Decision making for

treatment of rectal

lesions

Mr Amyn Haji MA MD MSc FRCS

Consultant Colorectal &

Laparoscopic Surgeon

Director of Endoscopy & Colorectal

Surgery

King’s College Hospital, London

Institute for

Therapeutic

Endoscopy

Endoscopic mucosal resection

Endoscopic submucosal dissection

Transanal endoscopic microsurgery / Laparoscopic surgery

Decisions often made on local expertise rather than diagnosis

Options for resection Page 1

Discussion regarding risk of lymph node metastases

Technically resectable by ESD for early submucosal invasion

More important to resect high risk benign lesions

Early rectal cancer Page 2

© UEG. 2014

Aim for quality specimen

When submucosal invasion is suspected, we should provide the

pathologist with a single fragment which includes the submucosa

Accurate diagnosis

King’s approach Page 4

Morphology of colorectal polyps

Assessment

Magnification colonoscopy

Pit pattern classification

Spectral imaging

High frequency colonoscopic ultrasound

Endoscopic resection – EMR/ESD

Lesion assessment Page 5

Pit pattern classification

I II

IIILIIIS IV

VI VN

From Showa Univ. Japan

Vascular pattern classification

From Showa Univ. Japan

faintnormal

network dense

irregular sparse

High frequency mini-probes

7.5 – 30 MHz

Introduced through instrument

channel

20 MHz ultrasound

9

20 MHz ultrasound

96% accuracy in differentiation between mucosal and submucosal lesions

Benign colorectal polyps

LST granular

homogenous – benign pit pattern

Comorbidity

Selection for Endoscopic Mucosal Resection

(EMR)

Homogeneous

(H)

Nodular mixed

(M)

Pseudo depressed

(PD)

Submucosal invasive rates of LSTs

Flat elevated

(F)

90/218**41.3%

4/514*0.8%

72/37919.0%

83/8519.8%

Granular type(LST-G)

Non granular type(LST-NG)

0/2030%

size (mm)

10-19 20-29 30-39

1/1420.7%

1/741.4%

16/10315.5%

18/8321.7%

28/9629.2%

40/8845.5%

18/2766.7%

26/4995.2%

30/23312.9%

12/7316.4%

total

5/4610.9%

40-

2/952.1%

33/14722.4%

15/4632.6%

4/757.1%

**Submucosal invasive rate is very high in PD

*Submucosal invasive rate is very low in H

Apr. 2001～Dec.2012

249/196212.7%

Benign pit – EMR or ESD

Decision making for large LST mixed nodular type Page 16

© UEG. 2014

Matsuda et al. Am J Gastroenterol 2008; 103: 2700

Benign pit pattern

High frequency ultrasound – mm maintained – EMR

Early submucosal invasion - ESD

Decision making for large LST mixed nodular type Page 19

granular type

non-granular type

Laterally spreading tumor (LST)

homogeneous type (Homo) nodular mixed type (Mix)

flat-elevated type (F) pseudo-depressed type (PD)

Kudo S：Early Colorectal Cancer, IGAKU-SHOIN, 150-154, 1996

Homogeneous

(H)

Nodular mixed

(M)

Pseudo depressed

(PD)

Submucosal invasive rates of LSTs

Flat elevated

(F)

90/218**41.3%

4/514*0.8%

72/37919.0%

83/8519.8%

Granular type(LST-G)

Non granular type(LST-NG)

0/2030%

size (mm)

10-19 20-29 30-39

1/1420.7%

1/741.4%

16/10315.5%

18/8321.7%

28/9629.2%

40/8845.5%

18/2766.7%

26/4995.2%

30/23312.9%

12/7316.4%

total

5/4610.9%

40-

2/952.1%

33/14722.4%

15/4632.6%

4/757.1%

**Submucosal invasive rate is very high in PD

*Submucosal invasive rate is very low in H

Apr. 2001～Dec.2012

249/196212.7%

LST – non granular type

Vi pit pattern

?Fibrosis

Up to 30% of endoscopic Vi pit pattern histologically Vn

Not good at differentiating Vi low grade vs high grade

Selection for Endoscopic Submucosal Dissection

20 MHz ultrasound

96% accuracy in differentiation between mucosal and submucosal lesions

ESD

Vn

Rectum

Colon

Pit Vi

Treatment of suspected cancer

Laparoscopic surgery

TEMS

Laparoscopic surgery

Patients often have previous attempted resection

Fibrosis

Large lesions

Problems in our tertiary referral practice Page 25

King’s data - challenges

485 cases endoscopic resection with 12 month follow up

124 ESD cases

Mean Age 71.8 (SD=11)

Mean size of polyp = 55.2 +/-30.1mm (range 20mm – 160mm)

91 lesions > 8 cm (21%)

30% previous failed EMR ; 60% - previous snare attempt or > 6 biopsies

Follow up endoscopy at 3, 12 months

Fibrosis Page 27

Endoscopic submucosal dissection (ESD) Page 28

LST-G nodular mixed

LST granular homogenous type – EMR

LST granular mixed nodular type – ESD / (en bloc of nodule)

LST NG – ESD

Rational approach for endoscopic treatment of

colorectal lesions Page 34

ESD increasing its presence in tertiary referral centres

Education regarding biopsy and attempted resection

Endoscopic diagnosis is the key for appropriate decision making

regarding EMR or ESD

Summary Page 35

Page 37