Malignant rectal polyp
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Joint Hospital Surgical Grand Round 18 Apr 2009. Malignant Rectal Polyp. Dr Kit-wai Lai Department of Surgery Tuen Mun Hospital. Malignant Rectal Polyp. Polyps with cancer cells penetrating the muscularis mucosa Invasion limited to submucosa i.e. T1 lesion. >1cm 38.5% >42mm 78.9%.

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Malignant Rectal Polyp

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Malignant rectal polyp

Joint Hospital Surgical Grand Round 18 Apr 2009

Malignant Rectal Polyp

Dr Kit-wai Lai

Department of Surgery

Tuen Mun Hospital


Malignant rectal polyp1

Malignant Rectal Polyp

  • Polyps with cancer cells penetrating the muscularis mucosa

  • Invasion limited to submucosa

  • i.e. T1 lesion


Malignant rectal polyp

>1cm 38.5%

>42mm 78.9%

Tytherleigh et al. BJS 2008;95:409-423

Malignant?

Sizethe most important factor determining risk of malignant transformation within a polyp


Haggitt classification

Level 0: noninvasive (severe dysplasia)

Level 1: invading through the muscularis mucosa but limited to the head of a pedunculated polyp

Level 2: invading the neck of a pedunculated polyp

Level 3: invading the stalk of a pedunculated polyp

Level 4: invading into the submucosa below the stalk of a pedunculated polyp

( Sessile malignant polyplevel 4 )

Haggitt Classification


Kikuchi classification of adenocarcinoma in sessile polyp

Kikuchi Classification of Adenocarcinoma in Sessile Polyp

Haggitt level 1,2,3 = Kikuchi Sm1

level 4 = Sm1, Sm2 or Sm3


Local therapy opportunity of cure with less detriment

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;95:409-423


Histopathological features

Histopathological Features

Best estimate of the probability of regional LN metastasis

Bretagnol et al. Dis Colon Rectum 2007;50:523-533

Rate of lymph node metastasis

Sm1 1-3% Sm2 8% Sm3 23%

Nascimbeni et al. Dis Colon Rectum 2002;45:200-206

Poorly differentiated 43%

Goldstein et al. Am J Clin Pathol 1999;111:51-8


Clinical scenario

2.

Post Colonoscopic polypectomy of rectal polyp

Pathology: adenocarcinoma arise from tubular adenoma

Clinical Scenario

  • 1.

  • Colonoscopy: 2.5cm rectal polyp (3cm from anal verge)

  • Biopsy: adenocarcinoma


Clinical scenario1

1.

Colonoscopy: 2.5cm rectal polyp (3cm from anal verge)

Biopsy: adenocarcinoma

Clinical Scenario


Scenario 1 2 5cm rectal polyp

LN -

LN +

T1

T2

Local Excision

High Risks Features

Sm3 (Sm2)

Grade

lymphovascular

No High Risks Features

Follow-up

Local Excision

+ Adj ChemoRT

Radical Sx

AR/TME/APR

Recurrence

No Recurrence

Salvage Surgery

Scenario 12.5cm rectal Polyp

Digital rectal exam

ERUS MRI CT


Malignant rectal polyp

ERUS

  • Best method to determining Tstage

Bretagnol et al. Dis Colon Rectum 2007;50:523-533


Malignant rectal polyp

ERUS

  • T1-slight (Sm1) detection

    Sensitivity (99%) Specificity (74%) Accuracy (96%)

    Akasu et al. World J Surg 2000;24:1061-1068

  • May assess residual tumour following polypectomy

  • Follow up after local excision or radical surgery

    Hernandez De Andaetal. Dis Colon Rectum 2004; 47: 818–824

  • Limitations

Sm1

  • Operator dependent

  • Tumor height

  • Tumour stenosis

  • Peritumoral fibrosis and inflammatory tissue

  • Effect of pre op radiotherapy or haemorrhage in bowel wall after bx

Sm2


Malignant rectal polyp

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;50:523-533


Scenario 1 2 5cm rectal polyp1

Scenario 12.5cm rectal Polyp

Digital rectal exam

ERUS MRI CT

LN -

LN +

T1

T2

Local Excision

High Risks Features

Sm3 (Sm2)

Grade

lymphovascular

No High Risks Features

Follow-up

Local Excision

+ Adj ChemoRT

Radical Sx

AR/TME/APR

Recurrence

No Recurrence

Salvage Surgery


Local excision

Local Excision

  • Potential advantage

    • Sphincter preservation

    • Minimal mortality and morbidity

    • Low urinary/sexual dysfunction risk


Local excision1

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


Local excision2

Local Excision

LR

Bretagnol et al. Dis Colon Rectum 2007;50:523-533


Local excision vs radical sx

Local Excision vs Radical Sx

T1sm3 lesion

Radical Surgery had lower rates of distant metastasis and better survival

Bretagnol et al. Dis Colon Rectum 2007;50:523-533


Scenario 1 2 5cm rectal polyp2

Scenario 12.5cm rectal Polyp

Digital rectal exam

ERUS MRI CT

LN -

LN +

T1

T2

Local Excision

High Risks Features

Sm3 (Sm2)

Grade

lymphovascular

No High Risks Features

Follow-up

Local Excision

+ Adj ChemoRT

Radical Sx

AR/TME/APR

Recurrence

No Recurrence

Salvage Surgery


Adjuvant chemoradiotherapy

Adjuvant chemoradiotherapy

  • 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;95:409-423)

Difficult to interpret

Most retrospective studies

Lack of controlled data

Adjuvant regime not always based on a defined protocol

Bretagnol et al. Dis Colon Rectum 2007;50:523-533


Scenario 1 2 5cm rectal polyp3

Scenario 12.5cm rectal Polyp

Digital rectal exam

ERUS MRI CT

LN -

LN +

T1

T2

Local Excision

High Risks Features

Sm3 (Sm2)

Grade

lymphovascular

No High Risks Features

Follow-up

Local Excision

+ Adj ChemoRT

Radical Sx

AR/TME/APR

Recurrence

No Recurrence

Salvage Surgery


Follow up

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


Follow up1

Follow up

  • ERUS

    • Advisable

    • Frequency: subject to debate

    • One study showed

      Moreisolated local recurrence in the follow-up ERUS group underwent SalvageSurgery (44% vs 23 %), but the differences were not significant

      Hernandez De Andaetal. Dis Colon Rectum 2004; 47: 818–824


Scenario 1 2 5cm rectal polyp4

Scenario 12.5cm rectal Polyp

Digital rectal exam

ERUS MRI CT

LN -

LN +

T1

T2

Local Excision

High Risks Features

Sm3 (Sm2)

Grade

lymphovascular

No High Risks Features

Follow-up

Local Excision

+ Adj ChemoRT

Radical Sx

AR/TME/APR

Recurrence

No Recurrence

Salvage Surgery


Recurrence

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;95:409-423


Salvage surgery

Salvage Surgery

  • 56-100% 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


Clinical scenario2

2.

Colonoscopic polypectomy of rectal polyp

Pathology: adenocarcinoma arise from tubular adenoma

Clinical Scenario


Scenario 2 post polypectomy adenoca arise from ta

Scenario 2 Post polypectomy (Adenoca arise from TA)

No High Risks Features

Haggitt level 1,2,3

Kikuchi Sm1

High Risks Features

Sm3 (Sm2)

Grade

lymphovascular

ERUS MRI CT

LN-

LN+

Margin involvement

Yes

Histological assessment not adequate

No

Local Excision

No

Yes

Follow up

Radical Surgery

High Risks Features


Summary

Summary

Stagingand

Adequate HistologicalAssessment is crucial in management of malignant rectal polyp


Summary1

Summary

  • Local excision

    Recommended for low risk T1 sm1 lesion

    • Adjuvant therapy considered in high risk T1, T2 if surgery not an option

  • Radical Surgery

    Recommended for high risk T1 , T2 lesion

  • Recurrence

    Diagnose early for salvage surgery


Thank you

Thank You


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