Transcript 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 Polyp
• Polyps with cancer cells penetrating the
muscularis mucosa
• Invasion limited to submucosa
• i.e. T1 lesion
Size Malignant?
the most important factor determining
risk of malignant transformation within a polyp
>1cm
38.5%
>42mm 78.9%
Tytherleigh et al. BJS 2008;95:409-423
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 )
Kikuchi Classification of
Adenocarcinoma in Sessile Polyp
Haggitt level 1,2,3 = Kikuchi Sm1
level 4
=
Sm1, Sm2 or Sm3
Staging is critical to management
Histological Assessment
Most important factor to predict risk of
lymphatic spread
 Local Therapy
Opportunity of cure with less detriment
Tytherleigh et al. BJS 2008;95:409-423
Histopathological Features
Low-risk ERC
High-risk ERC
Best estimate of the probability of regional LN
lymph node
1-3 metastasisKikuchi Sm3 &
Depth of wall Rate ofHaggitt
metastasis
(possibly
Sm2)
Sm1
1-3%
Sm3
23%
Kikuchi
Sm1 &Sm2 8%
invasion
Bretagnol et al. Dis Colon Rectum 2007;50:523-533
Nascimbeni
(possibly
Sm2)et al. Dis Colon Rectum 2002;45:200-206
Grade
Well Moderate
Poorlydifferentiated
differentiated
Poorly differentiated
43%
Undifferentiated
Goldstein et al. Am J Clin Pathol 1999;111:51-8
Lymphovascular
invasion
-
+
Clinical Scenario
1.
• Colonoscopy:
2.5cm rectal
polyp (3cm from
anal verge)
• Biopsy:
adenocarcinoma
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
Scenario 1
Digital rectal exam
2.5cm rectal Polyp
ERUS MRI CT
LN -
LN +
T1
T2
Local Excision
Radical Sx
AR/TME/APR
High Risks Features
No High Risks Features
Sm3 (Sm2)
Grade
lymphovascular
Follow-up
Local Excision
+ Adj ChemoRT
Salvage Surgery
Recurrence
No Recurrence
ERUS
• Best method to determining T
stage
T stage
Accuracy: 90 %
Sensitivity : 85%
Specificity: 95%
N stage
Accuracy: 80%
Sensitivity: 70%
Specificity: 80%
Bretagnol et al. Dis Colon Rectum 2007;50:523-533
ERUS
• T1-slight (Sm1) detection
Sm1
Sensitivity (99%) Specificity (74%) Accuracy (96%)
Akasu et al. World J Surg 2000;24:1061-1068
•Operator dependent
• May assess residual tumour following
•Tumor height
polypectomy
•Tumour stenosis
•
Follow
up
after
local
excision
or
radical
•Peritumoral fibrosis and inflammatory tissue
surgery
•Effect
of pre op radiotherapy or haemorrhage in
Hernandez De Anda et al. Dis Colon Rectum 2004; 47: 818–824
bowel wall after bx
• Limitations
Sm2
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
Digital rectal exam
2.5cm rectal Polyp
ERUS MRI CT
LN -
LN +
T1
T2
Local Excision
Radical Sx
AR/TME/APR
High Risks Features
No High Risks Features
Sm3 (Sm2)
Grade
lymphovascular
Follow-up
Local Excision
+ Adj ChemoRT
Salvage Surgery
Recurrence
No Recurrence
Local Excision
• Potential advantage
– Sphincter preservation
– Minimal mortality and morbidity
– Low urinary/sexual dysfunction risk
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 Excision
LR
Bretagnol et al. Dis Colon Rectum 2007;50:523-533
Local Excision vs Radical Sx
T1sm3 lesion
Bretagnol et al. Dis Colon Rectum 2007;50:523-533
Radical Surgery had lower rates of
distant metastasis and better survival
Scenario 1
Digital rectal exam
2.5cm rectal Polyp
ERUS MRI CT
LN -
LN +
T1
T2
Local Excision
Radical Sx
AR/TME/APR
High Risks Features
No High Risks Features
Sm3 (Sm2)
Grade
lymphovascular
Follow-up
Local Excision
+ Adj ChemoRT
Salvage Surgery
Recurrence
No Recurrence
Adjuvant chemoradiotherapy
Limited data
May be helpful
Difficult to interpret
If further surgery is not an option
Most retrospective studies
T1 lesions with adverse pathologic features
Lack of controlled data
T2 lesions
Adjuvant regime not always based on a defined protocol
(Tytherleigh et al. BJS 2008;95:409-423)
Bretagnol et al. Dis Colon Rectum 2007;50:523-533
Scenario 1
Digital rectal exam
2.5cm rectal Polyp
ERUS MRI CT
LN -
LN +
T1
T2
Local Excision
Radical Sx
AR/TME/APR
High Risks Features
No High Risks Features
Sm3 (Sm2)
Grade
lymphovascular
Follow-up
Local Excision
+ Adj ChemoRT
Salvage Surgery
Recurrence
No Recurrence
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 up
• ERUS
– Advisable
– Frequency: subject to debate
– One study showed
More isolated local recurrence in the
follow-up ERUS group underwent Salvage
Surgery (44% vs 23 %), but the
differences were not significant
Hernandez De Anda et al. Dis Colon Rectum 2004; 47: 818–824
Scenario 1
Digital rectal exam
2.5cm rectal Polyp
ERUS MRI CT
LN -
LN +
T1
T2
Local Excision
Radical Sx
AR/TME/APR
High Risks Features
No High Risks Features
Sm3 (Sm2)
Grade
lymphovascular
Follow-up
Local Excision
+ Adj ChemoRT
Salvage Surgery
Recurrence
No 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
• 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 Scenario
2.
• Colonoscopic polypectomy of rectal
polyp
• Pathology: adenocarcinoma arise from
tubular adenoma
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
Radical Surgery
Yes
High Risks Features
No
Follow up
Summary
Staging and
Adequate Histological Assessment
is crucial in management of malignant
rectal polyp
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