La maggior parte dei tumori del colon – retto deriva dalla trasformazione in senso maligno di polipi, ovvero di piccole escrescenze, di per se benigne, dovute al proliferare delle cellule della mucosa intestinale.

Sono più frequenti di quelli osservabili in altri segmenti del tubo gastrointestinale.

Clinicamente importanti perché la loro presenza è “subdola” nel senso che possono non dare alcun segno di sé: i sintomi, per esserci, richiedono che il polipo per la sua dimensione crei ostacoli al transito fecale oppure dia luogo a sanguinamento che peraltro può essere del tutto saltuario.

Il polipo può essere definito, in base alle sue caratteristiche, sessile (cioè con la base piatta) o peduncolato (ovvero attaccato alla parete intestinale mediante un piccolo gambo). Non tutti i polipi, però, sono a rischio di malignità. Ve ne sono infatti tre diversi tipi: i cosiddetti polipi iperplastici (cioè caratterizzati da una mucosa a rapida proliferazione), amartomatosi (detti anche polipi giovanili e polipi di Peutz-Jeghers) e adenomatosi. Solo questi ultimi costituiscono lesioni precancerose e di essi solo una piccola percentuale si trasforma in neoplasia maligna.

L’evoluzione oncogenetica di questi polipi e suffragata nel 1975 dagli studi di Mutuo e Morson con una scala che va dalla displasia lieve a quella moderata fino alla displasia severa, che costituisce gia un carcinoma in situ, che non ha oltrepassato cime la membrana basale dell’epitelio intestinale. La probabilità che un polipo del colon evolva verso una forma invasiva di cancro dipende dalla dimensione del polipo stesso: è minima (inferiore al 2 per cento) per dimensioni inferiori a 1,5 cm, intermedia (2-10 per cento) per dimensioni di 1,5-2,5 cm e significativa (10 per cento) per dimensioni maggiori di 2,5 cm. Una volta trasformatasi in tessuto canceroso, la mucosa intestinale può presentarsi con caratteristiche diverse a seconda dell’aspetto visibile al microscopio, e di conseguenza prendere un nome diverso: adenocarcinoma, adenocarcinoma mucinoso, adenocarcinoma a cellule ad anello con castone, carcinoma (più raro).

Nella maggior parte dei casi i polipi non danno sintomi; solo nel 5 per cento dei casi possono dar luogo a piccole perdite di sangue rilevabili con un esame delle feci per la ricerca del cosiddetto “sangue occulto”.

I campanelli d’allarme a cui prestare attenzione sono in sostanza due: il primo è un cambiamento significativo e senza apparente motivo delle proprie abitudini intestinali, che si prolunga per qualche settimana: per esempio una persona abitualmente regolare d’intestino non si libera per diversi giorni, oppure una persona che tende alla stitichezza va incontro a evacuazioni ricorrenti. Il secondo è che venga riscontrata la presenza nelle feci di sangue o di muco.

Esami diagnostici

Ricerca di sangue occulto nelle feci: permette di rilevare una perdita ematica occulta e per lo più cronica, dovuta alla presenza di polipi o carcinoma, ma non sempre presente in quest’ultimo caso.

Esplorazione rettale: e il primo esame da eseguire in caso di presenza di sangue nelle feci, permette di rilevare la presenza di escrescenze a livello del retto.

Colonscopia: effettuata con uno strumento flessibile a fibre ottiche, rappresenta l’esame diagnostico più accurato; consente, infatti, di esplorare tutto il colon-retto, di individuare la presenza e la localizzazione di una massa neoplastica e di eseguire una biopsia per una conferma istologica. Eventuali polipi possono essere asportati durante l’esame stesso (polipectomia endoscopica).

Clisma opaco con bario: e una radiografia dell’intestino, previa introduzione di una miscela di aria e bario, che funge da mezzo di contrasto. Utilissimo nei casi in cui la colonscopia non sia praticabile non e, tuttavia, una vera alternativa poiché non consente di individuare polipi piccoli (inferiori ai 2 cm), ne di effettuare prelievi bioptici.

Trattamento

In genere i polipi del colon possono essere asportati endoscopicamente, i polipi voluminosi, invece, richiedono l’intervento chirurgico di resezione colica.

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