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Management of Malignant Polyps
Santhat Nivatvongs, MD
Colon and Rectal Surgery
Mayo Clinic
Rochester Minnesota
U.S.A.
Literature ReviewHigh Risk of LNM in Malignant Polyps
• Lymphovascular invasion
• Poor differentiation
• Gender, positive margins
• Extensive budding, microacinar structures
• Depressed lesions
• Deep submucosal invasion (Sm3)
Pathologic Assessment of Malignant PolypsInter-observer Variability
Kappa Statistics--a measure of observer agreement
Characteristics Kappa Result
Lymphovascular invasion 0.017 poor
Histologic grade 0.163 poor
Haggitt’s classification 0.682 very good
T stage 0.725 very good Komuta K, Batts K, et al . Br J Surg 2004; 91:1479
Malignant Polyps Risk of Lymph Node Metastasis
LNM (%)
Pedunculated -- Level 1,2,3 < 1
Sessile & Pedunculated Level 4 12 Haggitt R, et al. Gastroent 1985; 89:328
Nivatvongs S, et al. DCR 1991; 34:323
Kyzer S, et al. Cancer 1992; 70:2044
Sessile Malignant PolypIndependent Risk Factors
Factor Odds ratio 95% CI p
LVI 3.5 1.4-8.9 0.009
Sm3 5.0 2.3-10.6 <0.001
Lower 1/3 R 6.0 2.2-14.2 <0.001 Nascimbeni R et al DCR 2002;45:200
High Risk of LN Metastasis In T1 Low Rectum
Author No. Treatment LNM (%)
Nascimbeni 2002 29 LAR / APR 34
Goldstein 1999 53 APR 17
Blumberg 1998 48 LAR / APR 10
Adequate Local Excision
Colon Clear margins
Clear depth > 2 mm
Low rectum Clear margins
Full thickness
LOCAL EXCISION FOR T1 CA. RECTUM
Standard Criteria
Size < 3 cm
Full thickness excision, 1 cm margin
Not undifferenciated Ca.
No lymphovascular invasion
LITERATURE REVIEWLocal Excision Ca. Rectum ( T1)
Author Yr No. Loc Recur(%) FU/ M0
Madbouly 2005 52 17 55
Nascimbeni 2004 70 7 60
Paty 2002 67 14 60
Mellgren 2000 69 18 52
OUTCOME OF MID OR LOW RECTAL CA
Local Excision Resection p
N=70 N=74
5 yr (%) 10 yr (%) 5 yr (%) 10 yr (%)
Local recurrence 6.6 12.2 2.8 6.2 0.26
Distant metastasis 14.2 20.5 6.9 10.2 0.13
Overall survival 72.4 44.3 90.4 72.0 0.008
Ca-free survival 66.6 39.6 83.6 69.8 0.003
Nascimbeni R et al. DCR 2004; 47: 1773
T1 Carcinoma of RectumLocal Excision vs Radical Resection
You YN, Baxter NN, Stewart A, Nelson H (ACOSOG)
National Data Base 1994-1996 ---Follow-up 6.3 yr
Local Excision Radical Resection p
Number of patient 601 493
Overall Survival (5 yr) 77 % 82% 0.09
Disease Free Survival (5 yr) 93% 97% 0.004
Local Recurrence (5 yr) 13% 7% 0.003
T1 Carcinoma of Rectum
The data favor radical surgery as the more definitive
cancer treatment but do not eliminate local excision as a
reasonable choice for many patients
Bentrem DJ, et al. Ann Surg 2005; 242:472
Local Excision Plus Chemoradiation
Author No. Recur. (%) FU (mo)
Lamont 2000 10 0 33
Bouvet 1999 37 5 51
( 68% treated )
Bailey 1992 35 T1 10 60
18 T2
Paty 2002 67 ( untreated ) 17 120
7 ( treated ) 17 120
PO Radiation After Local ExcisionR Benson, BJ Cummings, et al. Int J Rad Onc Biol Phy 2001; 50:1309 Princess Margaret Hosp. Toronto
24 T1-- Low Rectum ( median 4cm from anal verge )
Reasons for radiation ( no chemo) Fragmentaions 29 %
LVI 41 %
Positive margins 42 %
Recurrence at 5 yr 39 %
Disease-free survival at 5 yr 59 %
Immediate vs Salvage Resection
No Ca -free survival ( % )
Immediate radical resection 37 79 % at 5 yr Mayo Clinic DCR 2005; 48:429
Delayed radical resection 21 56 at 5 yr Cleveland Clinic DCR 2005; 48:711
Delayed radical resection 49 53 at 5 yr Memorial DCR 2005; 48:1169
Delayed radical resection 24 50 at 3 yr Univ Minn DCR 2000; 43:1064
Management of Malignant PolypsSummary
Patients’ risk Local excision
Radical resection
Cancer risk Lymphovascular invasion Sm3 or high grade
Lower 1/3 rectum
Adequate excision Size < 3 cm
Management of Malignant PolypsHigh Risk Group
• Colon, high rectum Radical Resection
• Low rectum LAR / APR
Loc. Exc. +/- Ch R?
OUTCOME OF MID OR LOW RECTAL CA
Local Excision Resection p
N=70 N=74
5 yr (%) 10 yr (%) 5 yr (%) 10 yr (%)
Local recurrence 6.6 12.2 2.8 6.2 0.26
Distant metastasis 14.2 20.5 6.9 10.2 0.13
Overall survival 72.4 44.3 90.4 72.0 0.008
Ca-free survival 66.6 39.6 83.6 69.8 0.003
Nascimbeni R et al. DCR 2004; 47: 1773
Local Excision Followed by Radical Resection
T1 Ca Rectum No. FU (mo) Loc Recur (%) Met (%)
Study group 37 101 3 11
Match control 78 122 5 12
Hahnloser D, et al. DCR 2005; 48: 429
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