Transcript 45 y/o female with familial adenomatous polyposis

Management of Malignant Polyps
Santhat Nivatvongs, MD
Colon and Rectal Surgery
Mayo Clinic
Rochester Minnesota
U.S.A.
Management of Malignant Polyps
I have no disclosure
Malignant Polyps
• Invasion into submucosa
• Early Ca
• T1NxMx
Malignant Polyps
Management
• Colonoscopic Polypectomy
• Transanal Excision
• Colorectal Resection
Malignant Polyps
Who can have a local excision?
Who needs a radical resection?
T1 Nx Mx
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)
Pathologic Assessment of Malignant Polyps
Inter-observer Variability
Kappa Statistics--a measure of observer agreement
Characteristics
Kappa
Lymphovascular invasion
Histologic grade
Haggitt’s classification
T stage
0.017
0.163
0.682
0.725
Result
poor
poor
very good
very good
Komuta K, Batts K, et al . Br J Surg 2004; 91:1479
Malignant Polyps
Risk of Lymph Node Metastasis
LNM (%)
Pedunculated -- Level 1,2,3
Sessile & Pedunculated Level 4
Haggitt R, et al. Gastroent 1985; 89:328
Nivatvongs S, et al. DCR 1991; 34:323
Kyzer S, et al. Cancer 1992; 70:2044
<1
12
Sessile Malignant Polyp
Independent Risk Factors
Factor
Odds ratio
95% CI
LVI
3.5
1.4-8.9
Sm3
5.0
2.3-10.6
<0.001
Lower 1/3 R
6.0
2.2-14.2
<0.001
Nascimbeni R et al DCR 2002;45:200
p
0.009
High Risk of LN Metastasis
In T1 Low Rectum
Author
Nascimbeni
2002
No.
Treatment
29
LAR / APR
Goldstein
1999
53
Blumberg
1998
48
APR
LAR / APR
LNM (%)
34
17
10
Adequate Local Excision
Colon
Clear margins
Clear depth > 2 mm
Low rectum
Clear margins
Full thickness
LOCAL EXCISION FOR T1 CA. RECTUM
Standard Criteria
Size < 3 cm
Full thickness excision, 1 cm margin
Not undifferenciated Ca.
No lymphovascular invasion
LITERATURE REVIEW
Local Excision Ca. Rectum ( T1)
Author
Yr
No.
Loc Recur(%)
FU/ M0
Madbouly
2005
52
17
55
Nascimbeni
2004
70
7
60
Paty
2002
67
14
60
Mellgren
2000
69
18
52
OUTCOME OF MID OR LOW RECTAL CA
Local Excision
Resection
N=70
5 yr (%)
Local recurrence
Distant metastasis
Overall survival
Ca-free survival
6.6
14.2
72.4
66.6
p
N=74
10 yr (%)
12.2
20.5
44.3
39.6
5 yr (%)
2.8
6.9
90.4
83.6
Nascimbeni R et al. DCR 2004; 47: 1773
10 yr (%)
6.2
10.2
72.0
69.8
0.26
0.13
0.008
0.003
T1 Carcinoma of Rectum
Local Excision vs Radical Resection
You YN, Baxter NN, Stewart A, Nelson H
(ACOSOG)
National Data Base 1994-1996 ---Follow-up 6.3 yr
Local Excision
Radical Resection
p
Number of patient
601
493
Overall Survival (5 yr)
77 %
82%
0.09
Disease Free Survival (5 yr)
93%
97%
0.004
Local Recurrence (5 yr)
13%
7%
0.003
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
Local Excision Plus Chemoradiation
Author
No.
Lamont 2000
10
Bouvet 1999
37
Recur. (%)
0
5
( 68% treated )
FU (mo)
33
51
Bailey 1992
35 T1
18 T2
10
60
Paty 2002
67 ( untreated )
7 ( treated )
17
17
120
120
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
Positive margins
41 %
42 %
Recurrence at 5 yr
Disease-free survival at 5 yr
39 %
59 %
Immediate vs Salvage Resection
No
Immediate radical resection
37
Ca -free survival ( % )
79 % at 5 yr
Mayo Clinic DCR 2005; 48:429
Delayed radical resection
21
56 at 5 yr
Cleveland Clinic DCR 2005; 48:711
Delayed radical resection
49
53 at 5 yr
Memorial DCR 2005; 48:1169
Delayed radical resection
24
50 at 3 yr
Univ Minn DCR 2000; 43:1064
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
Management of Malignant Polyps
High Risk Group
• Colon, high rectum
Radical Resection
• Low rectum
LAR / APR
Loc. Exc. +/- Ch R?
OUTCOME OF MID OR LOW RECTAL CA
Local Excision
Resection
N=70
5 yr (%)
Local recurrence
Distant metastasis
Overall survival
Ca-free survival
6.6
14.2
72.4
66.6
p
N=74
10 yr (%)
12.2
20.5
44.3
39.6
5 yr (%)
2.8
6.9
90.4
83.6
Nascimbeni R et al. DCR 2004; 47: 1773
10 yr (%)
6.2
10.2
72.0
69.8
0.26
0.13
0.008
0.003
Local Excision Followed by Radical
Resection
T1 Ca Rectum
No.
FU (mo)
Loc Recur (%)
Met (%)
Study group
37
101
3
11
Match control
78
122
5
12
Hahnloser D, et al. DCR 2005; 48: 429