Neoplastic Colonic Polyp Khalid

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Information about Neoplastic Colonic Polyp Khalid

Published on November 29, 2007

Author: Sodo

Source: slideshare.net

Neoplastic Colonic Polyps Dr. Saud Al-Subaie Department of Surgery Amiri Hospital Monday 17/04/2006

Introduction 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 :- 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

Carcinoma Adenoma Tubular Tubulovillous Villous Classification of polyps Hamartoma Hyperplastic Inflammatory (psuedopolyps) Lymphoid Neoplastic Non- Neoplastic

Carcinoma

Adenoma

Tubular

Tubulovillous

Villous

Hamartoma

Hyperplastic

Inflammatory (psuedopolyps)

Lymphoid

Epidemiology 10.5% (100 %) Weighted chance 40 % 10 % Villous adenoma 22% 15 % Tubulovillous 5% 75% Tubular adenoma % Malignant Prevalence TYPE

Size and % of Ca                                         54% 10% 10% Villous 45% 9% 4% Tubulo-villous 34% 10% 1 % Tubular > 2cm 1-2 cm < 1cm

Endoscopic appearance

                                       

Etiology Genetic predisposition (hereditary Vs. Sporadic) Adenomatous Polyposis Syndromes Hereditary Nonpolyposis Colorectal Cancer (HNPCC) Environmental Factors :- Diet Exposure to carcinogens Role of chemoprevention :- ASA & NSAID

Genetic predisposition (hereditary Vs. Sporadic)

Adenomatous Polyposis Syndromes

Hereditary Nonpolyposis Colorectal Cancer (HNPCC)

Environmental Factors :-

Diet

Exposure to carcinogens

Role of chemoprevention :- ASA & NSAID

Etiology of Ca

Etiology (FAP)

Clinical Presentation Asymptomatic: - incidental finding Symptomatic: - Usually > 1cm - Abdominal pain (intussusception) - Profuse watery diarrhea (large villous adenoma). - Bleeding PR (when ulcerated)

Asymptomatic:

- incidental finding

Symptomatic:

- Usually > 1cm

- Abdominal pain (intussusception)

- Profuse watery diarrhea (large villous adenoma).

- Bleeding PR (when ulcerated)

Management

Endoscopic Management Polypectomy is the best treatment. Cautary snare: caution !! Complete removal & retrieval of the polyp Sessile & Semisessile polyp:- Piecemeal removal. ?? tattoo with India ink

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 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)

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 Polyp Important Factors :- 1) Depth of invasion ( Haggitt’s classification) 2) Resection margin 3) Grade of differentiation 4) Vascular invasion

Important Factors :-

1) Depth of invasion ( Haggitt’s classification)

2) Resection margin

3) Grade of differentiation

4) Vascular invasion

Haggitt Highest Invasion of submucosa, not the muscularis propria, sessile polyp 4 Moderate Invasion of the (MM)& polyp stalk 3 Low Invasion of the (MM) & polyp neck 2 None Invasion of the (MM) & polyp head 1 None No invasion of the muscularis mucosa (MM), carcinoma in situ 0 Risk of LN mets Histologic description level

Histologic assessment Favorable ( low risk ) :- 1- Differentiation G I G II 2- Resection margin > 2mm 3- Vascular and lymphatic invasion None

Favorable ( low risk ) :-

1- Differentiation

G I G II

2- Resection margin

> 2mm

3- Vascular and lymphatic invasion

None

Histological assessment Unfavorable ( high risk ) 1- Differentiation :- G III 2- Resection margin :- < 2mm 3- Vascular and lymphatic invasion :- yes

Unfavorable ( high risk )

1- Differentiation :-

G III

2- Resection margin :-

< 2mm

3- Vascular and lymphatic invasion :-

yes

Cesare 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

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

Cesare Hassan et al Three histologic risk factors positive resection margin ( < 2 mm) poor differentiation of carcinoma, vascular / Lymphatic invasion Dis Colon Rectum 2005

Three histologic risk factors

positive resection margin ( < 2 mm)

poor differentiation of carcinoma,

vascular / Lymphatic invasion

Cesare Hassan et al Five unfavorable clinical outcomes residual disease recurrent disease lymph node metastasis hematogenous metastasis mortality Dis Colon Rectum 2005

Five unfavorable clinical outcomes

residual disease

recurrent disease

lymph node metastasis

hematogenous metastasis

mortality

Cesare 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

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.

Sitz et al Retrospective ( 1985 – 1996) 114 Pts with endoscopicaly removed polyps Low risk :- Complete resection G1 G 2 grade No Vascular invasion High risk :- others Dis Colon Rectum 2004

Retrospective ( 1985 – 1996)

114 Pts with endoscopicaly removed polyps

Low risk :-

Complete resection

G1 G 2 grade

No Vascular invasion

High risk :- others

Sitz et al 54 low risk :- - 5  surgery  no residual disease - 33 no surgery  no adverse outcome 60 high risk : - 52 surgery  residual disease in 27% - Significantly higher risk of adverse outcome( P < 0.0001) - No surgical complications Dis Colon Rectum 2004

54 low risk :-

- 5  surgery  no residual disease

- 33 no surgery  no adverse outcome

60 high risk :

- 52 surgery  residual disease in 27%

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

- No surgical complications

Sitz et al Conclusion:- 1- Low risk :- Endoscopic polypectomy alone is adequate 2- High risk :- The risk of adverse outcome should be weighed against the risk of surgery Dis Colon Rectum 2004

Conclusion:-

1- Low risk :- Endoscopic polypectomy alone is adequate

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

Volk / Fazio 47 pt 17 had favorable histology:- 16  polypectomy alone  no adverse outcome 30 pt unfavorable 21  surgery 10/30 had adverse outcome Conclusion:- Endoscopic polypectomy is adequate for polyps with favorable histology Gastroenterology 1995

47 pt

17 had favorable histology:-

16  polypectomy alone  no adverse outcome

30 pt unfavorable

21  surgery

10/30 had adverse outcome

Conclusion:- Endoscopic polypectomy is adequate for polyps with favorable histology

Operative Management - Transanal excision Transcoccygeal Transabdominal Malignant rectal polyps Anatomic resection with removal of adjacent LN Malignant / incompletely excised / Suspicious polyp - Colotomy+ Polypectomy - Segmental Resection Benign polyp(>3cm can’t be managed endoscopically) Surgical options Type of polyp

- Transanal excision

Transcoccygeal

Transabdominal

Summary Formal surgery should be advised for Malignant polyps with the following :- Poor differentiation Vascular and lymphatic invasion < 2mm resection margins Sessile polyps Haggitts’s level 3/4

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

Poor differentiation

Vascular and lymphatic invasion

< 2mm resection margins

Sessile polyps

Haggitts’s level 3/4

“ Colon cancer can only be found if looked for. And it can only be cured if found early.”

THANK YOU

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