Neoplastic Colonic Polyp
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1) Colonic polyps can be neoplastic or non-neoplastic, with adenomatous polyps being precursors for colon cancer. Larger and villous polyps carry higher cancer risk. 2) Management of polyps depends on size, histology, and risk factors. Low-risk polyps can be removed endoscopically, while malignant or high-risk polyps may require surgery based on factors like margins, invasion, and differentiation. 3) Studies have shown poor differentiation, vascular/lymphatic invasion, and margins less than 2mm to be histologic risk factors associated with residual disease and poorer outcomes, necessitating surgery for high-risk malignant polyps.
Neoplastic Colonic Polyp
- 1. Neoplastic Colonic Polyps Dr. Saud Al-Subaie Department of Surgery Amiri 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
- 4. Carcinoma Adenoma Tubular Tubulovillous Villous Classification of polyps Hamartoma Hyperplastic Inflammatory (psuedopolyps) Lymphoid Neoplastic Non- Neoplastic
- 5. Epidemiology 10.5% (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
- 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
- 17. Adenoma With Ca Adenoma With Ca
- 18. 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)
- 19. Malignant Polyp Important Factors :- 1) Depth of invasion ( Haggitt’s classification) 2) Resection margin 3) Grade of differentiation 4) Vascular invasion
- 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
- 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 Rectum 2005
- 24. Cesare Hassan et al Three histologic risk factors positive resection margin ( < 2 mm) poor differentiation of carcinoma, vascular / Lymphatic invasion Dis Colon Rectum 2005
- 25. Cesare Hassan et al Five unfavorable clinical outcomes residual disease recurrent disease lymph node metastasis hematogenous metastasis mortality Dis Colon Rectum 2005
- 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 Rectum 2005
- 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 Rectum 2004
- 28. 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
- 29. 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
- 30. 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
- 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 can’t be managed endoscopically) Surgical options Type of polyp
- 32. 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
- 33. “ Colon cancer can only be found if looked for. And it can only be cured if found early.”
- 34. THANK YOU