Neoplastic Colonic Polyp Khalid

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  • 1. Neoplastic Colonic Polyps Dr. Saud Al-Subaie Department of SurgeryAmiri Hospital Monday 17/04/2006

2. 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

3. Polyp- Cancer Sequence 4.

  • Carcinoma
  • Adenoma
    • Tubular
    • Tubulovillous
    • Villous

Classification of polyps

  • Hamartoma
  • Hyperplastic
  • Inflammatory (psuedopolyps)
  • Lymphoid

Neoplastic Non- Neoplastic 5. Epidemiology10.5% (100 %) Weighted chance 40 % 10 % Villous adenoma 22% 15 % Tubulovillous 5% 75% Tubular adenoma % Malignant Prevalence TYPE 6. Size and % of Ca 54% 10% 10% Villous 45% 9% 4% Tubulo-villous 34% 10% 1 % Tubular> 2cm 1-2 cm < 1cm 7. Endoscopic appearance 8. 9. 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

10. Etiology of Ca 11. Etiology (FAP) 12. Clinical Presentation

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

13. Management 14. 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

15. 16. 17. AdenomaWithCa AdenomaWithCa 18. What is next

    • Options :-
      • 1- No more intervention
      • 2- Surgery ( Formal Resection )
    • Whatis the risk of :-
      • 1- Residual disease
      • 2- Local Recurrence
      • 3- Risk of LN mets
      • 4- Distant metastasis
      • 5- mortality ( Cancer vs Surgery)

19. Malignant Polyp

  • Important Factors :-
    • 1)Depth of invasion ( Haggitts classification)
    • 2)Resection margin
    • 3)Grade of differentiation
    • 4)Vascular invasion

20. Haggitt HighestInvasion ofsubmucosa, not the muscularis propria, sessile polyp 4 Moderate Invasion of the (MM)& polyp stalk 3 LowInvasion of the (MM) & polyp neck2NoneInvasion of the (MM) & polyp head1 NoneNo invasion of the muscularis mucosa (MM), carcinoma in situ 0Risk of LN metsHistologic description level 21. Histologic assessment

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

22. Histological assessment

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

23. 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 Rectum2005 24. Cesare Hassan et al

  • Three histologic risk factors
  • positive resection margin ( < 2 mm)
  • poor differentiation of carcinoma,
  • vascular / Lymphatic invasion

Dis Colon Rectum2005 25. Cesare Hassan et al

  • Five unfavorable clinical outcomes
  • residual disease
  • recurrent disease
  • lymph node metastasis
  • hematogenous metastasis
  • mortality

Dis Colon Rectum2005 26. 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 Rectum2005 27. 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 Rectum2004 28. Sitz et al

  • 54 low risk :-
    • - 5surgeryno residual disease
    • - 33 no surgeryno adverse outcome
  • 60 high risk :
    • - 52surgeryresidual disease in 27%
    • - Significantly higher risk of adverse outcome( P < 0.0001)
    • - No surgical complications

Dis Colon Rectum2004 29. Sitz et al

  • Conclusion:-
    • 1- Low risk :- Endoscopic polypectomy alone is adequate
    • 2- High risk :- The risk of adverse outcome should be weighedagainst the risk of surgery

Dis Colon Rectum2004 30. Volk / Fazio

  • 47 pt
  • 17 had favorable histology:-
    • 16polypectomy aloneno adverse outcome
  • 30 pt unfavorable
    • 21surgery
    • 10/30 had adverse outcome
  • Conclusion:- Endoscopic polypectomy is adequate for polyps with favorable histology

Gastroenterology 1995 31. 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 cant be managed endoscopically) Surgical options Type of polyp 32. Summary

  • Formal surgery should be advisedfor Malignant polyps with the following :-
    • Poor differentiation
    • Vascular and lymphatic invasion
    • < 2mm resection margins
    • Sessile polyps
    • Haggittss level 3/4

33. Colon cancer can only be found if looked for. And itcan only be cured if found early. 34. THANK YOU