwent endoscopie polypectomy. The present lesion is the largest thus treated that has been documented. Endoscopie polypectomy seems to be a safe and preferable procedure for the diagnosis and treatment of small, solitary polypoid hemangiomas of the colon.     

Solitary juvenile polyp developing adenocarcinoma with submucosal invasion

Solitary juvenile polyps are generally non‐neoplastic hamartomatous polyps. Inflammation is suggested as the cause of proliferation and progression of these polyps, and adenomatous and carcinomatous changes are rare. We report a rare case of a solitary juvenile polyp with malignant transformation that developed in the sigmoid colon of a 12‐year‐old boy. A 3 cm, pedunculated polyp was endoscopically resected, and histologic evaluation revealed the characteristic features of a juvenile polyp. However, mucous‐filled ectatic glandular spaces were lined by mucin‐secreting columnar epithelial cells with atypical change, and an admixture of adenocarcinoma invading the submucosa was confirmed. The histologic features may suggest the involvement of the adenoma–carcinoma sequence in the development of adenocarcinoma in the present case. Although rare, solitary juvenile polyps should develop adenocarcinoma and thorough histologic evaluation of the resected polyps is warranted to identify the adenomatous tissue.     

Colonoscopic Follow-up Study after Polypectomy

One hundred and forty-seven patients with colonic adenoma and early cancer were followed by one or more total colonoscopies. A very precisely planned colonoscopic follow-up schedule for the polypectomized patients was then assessed. In patients who received a single follow-up examination, the incidence of developing new polyps was 46.7% (1 year), 53.9% (2 years) and 73.3% (3 years or more). Patients who received multiple follow-up examinations showed an average incidence of developing new polyps (polyp positive examinations/total examinations) of 46.9%. With regards to the location and histology of the polyps, there was no difference found between the initial and new polyps. Seventeen colon cancers (14 mucosal, 2 early invasive, 1 advanced) were detected in 16 patients in the follow-up examinations. The time elapsed from a diagnosis of ‘clean colon’ to a new cancer developing was 1.9±1.0 years. The rate of new pedunculated polyps was found to be significantly low (p <0.01), and their size was significantly smaller (p<0.01) when compared with polyps in the initial early colon cancer. Follow-up examinations every two years are recommended     

Colonofiberscopic management of colonic polyps

Conclusions Endoscopic removal of 343 colonic polyps more than 0.5 cm in size, located from the cecum to the sigmoid colon and beyond the reach of rigid sigmoidoscopes, is reported. Diagnostic colonofiberscopy is a valuable procedure permitting direct visual examination of the entire colon with a high degree of safety. More than 1,800diagnostic colonofiberscopies have been performed in our unit without a single complication. The polypectomy procedures via the colonofiberscope were done without mortality and with only a single immediate complication, which responded to conservative measures. Endoscopic removal of colonic polyps is proposed as a safe, practical alternative to either laparotomy and colotomy or repeated barium-enema studies in the management of the patient with a colonic polyp. The endoscopic approach allows differentiation of malignant from nonmalignant polyps by complete excision, thus permitting definitive cancer therapy measures to be undertaken promptly and with assurance. Endoscopic removal of colonic polyps is not advised for endoscopists who have not first achieved considerable experience and dexterity in diagnostic colonoscopy. Endoscopic removal of colonic polyps is best accomplished by an experienced endoscopist supported by the full spectrum of general hospital resources, after the patient has been thoroughly evaluated medically. It should be carried out on an inpatient basis. When a patient has a colonic polyp, an alert should be maintained for unsuspected colonic cancer unrelated to the polyp, lest the less serious lesion monopolize the clinical situation. Presented at the 58th Clinical Congress of the American College of Surgeons, San Francisco, California, October 2 to 6, 1972.     

Long-term follow-up of patients with malignant pedunculated colon polyps after colonoscopic polypectomy

BACKGROUND:

Previously published studies have suggested that patients with resected colon cancer have an increased risk for early metachronous colon cancer. Current screening guidelines recommend intense surveillance by colonoscopy for the initial five years after the initial colon cancer has been resected. Information regarding endoscopically removed malignant polyps is limited.

METHODS:

In the present study, 25 consecutive patients (14 male, 11 female) with malignant pedunculated colon polyps treated with snare cautery polypectomy were followed for more than one decade up to 20 years. Five patients required an additional resection to ensure that removal of the original cancer was complete. Annual colonoscopies were planned for five years. If an adenoma was detected in the fifth year, colonoscopy was performed annually until no adenomas were detected. Otherwise, colonoscopy was planned every three years after five years.

RESULTS:

In the present study, there was no mortality from colon cancer and no patient developed either recurrent colon cancer or an early metachronous colon cancer during the initial five-year period of surveillance. Two patients (one male, one female) ultimately developed late cecal cancers almost one decade after the original colon cancers were resected. One had an early stage cancer that was resected, while the other had an infiltrating mucinous carcinoma complicating a small tubulovillous adenoma with extension to a single lymph node. After surgical removal and adjuvant chemotherapy, no further neoplastic disease has been detected.

CONCLUSIONS:

Overall, patients with malignant pedunculated polyps do extremely well if appropriately managed at the time of the initial polypectomy. Short-term outcomes after removal of a malignant polyp(s) appear to be similar to those with a nonmalignant polyp. However, late metachronous colon cancer may still occur. Long-term follow-up should be considered in each patient, assuming reasonable life expectancy, because risk of additional adenomas and metachronous colon cancer persists even after the initial five years of currently recommended surveillance. Patients with resected malignant polyps may represent a special patient subgroup that requires surveillance for more extended periods than current guidelines have recommended.     

Acromegaly and colon cancer

The occurrence of colon cancer in 1 patient with acromegaly prompted a study of an additional 12 patients with acromegaly. In addition to the index case, 1 patient was retrospectively discovered to have colon cancer, and 1 was found to have colonic adenocarcinoma in the course of the study. One patient had a presumptive sigmoid polyp shown by barium enema but refused further studies. Eight patients received colonoscopy. Two patients had adenomatous polyps and 1 had two hyperplastic polyps. This study supports previously published data on the occurrence of colon polyps in patients with acromegaly and suggests that the incidence of colon cancer is much higher than that expected by chance.     

Hemorrhage following colonoscopic polypectomy

Clinically significant hemorrhage following colonoscopic polypectomy may occur primarily as the polyp is removed or manifest itself days to weeks later secondary to clot dissolution. The rate of hemorrhage following colonoscopic polypectomy ranges widely from 0.3 to 6.1 percent, depending on whether the data are derived from studies using the number of patients or number of polypectomies. A retrospective study was performed in our institution to study 4,721 patients who underwent polypectomy between January 1987 and December 1991. Twenty (0.4 percent) of these patients required hospital admission because of 9 primary and 11 delayed hemorrhages. Fifty-four polyps were removed from these patients: 11 in the right colon, 7 in the transverse colon, 17 in the descending colon, and 19 in the sigmoid colon. Eight polyps were 2 cm or larger, 10 were pedunculated, and 44 were sessile. Six patients underwent cauterization or resnaring of the bleeding polyp site, one patient underwent subtotal colectomy, and the remainder of the patients stopped bleeding spontaneously. Factors that could be associated with the outcome of hemorrhage include patient age, size, location, number and morphology of polyps (i.e.,sessile or thick stalk), and use of anticoagulants. An experienced endoscopist with knowledge of electrosurgical and technical principles may be the most important factor for prevention of postpolypectomy bleeding     

Adenocarcinoma in solitary large hyperplastic polyp diagnosed by magnifying colonoscope: report of a case

We report a case of carcinoma in a hyperplastic polyp in a 78-year-old female that was diagnosed before resection using a magnifying colonoscope. The patient presented with fecal occult blood and underwent total colonoscopy, which revealed a 12-mm sessile polyp in the cecum. When seen in magnified view, an irregularly shaped pit was evident at the center of the polyp that was distinct from the asteroid-type pits observed over most of the lesion. We diagnosed this lesion as a hyperplastic polyp with a carcinoma component. The patient underwent endoscopic mucosal resection, and histologic section revealed a well-differentiated intramucosal adenocarcinoma in the hyperplastic polyp. Hyperplastic polyps of the colon are regarded as benign, nonneoplastic lesions. Few have reported carcinomas in or with hyperplastic polyps, and most of those were diagnosed after resection and histologic investigation. The literature suggests a precise observation and consideration of resection for large solitary hyperplastic polyps in the right side of the colon, because the risk of malignancy is high. Magnifying colonoscopy is helpful for observing the surface in detail and for correctly diagnosing and managing the lesion.     

Ossification within an adenomatous polyp: a case report and review of the literature

Osseous metaplasia within the gastrointestinal tract is rare and occurs in benign, premalignant, and malignant neoplasms. Here, we report the youngest case of an adenomatous polyp with the presence of ossification and a concomitant review of the literature with regard to ossification of colonic polyps. A 28-year-old man underwent colonoscopy for 8 months of rectal bleeding. A 4.5-cm pedunculated polyp was found in the descending colon and excised. Histological examination showed adenomatous change with an area of calcification and osteoid formation. Ossification of colonic polyps is mainly associated with the clinical symptom of bleeding and may warrant consideration as a high-risk feature.     

Efficacy, risk factors and complications of endoscopic polypectomy： Ten year experience at a single center

AIM： To examine the efficacy and complications of colonoscopic resection of colorectal polypoid lesions. METHODS： We retrospectively reviewed 1354 polypectomies performed on 1038 patients over a ten- year period. One hundred and sixty of these were performed for large polyps, those measuring ≥ 20 mm. Size, shape, location, histology, the technique of polypectomy used, complications, drugs assumption and associated intestinal or extra intestinal diseases were analyzed. For statistical analysis, the Pearson χ2 test, NPC test and a Binary Logistic Regression were used. RESULTS： The mean patient age was 65.9 ± 12.4 years, with 671 men and 367 women. The mean size of polyps removed was 9.45 ± 9.56 mm while the size of large polyps was 31.5 ± 10.8 mm. There were 388 pedunculated and 966 sessile polyps and the most common location was the sigmoid colon （41.3%）. The most frequent histology was tubular adenoma （55.9%） while for the large polyps was villous （92/160 -57.5%）. Coexistent malignancy was observed in 28 polyps （2.1%） and of these, 20 were large polyps. There were 17 procedural bleeding （1.3%） and one perforation. The statistical analysis showed that cancer is correlated to polyp size （P 〈 0.0001）; sessile shape （P 〈 0.0001） and bleeding are correlated to cardiac disease （P = 0.034）, tubular adenoma （P = 0.016） and polyp size.CONCLUSION： The endoscopic resection is a simple and safe procedure for removing colon rectal neoplastic lesions and should be considered the treatment of choice for large colorectal polyps. The polyp size is an important risk factor for malignancy and for bleeding.     

MULTIPLE INFLAMMATORY MYOGLANDULAR POLYPS OF THE COLON

The patient was a 35‐year‐old man who was observed after bone marrow transplantation for acute lymphocytic leukemia. Polyps were found by colonoscopy performed after a positive fecal occult blood test, and the patient was admitted for polypectomy. There were three polyps, which were all reddened and pedunculated and were, respectively, located in the transverse, descending, and sigmoid colons. Polypectomy was performed, and all lesions were histopathologically diagnosed to be inflammatory myoglandular polyps. Inflammatory myoglandular polyps have been reported to occur solitarily only, and this is the first report of multiple occurrence.     

POLYPOID COLONIC HAMARTOMATOUS INVERTED POLYP

We herein present a unique polyp diagnosed as polypoid colonic hamartomatous inverted polyp. Colonoscopic examination revealed a clover‐like submucosal tumor about 30 mm in size with a long stalk at the mid‐transverse colon. The polyp consisted of elongated crypts with cystic dilatation located in the submucosal layer. To the best of our knowledge, there have been no previous reports of the same type of pedunculated colonic polyp, similar in appearance to inflammatory myoglandular polyps but covered with a layer of normal mucosa possessing the muscularis mucosae at the uppermost surface of the polyp.     

金属夹联合尼龙套圈在内镜带蒂大息肉摘除中的应用

背景：消化道出血是内镜息肉摘除术最常见的并发症。目的：观察金属夹联合尼龙套圈对内镜带蒂大息肉摘除术的效果和安全性。方法：选取2011年6月一2012年8月上海市第一人民医院分院89例带蒂大息肉患者,分为尼龙套圈组（A组）和金属夹联合尼龙圈套组（B组）,回顾性分析息肉形态、部位、大小以及并发症发生率。结果：A组和B组息肉形态均以山田Ⅳ型为主,主要位于乙状结肠,两组患者性别、年龄、息肉顶部、蒂部平均直径相比均无明显差异（P〉0．05）。A组和B组的术中出血发生率（12．8％对10．0％）、术后迟发性出血发生率（10．3％对4．0％）相比均无明显差异（P〉0．05）,经治疗后出血均停止。A组2例患者术后3个月息肉复发,B组手术创面愈合良好,无息肉残端残留。结论：金属夹联合尼龙套圈能有效预防内镜下带蒂大息肉切除术中和术后的出血。     

Treatment of colonic polyps--practical considerations

The adenomatous colonic polyp, a neoplastic lesion, is the precursor of most if not all carcinomas of the colon and rectum. Confirmatory evidence is derived from epidemiological, histological and clinical data demonstrating a close parallelism between adenomas and cancer of the colon. Based on current knowledge, all colonic polyps should be removed to prevent the development of colonic cancer. However, since the risk of malignancy within an adenoma is related to its size, histology and the degree of dysplasia, practical considerations dictate that all polyps 1 cm in diameter or larger should be removed upon their detection by barium enema or colonoscopy since such adenomas are the ones most likely to contain malignancy. The endoscopic removal of colon polyps can be efficiently and safely accomplished when established principles of colonoscopy and electrosurgery are followed. This technique requires the proper equipment, a skilled endoscopy assistant, and an experienced endoscopist with the ability to adeptly perform colonoscopy, an understanding of the basic concepts of electrocautery and knowledge of the various structural configurations of colonic polyps. Colonoscopic polypectomy will avoid the need for surgical resection in most instances. Management of the malignant colonic polyp remains controversial. The patient with a sessile or pseudo-pedunculated polyp containing invasive cancer should undergo colonic resection. Surgery is not necessary for the majority of patients whose pedunculated adenomas contain invasive cancer, unless the malignancy is poorly differentiated, the cancer invades lymphatics or vascular channels, or tumour is seen at or near the resection margin. Surveillance colonoscopy after endoscopic polypectomy should be performed in most instances within one year to look for recurrent tumour, missed polyps or a metachronous adenoma. Subsequently, colonoscopy should be performed every two years in patients with multiple index polyps, and every three years after removal of a single index adenoma.     

Sigmoid colon carcinoma that developed from a sessile-type cancer in a short period of time

We report a case of sigmoid colon carcinoma that developed from a sessile-type cancer in a short period of time. An 83-year-old man was found to have a round sessile polyp, about 2 cm in diameter, in the sigmoid colon. Because he had taken anticoagulants, immediate endoscopic mucosal resection and biopsy were not performed. Forty-three days later, the apical surface of the sessile polyp had become depressed and ulcerated, and we judged that an endoscopic resection was not indicated for this lesion. The histologic diagnosis of the biopsy specimens was a well-differentiated adenocarcinoma. We recommended surgical treatment; however, the patient was not in favor of surgical treatment and would not consent to surgery. Two more examinations were performed and the tumor was found to have developed into an invasive cancer with ulcerated, nodular margins involving 3/4 of the colonic lumen. At 271 days after the initial examination, the patient finally consented to surgery and a partial resection of the sigmoid colon was performed. The tumor was classified as stage I (T2N0M0). The several examinations performed from presentation within a short time span provide evidence of the morphologic changes that occur when a sessile-type cancer develops into an ulcerating invasive cancer. We hypothesize that remarkable configuration changes and development take place when a tumor becomes invasive in the muscularis propria from massive submucosal invasion. Our findings suggest that among the tumors discovered as typical ulcerating invasive type colon cancers are those that developed from protuberant tumors in a short period of time.     

Role of computed tomographic colonoscopy of postoperative surveillance in patient with gastric cancer

AIM: To examine the diagnostic yield of colorectal neoplasia at computed tomographic colonoscopy (CTC) as well as the feasibility of contrast enhanced CTC in patients with gastric cancer. METHODS: To examine the incidence of colon polyp we selected postoperative 188 gastric cancer patients, which we refer to as the 'colon polyp survey group'. To examine the feasibility of CTC for early detection of colon cancer or advanced colon adenoma, we selected 47 gastric cancer patients (M:F 29:18, mean age 53.8 years), which we call the 'CT colonoscopy group'. All the 47 patients underwent successive CTC and colonoscopy on the same day. RESULTS: Totally 109 colon polyps were observed from 59 out of 188 gastric cancer patients, the incidence rate of colon polyps in gastric cancer patients being 31.4%. The sensitivity of CTC in detecting individuals with at least 1 lesion of any size was 57.1%, the specificity was 72.7%, the positive predictive value was 47.1%, and the negative predictive value was 71.9%. When the cutoff size was decreased to 6 mm, the sensitivity and specificity were 80.0% and 92.9%, respectively, with positive and negative predictive values of 57.1% and 97.5%, respectively. Only one patient was classified as false negative by virtual colonoscopy. CONCLUSION: The diagnostic yield of colorectal polyp was 31.4% in patients with gastric cancer, and contrast enhanced CTC is an acceptable tool for the detection of synchronous colorectal advanced adenoma andpostoperative surveillance of gastric cancer patients.     

Clinicopathological study of juvenile polyp

Thirty-two cases of juvenile polyp were investigated for the clinical and pathological findings. This type polyps occured frequently in the first decade with male predominance. Melena and bloody stool were found in all cases, prolapse of the polyps in 28%, and spontaneous amputation in 9.4%. The duration of symptoms were usually within 6 months. The polyps were found frequently in the rectum and sigmoid colon, about 75%. One case of juvenile polyposis in a 12 years-old male was found. The size of the polyps was usually within 2 cm in diameter and the majority of the polyps were pedunculated. Polypectomy was performed for all cases and additional partial resection for 2 cases with multiple polyps and polyposis. Recurrence and malignant transformation were not found. It should be considered that these are at least two types of histogenesis for the so-called juvenile polyp like as hamartomatous and inflammatory.