Microcarcinoids in large intestinal adenomas

Composite adenoma-carcinoid tumors are rare colorectal lesions consisting of intermingled adenomatous and carcinoid components. Unlike other mixed endocrine-glandular colorectal neoplasms, which are generally malignant, their glandular component is histologically benign and their natural history is favorable. We present 4 cases of colonic adenomas containing microcarcinoids, a hitherto undescribed lesion that is either a precursor of composite adenoma-carcinoids or a related but independent entity. The cases, identified among our surgical and consultation files, were endoscopically routine sessile polyps removed from 4 otherwise normal individuals, 3 from the cecum and 1 from the distal colon. The microcarcinoids were 0.5 to 1.5 mm in size and situated within the basal lamina propria, where they interposed between the crypts and muscularis mucosae without disturbing the overall polyp architecture. Histologically, they consisted of collections of low-grade epithelial cells arranged in nests, cords, tubules, and irregular clusters and characterized by eosinophilic, granular, or clear cytoplasm and by round central nuclei with stippled or dusty chromatin. Endocrine differentiation of the microcarcinoids was confirmed by the expression of 3 or more of the following: Grimelius argyrophil, chromogranin, synaptophysin, neuron-specific enolase and somatostatin. No mitotic figures or MIB-1 or p53 positivity were observed. The glandular component of the polyps was unremarkable in 3 cases, but 1 polyp, in addition to a microcarcinoid, showed a diffuse pattern of mixed adenomatous-endocrine differentiation. The patients' clinical course was benign on the basis of 2 years' median follow-up (range, 6 mo to 10 y). Two patients with incomplete polypectomies underwent hemicolectomy revealing no residual endocrine neoplasia. Awareness of microcarcinoids in colonic adenomas should help avert potential diagnostic pitfalls posed by their pleomorphism, basal location, and infiltrative patterns, and may help clarify their natural history and possible relationship to composite glandular-carcinoid tumors.