colorectal polyps - med.alexu.edu.eg
TRANSCRIPT
![Page 1: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/1.jpg)
![Page 2: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/2.jpg)
![Page 3: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/3.jpg)
Colorectal polyps
• Visible protrusion above
the surface of the
surrounding normal
large bowel mucosa
![Page 4: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/4.jpg)
Classification of colorectal polyps
Histological classification Polyp type Malignant potential
Non-neoplastic Hyperplastic No
Hamartomatous (juvenile, Peutz-Jeghers)
Lymphoid
Inflammatory
Neoplastic (adenoma)Tubular adenoma(0-25% villous tissue)
Yes
Tubulovillous adenoma(25-75% villous tissue)
Villous adenoma(75-100% villous tissue)
![Page 5: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/5.jpg)
Hyperplastic polyps
• Majority of non-neoplastic polyps
• Prevalence rates of 20-34% (autopsy and
screening colonoscopy studies)
• Predominantly located in the distal colon
and rectum
• Generally small (<0.5cm) in size
![Page 6: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/6.jpg)
Classification of colorectal polyps
Histological classification Polyp type Malignant potential
Non-neoplastic Hyperplastic No
Hamartomatous (juvenile, Peutz-Jeghers)
Lymphoid
Inflammatory
Neoplastic (adenoma)Tubular adenoma(0-25% villous tissue)
Yes
Tubulovillous adenoma(25-75% villous tissue)
Villous adenoma(75-100% villous tissue)
![Page 7: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/7.jpg)
Hamartomatous polyposis syndromes
• Juvenile polyps
• Peutz-Jeghers polyps
• Cronkhite-Canada syndrome
![Page 8: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/8.jpg)
Juvenile polyposis
• Juvenile polyposis syndrome
(JPS) is a hereditary condition
that is characterized by the
presence of hamartomatous
polyps in the digestive tract.
![Page 9: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/9.jpg)
Juvenile polyposis
• Incidence: 1 in 100,000 persons
• Autosomal dominant
• Mutation of SMAD4 gene on
chromosome 18
![Page 10: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/10.jpg)
Juvenile polyposis
• The term “juvenile polyposis”
refers to the type of polyp
(juvenile polyp) that is found
after examination of the polyp
under a microscope, not the age
at which people are diagnosed
with JPS.
• Presence of around 5 to more
than 100 juvenile polyps in the
GI tract
![Page 11: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/11.jpg)
Juvenile polyposis
• Most juvenile polyps are noncancerous, but there
is an increased risk of cancer of the digestive tract,
such as stomach, small intestine, colon,
and rectum cancers, in families with JPS.
• Colon cancer risk 50%
• Pancreatic cancer
![Page 12: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/12.jpg)
Peutz-Jeghers syndrome
• Incidence: 1 in 200,000 persons
Autosomal dominant
• Mutations of the STK11 gene on
chromosome 19
• Characterized by perioral
pigmentations and hamartomatous
polyps throughout the GI tract
• GI and non-GI cancers are common
Site of polyps Frequency
Stomach 38%
Small bowel 78%
Colon 42%
Rectum 28%
![Page 13: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/13.jpg)
Peutz-Jeghers syndrome
![Page 14: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/14.jpg)
Cancer risk in P-J syndrome
GI cancers Cancer risks
Colon 39%
Pancreatic 36%
Stomach 29%
Small bowel 13%
Esophagus 0.5%
Non-GI cancers Cancer risks
Breast 54%
Ovarian 21%
Uterine 9%
Sex cord tumour with annular tubules (SCTAT) 20% become malignant
Sertoli cell tumour 10-20% become malignant
Lung 15%
![Page 15: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/15.jpg)
Cronkhite-Canada syndrome
• Gastrointestinal hamartomatous polyposis that lead to• Diarrhea,
• Weight loss and
• Abdominal pain
• Extra-intestinal manifestations• Alopecia,
• Cutaneous hyperpigmentation,
• Onycho-dystrophy
![Page 16: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/16.jpg)
Cronkhite-Canada syndrome
• Five-year mortality rates as high as 55 percent have been reported with most deaths due to • gastrointestinal bleeding,
• sepsis, and
• congestive heart failure.
• Treatment has included nutritional support, corticosteroids, acid suppression, and antibiotics
![Page 17: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/17.jpg)
Classification of colorectal polyps
Histological classification Polyp type Malignant potential
Non-neoplastic Hyperplastic No
Hamartomatous (juvenile, Peutz-Jeghers)
Lymphoid
Inflammatory
Neoplastic (adenoma)Tubular adenoma(0-25% villous tissue)
Yes
Tubulovillous adenoma(25-75% villous tissue)
Villous adenoma(75-100% villous tissue)
![Page 18: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/18.jpg)
Lymphoid polyps
Mucosal nodularity in representing lymphoid hyperplasia
![Page 19: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/19.jpg)
Classification of colorectal polyps
Histological classification Polyp type Malignant potential
Non-neoplastic Hyperplastic No
Hamartomatous (juvenile, Peutz-Jeghers)
Lymphoid
Inflammatory
Neoplastic (adenoma)Tubular adenoma(0-25% villous tissue)
Yes
Tubulovillous adenoma(25-75% villous tissue)
Villous adenoma(75-100% villous tissue)
![Page 20: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/20.jpg)
Inflammatory polyps/ pseudopolyps
• These lesions develop as by-products of the ulcers that penetrate into the submucosa, leaving islands of adjacent regenerative mucosa.
• Although most common in ulcerative colitis, inflammatory polyps may also be seen in Crohn's disease, ischemia, and other ulcerative conditions of the colon.
![Page 21: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/21.jpg)
Inflammatory polyps/ pseudopolyps
![Page 22: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/22.jpg)
Classification of colorectal polyps
Histological classification Polyp type Malignant potential
Non-neoplastic Hyperplastic No
Hamartomatous (juvenile, Peutz-Jeghers)
Lymphoid
Inflammatory
Neoplastic (adenoma)Tubular adenoma(0-25% villous tissue)
Yes
Tubulovillous adenoma(25-75% villous tissue)
Villous adenoma(75-100% villous tissue)
![Page 23: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/23.jpg)
Adenomas – facts and figures
• 70% of all colorectal polyps
• Increase with age (33% of population by 50yr, and in 50% by 70yr)
• 70% located in the left colon
• 70% are solitary (30% synchronous)
• 70% are small (<1cm in size)
• 7% have severe dysplasia, 3-5% have invasive cancer
![Page 24: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/24.jpg)
Adenoma-carcinoma sequence
Regardless of aetiology, most CRC arise from adenomas
Adenoma CRC
10 years
![Page 25: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/25.jpg)
Factors determining risk of malignant transformation within adenomas
High risk Low risk
Large size ( >1.5cm) Small size ( <1cm)
Sessile or flat Pedunculated
Severe dysplasia Mild dysplasia
Villous architecture Tubular architecture
Polyposis syndrome (multiple polyps) Single polyp
![Page 26: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/26.jpg)
Percent of adenomas containing invasive cancer by size and histology
![Page 27: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/27.jpg)
Malignant colorectal polyp
• Polyp that contains invasive cancer
• Malignant cells that have invaded through the
mucularis mucosa into the submucosa
mm
![Page 28: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/28.jpg)
Familial adenomatous polyposis (FAP)
• 1% of all CRC
• Present in about 1 in
8000 births
• Autosomal dominant
with near 100%
penetrance
![Page 29: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/29.jpg)
FAP
• >100 adenomas
• Patients develop adenomas by
the mean age of 16 years, and
CRC by 39 years
• Adenomas form early, but it
takes 20-30 years to develop CRC
from adenomas
• Disease of abnormal tumour
initiation
![Page 30: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/30.jpg)
Molecular genetics of FAP
• Caused by mutations of APC gene (tumour suppressor gene) on
chromosome 5q21
• Encodes for a protein, which functions in cell adhesion and signal
transduction
• Mutations will result in truncated protein and affect cell growth
![Page 31: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/31.jpg)
APC as gatekeeper geneadenoma-carcinoma sequence
Loeb 1991
![Page 32: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/32.jpg)
Mechanisms of Carcinogenesis in FAP
![Page 33: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/33.jpg)
Genotype vs. phenotype
Clinical
Presentation
Extracolonic
manifestations
Affected part of gene
Cell adhesion and structural
molecules
![Page 34: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/34.jpg)
Extracolonic manifestations
• Congenital hypertrophy of retinal
pigmented epithelium (CHRPE)
• Osteomas, desmoid tumours,
epidermoid cysts (Gardner’s
syndrome)
• CNS malignancies including
medulloblastoma and glioblastoma
(Turcot’s syndrome)
• Duodenal, hepatobiliary-pancreatic,
thyroid tumours
CHRPE
![Page 35: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/35.jpg)
Gardner’s syndrome
Desmoid Chest fibroma
Mandibular osteoma Skull osteoma
![Page 36: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/36.jpg)
Attenuated FAP (AFAP)
• Variant of FAP
• <100 adenomas
• Late age-of-onset (adenomas at 44; CRC at 56)
• Proximal distribution of adenomas
*Colonoscopy for surveillance
*Infrequent involvement of the rectum supports the role
of total colectomy and IRA
![Page 37: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/37.jpg)
Cancer risks in FAP
Cancer Cancer risks
Colon Near 100%
Duodenal or periampullary 5-10%
Pancreatic About 2%
Thyroid About 2%
Gastric About 0.5%
CNS, usually cerebellar
medulloblastoma (Turcot's syndrome)<1%
Hepatoblastoma 1.6% of children <5 years of age
![Page 38: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/38.jpg)
Diagnosis of FAP
Mutation
Protein truncation test
DNA sequencing
Genetic testsEndoscopy
![Page 39: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/39.jpg)
Screening of FAP
• Genetic screening of family members for APC mutations
• Annual flexible sigmoidoscopy beginning at age 10-12 until age
40, then every 3-5 years
*If polyposis is present, colectomy should be considered
• Upper GIT Endoscopy every 1-3 years is also recommended to
evaluate for upper GI adenomas
![Page 40: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/40.jpg)
Hereditary nonpolyposis colorectal cancer (HNPCC)
Dr. A. S. Warthin and the first
HNPCC pedigree, ‘the family G’
1895
Dr. Henry Lynch first described the term
‘cancer family syndrome’ in 1966 (later
renamed as Lynch syndrome and HNPCC)
![Page 41: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/41.jpg)
HNPCC
• 2-5% of all CRC
• Autosomal dominant
• 70-80% penetrance
• It takes only 3-5 years to develop
CRC from adenomas
Accelerated progression
![Page 42: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/42.jpg)
HNPCC: Lynch syndromes
Lynch syndrome I Lynch syndrome II
Early onset of CRC (40-45 years)Features of Lynch Syndrome I +
extracolonic malignancies
Predominantly proximal to the splenic
flexure (60-70%)
*Gastric, small bowel, hepatobiliary,
endometrial, ovarian, ureteral and renal
tumours
Increase frequency of synchronous and
metachronous lesions (33%)
![Page 43: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/43.jpg)
HNPCC related extracolonic tumors
78%
43%
19% 18%
10% 9%
0%
20%
40%
60%
80%
100%
Colorectal Endometrial Stomach Biliary tract Urinary tract Ovarian
Endometrial cancer is the most common extracolonic malignancy
![Page 44: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/44.jpg)
Diagnosis: Amsterdam criteria 1
Due to lack of phenotypic markers like polyps
Diagnosis is based on family history of CRC only
1. One member less than 50 years of age
2. Two involved generations
3. Three family members affected, one of whom is a first-
degree relative of the other two
![Page 45: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/45.jpg)
Diagnosis: Amsterdam criteria 2
Same as Amsterdam 1 but
includes all HNPCC
related tumors
![Page 46: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/46.jpg)
Molecular genetics of HNPCC
HNPCC is caused by mutations of
DNA mismatch repair (MMR) genes
Survey DNA for
replication errors
![Page 47: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/47.jpg)
Molecular genetics of HNPCC
• Mutations of these MMR genes will result in replication errors during DNA
synthesis (microsatellite instability) leading to acceleration of genetic
mutations
• HNPCC patients develop adenomas at the same rate as the general
population
• Once these adenomas develop, however, defective DNA repair ensues and
mismatches accumulates
• Thus, it takes only 3-5 years to develop CRC from adenomas
![Page 48: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/48.jpg)
Molecular genetics of HNPCC
![Page 49: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/49.jpg)
Screening of HNPCC
• Colonoscopy every 2 years starting at ages 20-25
or
5 years younger than the earliest diagnosis of CRC
whichever is earlier until 40yr , and then annually
• Flexible sigmoidoscopy is not acceptable, due to the proximal location of tumours
• Transvaginal US and endometrial aspiration annually starting at ages 25-35 years are also
recommended
![Page 50: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/50.jpg)
Average Risk Individuals
No Symptoms
Age 50
No risk factors
![Page 51: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/51.jpg)
Current RecommendationsAverage Risk
*Preferred strategy by ACG
Test Interval (years)
FOBT Yearly
Sigmoidoscopy Every 5
FOBT + Sigmoidoscopy Yearly, every 5
Colonoscopy Every 10*
Barium enema Every 5
![Page 52: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/52.jpg)
Approach to Colon Cancer TestingAsymptomatic
Men and Women
Age < 50 yr
No family Hx
No Screening
HNPCC or FAP
Genetic Counseling
1 first-degree
60 yrs
Average-risk
screening,
starting age 40
YES family Hx
2 or more first-degree or
1 first-degree < 60 yrs
Colonoscopy every
5 yrs, starting age 40
Age 50 yr
NO family Hx
Average Screening
![Page 53: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/53.jpg)
Management of colorectal polypsFactors Affecting
Location: colon or rectum
Number: solitary or multiple
Morphology: pedunculated or sessile
Histology: benign or malignant
![Page 54: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/54.jpg)
Management of colorectal polyps
Excision
Pedunculated
Colonoscopic polypectomy usually possible (Snaring)
![Page 55: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/55.jpg)
Rectal Ca Local excision – Latest Fashion Transanal approaches
• Transanal Endoscopic Microsurgery (TEM)• Developed for lesions out of reach from transanal approach
• Can be used for benign lesions above the peritoneal reflection
• Favourable T1 lesions have equivalent local recurrence and 5yr survival cf radical surgery
• Unfavourable T1 lesions have higher local recurrence (10-15%)
• TEM + XRT on T2 have local recurrence (25-46%)
![Page 56: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/56.jpg)
![Page 57: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/57.jpg)
![Page 58: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/58.jpg)
Management of colorectal polyps
Excision
Sessile
• Colonoscopic polypectomy if possible
• (larger polyps may require piecemeal removal)
• 5-8 snaring excision
• > 8 removal of affected segment segmental colectomy
• Endoscopic removable not possible operative removal
• Colon: colectomy
![Page 59: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/59.jpg)
Management of colorectal polyps
Excision
Sessile
• Colon: colectomy
• Rectum: staged with EUS or MRI
• Benign / Early malignant (T1No) : Transanal local
excision or TEMS (may need further radical surgery)
• Other malignant : radical excision (APR /anterior
resection)
![Page 60: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/60.jpg)
Management of colorectal polyps
Definitive Mx (histology)
Benign
Surveillance
colonoscopy
Malignant
Depends on histological characteristics
Radical Surgery
![Page 61: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/61.jpg)
Malignant PolypFactors determining need of radical surgery
Histology
• Poorly differentiated
• Margin <2mm
• Stalk invasion
• Lymphovascular invasion
Increase risk of recurrence and LN 2o
![Page 62: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/62.jpg)
Standard surgical treatment
Restorative proctocolectomy with ileal pouch-anal anastomosis
Suitable for most patients with FAP
![Page 63: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/63.jpg)
TPC IPIAA
![Page 64: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/64.jpg)
IPIAA
![Page 65: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/65.jpg)
Total colectomy Ileorectal anastmosis
![Page 66: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/66.jpg)
Other surgical options
Total colectomy with
ileorectal anastomosis
(IRA)
Proctocolectomy with ileostomy
Attenuated FAP
low rectal cancers
poor sphincters
Desmoid tumors
![Page 67: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/67.jpg)
Medical treatment of FAP?
• Sulindac (NSAID) and celecoxib (COX-2 inhibitor) shown to
control and reduce the number of colorectal adenomas in
FAP
• Not definitive treatment
• Temporizing treatment (eg when surgery needs to be
delayed)
• May control pouch and rectal polyposis after initial
prophylactic surgery
![Page 68: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/68.jpg)
Surgical treatment of HNPCC
• Total colectomy with ileorectal anastomosis
• Restorative proctocolectomy with ileal pouch-anal anastomosis
• Segmental colectomy not recommended because of high rate of
metachronous CRC
• TAHBSO for endometrial cancer
![Page 69: Colorectal polyps - med.alexu.edu.eg](https://reader034.vdocuments.mx/reader034/viewer/2022042107/6256cd698f2c871a26140625/html5/thumbnails/69.jpg)