neoplastic colonic polyp

Neoplastic Colonic PolypsNeoplastic Colonic Polyps

Dr. Saud Al-SubaieDr. Saud Al-Subaie

Department of Surgery Department of Surgery

Amiri HospitalAmiri Hospital

Monday 17/04/2006

IntroductionIntroduction • Polyp :- any protrusion arising from an

epithelial surface.

• Precursor for carcinoma

• Adenomatous polyp are premalignant

• 2/3 of polyps are adenomatous

• The bigger the size, the higher the risk of Ca

• < 1 cm :- ~10 yrs for transformation

Polyp- Cancer Sequence Polyp- Cancer Sequence

Classification of polyps

• Carcinoma• Adenoma

• Tubular

• Tubulovillous

• Villous

• Hamartoma • Hyperplastic• Inflammatory

(psuedopolyps)• Lymphoid

Neoplastic Non- Neoplastic

Epidemiology Epidemiology TYPETYPE PrevalencePrevalence % Malignant% Malignant

Tubular adenomaTubular adenoma 75%75% 5%5%

TubulovillousTubulovillous 15 %15 % 22%22%

Villous adenomaVillous adenoma 10 %10 % 40 %40 %

Weighted chanceWeighted chance (100 %)(100 %) 10.5%10.5%

Size and % of CaSize and % of Ca

< 1cm 1-2 cm > 2cm

Tubular 1 % 10% 34%

Tubulo-villous 4% 9% 45%

Villous 10% 10% 54%

Endoscopic appearanceEndoscopic appearance

Etiology Etiology Genetic predisposition Genetic predisposition (hereditary Vs. Sporadic)(hereditary Vs. Sporadic)

Adenomatous Polyposis SyndromesAdenomatous Polyposis Syndromes

Hereditary Nonpolyposis Colorectal Cancer Hereditary Nonpolyposis Colorectal Cancer (HNPCC)(HNPCC)

Environmental Factors :-Environmental Factors :-

DietDiet

Exposure to carcinogensExposure to carcinogens

Role of chemoprevention :- ASA & NSAIDRole of chemoprevention :- ASA & NSAID

Etiology of CaEtiology of Ca

Etiology (FAP)Etiology (FAP)

Clinical PresentationClinical Presentation

• Asymptomatic:

- incidental finding

• Symptomatic:

- Usually > 1cm

- Abdominal pain (intussusception)

- Profuse watery diarrhea (large villous adenoma).

- Bleeding PR (when ulcerated)

ManagementManagement

Endoscopic ManagementEndoscopic Management

• Polypectomy is the best treatment.

• Cautary snare: caution !!

• Complete removal & retrieval of the polyp

• Sessile & Semisessile polyp:- Piecemeal removal.

• ?? tattoo with India ink

Adenoma With Ca

Adenoma With Ca

What is next What is next • Options :-

1- No more intervention

2- Surgery ( Formal Resection )

• What is the risk of :-

1- Residual disease

2- Local Recurrence

3- Risk of LN mets

4- Distant metastasis

5- mortality ( Cancer vs Surgery)

Malignant PolypMalignant Polyp

• Important Factors :-Important Factors :-

1) Depth of invasion ( Haggitt’s classification)1) Depth of invasion ( Haggitt’s classification)

2) Resection margin2) Resection margin

3) Grade of differentiation3) Grade of differentiation

4) Vascular invasion4) Vascular invasion

HaggittHaggitt

level Histologic description Risk of LN mets

0 No invasion of the muscularis mucosa (MM), carcinoma in situ

None

1 Invasion of the (MM) & polyp head None

2 Invasion of the (MM) & polyp neck Low

3 Invasion of the (MM)& polyp stalk Moderate

4 Invasion of submucosa, not the muscularis propria, sessile polyp

Highest

Histologic assessment Histologic assessment

• Favorable ( low risk ) :-

1- Differentiation

G I G II

2- Resection margin

> 2mm

3- Vascular and lymphatic invasion

None

Histological assessment Histological assessment

• Unfavorable ( high risk )

1- Differentiation :-

G III

2- Resection margin :-

< 2mm

3- Vascular and lymphatic invasion :-

yes

Cesare Hassan et alCesare Hassan et al

• Histologic Risk Factors & Clinical Outcome

• A pooled- data analysis.

• Thirty-one studies

• 1,900 patients with malignant polyp.

• Three histologic risk factors

• Five unfavorable clinical outcomes

Dis Colon Rectum 2005

Cesare Hassan et alCesare Hassan et al

Three histologic risk factors

positive resection margin ( < 2 mm)

poor differentiation of carcinoma,

vascular / Lymphatic invasion

Dis Colon Rectum 2005

Cesare Hassan et alCesare Hassan et al

Five unfavorable clinical outcomes

- residual disease

- recurrent disease

- lymph node metastasis

- hematogenous metastasis

- mortality

Dis Colon Rectum 2005

Cesare Hassan et alCesare Hassan et al

CONCLUSION:  All three histologic risk factors are significantly associated with the clinical outcome.

Classification in low-risk and high-risk patients may be regarded as a meaningful staging procedure.

Dis Colon Rectum 2005

Sitz et alSitz et al

• Retrospective ( 1985 – 1996)Retrospective ( 1985 – 1996)• 114 Pts with endoscopicaly removed polyps114 Pts with endoscopicaly removed polyps• Low risk :-Low risk :-

• Complete resectionComplete resection

• G1 G 2 gradeG1 G 2 grade

• No Vascular invasionNo Vascular invasion• High risk :- othersHigh risk :- others

Dis Colon Rectum 2004

Sitz et alSitz et al

• 54 low risk :-54 low risk :-

- 5 - 5 surgery surgery no residual disease no residual disease

- 33 no surgery - 33 no surgery no adverse outcome no adverse outcome• 60 high risk :60 high risk :

- 52 surgery - 52 surgery residual disease in 27% residual disease in 27%

- Significantly higher risk of adverse - Significantly higher risk of adverse outcome( P < 0.0001)outcome( P < 0.0001)

- No surgical complications- No surgical complications

Dis Colon Rectum 2004

Sitz et alSitz et al

• Conclusion:-Conclusion:-

1- Low risk :- Endoscopic polypectomy alone 1- Low risk :- Endoscopic polypectomy alone is adequateis adequate

2- High risk :- The risk of adverse outcome 2- High risk :- The risk of adverse outcome should be weighed against the risk of should be weighed against the risk of surgerysurgery

Dis Colon Rectum 2004

Volk / FazioVolk / Fazio• 47 pt47 pt• 17 had favorable histology:-17 had favorable histology:-

16 16 polypectomy alone polypectomy alone no adverse no adverse outcomeoutcome

• 30 pt unfavorable 30 pt unfavorable

21 21 surgery surgery

10/30 had adverse outcome10/30 had adverse outcome• Conclusion:-Conclusion:- Endoscopic polypectomy is Endoscopic polypectomy is

adequate for polyps with favorable histologyadequate for polyps with favorable histology

Gastroenterology 1995

Operative ManagementOperative Management Type of polypType of polyp Surgical optionsSurgical options

Benign polyp(>3cm can’t be Benign polyp(>3cm can’t be managed endoscopically)managed endoscopically)

- Colotomy+ Polypectomy- Colotomy+ Polypectomy

- Segmental Resection- Segmental Resection

Malignant / incompletely Malignant / incompletely excised / Suspicious polypexcised / Suspicious polyp

Anatomic resection with Anatomic resection with removal of adjacent LNremoval of adjacent LN

Malignant rectal polypsMalignant rectal polyps

- Transanal excision - Transanal excision - Transcoccygeal Transcoccygeal - TransabdominalTransabdominal

SummarySummary

• Formal surgery should be advised for Formal surgery should be advised for Malignant polyps with the following :-Malignant polyps with the following :-

– Poor differentiationPoor differentiation

– Vascular and lymphatic invasionVascular and lymphatic invasion

– < 2mm resection margins< 2mm resection margins

– Sessile polypsSessile polyps

– Haggitts’s level 3/4 Haggitts’s level 3/4

““Colon cancer can only be Colon cancer can only be found if looked for.found if looked for.

And it can only be cured if And it can only be cured if

found early.” found early.”

THANK YOUTHANK YOU