Neoplastic Colonic Polyp Khalid

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<ul><li> 1. Neoplastic Colonic Polyps Dr. Saud Al-Subaie Department of SurgeryAmiri Hospital Monday 17/04/2006</li></ul> <p> 2. Introduction </p> <ul><li>Polyp :-any protrusion arising from an epithelial surface. </li></ul> <ul><li>Precursor for carcinoma </li></ul> <ul><li>Adenomatous polyp are premalignant</li></ul> <ul><li>2/3 of polyps are adenomatous </li></ul> <ul><li>The bigger the size, the higher the risk of Ca </li></ul> <ul><li>&lt; 1 cm :- ~10 yrs for transformation</li></ul> <p> 3. Polyp- Cancer Sequence 4. </p> <ul><li>Carcinoma </li></ul> <ul><li>Adenoma </li></ul> <ul><li><ul><li>Tubular</li></ul></li></ul> <ul><li><ul><li>Tubulovillous </li></ul></li></ul> <ul><li><ul><li>Villous </li></ul></li></ul> <p>Classification of polyps </p> <ul><li>Hamartoma</li></ul> <ul><li>Hyperplastic </li></ul> <ul><li>Inflammatory (psuedopolyps) </li></ul> <ul><li>Lymphoid </li></ul> <p>Neoplastic Non- Neoplastic 5. Epidemiology10.5% (100 %) Weighted chance 40 % 10 % Villous adenoma 22% 15 % Tubulovillous 5% 75% Tubular adenoma % Malignant Prevalence TYPE 6. Size and % of Ca 54% 10% 10% Villous 45% 9% 4% Tubulo-villous 34% 10% 1 % Tubular&gt; 2cm 1-2 cm &lt; 1cm 7. Endoscopic appearance 8. 9. Etiology</p> <ul><li>Genetic predisposition(hereditary Vs. Sporadic) </li></ul> <ul><li>Adenomatous Polyposis Syndromes </li></ul> <ul><li>Hereditary Nonpolyposis Colorectal Cancer (HNPCC) </li></ul> <ul><li>Environmental Factors :- </li></ul> <ul><li>Diet </li></ul> <ul><li>Exposure to carcinogens </li></ul> <ul><li>Role of chemoprevention :- ASA &amp; NSAID </li></ul> <p> 10. Etiology of Ca 11. Etiology (FAP) 12. Clinical Presentation </p> <ul><li>Asymptomatic: </li></ul> <ul><li><ul><li>- incidental finding </li></ul></li></ul> <ul><li>Symptomatic: </li></ul> <ul><li><ul><li>- Usually &gt; 1cm </li></ul></li></ul> <ul><li><ul><li>- Abdominal pain (intussusception) </li></ul></li></ul> <ul><li><ul><li>- Profuse watery diarrhea (large villous adenoma). </li></ul></li></ul> <ul><li><ul><li>- Bleeding PR (when ulcerated) </li></ul></li></ul> <p> 13. Management 14. Endoscopic Management </p> <ul><li>Polypectomy is the best treatment. </li></ul> <ul><li>Cautary snare: caution !! </li></ul> <ul><li>Complete removal &amp; retrieval of the polyp </li></ul> <ul><li>Sessile &amp; Semisessile polyp:-Piecemeal removal. </li></ul> <ul><li>?? tattoo with India ink </li></ul> <p> 15. 16. 17. AdenomaWithCa AdenomaWithCa 18. What is next</p> <ul><li><ul><li>Options :- </li></ul></li></ul> <ul><li><ul><li><ul><li>1- No more intervention </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>2- Surgery ( Formal Resection ) </li></ul></li></ul></li></ul> <ul><li><ul><li>Whatis the risk of :- </li></ul></li></ul> <ul><li><ul><li><ul><li>1- Residual disease</li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>2- Local Recurrence </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>3- Risk of LN mets </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>4- Distant metastasis </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>5- mortality ( Cancer vs Surgery) </li></ul></li></ul></li></ul> <p> 19. Malignant Polyp </p> <ul><li>Important Factors :- </li></ul> <ul><li><ul><li>1)Depth of invasion ( Haggitts classification) </li></ul></li></ul> <ul><li><ul><li>2)Resection margin </li></ul></li></ul> <ul><li><ul><li>3)Grade of differentiation </li></ul></li></ul> <ul><li><ul><li>4)Vascular invasion </li></ul></li></ul> <p> 20. Haggitt HighestInvasion ofsubmucosa, not the muscularis propria, sessile polyp 4 Moderate Invasion of the (MM)&amp; polyp stalk 3 LowInvasion of the (MM) &amp; polyp neck2NoneInvasion of the (MM) &amp; polyp head1 NoneNo invasion of the muscularis mucosa (MM), carcinoma in situ 0Risk of LN metsHistologic description level 21. Histologic assessment</p> <ul><li>Favorable ( low risk ) :- </li></ul> <ul><li><ul><li>1- Differentiation </li></ul></li></ul> <ul><li><ul><li><ul><li>G I G II </li></ul></li></ul></li></ul> <ul><li><ul><li>2- Resection margin </li></ul></li></ul> <ul><li><ul><li><ul><li>&gt; 2mm </li></ul></li></ul></li></ul> <ul><li><ul><li>3- Vascular and lymphatic invasion </li></ul></li></ul> <ul><li><ul><li><ul><li>None </li></ul></li></ul></li></ul> <p> 22. Histological assessment</p> <ul><li>Unfavorable ( high risk ) </li></ul> <ul><li><ul><li>1- Differentiation :-</li></ul></li></ul> <ul><li><ul><li><ul><li>G III </li></ul></li></ul></li></ul> <ul><li><ul><li>2- Resection margin :-</li></ul></li></ul> <ul><li><ul><li><ul><li>&lt; 2mm </li></ul></li></ul></li></ul> <ul><li><ul><li>3- Vascular and lymphatic invasion :-</li></ul></li></ul> <ul><li><ul><li><ul><li>yes </li></ul></li></ul></li></ul> <p> 23. Cesare Hassan et al </p> <ul><li>Histologic Risk Factors &amp; Clinical Outcome</li></ul> <ul><li>A pooled- data analysis. </li></ul> <ul><li>Thirty-one studies</li></ul> <ul><li>1,900 patients with malignant polyp.</li></ul> <ul><li>Three histologic risk factors</li></ul> <ul><li>Five unfavorable clinical outcomes </li></ul> <p>Dis Colon Rectum2005 24. Cesare Hassan et al </p> <ul><li>Three histologic risk factors </li></ul> <ul><li>positive resection margin ( &lt; 2 mm)</li></ul> <ul><li>poor differentiation of carcinoma,</li></ul> <ul><li>vascular / Lymphatic invasion</li></ul> <p>Dis Colon Rectum2005 25. Cesare Hassan et al </p> <ul><li>Five unfavorable clinical outcomes</li></ul> <ul><li>residual disease </li></ul> <ul><li>recurrent disease</li></ul> <ul><li>lymph node metastasis</li></ul> <ul><li>hematogenous metastasis</li></ul> <ul><li>mortality </li></ul> <p>Dis Colon Rectum2005 26. Cesare Hassan et al </p> <ul><li>CONCLUSION:All three histologic risk factors are significantly associated with the clinical outcome.</li></ul> <ul><li>Classification in low-risk and high-risk patients may be regarded as a meaningful staging procedure.</li></ul> <p>Dis Colon Rectum2005 27. Sitz et al </p> <ul><li>Retrospective ( 1985 1996) </li></ul> <ul><li>114 Pts with endoscopicaly removed polyps </li></ul> <ul><li>Low risk :- </li></ul> <ul><li><ul><li>Complete resection </li></ul></li></ul> <ul><li><ul><li>G1 G 2 grade </li></ul></li></ul> <ul><li><ul><li>No Vascular invasion </li></ul></li></ul> <ul><li>High risk :- others </li></ul> <p>Dis Colon Rectum2004 28. Sitz et al </p> <ul><li>54 low risk :- </li></ul> <ul><li><ul><li>- 5surgeryno residual disease </li></ul></li></ul> <ul><li><ul><li>- 33 no surgeryno adverse outcome </li></ul></li></ul> <ul><li>60 high risk : </li></ul> <ul><li><ul><li>- 52surgeryresidual disease in 27% </li></ul></li></ul> <ul><li><ul><li>- Significantly higher risk of adverse outcome( P &lt; 0.0001) </li></ul></li></ul> <ul><li><ul><li>- No surgical complications </li></ul></li></ul> <p>Dis Colon Rectum2004 29. Sitz et al </p> <ul><li>Conclusion:- </li></ul> <ul><li><ul><li>1- Low risk :- Endoscopic polypectomy alone is adequate </li></ul></li></ul> <ul><li><ul><li>2- High risk :- The risk of adverse outcome should be weighedagainst the risk of surgery </li></ul></li></ul> <p>Dis Colon Rectum2004 30. Volk / Fazio </p> <ul><li>47 pt </li></ul> <ul><li>17 had favorable histology:- </li></ul> <ul><li><ul><li>16polypectomy aloneno adverse outcome </li></ul></li></ul> <ul><li>30 pt unfavorable</li></ul> <ul><li><ul><li>21surgery </li></ul></li></ul> <ul><li><ul><li>10/30 had adverse outcome </li></ul></li></ul> <ul><li>Conclusion:- Endoscopic polypectomy is adequate for polyps with favorable histology </li></ul> <p>Gastroenterology 1995 31. Operative Management </p> <ul><li>- Transanal excision</li></ul> <ul><li>Transcoccygeal</li></ul> <ul><li>Transabdominal </li></ul> <p>Malignant rectal polyps Anatomic resection with removal of adjacent LN Malignant / incompletely excised / Suspicious polyp - Colotomy+ Polypectomy - Segmental Resection Benign polyp(&gt;3cm cant be managed endoscopically) Surgical options Type of polyp 32. Summary </p> <ul><li>Formal surgery should be advisedfor Malignant polyps with the following :- </li></ul> <ul><li><ul><li>Poor differentiation </li></ul></li></ul> <ul><li><ul><li>Vascular and lymphatic invasion </li></ul></li></ul> <ul><li><ul><li>&lt; 2mm resection margins </li></ul></li></ul> <ul><li><ul><li>Sessile polyps </li></ul></li></ul> <ul><li><ul><li>Haggittss level 3/4</li></ul></li></ul> <p> 33. Colon cancer can only be found if looked for. And itcan only be cured if found early. 34. THANK YOU</p>