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Malignant Rectal Polyp Dr Kit-wai Lai Department of Surgery Tuen Mun Hospital Joint Hospital Surgical Grand Round 18 Apr 2009.

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Presentation on theme: "Malignant Rectal Polyp Dr Kit-wai Lai Department of Surgery Tuen Mun Hospital Joint Hospital Surgical Grand Round 18 Apr 2009."— Presentation transcript:

1 Malignant Rectal Polyp Dr Kit-wai Lai Department of Surgery Tuen Mun Hospital Joint Hospital Surgical Grand Round 18 Apr 2009

2 Malignant Rectal Polyp Polyps with cancer cells penetrating the muscularis mucosa Invasion limited to submucosa i.e. T1 lesion

3 Malignant? Size the most important factor determining risk of malignant transformation within a polyp Tytherleigh et al. BJS 2008;95: >1cm 38.5% >42mm 78.9%

4 Level 0: noninvasive (severe dysplasia) headLevel 1: invading through the muscularis mucosa but limited to the head of a pedunculated polyp neckLevel 2: invading the neck of a pedunculated polyp stalkLevel 3: invading the stalk of a pedunculated polyp below the stalkLevel 4: invading into the submucosa below the stalk of a pedunculated polyp ( Sessile malignant polyp  level 4 ) Haggitt Classification

5 Kikuchi Classification of Adenocarcinoma in Sessile Polyp Haggitt level 1,2,3 = Kikuchi Sm1 level 4 = Sm1, Sm2 or Sm3

6  Local Therapy Opportunity of cure with less detriment Staging is critical to management Histological Assessment Most important factor to predict risk of lymphatic spread Tytherleigh et al. BJS 2008;95:

7 Histopathological Features Low-risk ERCHigh-risk ERC Depth of wall invasion Haggitt 1-3 Kikuchi Sm1 & (possibly Sm2) Kikuchi Sm3 & (possibly Sm2) Grade Well Moderate differentiated Poorly differentiated Undifferentiated Lymphovascular invasion -+ Poorly differentiated 43% Goldstein et al. Am J Clin Pathol 1999;111:51-8 Best estimate of the probability of regional LN metastasis Bretagnol et al. Dis Colon Rectum 2007;50: Rate of lymph node metastasis Sm1 1-3% Sm2 8% Sm3 23% Nascimbeni et al. Dis Colon Rectum 2002;45:

8 Clinical Scenario 2. Post Colonoscopic polypectomy of rectal polyp Pathology: adenocarcinoma arise from tubular adenoma 1. Colonoscopy: 2.5cm rectal polyp (3cm from anal verge) Biopsy: adenocarcinoma

9 Clinical Scenario 1. Colonoscopy: 2.5cm rectal polyp (3cm from anal verge) Biopsy: adenocarcinoma

10 Scenario 1 2.5cm rectal Polyp Digital rectal exam ERUS MRI CT LN + LN - Radical Sx AR/TME/APR T2 T1 Local Excision + Adj ChemoRT High Risks Features Sm3 (  Sm2) Grade lymphovascular No High Risks Features Local Excision Follow-up Recurrence No Recurrence Salvage Surgery

11 ERUS T stageBest method to determining T stage T stage Accuracy: 90 % Sensitivity : 85% Specificity: 95% N stage Accuracy: 80% Sensitivity: 70% Specificity: 80% Bretagnol et al. Dis Colon Rectum 2007;50:

12 ERUS T1-slight (Sm1) detection Sensitivity (99%) Specificity (74%) Accuracy (96%) Akasu et al. World J Surg 2000;24: May assess residual tumour following polypectomy Follow up after local excision or radical surgery Hernandez De Anda et al. Dis Colon Rectum 2004; 47: 818–824 Limitations Operator dependentOperator dependent Tumor heightTumor height Tumour stenosisTumour stenosis Peritumoral fibrosis and inflammatory tissuePeritumoral fibrosis and inflammatory tissue Effect of pre op radiotherapy or haemorrhage in bowel wall after bxEffect of pre op radiotherapy or haemorrhage in bowel wall after bx Sm1 Sm2

13 MRI Overall T stage accuracy 59-95% T1,2 lesion (vs ERUS) –Similar sensitivities –Lower specificity (69%) N stage –Comparable vs ERUS Bretagnol et al. Dis Colon Rectum 2007;50:

14 Scenario 1 2.5cm rectal Polyp Digital rectal exam ERUS MRI CT LN + LN - Radical Sx AR/TME/APR T2 T1 Local Excision + Adj ChemoRT High Risks Features Sm3 (  Sm2) Grade lymphovascular No High Risks Features Local Excision Follow-up Recurrence No Recurrence Salvage Surgery

15 Local Excision Potential advantage –Sphincter preservation –Minimal mortality and morbidity –Low urinary/sexual dysfunction risk

16 Local Excision Parks’ Per Anal Excision –Lesions 6-10cm from anal verge –Aid of anal retractors –Full thickness excision Transanal Endoscopic Microsurgery –Resectoscope –Usual below peritoneal reflection –Full thickness excision

17 Local Excision Bretagnol et al. Dis Colon Rectum 2007;50: LR

18 Local Excision vs Radical Sx Bretagnol et al. Dis Colon Rectum 2007;50: T1 sm3 lesion Radical Surgery had lower rates of distant metastasis and better survival

19 Scenario 1 2.5cm rectal Polyp Digital rectal exam ERUS MRI CT LN + LN - Radical Sx AR/TME/APR T2 T1 Local Excision + Adj ChemoRT High Risks Features Sm3 (  Sm2) Grade lymphovascular No High Risks Features Local Excision Follow-up Recurrence No Recurrence Salvage Surgery

20 Adjuvant chemoradiotherapy Bretagnol et al. Dis Colon Rectum 2007;50: Difficult to interpret Most retrospective studies Lack of controlled data Adjuvant regime not always based on a defined protocol  Limited data  May be helpful If further surgery is not an option T1 lesions with adverse pathologic features T2 lesions (Tytherleigh et al. BJS 2008;95: )

21 Scenario 1 2.5cm rectal Polyp Digital rectal exam ERUS MRI CT LN + LN - Radical Sx AR/TME/APR T2 T1 Local Excision + Adj ChemoRT High Risks Features Sm3 (  Sm2) Grade lymphovascular No High Risks Features Local Excision Follow-up Recurrence No Recurrence Salvage Surgery

22 Follow up Regular endoscopic surveillance of rectum and scar Digital rectal exam + Endoscopy + CEA –First 2 years: every 3 months –Next 3 years: every 6 months –Then annually Mellgren et al. Dis Colon Rectum 2000; 43: 1064–1071 NCCN guideline

23 Follow up ERUS –Advisable –Frequency: subject to debate –One study showed More isolated local recurrence in the follow-up ERUS group underwent Salvage Surgery (44% vs 23 %), but the differences were not significant Hernandez De Anda et al. Dis Colon Rectum 2004; 47: 818–824

24 Scenario 1 2.5cm rectal Polyp Digital rectal exam ERUS MRI CT LN + LN - Radical Sx AR/TME/APR T2 T1 Local Excision + Adj ChemoRT High Risks Features Sm3 (  Sm2) Grade lymphovascular No High Risks Features Local Excision Follow-up Recurrence No Recurrence Salvage Surgery

25 Recurrence Long-term FU beyond 10 years is necessary Unresected disease in regional lymphatics cause local failure Diagnose early for salvage surgery Tytherleigh et al. BJS 2008;95:

26 Salvage Surgery % of patients with recurrence suitable for salvage surgery Results controversial May not afford same outcomes as initial classical treatment Decreased survival if resection is delayed at time of recurrence (for adverse pathology of local excision specimen) Mellgren et al. Dis Colon Rectum 2000; 43: 1064–1071

27 Clinical Scenario 2. Colonoscopic polypectomy of rectal polyp Pathology: adenocarcinoma arise from tubular adenoma

28 Scenario 2 Post polypectomy (Adenoca arise from TA) Radical Surgery Follow up ERUS MRI CT LN+ High Risks Features Sm3 (  Sm2) Grade lymphovascular No High Risks Features Haggitt level 1,2,3 Kikuchi Sm1 Margin involvement Yes Local Excision Histological assessment not adequate No High Risks Features No Yes LN-

29 Summary Staging Staging and Adequate HistologicalAssessment Adequate Histological Assessment is crucial in management of malignant rectal polyp

30 Summary Local excisionLocal excision Recommended for low risk T1 sm1 lesion  Adjuvant therapy considered in high risk T1, T2 if surgery not an option Radical SurgeryRadical Surgery Recommended for high risk T1, T2 lesion RecurrenceRecurrence Diagnose early for salvage surgery

31 Thank You


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