Colorectal Carcinoma CARCINOID TUMOR Ipsid

COLORECTAL CARCINOMA
CARCINOID TUMOR
IPSID
LEARNING OBJECTIVES:
• GROUP 1 : To know the differences between left and right sided
colorectal carcinoma.
• GROUP 2 : To know the gross and microscopic features of left sided
• GROUP 3 : To know the gross and microscopic features of right sided
• GROUP 4 : To know the gross and microscopic features of carcinoid
tumor.
• GROUP 5 : To know the gross and microscopic features of IPSID.
SCENARIO: 1
40 -years-old man presented with acute abdominal pain and
Hematochezia. He had experienced abdominal pain at least 3
times and lost over 10 kg weight during the past 6 months. He
did not have any chronic diseases or gastrointestinal problems
before the onset of symptoms. Plain radiography revealed
mechanical obstruction in the descending colon. An
emergency surgical resection and a subtotal colectomy was
done. Histological examination revealed poorly differentiated
mucinous adenocarcinoma that had penetrated the surface of
the visceral peritoneum.
SCENARIO :2
A 50- years- old Caucasian male presented with pain in
right lower quadrant and difficulty in walking short
distances. He had a 2-month history of constipation,
general abdominal discomfort and significant weight
loss over 20 Kgs. Stool of occult blood was sent which
was positive. Laboratory findings remarkable for grade
2 anemia (Hb, 9.0 g/dL) and elevated CEA (6.7 ng/mL).
Colorectal carcinoma. A, Circumferential, ulcerated rectal cancer. Note the
anal mucosa at the bottom of the image. B, Cancer of the sigmoid colon that
has invaded through the muscularis propria and is present within subserosal
adipose tissue (left). Areas of chalky necrosis are present within the colon
wall (arrow).
A, Well-differentiated adenocarcinoma. Note the elongated, hyperchromatic nuclei.
Necrotic debris, present in the gland lumen. B, Poorly differentiated adenocarcinoma forms
a few glands but is largely composed of infiltrating nests of tumor cells. C, Mucinous
adenocarcinoma with signet-ring cells and extracellular mucin pools.
In histology, a signet ring cell is a cell with a large vacuole, the malignant type is seen
predominantly in carcinomas.
SCENARIO 3:
A 22-year-old female presented with recurrent right
lower abdominal pain of a three-year duration. The
patient underwent successful appendectomy and
recovered four days later. Histopathology report
revealed a tumor composed of nests of monomorphic
small round cells having small round nuclei and pink to
pale blue cytoplasm located at the tip of the appendix.
Follow-up examination one year after surgery revealed
that the patient was well with no discomfort.
Carcinoid tumors are a type of slow-growing tumors of
neuroendocrine origin and derived from primitive stem
cells in the gut wall, especially the appendix. They can
arise in several places throughout the body.
Sites:
lungs, mediastinum, thymus, liver, bile
ducts, pancreas, bronchus, ovaries, prostate, and kidneys
Carcinoid syndrome
• Facial flushing, which is redness and a warm feeling over
the face.
• Sweating.
Diarrhea.
• Shortness of breath.
Wheezing or asthma-like symptoms.
• Unexplained weight gain.
• Weakness.
• Fast heartbeat.
Clinical Features of the Carcinoid Syndrome
• Extraintestinal carcinoids produce CS without metastasis
• Survival rate for carcinoid is 5 years (90% cases) EXCEPT APPENDIX
• Small-bowel tumors → Hepatic metastases (↑50% cases)
• Widespread disease is FATAL

• Active substances directly release in the systemic circulation
◦ 5-hydroxytryptamine
◦ Histamine
◦ Bradykinin
◦ Kallikrein
◦ Prostaglandins
Carcinoid tumors
• Rare slow growing tumor:
◦ GIT (2/3rd )
◦ Lung (1/3rd)
• Arise from Enterochromaffin cells/
“KULCHITSKY CELLS” found in crypts of Lieberkϋn
• Most common location:
◦ Appendix
◦ Ileum
◦ Rectum
• Most common incidence → pancreatic carcinoid (20%)
• Most common metastasis occurs in pancreatic carcinoid→
◦ Liver
◦ Peritoneum
◦ Lymph node
Carcinoid tumor
Multiple protruding tumors are

present at the ileocecal junction
• Monotonous morphology
• Delicate intervening
fibrovascular stroma
Electron micrograph showing

dense core bodies in the
cytoplasm
CLASSIFICATION OF GASTROINTESTINAL CARCINOIDS
FOREGUT CARCINOIDS→ Rarely metastasize

1. Stomach, duodenum and esophagus
2. Gastric carcinoids (atrophic gastritis) are cured by surgical resection
MIDGUT CARCINOIDS
1. Jejunum & ileum →Multiple → Aggressive
2. Large size, local invasion, tumor necrosis & abnormal mitotic figures
HINDGUT CARCINOIDS
1. Tip of the appendix at any age→ Benign
2. Proximal colon, uncommon →Large → Metastasize
3. RECTAL →polypeptide hormones →Rarely metastasize
Abdominal pain and weight loss
APPENDIX CARCINOID TUMOR
GROSS EXAMINATION:
A well-circumscribed
but not encapsulated,
round to oval, yellow-
tan in appearance and
usually located in
the tip of the appendix.
MICROSCOPIC FINDINGS:
The nests of carcinoid tumor

have a typical endocrine
appearance with small round
cells having small round nuclei
and pink to pale blue cytoplasm.
Rarely, a malignant carcinoid
tumor can occur as a large bulky
mass. Metastatic carcinoid to the
liver can rarely result in the
carcinoid syndrome.
SCENARIO :3
A 26-year-old previously healthy sanitation worker presented
with a 6-month history of copious diarrhea (10–20 watery stools
per day), persistent hypokalemia, and 40-lb weight loss. His
diarrhea had failed to respond to multiple courses of empiric
oral antibiotics. Initial laboratory investigations noted
leukocytosis, mild anemia, and multiple biochemical
abnormalities, including hypokalemia, Hyponatremia, and a
normal-anion gap metabolic acidosis. CT of the abdomen and
pelvis demonstrated massive mesenteric and retroperitoneal
lymphadenopathy with diffuse bowel-wall edema and mild
hepatomegaly.
Lymphoma
Non Hodgkin
Hodgkin
Lymphoma(NH L)
Lymphoma
Extranodal Nodal N H L
(67%)
N H L(33%
)
Primary GI Lymphoma
30-45%
Lymphoma are proliferations that arise as discrete tissue masses in the
lymphatic system.
• EXTRANODAL LYMPHOMA- involves sites other than lymph nodes,
spleen, thymus and the pharyngeal lymphatic ring.
• they can arise in virtually any tissue, like GI tract, particularly the
stomach. Extranodal marginal zone B-cell lymphomas usually arise at
sites of chronic inflammation.
• They can originate in the GI tract at sites of preexisting MALT, such as
the Peyer patches of the small intestine, but more commonly arise
within tissues that are normally devoid of organized lymphoid tissue.
• In the stomach, MALT is induced, typically as a result of chronic
gastritis. H. pylori infection. Remarkably, H. pylori eradication results
in durable remissions with low rates of recurrence in most MALToma
patients.
IMMUNOPROLIFERATIVE SMALL INTESTINAL DISEASE /
ALPHA CHAIN DISEASE
mucosa-associated lymphoid-tissue (MALT) lymphoma
infiltration of the bowel wall with a plasma-cell population that secretes a
monotypic, truncated immunoglobulin α heavy chain lacking an associated light
chain.
B cell lymphoma that arises in background of chronic diffuse mucosal
plasmacytosis, with IgA heavy chain synthesis (no variable chain
synthesized)
Clinical features
Many have preexisting malabsorption
May initially respond to antibiotics
Often due to Campylobacter jejuni, another human pathogen responsible for
immunoproliferative states
• Usually secondary to widespread nodal disease
• Gastrointestinal tract – most common extra-nodal
site Primary gastrointestinal lymphoma
-1-4% of all GI malignancies
-10-15% of all lymphomas
-30-40% of all extra nodal lymphomas
• Majority – Non Hodgkins Lymphoma [B cell-
90%]
• Most common site – stomach (60-65%)
• Rare sites – esophagus, pancreas, liver

• Immunoproliferative small intestinal disease (IPSID) is a special variant
of, extra nodal marginal zone B-cell lymphoma, which affects the
small intestine.
• truncated alpha heavy chains which may appear in the serum and
other body fluids. It can be treated with broad spectrum antibiotics at
its early stage.
Gross description
Low grade: non-flattened mucosa
High grade: diffusely thickened folds with small
nodules in distal duodenum / proximal jejunum
Microscopic (histologic) description

Low grade: Heavy lymphoplasmacytic infiltrate
by mature cells
High grade: Resembles diffuse large cell
lymphoma with plasmacytoid features
May have starry sky pattern, follicular
hyperplasia

Colorectal Carcinoma CARCINOID TUMOR Ipsid

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COLORECTAL CARCINOMA

• Survival rate for carcinoid is 5 years (90% cases) EXCEPT APPENDIX

• Small-bowel tumors → Hepatic metastases (↑50% cases)

• Widespread disease is FATAL

Multiple protruding tumors are

Electron micrograph showing

FOREGUT CARCINOIDS→ Rarely metastasize

The nests of carcinoid tumor

• Rare sites – esophagus, pancreas, liver

Microscopic (histologic) description

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