SAL: This is Sal, and I’mstill at Stanford Medical School with Dr. Connolly. DOCTOR CONNOLLY: Sal, we’regoing to continue going. You going to get oneunit of credit for today. SAL: Excellent. My mother would be proud. DOCTOR CONNOLLY: So whatwe’re going to look at today is a colon polyp. We had said beforepolyp is something that’s going tostick up like this. SAL: So in that last videowe saw, it was not a polyp. That was like an irritatedpart of the bowel? DOCTOR CONNOLLY: Yeah. It was very low lying. It was– SAL: Let me getyou the pen here. We’ve got it all tangled up. DOCTOR CONNOLLY: Itwas really just kind of a patch ofirritant right there. SAL: I see. DOCTOR CONNOLLY: So we’vegot a bigger piece now. SAL: I see. That’s why it just looks–everything is more– DOCTOR CONNOLLY: So you can seethe glands look tiny in here. SAL: So roughly that last slide,how big would it be on this? DOCTOR CONNOLLY: It wouldbe about a piece like that. To be fair, itprobably was what was underlying this area right here. SAL: I see. DOCTOR CONNOLLY:And then it grew on to be something more than that. SAL: It wasn’t this exact one. DOCTOR CONNOLLY: No, it wasn’t. SAL: It could grow on to besomething like this polyp. DOCTOR CONNOLLY: Itcould grow into this. So this is something wherewhen we have a colon resection, if there’s a cancer,often there’s a polyp. SAL: Right. DOCTOR CONNOLLY: There’san area of that patch like we saw with hyperplasia. SAL: Not necessarilywhere the cancer is? It’s in that samesection of colon. DOCTOR CONNOLLY: Yeah. We find that people, ifthey have colon cancer, often they have lots ofother pre-cancer lesions. And you can see– SAL: I see. Their bowels are just goingthrough a lot of trauma. DOCTOR CONNOLLY: Some ofit’s familial susceptibility, but a lot of it is that they areshowing a propensity to this. I don’t know if it’s fromenvironmental exposures or what. SAL: I see. And just to remind myselfon what we’re doing here, so you cut out abit of colon– you can kind of view it asa tube– because there was some cancer there. DOCTOR CONNOLLY: Right. SAL: And then this thing mightbe some other polyp that’s sitting in that samesection you cut out. DOCTOR CONNOLLY: Yeah. SAL: And maybe thatsecond slide we saw with the irritation, thatcould be like right there. I see. DOCTOR CONNOLLY:As matter of fact, it’s important that younormally wouldn’t see this slide in a patient, because almostall polyps, the colonoscopist is coming in. And they remove itthrough the colonoscope. SAL: I see, because they don’tknow whether it’s cancerous or not. DOCTOR CONNOLLY:They’ll remove it, but you wouldn’tsee the full wall. So right out here–I mean, that’s all the way throughthe wall and which you’ve got muscle up here.
SAL: I see DOCTOR CONNOLLY: That’s themuscular part of the wall. And so this is, really,kind of going down to a full piece of the wall. SAL: I see. Wow. DOCTOR CONNOLLY: Sothis is a larger piece, and this is in orderto show the polyp in its natural environment. So what we’re goingto do is we’re going to begin lookingat the polyp here. And so we’ll firststart way out here, which is to go back againto the normal architecture. SAL: Right. DOCTOR CONNOLLY: So we had saidthere are supposed to be tubes. Luckily, this one,it’s cut right down the middle of the tube. So you can see how big thehole is supposed to be. And so this is normalarchitecture there. And then if I justgo out a little bit and I’m just goingto come along, you can see that youhave an area here in which there wasa bit of irritation. So it’s thrown up a littlebit like we saw before, but the real trouble isthis thing sticking out. SAL: Right. DOCTOR CONNOLLY:And we wonder what is that thing sticking out.
And so for themedical students, we try to tell them to think likethe way the pathologist would be, that you first need to lookat the overall architecture. This is an abnormalarchitecture. SAL: Yes. DOCTOR CONNOLLY:You don’t usually have bumps sticking out. Then the next thingyou’re going to do– SAL: In 3D it wouldlook like a mushroom? DOCTOR CONNOLLY: Yeah. So it would looklike a mushroom. Actually, they tend to havefoldings on the top of them, so a little more likecauliflower, because they tend to be cauliflower colored. SAL: I see. DOCTOR CONNOLLY: So thenwhen you look here– SAL: That color, too? DOCTOR CONNOLLY: Yeah. They don’t havemuch color to them. In fact, the colonoscopist,when they look at a polyp, can kind of tell ifthere’s a chance of cancer, because they begin havingweird blood vessel samples. SAL: And just to be clear,they’re not this purplish color that we’re seeing on this slide. DOCTOR CONNOLLY: No. SAL: This is color added. DOCTOR CONNOLLY:Thin section and we had to put the– it wouldbe colorless otherwise, so we had to put a stain on it. SAL: Right, right. Makes sense. DOCTOR CONNOLLY: So nowwhat I’m going to do is I’m going todraw the area where I’m going to do a comparison. See this thingamabob here? SAL: Yeah. DOCTOR CONNOLLY:You’re going too– SAL: Look at that. DOCTOR CONNOLLY: So now– SAL: Miracles of science. DOCTOR CONNOLLY: Yeah. SAL: Technology. DOCTOR CONNOLLY:So these are cells which are relatively normal. These are cellswhich are abnormal. And when we look them, apathologist immediately says these look angry. SAL: They do. I would say that, too. DOCTOR CONNOLLY: Andso when you look– so what’s angry aboutthem is, first of all, they’re not committedto behaving. Proper behavior over here. Nuclei belong at the bottom. Things that you’re supposedto do for your job, J-O-B, are at the top. SAL: Yes. DOCTOR CONNOLLY: And sowhen you look at these guys, it’s like, where’s your job? And so a few of themare making mucin, but these ones have nuclei ofdifferent sizes and shapes. SAL: Yeah. And they’re all just– DOCTOR CONNOLLY: They’rejust doing their own thing. SAL: They’re noteven doing mucin. DOCTOR CONNOLLY:No, some make mucin, but a lot of them allthey’re doing is growing. And so usually there’sa playoff between that if you’re committedto your specific job– and we call it differentiation. SAL: Right, right. DOCTOR CONNOLLY: Soif you’re committed to your differentiation,you tend not to have as muchpropensity to grow. And if you tendto grow a lot, you tend not to do thedifferentiation. And so this islargely that you have this sort of chaosof nuclei, less commitment to thenormal structures. And you’re notproducing as much. And so what this, thisis now called dysplasia. SAL: Dysplasia. DOCTOR CONNOLLY: D-Y-S. SAL: Right, plasiain the wrong thing. DOCTOR CONNOLLY: Soit’s the wrong growth. And so that’s whatwe’re saying is we don’t like thelooks of these ones, and so these individual cellslook dysplastic and they grow. So then to tellwhether it’s cancer, cancer means in thisorgan that you’ve grown across thisline in the sand. SAL: So let me– soliterally if you’ve crossed this boundaryright over here, cancer? DOCTOR CONNOLLY: Right. SAL: So even if I’min the polyp up here and I’m controllinguncontrollably cancer cells and it’s mutated andit’s not killing itself the way it’s supposedto, you still would not call itofficially cancer? DOCTOR CONNOLLY: No. So what happens is that there’sa middle term where it’s a cancer still inthe usual place, and that’s carcinoma in situ. SAL: I see. DOCTOR CONNOLLY: Socarcinoma in situ means it’s not aninvasive cancer. And therefore, most people wouldnot really call it a cancer. It’s just so wildlooking up here, you know that itwould do that if it was given any chance or time. SAL: I see. So what we’re sayingis if something was out here, carcinomain situ, that eventually it probably would make its way. DOCTOR CONNOLLY: Yeah. It just looks socommitted to growth and so aggressive and solittle differentiation that you know ifyou gave it time, you’d worry that it would grow. SAL: Makes sense. DOCTOR CONNOLLY: Sowith here though, this is dysplasia, whereit’s very upsetting that it’s growing so fast. But what’s important about thisis in hyperplasia, if you took away the stimulus or irritant,it would go back to normal. This will not. SAL: I see. Like we said, ifthere’s some irritant unless we do–like a week later, we had a couple weeks laterthat hyperplasia would go away. Dysplasia is here to stay. DOCTOR CONNOLLY: That’s right. And so the key wordwe use is autonomous. SAL: Autonomous. It’s independent. DOCTOR CONNOLLY:It’s just whatever. So it will grow no matter what. It doesn’t care about cluesfrom neighboring cells. It doesn’t needsomething driving it. So what you have thenis this is growing. And if it’s growing and it’sall by itself and growing, it’s then called a neoplasia. So that’s our last plasia. SAL: So neoplasiashowing dysplasia– DOCTOR CONNOLLY: Yep. So dysplasia just ismore of when you go in to look at theseguys, these features– SAL: Oh. It’s like a particular feature. DOCTOR CONNOLLY: Thesecells aren’t growing right. SAL: So that’s anexample of dysplasia. DOCTOR CONNOLLY: Right. That’s dysplasia. And then overall, thislump is a new growth. SAL: New growth, neo. DOCTOR CONNOLLY:It’s a new plasia, and we you reserve it in themedical field for meaning it’s growing on its own. SAL: And how dowe know it’s new? Because as you said, it sticksaround like the hyperplasia. So how do we know thiswasn’t around for a year? DOCTOR CONNOLLY:Oh, it probably was. So I think it actuallycame from an area here. And the thinking wouldbe that you probably had irritants or hyperplasia. It would continue to grow. Cells divide. Cells divide too much, and thenone of them made a mistake.
And so then it clicked onsomething where it would say, you know what, from now on I’mnot listening to any clues. SAL: And then all of itsdescendants were crazy, too. DOCTOR CONNOLLY: That’s right. So then it would thenhave a real mean streak, and so then theywould grow from here. So this is an areawhere you can see– SAL: I see that patternin my own family. DOCTOR CONNOLLY: Yeah, exactly. So then here, theseare more normal glands. But even these,that’s dysplasia. So these are growing,and they do not have a good pattern of growth. And overall, thislump is a neoplasia. SAL: I see. So when we say new, it’s kindof newer than the other tissue. DOCTOR CONNOLLY: Yeah. We don’t reallymean so much the new for– meaning that’s newas much as its own thing. New kid on the block. SAL: OK. DOCTOR CONNOLLY: Sothis is the neoplasia. So this one here is a polyp. It has features ofdysplasia, but we would say we see no cancer. SAL: How would you know that? DOCTOR CONNOLLY: And so– SAL: Right, because it nevercrossed a boundary line. DOCTOR CONNOLLY:And there’s a reason why the boundary is important,is that if you look here, these are all the surface cells. Down here, theseare the vessels that go to the rest of the body. These are blood vessels. These ones arecalled lymphatics, and what lymphaticsare is they just take the clearfluid around there. SAL: So these right here arethe lymphatics, the clear fluid. Fluid can go back andforth between blood vessels and the lymph system? DOCTOR CONNOLLY: Yeah. Usually what happensis that blood comes in an artery like this, goes ondown to these little vessels. And then a little bitof the clear parts of it will kind of leak out into it. SAL: The red blood cells aretoo big, kind of leak out. DOCTOR CONNOLLY: Yeah.
So then the lymph is theclear stuff that comes out. And then this ishow it gets back to the rest of your body arethrough these lymphatics, so you can see you do notwant neoplastic cells in the– SAL: Right, becauseonce they’re in there, they can get to anypart of the body. DOCTOR CONNOLLY: Go anyplace. And then guess what. Set up shop. New kids on the block. They just do what they want. SAL: Mis-mis-stas. I can’t say the word. DOCTOR CONNOLLY: Metastasis. So metastasis would be ifit gets into these things, it can get out ofthe colon in a hurry. SAL: Go anywherein the body, right. DOCTOR CONNOLLY: So this isone where it is not cancer, and it has notinvaded these areas where it gets therest of the body. SAL: Fascinating.