Dr Oreoluwa Suleiman
FRCPath Part 1 Course
January 2025
LOWER GI PATHOLOGY
MCQs and EMQs
Based on past papers
Certain topics keep coming up.....
PLAN
1. SELECT THE APPROPRIATE CONDITION FROM THE LIST OF OPTIONS FOR EACH OF THE CLINICOPATHOLOGICAL DESCRIPTIONS.
A. Infective colitis
B. Pseudomembranous colitis
1.A64 year old male admitted in ITU for sepsis develops acute onset diarrhoea. Colonic biopsies show a luminal spray of mucus and neutrophils. The background mucosa shows minimal inflammatory changes.
2.A55 year old female with watery diarrhoea and normal colonoscopy. The colonic biopsies show increased intraepithelial lymphocytes with a thickened sub epithelial collagen plate.
C. Ulcerative colitis
D. Crohn’s disease
3.A28 year old male with bloody diarrhoea and abdominal pain.A colonoscopy shows patchy inflammation affecting the right side colon with apthous ulcers. The colonic biopsies show mild crypt distortion with patchy discontinuous inflammation with cryptitis
4.A42 year old female with acute onset bloody diarrhoea and granular and congested rectum on endoscopy. The rectal biopsy shows oedematous mucosa with dispersed ‘sprinkled salt’ inflammatory cells, cryptitis and dilatation and withering of crypts.
E. Lymphocytic colitis
F. Collagenous colitis
G. Ischaemic colitis
5.A72 year old male with abdominal pain and bloody diarrhoea. Sigmoidoscopy shows inflammation in the left side of the colon, most prominent in the sigmoid colon. Biopsies show extensive ulceration with preservation of basal crypts and active inflammation. There is no crypt distortion or crypt abscess formation.
A. Infective colitis
B. Pseudomembranous colitis
1.A64 year old male admitted in ITU for sepsis develops acute onset diarrhoea. Colonic biopsies show a luminal spray of mucus and neutrophils. The background mucosa shows minimal inflammatory changes.
2.A55 year old female with watery diarrhoea and normal colonoscopy. The colonic biopsies show increased intraepithelial lymphocytes with a thickened sub epithelial collagen plate.
C. Ulcerative colitis
D. Crohn’s disease
3.A28 year old male with bloody diarrhoea and abdominal pain.A colonoscopy shows patchy inflammation affecting the right side colon with apthous ulcers. The colonic biopsies show mild crypt distortion with patchy discontinuous inflammation with cryptitis
4.A42 year old female with acute onset bloody diarrhoea and granular and congested rectum on endoscopy. The rectal biopsy shows oedematous mucosa with dispersed ‘sprinkled salt’ inflammatory cells, cryptitis and dilatation and withering of crypts.
E. Lymphocytic colitis
F. Collagenous colitis
G. Ischaemic colitis
5.A72 year old male with abdominal pain and bloody diarrhoea. Sigmoidoscopy shows inflammation in the left side of the colon, most prominent in the sigmoid colon. Biopsies show extensive ulceration with preservation of basal crypts and active inflammation. There is no crypt distortion or crypt abscess formation.
A. Infective colitis
B. Pseudomembranous colitis
1.A64 year old male admitted in ITU for sepsis develops acute onset diarrhoea. Colonic biopsies show a luminal spray of mucus and neutrophils. The background mucosa shows minimal inflammatory changes.
2.A55 year old female with watery diarrhoea and normal colonoscopy. The colonic biopsies show increased intraepithelial lymphocytes with a thickened sub epithelial collagen plate.
C. Ulcerative colitis
D. Crohn’s disease
3.A28 year old male with bloody diarrhoea and abdominal pain.A colonoscopy shows patchy inflammation affecting the right side colon with apthous ulcers. The colonic biopsies show mild crypt distortion with patchy discontinuous inflammation with cryptitis
4.A42 year old female with acute onset bloody diarrhoea and granular and congested rectum on endoscopy. The rectal biopsy shows oedematous mucosa with dispersed ‘sprinkled salt’ inflammatory cells, cryptitis and dilatation and withering of crypts.
E. Lymphocytic colitis
F. Collagenous colitis
G. Ischaemic colitis
5.A72 year old male with abdominal pain and bloody diarrhoea. Sigmoidoscopy shows inflammation in the left side of the colon, most prominent in the sigmoid colon. Biopsies show extensive ulceration with preservation of basal crypts and active inflammation. There is no crypt distortion or crypt abscess formation.
A. Infective colitis
B. Pseudomembranous colitis
1.A64 year old male admitted in ITU for sepsis develops acute onset diarrhoea. Colonic biopsies show a luminal spray of mucus and neutrophils. The background mucosa shows minimal inflammatory changes.
2.A55 year old female with watery diarrhoea and normal colonoscopy. The colonic biopsies show increased intraepithelial lymphocytes with a thickened sub epithelial collagen plate.
C. Ulcerative colitis
D. Crohn’s disease
3.A28 year old male with bloody diarrhoea and abdominal pain.A colonoscopy shows patchy inflammation affecting the right side colon with apthous ulcers. The left colon biopsies show mild crypt distortion with patchy discontinuous inflammation with cryptitis
4.A42 year old female with acute onset bloody diarrhoea and granular and congested rectum on endoscopy. The rectal biopsy shows oedematous mucosa with dispersed ‘sprinkled salt’ inflammatory cells, cryptitis and dilatation and withering of crypts.
E. Lymphocytic colitis
F. Collagenous colitis
G. Ischaemic colitis
5.A72 year old male with abdominal pain and bloody diarrhoea. Sigmoidoscopy shows inflammation in the left side of the colon, most prominent in the sigmoid colon. Biopsies show extensive ulceration with preservation of basal crypts and active inflammation. There is no crypt distortion or crypt abscess formation.
A. Infective colitis
B. Pseudomembranous colitis
1.A64 year old male admitted in ITU for sepsis develops acute onset diarrhoea. Colonic biopsies show a luminal spray of mucus and neutrophils. The background mucosa shows minimal inflammatory changes.
2.A55 year old female with watery diarrhoea and normal colonoscopy. The colonic biopsies show increased intraepithelial lymphocytes with a thickened sub epithelial collagen plate.
C. Ulcerative colitis
D. Crohn’s disease
3.A28 year old male with bloody diarrhoea and abdominal pain.A colonoscopy shows patchy inflammation affecting the right side colon with apthous ulcers. The colonic biopsies show mild crypt distortion with patchy discontinuous inflammation with cryptitis
4.A42 year old female with acute onset bloody diarrhoea and granular and congested rectum on endoscopy. The rectal biopsy shows oedematous mucosa with dispersed ‘sprinkled salt’ inflammatory cells, cryptitis and dilatation and withering of crypts.
E. Lymphocytic colitis
F. Collagenous colitis
G. Ischaemic colitis
5.A72 year old male with abdominal pain and bloody diarrhoea. Sigmoidoscopy shows inflammation in the left side of the colon, most prominent in the sigmoid colon. Biopsies show extensive ulceration with preservation of basal crypts and active inflammation. There is no crypt distortion or crypt abscess formation.
A. Infective colitis
B. Pseudomembranous colitis
1.A64 year old male admitted in ITU for sepsis develops acute onset diarrhoea. Colonic biopsies show a luminal spray of mucus and neutrophils. The background mucosa shows minimal inflammatory changes.
2.A55 year old female with watery diarrhoea and normal colonoscopy. The colonic biopsies show increased intraepithelial lymphocytes with a thickened sub epithelial collagen plate.
C. Ulcerative colitis
D. Crohn’s disease
3.A28 year old male with bloody diarrhoea and abdominal pain.A colonoscopy shows patchy inflammation affecting the right side colon with apthous ulcers. The colonic biopsies show mild crypt distortion with patchy discontinuous inflammation with cryptitis
4.A42 year old female with acute onset bloody diarrhoea and granular and congested rectum on endoscopy. The rectal biopsy shows oedematous mucosa with dispersed ‘sprinkled salt’ inflammatory cells, cryptitis and dilatation and withering of crypts.
E. Lymphocytic colitis
F. Collagenous colitis
G. Ischaemic colitis
5.A72 year old male with abdominal pain and bloody diarrhoea. Sigmoidoscopy shows inflammation in the left side of the colon, most prominent in the sigmoid colon. Biopsies show extensive ulceration with preservation of basal crypts and active inflammation. There is no crypt distortion or crypt abscess formation.
Acute, self limiting
Most commonly due to enteric viruses, most common Rotavirus
Bacterial causes include Campylobacter, Shigella, Salmonella
Parasitic causes include Entamoeba histolytica
INFECTIVE COLITIS
Bacterial enterocolitis
Ingestion of preformed toxin
S.aureus, Vibrio, C.perfringens
Infection by toxigenic organisms
C.difficile
Infection by enteroinvasive organisms
Shigella, Salmonella
INFECTIVE COLITIS
INFECTIVE COLITIS
Non-specific histology
Damage to surface epithelium
Decreased epithelial maturation
Hyperaemia
Oedema of lamina propria
Variable polymorph infiltrates in epithelium and lamina propria
INFECTIVE COLITIS
C.difficile
Prior antibiotic exposure
Mild diarrhoea or fulminant toxic megacolon
‘Pseudomembrane’ composed of mucin, inflammatory cells and debris over site of mucosal injury
Toxin A and B modify cytokine pathways inducing cell apoptosis
PSEUDOMEMBRANOUS COLITIS
PSEUDOMEMBRANOUS COLITIS
MICROSCOPIC COLITIS
Criteria for diagnosis: Chronic watery diarrhoea, normal endoscopy, typical histology
Lymphocytic colitis
Equal male and female
Associated with autoimmune diseases
15-20+ lymphocytes/100 epithelial cells
Collagenous colitis
Middle aged elderly females
Thickened subepithelial collagen plate (>10mcm)
MICROSCOPIC COLITIS
MICROSCOPIC COLITIS
ISCHAEMIC COLITIS
Can be mucosal, mural or transmural
Specific causes
Arterial thrombosis
Atheroma, post-vascular surgery, vasculitis, hypercoagulable states
Venous thrombosis
Hypercoagulable states, intraabdominal sepsis, malignancy, cirrhosis
Non-occlusive ischaemia
Cardiac failure, shock, drugs, hypotension
Other
Radiation, amyloidosis, diabetes, herniation
ISCHAEMIC COLITIS
2. SELECT THE APPROPRIATE SYNDROME FROM THE LIST OF OPTIONS FOR EACH OF THE CONDITIONS DESCRIBED. EACH OF THE OPTIONS MAY BE USED ONCE, MORE THAN ONCE OR NOT AT ALL
A. Gardner’s syndrome
B. Turcot syndrome
C. Peutz-Jeghers syndrome
D. Cowden syndrome
E. Cronkhite-Canada syndrome
1.Autosomal dominant disorder characterised by intestinal hamartomatous polyps, facial trichilemmomas, acral keratosis and oral papillomas
2. Non hereditary condition characterised by gastrointestinal hamartomatous polyps, nail atrophy and alopecia
3. Familial disorder with intestinal adenomatous polyps, osteomas, epidermal cysts and fibromatosis
4.Autosomal dominant condition with microsatellite instability, gastrointestinal malignancy and sebaceous neoplasms
5. Condition characterised by colonic adenomatous polyposis and CNS tumours
F. Carney triad
G. Muir Torre syndrome
A. Gardner’s syndrome
B. Turcot syndrome
C. Peutz-Jeghers syndrome
D. Cowden syndrome
E. Cronkhite-Canada syndrome
1.Autosomal dominant disorder characterised by intestinal hamartomatous polyps, facial trichilemmomas, acral keratosis and oral papillomas
2. Non hereditary condition characterised by gastrointestinal hamartomatous polyps, nail atrophy and alopecia
3. Familial disorder with intestinal adenomatous polyps, osteomas, epidermal cysts and fibromatosis
4.Autosomal dominant condition with microsatellite instability, gastrointestinal malignancy and sebaceous neoplasms
5. Condition characterised by colonic adenomatous polyposis and CNS tumours
F. Carney triad G. Muir Torre syndrome
A. Gardner’s syndrome
B. Turcot syndrome
C. Peutz-Jeghers syndrome
D. Cowden syndrome
E. Cronkhite-Canada syndrome
1.Autosomal dominant disorder characterised by intestinal hamartomatous polyps, facial trichilemmomas, acral keratosis and oral papillomas
2. Non hereditary condition characterised by gastrointestinal hamartomatous polyps, nail atrophy and alopecia
3. Familial disorder with intestinal adenomatous polyps, osteomas, epidermal cysts and fibromatosis
4.Autosomal dominant condition with microsatellite instability, gastrointestinal malignancy and sebaceous neoplasms
5. Condition characterised by colonic adenomatous polyposis and CNS tumours
F. Carney triad G. Muir Torre syndrome
A. Gardner’s syndrome
B. Turcot syndrome
C. Peutz-Jeghers syndrome
D. Cowden syndrome
E. Cronkhite-Canada syndrome
1.Autosomal dominant disorder characterised by intestinal hamartomatous polyps, facial trichilemmomas, acral keratosis and oral papillomas
2. Non hereditary condition characterised by gastrointestinal hamartomatous polyps, nail atrophy and alopecia
3. Familial disorder with intestinal adenomatous polyps, osteomas, epidermal cysts and fibromatosis
4.Autosomal dominant condition with microsatellite instability, gastrointestinal malignancy and sebaceous neoplasms
5. Condition characterised by colonic adenomatous polyposis and CNS tumours
F. Carney triad G. Muir Torre syndrome
A. Gardner’s syndrome
B. Turcot syndrome
C. Peutz-Jeghers syndrome
D. Cowden syndrome
E. Cronkhite-Canada syndrome
1.Autosomal dominant disorder characterised by intestinal hamartomatous polyps, facial trichilemmomas, acral keratosis and oral papillomas
2. Non hereditary condition characterised by gastrointestinal hamartomatous polyps, nail atrophy and alopecia
3. Familial disorder with intestinal adenomatous polyps, osteomas, epidermal cysts and fibromatosis
4.Autosomal dominant condition with microsatellite instability, gastrointestinal malignancy and sebaceous neoplasms
5. Condition characterised by colonic adenomatous polyposis and CNS tumours
F. Carney triad G. Muir Torre syndrome
A. Gardner’s syndrome
B. Turcot syndrome
C. Peutz-Jeghers syndrome
D. Cowden syndrome
E. Cronkhite-Canada syndrome
1.Autosomal dominant disorder characterised by intestinal hamartomatous polyps, facial trichilemmomas, acral keratosis and oral papillomas
2. Non hereditary condition characterised by gastrointestinal hamartomatous polyps, nail atrophy and alopecia
3. Familial disorder with intestinal adenomatous polyps, osteomas, epidermal cysts and fibromatosis
4.Autosomal dominant condition with microsatellite instability, gastrointestinal malignancy and sebaceous neoplasms
5. Condition characterised by colonic adenomatous polyposis and CNS tumours
F. Carney triad G. Muir Torre syndrome
FAP SYNDROMES
Syndrome Colorectal polyps Extracolonic lesions
>100 Gastric fundic polyps, duodenal adenomas
Gardner’ s syndrome >100 Osteomas, fibromas, desmoid tumours etc
Turcot’ s
(medullobalstomas)
Autosomal dominant – PTEN gene mutations on chromosome 10
90-100% - mucocutaneous lesions like trichilemmomas, acral keratosis, papillomas
35-45% - GI hamartomatous polyps
Breast carcinoma, thyroid neoplasms
?risk of GI malignancy
COWDEN’S SYNDROME
Non familial
GI hamatomous polyposis
Ectodermal abnormalities-
Alopecia
Onychodystropy
Cutaneous hyperpigmentation
CRONKHITE-CANADA SYNDROME
CRONKHITE CANADA SYNDROME
CRONKHITE CANADA SYNDROME
HAMARTOMATOUS
TYPE POLYPS
–
JUVENILE
3. SELECT THE APPROPRIATE TERM FROM THE LIST OF OPTIONS FOR EACH OF THE POLYPS DESCRIBED.
A. Tubulovillous adenoma
B. Tubular adenoma
C. Villous adenoma
D. Serrated adenoma
E. Sessile serrated lesion/polyp
F. Mixed hyperplastic polyp – serrated adenoma
1. Polyp with low grade dysplasia and approximately 10% villous architecture
2. Polyp with high grade dysplasia and approximately 60% villous architecture
3.A 3 mm polyp in the rectum with a serrated architecture and no dysplasia
4.A 25 mm polyp in the ascending colon with a serrated architecture and no dysplasia. The bases of the crypts show dilatation and branching.
5.A30 mm polyp in the rectum with oedematous lamina propria, ulcerated surface and many cystically dilated glands
6.A 15 mm pedunculated polyp in the sigmoid colon with a serrated architecture, ectopic crypts and eosinophilic cytoplasm and low grade dysplasia
G. Juvenile polyp
H. Hamartomatous polyp
I. Hyperplastic polyp
A. Tubulovillous adenoma
B. Tubular adenoma
C. Villous adenoma
D. Serrated adenoma
E. Sessile serrated polyp
F. Mixed hyperplastic polyp – serrated adenoma
G. Juvenile polyp
H. Hamartomatous polyp
I. Hyperplastic polyp
1. Polyp with low grade dysplasia and approximately 10% villous architecture
2. Polyp with high grade dysplasia and approximately 60% villous architecture
3.A3 mm polyp in the rectum with a serrated architecture and no dysplasia
4.A25 mm polyp in the ascending colon with a serrated architecture and no dysplasia. The bases of the crypts show dilatation and branching.
5.A30 mm polyp in the rectum with oedematous lamina propria, ulcerated surface and many cystically dilated glands
6.A14 mm polyp is the transverse colon with a serrated architecture and low grade dysplasia
A. Tubulovillous adenoma
B. Tubular adenoma
C. Villous adenoma
D. Serrated adenoma
E. Sessile serrated polyp
F. Mixed hyperplastic polyp – serrated adenoma
G. Juvenile polyp
H. Hamartomatous polyp
I. Hyperplastic polyp
1. Polyp with low grade dysplasia and approximately 10% villous architecture
2. Polyp with high grade dysplasia and approximately 60% villous architecture
3.A3 mm polyp in the rectum with a serrated architecture and no dysplasia
4.A25 mm polyp in the ascending colon with a serrated architecture and no dysplasia. The bases of the crypts show dilatation and branching.
5.A30 mm polyp in the rectum with oedematous lamina propria, ulcerated surface and many cystically dilated glands
6.A14 mm polyp is the transverse colon with a serrated architecture and low grade dysplasia
A. Tubulovillous adenoma
B. Tubular adenoma
C. Villous adenoma
D. Serrated adenoma
E. Sessile serrated polyp
F. Mixed hyperplastic polyp – serrated adenoma
G. Juvenile polyp
H. Hamartomatous polyp
I. Hyperplastic polyp
1. Polyp with low grade dysplasia and approximately 10% villous architecture
2. Polyp with high grade dysplasia and approximately 60% villous architecture
3.A3 mm polyp in the rectum with a serrated architecture and no dysplasia
4.A25 mm polyp in the ascending colon with a serrated architecture and no dysplasia. The bases of the crypts show dilatation and branching.
5.A30 mm polyp in the rectum with oedematous lamina propria, ulcerated surface and many cystically dilated glands
6.A14 mm polyp is the transverse colon with a serrated architecture and low grade dysplasia
A. Tubulovillous adenoma
B. Tubular adenoma
C. Villous adenoma
D. Serrated adenoma
E. Sessile serrated polyp
F. Mixed hyperplastic polyp – serrated adenoma
G. Juvenile polyp
H. Hamartomatous polyp
I. Hyperplastic polyp
1. Polyp with low grade dysplasia and approximately 10% villous architecture
2. Polyp with high grade dysplasia and approximately 60% villous architecture
3.A3 mm polyp in the rectum with a serrated architecture and no dysplasia
4.A25 mm polyp in the ascending colon with a serrated architecture and no dysplasia. The bases of the crypts show dilatation and branching.
5.A 30 mm polyp in the rectum with oedematous lamina propria, ulcerated surface and many cystically dilated glands
6.A 14 mm polyp is the transverse colon with a serrated architecture and low grade dysplasia
A. Tubulovillous adenoma
B. Tubular adenoma
C. Villous adenoma
D. Serrated adenoma
E. Sessile serrated polyp
F. Mixed hyperplastic polyp – serrated adenoma
G. Juvenile polyp
H. Hamartomatous polyp
I. Hyperplastic polyp
1. Polyp with low grade dysplasia and approximately 10% villous architecture
2. Polyp with high grade dysplasia and approximately 60% villous architecture
3.A3 mm polyp in the rectum with a serrated architecture and no dysplasia
4.A25 mm polyp in the ascending colon with a serrated architecture and no dysplasia. The bases of the crypts show dilatation and branching.
5.A 30 mm polyp in the rectum with oedematous lamina propria, ulcerated surface and many cystically dilated glands
6.A 14 mm polyp is the transverse colon with a serrated architecture and low grade dysplasia
A. Tubulovillous adenoma
B. Tubular adenoma
C. Villous adenoma
D. Traditional Serrated adenoma
E. Sessile serrated polyp
F. Mixed hyperplastic polyp – serrated adenoma
1. Polyp with low grade dysplasia and approximately 10% villous architecture
2. Polyp with high grade dysplasia and approximately 60% villous architecture
3.A3 mm polyp in the rectum with a serrated architecture and no dysplasia
4.A25 mm polyp in the ascending colon with a serrated architecture and no dysplasia. The bases of the crypts show dilatation and branching.
5.A30 mm polyp in the rectum with oedematous lamina propria, ulcerated surface and many cystically dilated glands
6.A14 mm polyp in the sigmoid colon with a serrated architecture, eosinophilic cytoplasm and ectopic crypts and low grade dysplasia
G. Juvenile polyp
H. Hamartomatous polyp
I. Hyperplastic polyp
Tubular adenoma (<20% villous component)
Tubulovillous adenoma (25-80% villous component)
Villous adenoma (>80% villous component)
ADENOMATOUS POLYPS
Hyperplastic polyp
Sessile serrated lesion/polyp
Traditional serrated adenoma
Mixed hyperplastic polyp - adenoma
SERRATED LESIONS
HYPERPLASTIC POLYPS
Left >right
Males> females
Usually less than 10 mm
Frequent k-ras mutations
SESSILE SERRATED LESION
Right > Left
Females> males
Usually > 10 mm
Cytologically bland
BRAF mutation
SESSILE SERRATED LESION/POLYP
SERRATED ADENOMATOUS LESIONS
A. Kikuchi level sm1
B. Kikuchi level sm2
C. Kikuchi level sm3
D. Haggit level 1
E. Haggit level 2
F. Haggit level 3
4. SECTIONS FROM A PEDUNCULATED POLYP RECEIVED THROUGH THE BOWEL CANCER SCREENING PROGRAMME SHOW AN INVASIVE CARCINOMA ARISING WITHIN A TUBULOVILLOUS ADENOMA. THE CARCINOMA INFILTRATES INTO AND APPEARS LIMITED TO THE STALK OF THE POLYP. NO VASCULAR INVASION IS SEEN. THE DEEP MARGIN IS 3 MM AWAY. WHICH OF THE FOLLOWING BEST DESCRIBES THE LEVEL OF SUBMUCOSAL INFILTRATION?
4. SECTIONS FROM A PEDUNCULATED POLYP RECEIVED THROUGH THE BOWEL CANCER SCREENING PROGRAMME SHOW AN INVASIVE CARCINOMA ARISING WITHIN A TUBULOVILLOUS ADENOMA. THE CARCINOMA INFILTRATES INTO AND APPEARS LIMITED TO THE STALK OF THE POLYP. NO VASCULAR INVASION IS SEEN. THE DEEP MARGIN IS 3 MM AWAY. WHICH OF THE FOLLOWING BEST DESCRIBES THE LEVEL OF SUBMUCOSAL INFILTRATION?
A. Kikuchi level sm1
B. Kikuchi level sm2
C. Kikuchi level sm3
D. Haggitt level 1
E. Haggitt level 2
F. Haggitt level 3
HAGGITT LEVELS
Sm1
2% risk of LN metastasis Sm2 8% risk of LN metastasis Sm3 23% risk of LN metastasis
KIKUCHI LEVELS
5. SELECT THE APPROPRIATE PATHOLOGICAL TUMOUR AND NODAL STAGE FROM THE OPTIONS FOR EACH OF THE COLORECTAL TUMOURS DESCRIBED. EACH OPTION MAY BE USED ONCE, MORE THAN ONCE OR NOT AT ALL.
A. pT3,N2a
B. pT1, N0
C. ypT2, yN1
D. pT4, N0
E. pT3N1
F. pT4N1
G. ypT2yN2
H. pT4N0
1. Caecal adenocarcinoma with intramural extension into terminal ileum and infiltration into subserosal fat; 3/22 lymph nodes involved, apical node clear.
2. Low rectal adenocarcinoma infiltrating into the levator muscles; lymph nodes free of tumour.
3. Large rectal adenocarcinoma with macroscopic tumour perforation through the mesorectal fat into the retroperitoneum, 2/13 nodes involved, apical node clear
4. Rectal adenocarcinoma with preoperative long course chemoradiation. Residual tumour infiltrating into but not beyond muscularis propria.Atotal of 7 lymph nodes retrieved of which 3 show carcinoma and one contains mucin lakes with no demonstrable tumour cells. Apical node clear
5. Polypoid adenocarcinoma infiltrating into the submucosa. No lymph nodes involved.
A. pT3N2
B. pT1N0
C. ypT2yN1
D. pT4N0
E. pT3, N1c,
F. pT4N1
G. ypT2yN2
H. pT4N0
1. Caecal adenocarcinoma with intramural extension into terminal ileum and infiltration into subserosal fat; 3/22 lymph nodes involved, apical node clear.
2. Low rectal adenocarcinoma infiltrating into the levator muscles; lymph nodes free of tumour.
3. Large rectal adenocarcinoma with macroscopic tumour perforation through the mesorectal fat into the retroperitoneum, 2/13 nodes involved, apical node clear
4. Rectal adenocarcinoma with preoperative long course chemoradiation. Residual tumour infiltrating into but not beyond muscularis propria.Atotal of 7 lymph nodes retrieved of which 3 show carcinoma and one contains mucin lakes with no demonstrable tumour cells. Apical node clear
5. Polypoid adenocarcinoma infiltrating into the submucosa. No lymph nodes involved.
A. pT3N2, 1. Caecal adenocarcinoma with intramural extension into terminal ileum and infiltration into subserosal fat; 3/22 lymph nodes involved, apical node clear.
B. pT1N0, 2. Low rectal adenocarcinoma infiltrating into the levator muscles; lymph nodes free of tumour.
C. ypT2yN1, 3. Large rectal adenocarcinoma with macroscopic tumour perforation through the mesorectal fat into the retroperitoneum, 2/13 nodes involved, apical node clear
D. pT4, N0
4. Rectal adenocarcinoma with preoperative long course chemoradiation. Residual tumour infiltrating into but not beyond muscularis propria.Atotal of 7 lymph nodes retrieved of which 3 show carcinoma and one contains mucin lakes with no demonstrable tumour cells. Apical node clear
E. pT3N1, 5. Polypoid adenocarcinoma infiltrating into the submucosa. No lymph nodes involved.
F. pT4N1,
G. ypT2yN2
H. pT4N0,
A. pT3N2, 1. Caecal adenocarcinoma with intramural extension into terminal ileum and infiltration into subserosal fat; 3/22 lymph nodes involved, apical node clear.
B. pT1N0, 2. Low rectal adenocarcinoma infiltrating into the levator muscles; lymph nodes free of tumour.
C. ypT2yN1, 3. Large rectal adenocarcinoma with macroscopic tumour perforation through the mesorectal fat into the retroperitoneum, 2/13 nodes involved, apical node clear
D. pT4N0, 4. Rectal adenocarcinoma with preoperative long course chemoradiation. Residual tumour infiltrating into but not beyond muscularis propria.Atotal of 7 lymph nodes retrieved of which 3 show carcinoma and one contains mucin lakes with no demonstrable tumour cells. Apical node clear
E. pT3N1, 5. Polypoid adenocarcinoma infiltrating into the submucosa. No lymph nodes involved.
F. pT4N1,
G. ypT2yN2,
H. pT4N0,
A. pT3N2, 1. Caecal adenocarcinoma with intramural extension into terminal ileum and infiltration into subserosal fat; 3/22 lymph nodes involved, apical node clear.
B. pT1N0, 2. Low rectal adenocarcinoma infiltrating into the levator muscles; lymph nodes free of tumour.
C. ypT2yN1, 3. Large rectal adenocarcinoma with macroscopic tumour perforation through the mesorectal fat into the retroperitoneum, 2/13 nodes involved, apical node clear
D. pT4N0, 4. Rectal adenocarcinoma with preoperative long course chemoradiation. Residual tumour infiltrating into but not beyond muscularis propria.Atotal of 7 lymph nodes retrieved of which 3 show carcinoma and one contains mucin lakes with no demonstrable tumour cells. Apical node clear
E. pT3N1, 5. Polypoid adenocarcinoma infiltrating into the submucosa. No lymph nodes involved.
F. pT4, N1
G. ypT2yN2,
H. pT4N0,
A. pT3N2, 1. Caecal adenocarcinoma with intramural extension into terminal ileum and infiltration into subserosal fat; 3/22 lymph nodes involved, apical node clear.
B. pT1N0, 2. Low rectal adenocarcinoma infiltrating into the levator muscles; lymph nodes free of tumour.
C. ypT2yN1 3. Large rectal adenocarcinoma with macroscopic tumour perforation through the mesorectal fat into the retroperitoneum, 2/13 nodes involved, apical node clear
D. pT4N0, 4. Rectal adenocarcinoma with preoperative long course chemoradiation. Residual tumour infiltrating into but not beyond muscularis propria.Atotal of 7 lymph nodes retrieved of which 3 show carcinoma and one contains mucin lakes with no demonstrable tumour cells. Apical node clear
E. pT3N1, 5. Polypoid adenocarcinoma infiltrating into the submucosa. No lymph nodes involved.
F. pT4N1,
G. ypT2yN2,
H. pT4N0,
pT1 – Submucosa
pT2 – Into but not beyond muscularis propria
pT3 – Subserosal fat/mesorectum
pT4 – Serosal involvement/involvement of adjacent organs
pN1 – 1-3 LN
pN2 – 4+ LN
T STAGING – COLORECTAL CARCINOMA
Intramural extension into adjacent small bowel loop does not affect T staging
Extramural invasion into adjacent organs – pT4a
Mesorectal invasion with involvement of non peritonealised margin – pT3
Macroscopic tumour perforation – pT4b
T STAGING
M – Metastasis
G – Grade
R – Completeness of excision
L – Presence of lymphatic invasion
V – Presence of venous invasion
OTHER PARAMETERS
‘c’ – Clinical ‘p’ – Pathological ‘y’ – Denotes post chemo/radiotherapy
‘r’ – Recurrent tumour
‘a’ – Tumour diagnosed at autopsy ‘(m)’ – Multiple tumours
MODIFIERS
6. A 52-YEAR OLD FEMALE IS FOUND TO HAVE A PELVIC MASS ARISING FROM THE RECTUM, WHICH IS RESECTED. THE MASS MEASURES 12 CM IN MAXIMUM DIMENSION AND HAS A UNIFORM SOLID CUT SURFACE. ON HISTOLOGICAL EXAMINATION, THIS IS A PREDOMINANTLY SPINDLE CELL LESION, WITH THE CELLS SHOWING MINIMAL NUCLEAR PLEOMORPHISM, NO NECROSIS AND UP TO 3 MITOSES PER 50 HPF. THE CELLS HAVE THE FOLLOWING IMMUNOPROFILE: AE1/AE3 NEGATIVE, SMA FOCALLY POSITIVE, DESMIN NEGATIVE, S100 NEGATIVE, CD117 NEGATIVE, CD34 POSITIVE AND DOG-1 POSITIVE. WHAT IS THE RISK OF PROGRESSIVE DISEASE FOR THIS TUMOUR?
A. None
B. Low
C. Intermediate
D. High
E. Very high
6. A 52 YEAR OLD FEMALE IS FOUND TO HAVE A PELVIC MASS ARISING FROM THE RECTUM, WHICH IS RESECTED. THE MASS MEASURES 12 CM IN MAXIMUM DIMENSION AND HAS A UNIFORM SOLID CUT SURFACE. ON HISTOLOGICAL EXAMINATION, THIS IS A PREDOMINANTLY SPINDLE CELL LESION, WITH THE CELLS SHOWING MINIMAL NUCLEAR PLEOMORPHISM, NO NECROSIS AND UP TO 3 MITOSES PER 50 HPF. THE CELLS HAVE THE FOLLOWING IMMUNOPROFILE: AE1/AE3 NEGATIVE, SMA FOCALLY POSITIVE, DESMIN NEGATIVE, S100 NEGATIVE, CD117 NEGATIVE, CD34 POSITIVE AND DOG-1 POSITIVE. WHAT IS THE RISK OF PROGRESSIVE DISEASE FOR THIS TUMOUR?
A. None B. Low C. Intermediate
D. High
E. Very high
KIT (CD117) ................. Almost 95% positive
DOG1 ........................... > 95%
CD34 ............................ 65% positive (40–72%)
Desmin ......................... Negative (0.2%)
Smooth muscle actin .... Variably positive (34%)
S100 ............................. Variably positive (14%)
Cytokeratin ................... Very rarely positive.
GIST IMMUNOHISTOCHEMISTRY
80% have cKIT mutation
2/3 exon 11 – best response to imatinib
1/8 exon 9 – some response with dose escalation
Others – exon 13 and 17
10% PDGFRA mutation
10% other mutations
GIST
Colon bx in infants
Milk allergy
Hirschsprung’s disease
Rectal biopsy with eosinophilic material –amyloid (Congo Red)
Genes involved in HNPCC
Diversion colitis
Graft versus host disease
OTHER LOWER GI TOPICS
GENES IN HNPCC
Mismatch repair genes
MLH1 or MSH2 (90%)
MSH6 (7-10%)
PMS2 (less common)
80% develop colorectal carcinoma
Also increased risk of:
Endometrial carcinoma (33%)
Ovarian carcinoma (5%)
Cancers of small bowel, stomach, urinary tract and brain
History of previous surgery leaving rectal stump
Due to lack of short chain fatty acids
Histology: abnormal crypt architecture, fissuring, crypt abscesses
Increased lymphoid aggregates
DIVERSION COLITIS
Post stem cell transplant
Acute – within 100 days
Acute GVHD grading:
1 - apoptosis (collection of eosinophilic globules and nuclear debris)
2 - apoptosis and crypt abscesses
3 - total necrosis of individual crypts
4 - total denudation of areas of bowel
GRAFT VERSUS HOST DISEASE
Taken from all the resources available
GI definitely ‘under represented’
Hopefully this should cover most topics
EXTRA QUESTIONS
A 29 year old woman was found to have multiple polyps on colonoscopy. Her father died of colorectal carcinoma aged 50.
Identify the gene she is most likely to have a mutation of
A APC B p53
C MLH1
D c-KIT
E MSH2
MCQ
A 40-year-old woman presents with a colonic polyp which is found on histology to be an adenocarcinoma. Her father died aged 40 from colon cancer.
Identify the familial syndrome she is most likely to have inherited.
A FAP B HNPCC
C Marfans syndrome
D Muir Torre syndrome
E Gardner’s syndrome
MCQ
A 35-year-old male is diagnosed with Lynch syndrome (HNPCC).
Identify the most common genetic mutation related to this condition.
A p53
B MSH2
C MLH3 D PMS2 E APC
A 32-year-old woman complains of abdominal pain. She is found to have an 8cm small bowel tumour. Following resection, immunohistochemistry is performed. The tumour cells are positive for CD34, SMA and CD117.
Identify the correct diagnosis.
A Gastrointestinal stromal tumour
B Leiomyoma
C Leiomyosarcoma
D Fibromatosis
E Hodgkin’s lymphoma
Causes of diarrhoea
A 32-year-old female. Recent travel to Russia. Had a few episodes of diarrhoea on return. Now weight loss. Otherwise well.
EMQ - ANSWER: GIARDIA
B 78-year-old lady admitted with confusion and diagnosed with urinary tract infection. Started on ciprofloxacin. Develops high volume watery diarrhoea.
EMQ - ANSWER:
PSEUDOMEMBRANOUS COLITIS
C 72-year-old male post coronary artery bypass graft surgery. Develops abdominal pain and acidosis.
EMQ
- ANSWER: ISCHAEMIC COLITIS
D 52-year-old male with HIV. Develops chronic diarrhoea, weight loss and skin pigmentation. On duodenal biopsy, PAS positive bacilli seen in macrophages.
EMQ - ANSWER: WHIPPLE’S DISEASE
29-year-old woman with diarrhoea, weight loss, tremor, exophthalmos, and increased appetite.
EMQ - ANSWER: HYPERTHYROIDISM
Intestinal polyps
A Pedunculated polyp with arborising branching architecture
Answer: Peutz-Jeughers polyp
B 5-year-old girl with pedunculated polyp
Answer: Juvenile polyp
C 21-year-old male with hundreds of polyps throughout the entire bowel
Answer: Familial Adenomatous Polyposis
Tumours matched with associated conditions
T cell lymphoma and …
H pylori and …
Barretts oesophagus and …
EMQ
– ANSWERS ON NEXT SLIDE
Coeliac disease
MALToma of the stomach
adenocarcinoma
APC as first step in adenoma-carcinoma sequence
HNPCC genes
MSH 2 60%
MLH 1 30%
MSH 6 7-10%
PMS 2 <5%
MCQ AND EMQ
APR anatomy
Skin
Peritoneal reflection
Mesorectal v intramesorectal v muscularis
Dentate line