Joint Hospital Surgical Grand Round 18 Apr 2009

Malignant Rectal Polyp • Polyps with cancer cells penetrating the muscularis mucosa • Invasion

Size Malignant? the most important factor determining risk of malignant transformation within a polyp

Haggitt Classification • Level 0: noninvasive (severe dysplasia) • Level 1: invading through the

Kikuchi Classification of Adenocarcinoma in Sessile Polyp Haggitt level 1, 2, 3 = Kikuchi

Staging is critical to management Histological Assessment Most important factor to predict risk of

Histopathological Features Low-risk ERC High-risk ERC Best estimate of the probability of regional LN

Clinical Scenario 1. 2. • Colonoscopy: 2. 5 cm rectal polyp (3 cm from

Clinical Scenario 1. • Colonoscopy: 2. 5 cm rectal polyp (3 cm from anal

Scenario 1 2. 5 cm rectal Polyp Digital rectal exam ERUS MRI CT LN

ERUS • Best method to determining T stage Accuracy: 90 % Sensitivity : 85%

ERUS • T 1 -slight (Sm 1) detection Sm 1 Sensitivity (99%) Specificity (74%)

MRI • Overall T stage accuracy 59 -95% • T 1, 2 lesion (vs

Local Excision • Potential advantage – Sphincter preservation – Minimal mortality and morbidity –

Local Excision • Parks’ Per Anal Excision – Lesions 6 -10 cm from anal

Local Excision LR Bretagnol et al. Dis Colon Rectum 2007; 50: 523 -533

Local Excision vs Radical Sx T 1 sm 3 lesion Bretagnol et al. Dis

Adjuvant chemoradiotherapy ØLimited data ØMay be helpful Difficult to interpret If further surgery is

Follow up • Regular endoscopic surveillance of rectum and scar • Digital rectal exam

Follow up • ERUS – Advisable – Frequency: subject to debate – One study

Recurrence • Long-term FU beyond 10 years is necessary • Unresected disease in regional

Salvage Surgery • 56 -100% of patients with recurrence suitable for salvage surgery •

Clinical Scenario 2. • Colonoscopic polypectomy of rectal polyp • Pathology: adenocarcinoma arise from

Scenario 2 Post polypectomy (Adenoca arise from TA) No High Risks Features Haggitt level

Summary Staging and Adequate Histological Assessment is crucial in management of malignant rectal polyp

Summary • Local excision Recommended for low risk T 1 sm 1 lesion Adjuvant

Slides: 31

Download presentation

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. T 1 lesion

Size Malignant? the most important factor determining risk of malignant transformation within a polyp >1 cm 38. 5% >42 mm 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 Sm 1 level 4 = Sm 1, Sm 2 or Sm 3

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 metastasis. Kikuchi Sm 3 & Depth of wall Rate of. Haggitt metastasis (possibly Sm 2) Sm 1 1 -3% Sm 3 23% Kikuchi Sm 1 &Sm 2 8% invasion Bretagnol et al. Dis Colon Rectum 2007; 50: 523 -533 (possibly Sm 2) Nascimbeni et al. Dis Colon Rectum 2002; 45: 200 -206 Grade Well Moderate Poorlydifferentiated Poorly differentiated 43% Undifferentiated Goldstein et al. Am J Clin Pathol 1999; 111: 51 -8 Lymphovascular invasion - +

Clinical Scenario 1. 2. • Colonoscopy: 2. 5 cm rectal polyp (3 cm from anal verge) • Post Colonoscopic polypectomy of rectal polyp • Biopsy: adenocarcinoma • Pathology: adenocarcinoma arise from tubular adenoma

Clinical Scenario 1. • Colonoscopy: 2. 5 cm rectal polyp (3 cm from anal verge) • Biopsy: adenocarcinoma

Scenario 1 2. 5 cm rectal Polyp Digital rectal exam ERUS MRI CT LN - LN + T 1 T 2 Local Excision Radical Sx AR/TME/APR High Risks Features No High Risks Features Sm 3 ( Sm 2) Grade lymphovascular Follow-up Local Excision + Adj Chemo. RT Salvage Surgery Recurrence No Recurrence

ERUS • Best method to determining 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 • T 1 -slight (Sm 1) detection Sm 1 Sensitivity (99%) Specificity (74%) Accuracy (96%) Akasu et al. World J Surg 2000; 24: 1061 -1068 • Operator dependent • May assess residual • Tumor height tumour following polypectomy • Tumour stenosis • Follow up after local excision or radical • Peritumoral fibrosis and inflammatory tissue surgery • Effect of pre op radiotherapy or haemorrhage in bowel Hernandez De Anda et al. Dis Colon Rectum 2004; 47: 818– 824 wall after bx • Limitations Sm 2

MRI • Overall T stage accuracy 59 -95% • T 1, 2 lesion (vs ERUS) – Similar sensitivities – Lower specificity (69%) • N stage – Comparable vs ERUS Bretagnol et al. Dis Colon Rectum 2007; 50: 523 -533

Local Excision • Potential advantage – Sphincter preservation – Minimal mortality and morbidity – Low urinary/sexual dysfunction risk

Local Excision • Parks’ Per Anal Excision – Lesions 6 -10 cm 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 T 1 sm 3 lesion Bretagnol et al. Dis Colon Rectum 2007; 50: 523 -533 Radical Surgery had lower rates of distant metastasis and better survival

Adjuvant chemoradiotherapy ØLimited data ØMay be helpful Difficult to interpret If further surgery is not an option Most retrospective studies T 1 lesions with adverse pathologic features Lack of controlled data T 2 regime lesions Adjuvant 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

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 followup 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

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 Sm 1 High Risks Features Sm 3 ( Sm 2) 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 T 1 sm 1 lesion Adjuvant therapy considered in high risk T 1, T 2 if surgery not an option • Radical Surgery Recommended for high risk T 1 , T 2 lesion • Recurrence Diagnose early for salvage surgery

Thank You