Post-polypectomy surveillance has become a major indication for colonoscopy as a result of increased use of screening colonoscopy in Korea. However, because the medical resource is limited, and the first screening colonoscopy produces the greatest effect on reducing the incidence and mortality of colorectal cancer, there is a need to increase the efficiency of postpolypectomy surveillance. In the present report, a careful analytic approach was used to address all available evidences to delineate the predictors for advanced neoplasia at surveillance colonoscopy. Based on the results of review of the evidences, we elucidated the high risk findings of the index colonoscopy as follows: 1) 3 or more adenomas, 2) any adenoma larger than 10 mm, 3) any tubulovillous or villous adenoma, 4) any adenoma with high-grade dysplasia, and 5) any serrated polyps larger than 10 mm. In patients without any high-risk findings at the index colonoscopy, surveillance colonoscopy should be performed five years after index colonoscopy. In patients with one or more high risk findings, surveillance colonoscopy should be performed three years after polypectomy. However, the surveillance interval can be shortened considering the quality of the index colonoscopy, the completeness of polyp removal, the patient's general condition, and family and medical history. This practical guideline cannot totally take the place of clinical judgments made by practitioners and should be revised and supplemented in the future as new evidence becomes available.
Adenoma/*diagnosis/surgery ; Adenoma, Villous/diagnosis/surgery ; Colonic Polyps/pathology/*surgery ; *Colonoscopy ; Colorectal Neoplasms/*diagnosis/surgery ; Databases, Factual ; Humans ; Republic of Korea ; Risk Factors ; Time Factors

Endoscopic submucosal dissection (ESD) is an useful therapeutic technique for large gastrointestinal epithelial tumors that it provides an en bloc resection. Although there is some controversy about the role of ESD for colorectal lesions, for large lesions in the distal rectum, ESD has the advantage of preserving anal function. However, the large amount of insufflating gas used during the procedure can cause severe abdominal pain and discomfort. Moreover, high intra-luminal pressure caused by a by large amount of gas can cause a micro-perforation. There is no consensus as to whether ESD is the optimal treatment for synchronous large colorectal laterally spreading tumors (LSTs) that cannot be removed en-bloc by conventional endoscopic mucosal resection. Here, a case with two neighboring synchronous large LSTs, one located in the rectum and the other in the distal sigmoid colon, were sequentially removed by separate ESD procedures performed on two consecutive days in a patient who could not tolerate a long procedure.
Adenoma, Villous/diagnosis ; Colonoscopy ; Colorectal Neoplasms/*diagnosis/pathology/surgery ; *Dissection ; Humans ; Intestinal Mucosa/pathology/surgery ; Male ; Middle Aged ; Neoplasms, Multiple Primary/*diagnosis/pathology/surgery ; Rectum/pathology

OBJECTIVETo investigate the clinicopathological characteristics and expression status of Ki67, p53, CEA, CDX, CK7 in colorectal sessile serrated adenoma (SSA).

METHODSThe clinicopathological data of 11 cases of SSA, 51 cases of hyperplastic polyp (HP) and one case with mixed HP/SSA were reviewed and analyzed retrospectively. The expression of Ki67, p53, CEA, CDX and CK7 were detected by immunohistochemistry.

RESULTSThe major histological features in SSA were architectural abnormality in crypts, dilatation of serrated crypt bases like an inverted "T" or "L" shape adjacent to muscularis mucosa. Atypical cells containing round to oval nuclei and nucleoli were also observed. The immunohistochemical staining showed that the expression of p53 increased gradually from HP to TA: 11.8% in HP, 20.0% in SSA, 41.2% in VTA and 75.0% in TA, with a significant difference among the groups (chi(2) = 17.996, P = 0.000). However, no significant difference in the expression of CDX and CK7 was observed between HP and SSA. Of the 10 SSA cases, positive expression of Ki67 was found in cells located in the base or middle part of crypt in 6 cases, positive cells index was 26% - 50% in 5 cases, and > 50% in 3. Compared with the expression of Ki67 in the HP, VTA and VA, SSA showed a significant difference in both the positive cell number and in the positive regions. (positive number: chi(2) = 34.601, P = 0.000; positive regions: chi(2) = 63.077, P = 0.000).

CONCLUSIONMorphological diagnosis of SSA was mainly based on crypt architectural and cellular abnormalities, and the crypt architectural abnormality may be more important than cellular features. Detection of p53 and Ki67 expression may be helpful in differential diagnosis and understanding the nature of SSA.

Adenoma ; metabolism ; pathology ; Adenoma, Villous ; metabolism ; pathology ; Adult ; Aged ; CDX2 Transcription Factor ; Carcinoembryonic Antigen ; metabolism ; Colonic Neoplasms ; metabolism ; pathology ; Colonic Polyps ; metabolism ; pathology ; Diagnosis, Differential ; Female ; Homeodomain Proteins ; metabolism ; Humans ; Immunohistochemistry ; Keratin-7 ; metabolism ; Ki-67 Antigen ; metabolism ; Male ; Middle Aged ; Rectal Neoplasms ; metabolism ; pathology ; Retrospective Studies ; Trans-Activators ; metabolism ; Tumor Suppressor Protein p53 ; metabolism

Choledochal cyst is an uncommon premalignant anomaly. The morphology and pathogenesis of the premalignant lesion of cholangiocarcinoma arising from the choledochal cyst has not been well described. Herein, we report a rare case of bile duct adenoma arising from choledochal cyst with anomalous union of pancreaticobiliary duct (AUPBD). 50-year-old woman was admitted to our hospital with the complaint of epigastric pain. She had received common bile duct (CBD) exploration and choledocholithotomy and cholecystectomy 3 months earlier under the diagnosis of multiple CBD stones. Intraoperalive cholangiogram was not remarkable except CBD dilatation at that time. Endoscopic retrograde cholangiopancreatography revealed choledochal cyst with AUPBD and round filling defect which disappeared easily on the balloon cholaniogram. On magnetic resonance cholangiopancreatography, the filling defect was confirmed as 2 cm polypoid mass attached to the distal bile duct wall. At laparotomy, a soft whitish mass was palpable on the lower CBD. On histological examination, adenoma with focal carcinoma change arising from choledochal cyst was diagnosed.
Adenoma, Villous/*diagnosis/pathology/radiography ; Bile Duct Neoplasms/*diagnosis/pathology/radiography ; Cholangiopancreatography, Magnetic Resonance ; Choledochal Cyst/*radiography/secretion/surgery ; Female ; Humans ; Middle Aged ; Tomography, X-Ray Computed

Adenoma, Villous ; metabolism ; pathology ; surgery ; Aged ; Diagnosis, Differential ; Female ; Humans ; Keratin-20 ; metabolism ; Keratin-7 ; metabolism ; Mullerian Ducts ; pathology ; Papilloma ; pathology ; Vaginal Neoplasms ; metabolism ; pathology ; surgery

OBJECTIVETo study the clinicopathologic features and proliferative status of colorectal hyperplastic polyp (HP), sessile serrated adenoma (SSA) and traditional serrated adenoma (TSA).

METHODSOne hundred and four cases colorectal serrated lesions were collected from 2628 cases of colorectal polyps during the period from November, 2002 to December, 2007. The clinicopathologic features and expression of proliferation marker Ki-67 were studied.

RESULTSOn the basis of morphologic examination, 60 cases were classified as HP, 20 cases as TSA, 11 cases as SSA, 7 cases as mixed HP/SSA/TSA, and 6 cases as mixed serrated polyp/adenoma and tubular adenoma. Immunohistochemical study for Ki-67 showed that 40 cases (78%) of the 51 cases of HP were either mostly negative or rarely (<25% cells) positive. Most of the positive cells were located at crypt bases. Among the 15 cases of TSA, 11 of them revealed positive cryptal cells (25% to 50% or>50% positivity). Most of the positive cells were located in mid portion of crypts. The number and distribution of Ki-67 positive cells in SSA were similar to those in TSA but were significantly different from those in tubular adenoma and adenocarcinoma (chi2=34.601, P=0.000; chi2=63.077, P=0.000, respectively).

CONCLUSIONSHP, SSA and TSA have their morphologic characteristics, with some overlapping features noted. The distinction between SSA and HP can be difficult. Diagnosis of SSA relies mostly on architectural rather than cytologic features. The distinction between TSA and SSA depends mainly on the presence of dysplasia. Ectopic crypt formation is almost exclusively seen in TSA. The distribution and percentage of Ki-67-positive cells are also helpful in subtyping of various colorectal serrated lesions. In general, the proliferative index is lower in serrated adenoma (TSA or SSA) than in tubular adenoma.

Adenocarcinoma ; pathology ; Adenoma ; metabolism ; pathology ; Adenoma, Villous ; metabolism ; pathology ; Adult ; Aged ; Aged, 80 and over ; Cell Proliferation ; Colorectal Neoplasms ; metabolism ; pathology ; Diagnosis, Differential ; Female ; Humans ; Intestinal Polyps ; metabolism ; pathology ; Ki-67 Antigen ; metabolism ; Male ; Middle Aged ; Young Adult

Adenoma, Villous ; metabolism ; pathology ; surgery ; Diagnosis, Differential ; Humans ; Immunohistochemistry ; Kidney Neoplasms ; metabolism ; pathology ; surgery ; Lymphoma ; metabolism ; pathology ; surgery ; Male ; Middle Aged ; Myosins ; metabolism ; Neoplasms, Multiple Primary ; metabolism ; pathology ; surgery ; Rhabdomyosarcoma, Alveolar ; metabolism ; pathology ; surgery ; Ureteral Neoplasms ; metabolism ; pathology ; surgery ; Vimentin ; metabolism

BACKGROUND: EMR is an alternative to surgical removal of superficial neoplastic lesions of the gastrointestinal tracts. The aim of this study is to assess the diagnostic efficacy of EMR in gastric flat adenoma. METHODS: Ninety five lesions of gastric flat adenoma removed by EMR in 89 patients were enrolled in this study at Kyungpook National University Hospital from January 1999 to June 2002. We have analysed diagnostic efficacy of EMR in gastric flat adenoma. RESULTS: Tubular adenoma were 78 cases (82.1%), tubular adenoma with high grade dysplasia were 16 cases (16.8%) and villous adenoma was 1 case (1.1%). Locations were antrum 57 cases (60.0%), body 22 cases (23.1%), angle 14 cases (14.7%), pylorus 1 case (1.1%) and cardia 1 case (1.1%). Among 95 lesions of gastric flat adenoma, 26 cases (27.4%) revealed upgraded histologic diagnosis between endoscopic biopsy and EMR. Twenty two lesions (37.3%) among 59 lesions that were 1cm size or more were upgraded in the histologic staging to carcinoma or high grade dysplasia, compared with 4 lesions (11.1%) among 36 lesions less than 1cm size (p<0.01). Eight lesions (50.0%) among 16 lesions diagnosed in tubular adenoma with high grade dysplasia were upgraded in the histologic staging to carcinoma, compared with 12 lesions (15.4%) among 78 lesions diagnosed in tubular adenoma (p<0.01). Bleeding was the only complication and occurred in 24 lesions (25.3%). CONCLUSION: EMR resulted in upgrading of the histologic staging to carcinoma or high grade dysplasia in 27.4% of gastric flat adenomas.
Adenoma* ; Adenoma, Villous ; Biopsy ; Cardia ; Diagnosis ; Gastrointestinal Tract ; Gyeongsangbuk-do ; Hemorrhage ; Humans ; Pylorus

Herpes zoster infection may herald the presence of a hidden malignancy. We encountered a case of a carcinoma of the ampulla of Vater in a 72-year-old female in which the ampullary lesion was found during a work-up for excluding certain causes of Herpes zoster infection. An esophagogastroduodenoscopy showed a polypoid mass at the ampulla of Vater. A pylorus-preserving pancreaticoduodenectomy was performed and the pathology of the resected specimen confirmed well differentiated adenocarcinoma in the background of villous adenoma. The stage of the tumor was T2N0M0. This case illustrates that it may be necessary to do some diagnostic work-ups in patients with Herpes zoster infection to exclude underlying diseases. However, the extent of the work-ups should be determined in the future based on the cost-effectiveness data.
Adenocarcinoma* ; Adenoma, Villous ; Aged ; Ampulla of Vater* ; Early Diagnosis* ; Endoscopy, Digestive System ; Female ; Herpes Zoster* ; Humans ; Pancreaticoduodenectomy ; Pathology

Herpes zoster infection may herald the presence of a hidden malignancy. We encountered a case of a carcinoma of the ampulla of Vater in a 72-year-old female in which the ampullary lesion was found during a work-up for excluding certain causes of Herpes zoster infection. An esophagogastroduodenoscopy showed a polypoid mass at the ampulla of Vater. A pylorus-preserving pancreaticoduodenectomy was performed and the pathology of the resected specimen confirmed well differentiated adenocarcinoma in the background of villous adenoma. The stage of the tumor was T2N0M0. This case illustrates that it may be necessary to do some diagnostic work-ups in patients with Herpes zoster infection to exclude underlying diseases. However, the extent of the work-ups should be determined in the future based on the cost-effectiveness data.
Adenocarcinoma* ; Adenoma, Villous ; Aged ; Ampulla of Vater* ; Early Diagnosis* ; Endoscopy, Digestive System ; Female ; Herpes Zoster* ; Humans ; Pancreaticoduodenectomy ; Pathology