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Neoplastic Colonic Polyp Khalid

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Neoplastic Colonic Polyp Khalid

  1. 1. Neoplastic Colonic Polyps Dr. Saud Al-Subaie Department of Surgery Amiri Hospital Monday 17/04/2006
  2. 2. Introduction <ul><li>Polyp :- any protrusion arising from an epithelial surface. </li></ul><ul><li>Precursor for carcinoma </li></ul><ul><li>Adenomatous polyp are premalignant </li></ul><ul><li>2/3 of polyps are adenomatous </li></ul><ul><li>The bigger the size, the higher the risk of Ca </li></ul><ul><li>< 1 cm :- ~10 yrs for transformation </li></ul>
  3. 3. Polyp- Cancer Sequence
  4. 4. <ul><li>Carcinoma </li></ul><ul><li>Adenoma </li></ul><ul><ul><li>Tubular </li></ul></ul><ul><ul><li>Tubulovillous </li></ul></ul><ul><ul><li>Villous </li></ul></ul>Classification of polyps <ul><li>Hamartoma </li></ul><ul><li>Hyperplastic </li></ul><ul><li>Inflammatory (psuedopolyps) </li></ul><ul><li>Lymphoid </li></ul>Neoplastic Non- Neoplastic
  5. 5. Epidemiology 10.5% (100 %) Weighted chance 40 % 10 % Villous adenoma 22% 15 % Tubulovillous 5% 75% Tubular adenoma % Malignant Prevalence TYPE
  6. 6. Size and % of Ca                                         54% 10% 10% Villous 45% 9% 4% Tubulo-villous 34% 10% 1 % Tubular > 2cm 1-2 cm < 1cm
  7. 7. Endoscopic appearance
  8. 8.                                        
  9. 9. Etiology <ul><li>Genetic predisposition (hereditary Vs. Sporadic) </li></ul><ul><li>Adenomatous Polyposis Syndromes </li></ul><ul><li>Hereditary Nonpolyposis Colorectal Cancer (HNPCC) </li></ul><ul><li>Environmental Factors :- </li></ul><ul><li>Diet </li></ul><ul><li>Exposure to carcinogens </li></ul><ul><li>Role of chemoprevention :- ASA & NSAID </li></ul>
  10. 10. Etiology of Ca
  11. 11. Etiology (FAP)
  12. 12. Clinical Presentation <ul><li>Asymptomatic: </li></ul><ul><ul><li>- incidental finding </li></ul></ul><ul><li>Symptomatic: </li></ul><ul><ul><li>- Usually > 1cm </li></ul></ul><ul><ul><li>- Abdominal pain (intussusception) </li></ul></ul><ul><ul><li>- Profuse watery diarrhea (large villous adenoma). </li></ul></ul><ul><ul><li>- Bleeding PR (when ulcerated) </li></ul></ul>
  13. 13. Management
  14. 14. Endoscopic Management <ul><li>Polypectomy is the best treatment. </li></ul><ul><li>Cautary snare: caution !! </li></ul><ul><li>Complete removal & retrieval of the polyp </li></ul><ul><li>Sessile & Semisessile polyp:- Piecemeal removal. </li></ul><ul><li>?? tattoo with India ink </li></ul>
  15. 17. Adenoma With Ca Adenoma With Ca
  16. 18. What is next <ul><ul><li>Options :- </li></ul></ul><ul><ul><ul><li>1- No more intervention </li></ul></ul></ul><ul><ul><ul><li>2- Surgery ( Formal Resection ) </li></ul></ul></ul><ul><ul><li>What is the risk of :- </li></ul></ul><ul><ul><ul><li>1- Residual disease </li></ul></ul></ul><ul><ul><ul><li>2- Local Recurrence </li></ul></ul></ul><ul><ul><ul><li>3- Risk of LN mets </li></ul></ul></ul><ul><ul><ul><li>4- Distant metastasis </li></ul></ul></ul><ul><ul><ul><li>5- mortality ( Cancer vs Surgery) </li></ul></ul></ul>
  17. 19. Malignant Polyp <ul><li>Important Factors :- </li></ul><ul><ul><li>1) Depth of invasion ( Haggitt’s classification) </li></ul></ul><ul><ul><li>2) Resection margin </li></ul></ul><ul><ul><li>3) Grade of differentiation </li></ul></ul><ul><ul><li>4) Vascular invasion </li></ul></ul>
  18. 20. 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
  19. 21. Histologic assessment <ul><li>Favorable ( low risk ) :- </li></ul><ul><ul><li>1- Differentiation </li></ul></ul><ul><ul><ul><li>G I G II </li></ul></ul></ul><ul><ul><li>2- Resection margin </li></ul></ul><ul><ul><ul><li>> 2mm </li></ul></ul></ul><ul><ul><li>3- Vascular and lymphatic invasion </li></ul></ul><ul><ul><ul><li>None </li></ul></ul></ul>
  20. 22. Histological assessment <ul><li>Unfavorable ( high risk ) </li></ul><ul><ul><li>1- Differentiation :- </li></ul></ul><ul><ul><ul><li>G III </li></ul></ul></ul><ul><ul><li>2- Resection margin :- </li></ul></ul><ul><ul><ul><li>< 2mm </li></ul></ul></ul><ul><ul><li>3- Vascular and lymphatic invasion :- </li></ul></ul><ul><ul><ul><li>yes </li></ul></ul></ul>
  21. 23. Cesare Hassan et al <ul><li>Histologic Risk Factors & Clinical Outcome </li></ul><ul><li>A pooled- data analysis. </li></ul><ul><li>Thirty-one studies </li></ul><ul><li>1,900 patients with malignant polyp. </li></ul><ul><li>Three histologic risk factors </li></ul><ul><li>Five unfavorable clinical outcomes </li></ul>Dis Colon Rectum 2005
  22. 24. Cesare Hassan et al <ul><li>Three histologic risk factors </li></ul><ul><li>positive resection margin ( < 2 mm) </li></ul><ul><li>poor differentiation of carcinoma, </li></ul><ul><li>vascular / Lymphatic invasion </li></ul>Dis Colon Rectum 2005
  23. 25. Cesare Hassan et al <ul><li>Five unfavorable clinical outcomes </li></ul><ul><li>residual disease </li></ul><ul><li>recurrent disease </li></ul><ul><li>lymph node metastasis </li></ul><ul><li>hematogenous metastasis </li></ul><ul><li>mortality </li></ul>Dis Colon Rectum 2005
  24. 26. Cesare Hassan et al <ul><li>CONCLUSION:  All three histologic risk factors are significantly associated with the clinical outcome. </li></ul><ul><li>Classification in low-risk and high-risk patients may be regarded as a meaningful staging procedure. </li></ul>Dis Colon Rectum 2005
  25. 27. Sitz et al <ul><li>Retrospective ( 1985 – 1996) </li></ul><ul><li>114 Pts with endoscopicaly removed polyps </li></ul><ul><li>Low risk :- </li></ul><ul><ul><li>Complete resection </li></ul></ul><ul><ul><li>G1 G 2 grade </li></ul></ul><ul><ul><li>No Vascular invasion </li></ul></ul><ul><li>High risk :- others </li></ul>Dis Colon Rectum 2004
  26. 28. Sitz et al <ul><li>54 low risk :- </li></ul><ul><ul><li>- 5  surgery  no residual disease </li></ul></ul><ul><ul><li>- 33 no surgery  no adverse outcome </li></ul></ul><ul><li>60 high risk : </li></ul><ul><ul><li>- 52 surgery  residual disease in 27% </li></ul></ul><ul><ul><li>- Significantly higher risk of adverse outcome( P < 0.0001) </li></ul></ul><ul><ul><li>- No surgical complications </li></ul></ul>Dis Colon Rectum 2004
  27. 29. Sitz et al <ul><li>Conclusion:- </li></ul><ul><ul><li>1- Low risk :- Endoscopic polypectomy alone is adequate </li></ul></ul><ul><ul><li>2- High risk :- The risk of adverse outcome should be weighed against the risk of surgery </li></ul></ul>Dis Colon Rectum 2004
  28. 30. Volk / Fazio <ul><li>47 pt </li></ul><ul><li>17 had favorable histology:- </li></ul><ul><ul><li>16  polypectomy alone  no adverse outcome </li></ul></ul><ul><li>30 pt unfavorable </li></ul><ul><ul><li>21  surgery </li></ul></ul><ul><ul><li>10/30 had adverse outcome </li></ul></ul><ul><li>Conclusion:- Endoscopic polypectomy is adequate for polyps with favorable histology </li></ul>Gastroenterology 1995
  29. 31. Operative Management <ul><li>- Transanal excision </li></ul><ul><li>Transcoccygeal </li></ul><ul><li>Transabdominal </li></ul>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
  30. 32. Summary <ul><li>Formal surgery should be advised for Malignant polyps with the following :- </li></ul><ul><ul><li>Poor differentiation </li></ul></ul><ul><ul><li>Vascular and lymphatic invasion </li></ul></ul><ul><ul><li>< 2mm resection margins </li></ul></ul><ul><ul><li>Sessile polyps </li></ul></ul><ul><ul><li>Haggitts’s level 3/4 </li></ul></ul>
  31. 33. “ Colon cancer can only be found if looked for. And it can only be cured if found early.”
  32. 34. THANK YOU

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