BC CRC Update Malignant Polyp Who Needs Surgery
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1 BC CRC Update Malignant Polyp Who Needs Surgery Anthony MacLean, MD, FRCSC, FACS, FASCRS Colorectal Surgeon Foothills Medical Centre Clinical Associate Professor of Surgery and Oncology University of Calgary
2 I have no disclosures Disclosures
3 ObjecGves Who needs surgery? When is a more extended resecgon indicated? Colectomy + ileorectal anastomosis Proctocolectomy (+/- reconstrucgon)
4 First Things First As soon as you get path or referral Make sure site tarooed Make sure you re clear on morphology Get Path review Then
5 Decision Time! Does This PaGent Need Surgery? Likelihood of residual luminal cancer? Likelihood of posigve nodes? Health of pagent? Morbidity of procedure FuncGonal outcome of pagent Wishes of pagent? Risk tolerance
6 What is a Malignant Polyp? What it s not: High grade dysplasia Carcinoma in- situ Intra- mucosal carcinoma Serrated adenoma There must be invasion into submucosa!
7 What is a malignant polyp?
8 Endoluminal Risk? PosiGve margins: < 1 mm (or 2mm) Considered an indicagon for surgery. If margin unclear or < 1mm, risk of luminal cancer 11% BuRe et.al. Dis Colon Rectum. 2012;55: Piecemeal resecgon Risk of endoluminal recurrence if no surgery?
9 Risk of posigve lymph nodes in T1? What marers??polyp ConfiguraGon: Pedunculated vs. Sessile?HaggiR ClassificaGon Depth of invasion (sm1, sm2, sm3) Lymphovascular invasion Grade Tumor Budding
10 HaggiR ClassificaGon
11 Risk of + LN s according to HaggiR Level HaggiR RC. Gastroenterology HaggiR Level 1 HaggiR Level 2 HaggiR Level 3 < 1% risk of +LN s HaggiR Level 4* (3% - 25% depending on other features including Sm depth of invasion) * All sessile polyps are HaggiR level 4. * Sm Level can be applied to HaggiR level 4 polyps both pedunculated and sessile
12 HaggiR s level Forget about it What do you need to know? Pedunculated vs sessile? Is margin of excision clearly negagve? Other high risk features? What about sessile lesions?
13 Sm Level Nascembeni R et al. DCR 2002
14 Risk of + LN s according to Sm Level Sm1: 0-3% Sm2: 8-10% Sm3: 23-25% Nascinbeni R. DCR 2002 Kikuchi R. DCR 1995
15 Tumor Grade Other Risks for LN Mets # tumors Nodal Involvement Favorable % Odds ra3o P value Unfavorable % Vascular Invasion Absent % Present % Cribriform pa>ern Absent % Present % Tumor budding NegaGve % PosiGve % Ueno et.al. Gastro. 2004; 127:
16 Meta- analysis of features that predict LN metastases EMBASE and OVID Medline argcles met inclusion criteria and exclusion criteria 42 different histopathological features idengfied. 15 were described in more than 2 studies. LVI OR 8.62, differengagon No single risk factor reliably predicts LN mets. Glasgow SC, Lowry AC. J Gastrointest Surg. 2012
17 Outcomes of Malignant Polyps treated Endoscopically Authour Year Favourable Polyps with Adverse Outcomes Unfavourable Polyps with Adverse Outcomes Cooper /46 14/71 (19.7%) Volk /16 10/30 (33%) Hackelsberger /42 7/34 (21%) Netzer /32 16/38 (42%) Seitz /54 14/52 (27%) Overall 0/190 61/225 (27%) Church JM, Clinics of Colon and Rectal Surgery 2005
18 PopulaGon- Based Analysis SEER database in United States 2077 pagents with T1 N ResecGon in 1340 (64.5%) vs. polypectomy 737 (35.5%) Adjusted for comorbidity using propensity scores No different between surgery vs. polypectomy 1 and 5 year survival Cooper GS, Cancer 2012
19 Why do you need path review? As with most things expergse marers.
20 Pathology Concerns 2 expert GI pathologists in France reviewed 200 colorectal polyps inigally examined in the community HGD was over read in 22% of cases Malignant polyps were over read in 17% Malignant Missed in 4/300 Complete reports in 37.5% (margins, LVI, differengagon). Denis B, et al. Eur J Gastro Hep. 2009
21 Pathology Concerns 3 experienced GI pathologists re- reviewed the slides of 88 pts with malignant polyps. 12/88 pts were found to have only HGD Agreement even between experienced pathologists was poor with respect to histologic grade and LVI Komuta et.al. Br J Surg. 2004; 91:
22 Summary Polypectomy is adequate treatment for: High grade dysplasia even with posigve margins carcinoma in situ intramucosal carcinoma Low risk Malignant polyps Higher risk T1 lesions that should be considered for resecgon include the following features: PosiGve Margins LVI Poorly differengated Sm 3, maybe Sm2 for sessile and HaggiR level 4
23 IndicaGons for Extended ResecGons Underlying disease IBD Proven or likely GeneGc disorder HNPCC FAP MYH, other Synchronous tumors Ex. Ascending + distal transverse Serrated polyposis / hyperplasgc polyposis
24 Thanks!
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