joint hospital surgical grand round 19 june 2004

Joint Hospital Surgical Joint Hospital Surgical Grand RoundGrand Round

19 June 2004 19 June 2004

Colorectal PolypsColorectal PolypsManagementManagement

Dr. Kwong Wing HangDr. Kwong Wing Hang

Department of SurgeryDepartment of Surgery

NDH / AHNHNDH / AHNH

Adenomatous colonic polypAdenomatous colonic polyp

What is the clinical significant value What is the clinical significant value of colorectal adenomatous polyps?of colorectal adenomatous polyps?

Adenomatous polyp is precursor of Adenomatous polyp is precursor of colorectal cancercolorectal cancer

EpidemiologyEpidemiology PathologyPathology Adenoma-carcinoma sequence Adenoma-carcinoma sequence

Adenoma-Carcinoma sequenceAdenoma-Carcinoma sequence

Multi-steps and Multi-steps and accumulative DNA accumulative DNA changeschangesNormal Colonic epithelium

Small adenoma

Large adenoma

Pre-malignant changes

Colorectal cancer

Invasion

APC

Ki-ras

Smad 4

p53

E-cadherin

95% colorectal cancers arise in benign 95% colorectal cancers arise in benign colonic adenomatous polypscolonic adenomatous polyps

Takes 10 years to become invasive cancerTakes 10 years to become invasive cancer

Interruption of adenoma-carcinoma Interruption of adenoma-carcinoma sequence sequence

Do all colorectal adenomatous Do all colorectal adenomatous polyps have high malignant polyps have high malignant

potential?potential?

Small (<1cm) simple tubular adenomas Small (<1cm) simple tubular adenomas are found in 30-50% of older adults (>60) are found in 30-50% of older adults (>60)

Correa P. Gastroenterology 1979Correa P. Gastroenterology 1979

Do all colorectal adenomatous polyps Do all colorectal adenomatous polyps have high malignant potential?have high malignant potential?

Tubular adenoma have low malignant potential Tubular adenoma have low malignant potential

Most of them remain static or regressMost of them remain static or regress

Few will increase in size, develop villous Few will increase in size, develop villous changes, high grade dysplasia and invasive changes, high grade dysplasia and invasive carcinoma carcinoma

Hoff G. Scand J Gastroenterology 1986Hoff G. Scand J Gastroenterology 1986

Advanced adenoma ConceptAdvanced adenoma Concept

>1cm, villous change, high grade >1cm, villous change, high grade dysplasia, invasive carcinomadysplasia, invasive carcinoma

US National Polyp StudyUS National Polyp Study

Natural history of untreated colonic polypsNatural history of untreated colonic polyps

Total 226 patients with polyps >1cmTotal 226 patients with polyps >1cm

Mean 68 monthsMean 68 months

mean 5.2 surveillance barium enemamean 5.2 surveillance barium enema

83 (37%) polyps enlarged83 (37%) polyps enlarged

21 (9%) cancers21 (9%) cancers

Stryker SJ. Gastroenterology 1987Stryker SJ. Gastroenterology 1987

Natural history of untreated colonic polypsNatural history of untreated colonic polyps

Cumulative risk of malignancy with polyp Cumulative risk of malignancy with polyp >1cm at 5, 10, and 20 years was 2.5%, >1cm at 5, 10, and 20 years was 2.5%, 8% and 24%8% and 24%

Stryker SJ. Gastroenterology 1987Stryker SJ. Gastroenterology 1987

Management Management of colorectal polypof colorectal polyp

PathologicalDiagnosis and risks

stratification

Diagnosis and

EndoscopicPolypectomy

Follow up surveillance

Diagnosis and Surveillance ToolsDiagnosis and Surveillance Tools

Colonoscopy Vs Double contrast barium enemaColonoscopy Vs Double contrast barium enema

Colonoscopy more accurate with sensitivity of Colonoscopy more accurate with sensitivity of 94%94%

Barium enema 67%Barium enema 67%

Hogan et al. Gastrointest Endosc 1977Hogan et al. Gastrointest Endosc 1977

Effect of PolypectomyEffect of Polypectomy

Several Case control studies from US, Norway Several Case control studies from US, Norway and Italy demonstrated that and Italy demonstrated that Endoscopic Endoscopic polypectomypolypectomy decreased in incidence and decreased in incidence and mortality of colorectal cancermortality of colorectal cancer

Winawer SJ. N Engl J Med 1995Winawer SJ. N Engl J Med 1995

This-Evensen E. Scnd J Gastroenterol 1999This-Evensen E. Scnd J Gastroenterol 1999

Zauber AG. Gastroenterology 2000Zauber AG. Gastroenterology 2000

Initial Management of PolypsInitial Management of Polyps

Endoscopic polypectomyEndoscopic polypectomy Complete colonoscopy to remove all the Complete colonoscopy to remove all the

synchronous adenomasynchronous adenoma

Achieve detailed histological diagnosis Achieve detailed histological diagnosis

Treatment of Small benign polypsTreatment of Small benign polyps

Endoscopic polypectomyEndoscopic polypectomy

Electro-cauteryElectro-cauterySnaringSnaring

Hot biopsyHot biopsy

Treatment of Large sessile polypsTreatment of Large sessile polyps

Large sessile polyp (>2cm) contains Large sessile polyp (>2cm) contains villous tissuevillous tissue high malignant potentialhigh malignant potential High local recurrenceHigh local recurrence

Follow up colonoscopy 3-6 monthsFollow up colonoscopy 3-6 months

SurgerySurgery

Long term results of endoscopic removal Long term results of endoscopic removal of large colorectal adenomasof large colorectal adenomas

288 patients with total 302 polyps larger 288 patients with total 302 polyps larger than 3cm removed endoscopically in 12 than 3cm removed endoscopically in 12 yearsyears244 sessile and 78 pedunculated244 sessile and 78 pedunculatedRecurrence rate 17%Recurrence rate 17%2 patients developed malignant recurrence2 patients developed malignant recurrence

U. Seitz. Endoscopy 2003U. Seitz. Endoscopy 2003

Treatment of Malignant Colonic Treatment of Malignant Colonic PolypPolyp

Risk of local recurrence and lymph node Risk of local recurrence and lymph node metastasis vs Risk of Surgerymetastasis vs Risk of Surgery

Malignant Polyp with High recurrence risk vs Malignant Polyp with High recurrence risk vs Low recurrence risk Low recurrence risk

High surgical risk patient vs Low surgical risk High surgical risk patient vs Low surgical risk patientpatient

Unfavorable criteria for malignant polypUnfavorable criteria for malignant polyp

with high recurrence risk with high recurrence risk

Positive margin involvement of resected polypPositive margin involvement of resected polyp

Poorly differentiated Poorly differentiated

Presence of vascular or lymphatic invasionPresence of vascular or lymphatic invasion

Coutsoftides T. Ann Surg1978Coutsoftides T. Ann Surg1978

Unfavorable criteria for malignant Unfavorable criteria for malignant polyp with high recurrence riskpolyp with high recurrence risk

Cleveland clinicCleveland clinic Without unfavorable criteriaWithout unfavorable criteria

Cranley JP. Gastroenterology 1986Cranley JP. Gastroenterology 1986

pedunculatedpedunculated sessilesessile

Incidence of Incidence of residual cancerresidual cancer

0.3%0.3% 1.5%1.5%

Unfavorable criteria for malignant Unfavorable criteria for malignant polyp with high recurrence riskpolyp with high recurrence risk

Italian studyItalian study Cases with one or more unfavorable criteria Cases with one or more unfavorable criteria

Coverlizza S. Cancer 1989Coverlizza S. Cancer 1989

Pedunculated Pedunculated Sessile Sessile

Incidence Incidence of residual of residual

cancercancer

8.5%8.5% 14.4%14.4%

Management Of Malignant PolypManagement Of Malignant Polyp

High recurrent High recurrent risk malignant risk malignant

polyppolyp

Low recurrent Low recurrent risk malignant risk malignant

polyppolyp

Low surgical Low surgical risk patientrisk patient

SurgerySurgery SurgerySurgery

oror

FU surveillanceFU surveillance

High surgical High surgical risk patientrisk patient

Endoscopic polypEndoscopic polypectomy and FU sectomy and FU s

urveillanceurveillance

Endoscopic Endoscopic polypectomy and polypectomy and FU surveillanceFU surveillance

Post polypectomy SurveillancePost polypectomy Surveillance

When?When?

Relative risk of developing colorectal cancer after Relative risk of developing colorectal cancer after polypectomy in polypectomy in Mayo clinicMayo clinic

Mayo Clin Proc 1986Mayo Clin Proc 1986

RR RR

<1cm<1cm 11

>1cm>1cm 2.72.7

No =3 / >3No =3 / >3 55

1618 patients in 1618 patients in St Mark Hospital, LondonSt Mark Hospital, London

Atkin WS. N Engl J Med 1992Atkin WS. N Engl J Med 1992

RRRR

If resected polyp <1cmIf resected polyp <1cm 11

>1cm or presence of villous tissue>1cm or presence of villous tissue 3.63.6

If number of polyps> 3If number of polyps> 3 6.66.6

US National Polyp Study US National Polyp Study

7-center trial7-center trial

1418 patients with at least one newly diagnosed 1418 patients with at least one newly diagnosed colorectal adenoma after colonoscopy and colorectal adenoma after colonoscopy and polypectomy polypectomy

FU colonoscopy at 1 year then 3 years Vs every FU colonoscopy at 1 year then 3 years Vs every 3 years3 years

US National Polyp StudyUS National Polyp Study

FU colonoscopy FU colonoscopy at 1 years and at 1 years and then 3 yearsthen 3 years

FU colonoscopy FU colonoscopy at 3 yearsat 3 years

““Recurrent” Recurrent” adenomaadenoma

41.7%41.7% 32-42%32-42%

Large Large advanced advanced adenomaadenoma

3.3%3.3% 3.3%3.3%

Winawer SJ, N Eng J Med 1993Winawer SJ, N Eng J Med 1993

Predictive factorsPredictive factors - - Increase chance of Increase chance of

having advanced adenomahaving advanced adenoma

if n >/= 3if n >/= 3 large adenoma >/= 1cm large adenoma >/= 1cm Family history of Colorectal cancer (1st Family history of Colorectal cancer (1st

degree relative)degree relative)

US National Polyp Prevention Study US National Polyp Prevention Study

479 patients479 patientsPredictors for advanced metachronous adenomaPredictors for advanced metachronous adenoma

Multiple adenoma >/=3Multiple adenoma >/=3 Presence of villous histologyPresence of villous histology

Van Stolk RU. Gastroenterology 1998Van Stolk RU. Gastroenterology 1998

Very low risk of recurrent advanced Very low risk of recurrent advanced adenoma at 3 yearsadenoma at 3 years

Only one or two small tubular adenomaOnly one or two small tubular adenoma No family history of colorectal cancerNo family history of colorectal cancer

Post Polypectomy surveillance Post Polypectomy surveillance recommendationsrecommendations

Complete colonoscopy to clear all polypsComplete colonoscopy to clear all polyps

Additional clearing exam after resection of a large sessile Additional clearing exam after resection of a large sessile adenoma or uncertainty of complete resectionadenoma or uncertainty of complete resection

High risk patients (n>/=3 , >/=1cm, villous histology, High risk patients (n>/=3 , >/=1cm, villous histology, high grade dysplasia, Family Hx of CR cancer) high grade dysplasia, Family Hx of CR cancer) FU colonoscopy at 3 yearsFU colonoscopy at 3 years

Low risk patientLow risk patient FU colonoscopy at 5 yearsFU colonoscopy at 5 years

Post Polypectomy surveillance Post Polypectomy surveillance recommendationsrecommendations

Selected low risk patients may not require follow–up Selected low risk patients may not require follow–up surveillance colonoscopy for advanced age or co-surveillance colonoscopy for advanced age or co-morbiditymorbidity

After one negative follow-up surveillance colonoscopy, After one negative follow-up surveillance colonoscopy, subsequent surveillance interval increase to 5 yearssubsequent surveillance interval increase to 5 years

Surveillance should be discontinued for advanced age or Surveillance should be discontinued for advanced age or co-morbidity co-morbidity

Winawer SJ. Gastroenterology 2003Winawer SJ. Gastroenterology 2003

SummarySummaryColorectal polyps

Endoscopic polypectomy

Benign Malignant

Risk stratificationLow risk High risk

FU Colonoscopy 3 years

Fu colonoscopy5 year

High risk High risk malignant malignant

polyppolyp

Low risk Low risk malignant malignant

polyppolyp

Low Low surgical surgical

risk patientrisk patient

SurgerySurgery SurgerySurgery

OrOr

SurveillanceSurveillance

High High surgical surgical

risk patientrisk patient

Endoscopic Endoscopic polypectomypolypectomy

Endoscopic Endoscopic polypectomypolypectomy

Normal FUColonoscopy

Surgery

Thank YouThank You