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Management of Malignant Polyps Santhat Nivatvongs, MD Colon and Rectal Surgery Mayo Clinic Rochester Minnesota U.S.A.

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Presentation on theme: "Management of Malignant Polyps Santhat Nivatvongs, MD Colon and Rectal Surgery Mayo Clinic Rochester Minnesota U.S.A."— Presentation transcript:

1 Management of Malignant Polyps Santhat Nivatvongs, MD Colon and Rectal Surgery Mayo Clinic Rochester Minnesota U.S.A.

2 Management of Malignant Polyps I have no disclosure

3 Malignant Polyps Invasion into submucosa Early Ca T1NxMx

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5 Malignant Polyps Management Colonoscopic Polypectomy Transanal Excision Colorectal Resection

6 Malignant Polyps Who can have a local excision? Who needs a radical resection? T1 Nx Mx

7 Literature Review High Risk of LNM in Malignant Polyps Lymphovascular invasion Poor differentiation Gender, positive margins Extensive budding, microacinar structures Depressed lesions Deep submucosal invasion (Sm3)

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9 Pathologic Assessment of Malignant Polyps Inter-observer Variability Kappa Statistics--a measure of observer agreement Characteristics Kappa Result Lymphovascular invasion poor Histologic grade poor Haggitt’s classification very good T stage very good Komuta K, Batts K, et al. Br J Surg 2004; 91:1479

10 Malignant Polyps Risk of Lymph Node Metastasis LNM (%) Pedunculated -- Level 1,2,3 < 1 Sessile & Pedunculated Level 4 12 Haggitt R, et al. Gastroent 1985; 89:328 Nivatvongs S, et al. DCR 1991; 34:323 Kyzer S, et al. Cancer 1992; 70:2044

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13 Sessile Malignant Polyp Independent Risk Factors Factor Odds ratio 95% CI p LVI Sm <0.001 Lower 1/3 R <0.001 Nascimbeni R et al DCR 2002;45:200

14 High Risk of LN Metastasis In T1 Low Rectum Author No. Treatment LNM (%) Nascimbeni LAR / APR 34 Goldstein APR 17 Blumberg LAR / APR 10

15 Adequate Local Excision Colon Clear margins Clear depth > 2 mm Low rectum Clear margins Full thickness

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17 LOCAL EXCISION FOR T1 CA. RECTUM Standard Criteria Size < 3 cm Full thickness excision, 1 cm margin Not undifferenciated Ca. No lymphovascular invasion

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19 LITERATURE REVIEW Local Excision Ca. Rectum ( T1) Author Yr No. Loc Recur(%) FU/ M0 Madbouly Nascimbeni Paty Mellgren

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21 OUTCOME OF MID OR LOW RECTAL CA Local Excision Resection p N=70 N=74 5 yr (%) 10 yr (%) 5 yr (%) 10 yr (%) Local recurrence Distant metastasis Overall survival Ca-free survival Nascimbeni R et al. DCR 2004; 47: 1773

22 T1 Carcinoma of Rectum Local Excision vs Radical Resection You YN, Baxter NN, Stewart A, Nelson H (ACOSOG) National Data Base Follow-up 6.3 yr Local Excision Radical Resection p Number of patient Overall Survival (5 yr) 77 % 82% 0.09 Disease Free Survival (5 yr) 93% 97% Local Recurrence (5 yr) 13% 7% 0.003

23 T1 Carcinoma of Rectum The data favor radical surgery as the more definitive cancer treatment but do not eliminate local excision as a reasonable choice for many patients Bentrem DJ, et al. Ann Surg 2005; 242:472

24 Local Excision Plus Chemoradiation Author No. Recur. (%) FU (mo) Lamont Bouvet ( 68% treated ) Bailey T T2 Paty ( untreated ) ( treated )

25 PO Radiation After Local Excision R Benson, BJ Cummings, et al. Int J Rad Onc Biol Phy 2001; 50:1309 Princess Margaret Hosp. Toronto 24 T1-- Low Rectum ( median 4cm from anal verge ) Reasons for radiation ( no chemo) Fragmentaions 29 % LVI 41 % Positive margins 42 % Recurrence at 5 yr 39 % Disease-free survival at 5 yr 59 %

26 Immediate vs Salvage Resection No Ca -free survival ( % ) Immediate radical resection % at 5 yr Mayo Clinic DCR 2005; 48:429 Delayed radical resection at 5 yr Cleveland Clinic DCR 2005; 48:711 Delayed radical resection at 5 yr Memorial DCR 2005; 48:1169 Delayed radical resection at 3 yr Univ Minn DCR 2000; 43:1064

27 Management of Malignant Polyps Summary Patients’ risk Local excision Radical resection Cancer risk Lymphovascular invasion Sm3 or high grade Lower 1/3 rectum Adequate excision Size < 3 cm

28 Management of Malignant Polyps High Risk Group Colon, high rectum Radical Resection Low rectum LAR / APR Loc. Exc. +/- Ch R?

29 OUTCOME OF MID OR LOW RECTAL CA Local Excision Resection p N=70 N=74 5 yr (%) 10 yr (%) 5 yr (%) 10 yr (%) Local recurrence Distant metastasis Overall survival Ca-free survival Nascimbeni R et al. DCR 2004; 47: 1773

30 Local Excision Followed by Radical Resection T1 Ca Rectum No. FU (mo) Loc Recur (%) Met (%) Study group Match control Hahnloser D, et al. DCR 2005; 48: 429

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