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Polyps – Where do they come from and what do you do with them?! Ron G. Landmann, MD Grand Rounds Department of Surgery St. Luke’s-Roosevelt Hospital Center.

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Presentation on theme: "Polyps – Where do they come from and what do you do with them?! Ron G. Landmann, MD Grand Rounds Department of Surgery St. Luke’s-Roosevelt Hospital Center."— Presentation transcript:

1 Polyps – Where do they come from and what do you do with them?! Ron G. Landmann, MD Grand Rounds Department of Surgery St. Luke’s-Roosevelt Hospital Center March 21, 2007

2 Polyps Cancer epidemiology Cancer epidemiology Definition of the malignant polyp Definition of the malignant polyp Natural history of adenomatous polyps Natural history of adenomatous polyps Biology of polyps Biology of polyps The anatomy of the polyp The anatomy of the polyp Correlations with Malignancy Correlations with Malignancy Endoscopic polypectomy alone??? Endoscopic polypectomy alone??? Special considerations Special considerations * No discussion of technique

3 Colorectal Cancer – Epidemiology Incidence: Approx. 150,000 cases/year Incidence: Approx. 150,000 cases/year Deaths: Approx. 50,000 deaths/year Deaths: Approx. 50,000 deaths/year At diagnosis At diagnosis 10% in situ disease 10% in situ disease 30% local disease 30% local disease 30% regional disease 30% regional disease 30% distant disease 30% distant disease 5 year survival, all patients: 50% 5 year survival, all patients: 50% local - 90% local - 90% regional - 60% regional - 60% distant - 5% distant - 5% U.S. Cancer Statistics Working Group. United States Cancer Statistics: 2003 Incidence and Mortality (preliminary data). Atlanta (GA): Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute; 2006.

4 Incidence/Prevalence of Polyps Adenomatous polyps Adenomatous polyps 30% of Western population 30% of Western population Most cancers arise from polyps Most cancers arise from polyps *excludes syndromes *excludes syndromes

5 Carcinoma in situ vs. cancer  Think  Think Carcinoma in situ = high grade dysplasia Carcinoma in situ = high grade dysplasia Carcinoma in situ ≠ cancer Carcinoma in situ ≠ cancer Histology Colorectal cancer is defined by invasion of/through muscularis mucosa

6 Genetic model of colorectal tumorigenesis Histology 1.Colorectal cancer is defined by invasion of muscularis mucosa 2.Lymphatics are located in submucosa

7 Colon Cancer Staging T-stage Tis Intraepithelial or invasion of lamina propria T1 Invades submucosa T2 Invades muscularis propria T3 Invades subserosa or pericolic/rectal tissues T4 Into other organs/perforates visceral peritoneum N-stage 0 0 LN positive LNs 2 > 3 positive LNs

8 Colon Cancer Staging AJCC 5 StageTNM 5 year DSS (%) ColonRectum 0Tis00 I II IIIAny IVAnyAny155

9 Relationship Between TNM Stage and Survival in Colorectal Carcinoma CA Cancer J Clin 2004;54;

10 Treatment of CRC Polypectomy Polypectomy Colonic Resection Colonic Resection Treatment depends on the risk of lymph node metastasis. Treatment depends on the risk of lymph node metastasis.  Pathology is key! 1.Colorectal cancer is defined by invasion of muscularis mucosa 2.Lymphatics are located in submucosa

11 Incidence of malignant polyps Definition Definition Malignant polyps or T1 lesions (limited to the submucosa) Malignant polyps or T1 lesions (limited to the submucosa) Represent 5% of all adenomas Represent 5% of all adenomas Colonoscopy polypectomy series: 2 – 12% Colonoscopy polypectomy series: 2 – 12% Colorectal resection series: 4 – 9% Colorectal resection series: 4 – 9%

12 Haggitt Level (1985) Classification of polyps with invasive cancer Haggitt RC, Glotzbach RE, Soffer EE, Wruble LD. Prognostic factors in colorectal carcinoma arising in adenomas: Implications for lesions removed by endoscopic polypectomy. Gastroenterology 89:328-36, 1985, p 330.LevelDefinition Resected (N) + LN (N) 0 Carcinoma in situ 1 Invasion of head 6 0 (< 1%) 2 Invasion of neck 3 0 (< 1%) 3 Invasion of stalk 4 0 (< 1%) 4 Invasion of submucosa of bowel wall below polyp 13 4 (31%, 12-25%) Villuous/sessile (flat) polyps with invasive cancer are by definition Haggitt 4.

13 Sessile Polyps Kudo, 1993 Risk of lymph node metastasis in each sessile lesion is not the same Risk of lymph node metastasis in each sessile lesion is not the same Haggitt’s: no detail for sessile lesions Haggitt’s: no detail for sessile lesions Classification of submucosal invasion: Classification of submucosal invasion: Sm1—Invasion into the upper third of the submucosa Sm1—Invasion into the upper third of the submucosa Sm2—Invasion into the middle third of the submucosa Sm2—Invasion into the middle third of the submucosa Sm3—Invasion into the lower third of the submucosa Sm3—Invasion into the lower third of the submucosa High rate of LN metastasis: 12-25% High rate of LN metastasis: 12-25%

14 Sm system Able to determine Sm1, Sm2, Sm3 in 97% of cases Able to determine Sm1, Sm2, Sm3 in 97% of cases Haggitt Level 1, 2, 3 = Sm1 Haggitt Level 1, 2, 3 = Sm1 Haggitt Level 4 = Sm1, Sm2, or Sm3 Haggitt Level 4 = Sm1, Sm2, or Sm3 Endoscopist must properly resect and prepare specimen Endoscopist must properly resect and prepare specimen Pathologist must properly section and examine all layers Pathologist must properly section and examine all layers

15 Correlations with Malignancy Morphology MorphologyIncidence % Malignant Tubular755 Tubulovillous1520 Villous1040

16 Correlations with Malignancy Grade Dysplasia % malignant Mild5 Moderate20 Severe30

17 Correlations with Malignancy Size Size (cm) % malignant < – 2 10 ≥ 2 50 Muto, 1975

18 Correlations with Malignancy Size Muto, 1975 Size (cm) % malignant ≤ 0.5 Negligible 0.6 – – ≥ Nusco, 1997 Size (cm) % malignant < – 2 10 ≥ 2 50

19 Relationship between Size and Morphology TubularTubulovillousVillous < 1 cm 76%25%14% 1-2cm20%47%26% > 2 cm 4%28%60% St. Mark’s Hospital Data

20 Increased risk of LN Metastasis Unfavorable pathologic features of malignant CR polyps Unfavorable pathologic features of malignant CR polyps Poor differentiation (only on univariate) Poor differentiation (only on univariate) Lymphovascular invasion (P < 0.009) Lymphovascular invasion (P < 0.009) Invasion below submucosa (Haggitt Level 4) Invasion below submucosa (Haggitt Level 4) Depth of invasion in Sm3 (P < 0.001) Depth of invasion in Sm3 (P < 0.001) Site in lower 1/3 of the rectum (P < 0.001) Site in lower 1/3 of the rectum (P < 0.001) Positive resection margin (< 1 mm or 1 HPF) Positive resection margin (< 1 mm or 1 HPF) Not really – this is inadequate treatment, not an adverse risk factor! Not really – this is inadequate treatment, not an adverse risk factor! P-values from Nascimbeni et al. N = 353 T1 colorectal sessile lesions

21 Management of Pedunculated Malignant Polyps Haggitt Level 1, 2, 3 Haggitt Level 1, 2, 3 Complete excision or snaring Complete excision or snaring Risk of LN metastasis < 1% Risk of LN metastasis < 1% Haggitt Level 4 Haggitt Level 4 Treat as sessile lesions Treat as sessile lesions

22 Management of Sessile Malignant Polyps < 2cm in diameter < 2cm in diameter Adequate snare in one piece via colonoscopy Adequate snare in one piece via colonoscopy Requires microscopic free margin of at least 2mm Requires microscopic free margin of at least 2mm Piecemeal removal Piecemeal removal Requires further excision/follow-up or resection Requires further excision/follow-up or resection High risk factors (LVI, Sm3, distal 1/3 rectum) High risk factors (LVI, Sm3, distal 1/3 rectum) Oncologic resection Oncologic resection Full thickness transanal excision Full thickness transanal excision

23 Lesions amenable to colonoscopic polypectomy Pedunculated or sessile < 2cm Pedunculated or sessile < 2cm Well/moderately differentiated Well/moderately differentiated No lymphovascular invasion No lymphovascular invasion Haggitt Level 1-3 or Sm1 Haggitt Level 1-3 or Sm1 Close follow-up available Close follow-up available Endoscopically complete excision Endoscopically complete excision Negative resection margins (2mm) Negative resection margins (2mm)

24 Criteria for Treatment of Malignant CR Polyps by Polypectomy Alone Determined by risk of metastasis Determined by risk of metastasis Low risk of Lymph Node Metastasis Low risk of Lymph Node Metastasis Pedunculated Pedunculated Haggitt Level 1, 2, 3 Haggitt Level 1, 2, 3 Level 4 Sm1, Sm2 Level 4 Sm1, Sm2 Sessile Sessile Sm1, Sm2 Sm1, Sm2 High risk of Lymph Node Metastasis High risk of Lymph Node Metastasis Lower 1/3 of the submucosa (Sm3) Lower 1/3 of the submucosa (Sm3) LVI LVI Distal 1/3 of rectum Distal 1/3 of rectum

25 Malignant Colorectal Polyps that Should have an Oncologic Bowel Resection Lesions in colon Lesions in colon Pedunculated Haggitt Level 4 with invasion into distal third of submucosa (Sm3) or LVI Pedunculated Haggitt Level 4 with invasion into distal third of submucosa (Sm3) or LVI Sessile lesions removed with margin < 2mm Sessile lesions removed with margin < 2mm Sessile lesions removed piecemeal Sessile lesions removed piecemeal Sessile lesions with depth of invasion into distal third of submucosa (Sm3) Sessile lesions with depth of invasion into distal third of submucosa (Sm3) Sessile lesions with LVI Sessile lesions with LVI Lesions in middle third and upper third rectum Lesions in middle third and upper third rectum Same as lesions in colon Same as lesions in colon Lesions in distal third rectum Lesions in distal third rectum Pedunculated Haggitt Level 4 with invasion into distal third of submucosa (Sm3) or pedunculated lesions with LVI Pedunculated Haggitt Level 4 with invasion into distal third of submucosa (Sm3) or pedunculated lesions with LVI All sessile lesions All sessile lesions

26 Why not just resect anyway?!

27 What if ??? What if it’s clipped in ½? What if it’s clipped in ½? Pedunculated Pedunculated Repeat endoscopy. Repeat endoscopy. Require good resection with margin (2mm) Require good resection with margin (2mm) Sessile Sessile Requires operative oncologic resection (even if Sm1, Sm2) Requires operative oncologic resection (even if Sm1, Sm2) Unable to determine exact pathologic depth Unable to determine exact pathologic depth What if it’s shredded by forceps? What if it’s shredded by forceps? Requires operative oncologic resection Requires operative oncologic resection What if it’s a very small lesion? What if it’s a very small lesion? Requires marking/tattoo CIRCUMFERENTIALLY Requires marking/tattoo CIRCUMFERENTIALLY What if it’s carcinoma in situ? What if it’s carcinoma in situ? It’s not cancer. This is high grade dysplasia. Requires close follow-up. It’s not cancer. This is high grade dysplasia. Requires close follow-up. Unless, Unless, poor margins: repeat endoscopy with good margins poor margins: repeat endoscopy with good margins Piecemeal resection: discussion with pathologist and patient Piecemeal resection: discussion with pathologist and patient What if it’s a large, non-endoscopically resectable polyp? What if it’s a large, non-endoscopically resectable polyp? Repeat endoscopy (2 nd MD?) Repeat endoscopy (2 nd MD?) Oncologic resection Oncologic resection

28 Other considerations… When in doubt When in doubt Repeat colonoscopy (endoscopy) Repeat colonoscopy (endoscopy) Personally review pathology Personally review pathology Get a second opinion Get a second opinion Have a frank discussion with patient Have a frank discussion with patient

29

30 Polyps Natural history of adenomatous polyps Natural history of adenomatous polyps Biology of polyps Biology of polyps Cancer epidemiology Cancer epidemiology The anatomy of the polyp The anatomy of the polyp Correlations with Malignancy Correlations with Malignancy Endoscopic polypectomy alone??? Endoscopic polypectomy alone??? Special considerations Special considerations Indications for Polypectomy Indications for Polypectomy What if it’s clipped in ½ What if it’s clipped in ½ What if it’s shredded by forceps? What if it’s shredded by forceps? Pathology… Pathology… Marking/tattoo Marking/tattoo Chances of Malignancy by histopath and size/morphology Chances of Malignancy by histopath and size/morphology * NO technique ** * NO technique **


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