J. Coloproctol. (Rio J.) vol.35 número1

jcoloproctol(rioj).2015;35(1):63–66

w w w . j c o l . o r g . b r

Journal

of

Coloproctology

Case

Report

Hyperplastic

polyposis:

a

case

report

Thiago

Almeida

Flauzino

,

Gabriela

N.S.

Fardin

,

Adriana

F.

Sena

,

Leonardo

R.F.

Gama

_,

_Flávia

_L.M.

_Ribeiro

_,

_Giovanni

_J.Z.

_Loureiro

_,

Luciano

P.N.

Gama

_,

_Rossini

_C.

_Gama

a_{VitóriaApartHospital,Serra,ES,Brazil} b_{Gastrenterologist,Brazil}

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Articlehistory:

Received20January2014 Accepted11August2014 Availableonline28January2015

Keywords:

Hyperplasticpolyposissyndrome Videolaparoscopiccolectomy Polyposis

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b

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Objective:Theauthorspresentacasereportofhyperplasticpolyposissyndromefromthe ColoproctologyService,VitóriaApartHospital,Vitória-ES.

Casestudy:Ourcaseisa24-year-oldmanwhosufferedfromfatigue,malaiseandmicrocytic andhypochromicanemia,whoseupperdigestiveendoscopypresentedseveralhyperplastic polypsinthestomachandwhosecolonoscopyrevealedcolonicpolyposismainlyintheright colon;thehistopathologyshowedtubularadenomawithmoderateatypiaintheascending colon.Thus,avideolaparoscopicrightcolectomywasperformed;theanalysisofthe sur-gicalfragmentshowedmultiple(morethan30)polypsdistributedthroughthececumand ascendingcolon.

Conclusion: Thehistopathologicaldiagnosisofhyperplasticpolyposisisachallengingtask. Ingeneral,mostpolypsarehyperplastic,but serratedandclassicadenomasalsooccur. Theseassociatedadenomatousinjuriescanbethecauseofmalignanttransformation.So far,thereisnoconsensusabouttheappropriatetreatment;however,acolectomyprocedure maybebeneficialinascenarioofalargenumberofhyperplasticpolyps,concurrentserrated adenomas,ormultiplehigh-riskadenomatouslesions.

©2015SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.All rightsreserved.

Polipose

hiperplásica:

relato

de

caso

Palavras-chave:

Síndromepoliposehiperplásica Colectomiavideolaparoscópica Polipose

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ASíndromePoliposeHiperplásica(HPS),descritaem1980,éconsideradacomoapresenc¸a depóliposhiperplásicosmúltiplos,grandese/ouproximaise,ocasionalmente,umnúmero menordeadenomasserrados,adenomasclássicosepóliposmistos.Agrandemaioriados pacientessãoassintomáticos,sendoodiagnósticoumachadoincidentaldacolonoscopia. Notocanteaoprognóstico,amaioriadosautoresconsideraHPSumachadoincidentalsem

∗ _{Correspondingauthor.}

E-mail:tflauzino@gmail.com(T.A.Flauzino).

http://dx.doi.org/10.1016/j.jcol.2014.08.013

64

potencialdemalignizac¸ão,porém,estudosrecentestêmdescritolesõesgenéticas sincrôni-casàHPSeaocâncercolorretal.

Objetivo: OsautoresapresentamumrelatodecasodeSíndromePoliposeHiperplásicado servic¸odecoloproctologiadoVitóriaApartHospital,Vitória-ES.

CasoClínico: Trata-sedeumpacientede24anos,masculino,queapresentavafadiga, adi-namiaeanemiamicrociticaehipocrômicaqueapresentounaEndoscopiaDigestivaAlta: diversospóliposhiperplásicosnoestômagoenaColonoscopia:poliposecolônica princi-palmenteemcólondireitocujohistopatológicodemonstrouadenomatubularcomatipia moderadanoascendente.Paratalfoirealizadocolectomiadireitavideolaparoscópicaem queaanálisedapec¸amostroumúltiplospóliposhiperplásicosdistribuídospelocecoecólon ascendente,superiora30.

Conclusão:OdiagnósticohistopatológicodeHPSédesafiador.Emgeral,amaioriadospólipos sãohiperplásicos,mastambémocorremadenomasserradoseadenomasclássicos.Tais lesõesadenomatosasassociadaspodemseracausadetransformac¸õesmalignas.Ainda nãoháconsensodotratamentoadequado,porém,acolectomiapodeserbenéficaquando hágrandenúmerodepóliposhiperplásicos,adenomasserradosconcomitantesoumúltiplas lesõesadenomatosasdealtorisco.

©2015SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda. Todososdireitosreservados.

Introduction

Hyperplasicpolyposiswasdescribedin1980.Thisdiseaseis regardedasthe presenceofmultiplelargeand/or proximal hyperplastic polyps, and sometimes fewerserrated adeno-mas,classicalpolypsandmixedadenomas.Theydifferfrom isolatedhyperplasticpolyps,ascanreachupto3cm.1

Usu-allythesehyperplasticpolypsarefoundintheproximalcolon, occurequally amongmenand womenandexhibitfamilial character.Whileitisacceptedthatsmallhyperplasticpolyps havenomalignantpotential,therearecasesof adenocarcino-mataassociatedwithhyperplasticpolyposis(HPS).

Theguidelinesrecommendsomecriteriaforadefinitionof thediagnosisofHPS;thesecriteriaarealsousedbytheWorld HealthOrganization(WHO)andwereintroducedin2000.The criteriaare1_{:atleastfivehyperplasticpolyps}

histopatholog-icallydiagnosedproximally tothe sigmoidcolon,with two ofthemmeasuringmorethan 10mmindiameter; or2 _any

numberofhyperplasticpolypsoccurringproximallytothe sig-moidcoloninapatientwithafirst-degreerelativewithHPS; or3_{morethan30hyperplasticpolypsofanysize,butspread}

throughoutthecolon.3

Althoughahyperplasticpolypisanon-neoplasticpolyp, it may present genetic changes, including chromosomal rearrangements, such as: Kras and BRAF proto-oncogenes’ mutation and low levels of DNA’s unstable microsatellites (MSI-H).TP53mutationsandincreasedp53 immunosuppres-sion are limited to areas of intraepithelial neoplasia and serratedadenomas.HighlevelsofMSI-Hareassociatedwith lossofDNAcapacityforerrorrepair,andthisisthelikelycause ofcolorectalinjuriesinHPSpatients.TheHPSalsoexhibits histopathologicfeaturesthatdifferfromnormalmucosa,for instance,anincreaseinthecryptproliferationzone(although confinedtothebaseofthecrypt),serratedarchitectural orga-nizationinbasilarareasofthecrypt,basilarexpansionofthe crypt,invertedcryptsandprevalenceofcryptswithreduced

maturation.Asmallportionofcasespresentssomedegreeof dysplasia,andevenanassociationwithtubular,tubulovillous, villousandserratedadenomata.4

Thevastmajorityofpatientsareasymptomatic,andthe diagnosisisanincidentalfindingfromcolonoscopy;aportion of patients may suffer rectal bleeding. Therefore, a high-definitioncolonoscopyandmultiplebiopsiesareessentialfor obtainingthisdiagnosis.

Withregardtoprognosis,mostauthorsconsiderHPSasan incidentalfinding,withnopotentialforcolorectal adenocarci-noma;however,recentstudieshavedescribedgeneticlesions occurringsynchronouslytoHPSandtocolorectalcancer, sup-porting the concept of the sequence:hyperplastic polyp – adenoma–colorectalcarcinoma.5-13

jcoloproctol(rioj).2015;35(1):63–66

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Fig.2–Colonoscopy:colonpolyposis.

Fig.3–Surgicalfragmentfromrightcolectomy,with intestinalpolyposis.

Objective

TheauthorspresentacasereportofHPSsyndromefrom Colo-proctologyService,VitóriaApartHospital,Vitória-ES.

Case

report

Our case is a 24-year-old man who suffered from fatigue, malaiseand microcytic and hypochromicanemia. No fam-ily historyofcolorectal canceror familialpolyposis.In the diagnosis,UpperDigestiveEndoscopy(UDE)revealedseveral polypsinthestomach,thelargestofthemmeasuring3cm, with a histopathologic study compatible withhyperplastic polyps;colonoscopy:colonicpolyposis(cecumandascending andtransversecolon),measuring1–5cm,witha1.5-cmpolyp inthesigmoidcolonandtwo1-cmsessilepolypsinthe rec-tum.Inthefaceofsuchfindings,polypectomywasperformed inthedistalcolonicsegmentsand,bysampling,intheright colon.Histopathologicalstudy(HPTL):retentionpolyp asso-ciatedwithlymphoidhyperplasiaintherectumandsigmoid colon;tubularadenomawithmoderateatypiainthe ascend-ingcolon(Figs.1–5).

Results

The patient underwent a partial right colectomy by videolaparoscopy; the surgical fragment measured

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Fig.5–Colonoscopyfromnormalcontrol.

162mm, containing 50 sessile and pedunculated polypoid lesions.

The histopathological study of the surgical specimen revealed multiple (more than 30) hyperplastic polyps dis-tributed throughout the cecum and ascending colon; this findingfulfillsthecriteriaforHPSsyndrome.Theresearchfor BRAFgenemutationwasinconclusive.

Apolypoidlesionwithacentralfibrovascularbundleand disorganization of crypt architecture was also noted; the cryptsshowed attheirbaseaproliferativezone, withhigh numberofcells,butwithoutdysplasia,characterizinga hyper-plasticpolyp.

Thepatient’s recovery wasuneventful, and he was dis-chargedonthe4thpostoperativeday.Currentlythepatient isunderrigorousclinicalandendoscopicfollow-up.

Conclusion

ThehistopathologicaldiagnosisofHPSisachallengingtask. Ingeneral,mostofthepolypsarehyperplastic,butserrated andclassicadenomascanalsooccur.Theseassociated adeno-matouslesionscanbethecauseofmalignanttransformation. There is no consensus about the appropriate treatment;

however,colectomymaybebeneficialincasesofalarge num-berofhyperplasticpolyps,concurrentserratedadenomas,or multiplehigh-riskadenomatouslesions.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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