Management of Malignant Polyps

Santhat Nivatvongs, MD

Colon and Rectal Surgery

Mayo Clinic

Rochester Minnesota

U.S.A.

Management of Malignant Polyps

I have no disclosure

Malignant Polyps

• Invasion into submucosa

• Early Ca

• T1NxMx

Malignant PolypsManagement

• Colonoscopic Polypectomy

• Transanal Excision

• Colorectal Resection

Malignant Polyps

Who can have a local excision?

Who needs a radical resection?

T1 Nx Mx

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