Joint Hospital Surgical Grand Round 19 June 2004.
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Transcript of Joint Hospital Surgical Grand Round 19 June 2004.
Joint Hospital Surgical Joint Hospital Surgical Grand RoundGrand Round
19 June 2004 19 June 2004
Colorectal PolypsColorectal PolypsManagementManagement
Dr. Kwong Wing HangDr. Kwong Wing Hang
Department of SurgeryDepartment of Surgery
NDH / AHNHNDH / AHNH
Adenomatous colonic polypAdenomatous colonic polyp
What is the clinical significant value What is the clinical significant value of colorectal adenomatous polyps?of colorectal adenomatous polyps?
Adenomatous polyp is precursor of Adenomatous polyp is precursor of colorectal cancercolorectal cancer
EpidemiologyEpidemiology PathologyPathology Adenoma-carcinoma sequence Adenoma-carcinoma sequence
Adenoma-Carcinoma sequenceAdenoma-Carcinoma sequence
Multi-steps and Multi-steps and accumulative DNA accumulative DNA changeschangesNormal Colonic epithelium
Small adenoma
Large adenoma
Pre-malignant changes
Colorectal cancer
Invasion
APC
Ki-ras
Smad 4
p53
E-cadherin
95% colorectal cancers arise in benign 95% colorectal cancers arise in benign colonic adenomatous polypscolonic adenomatous polyps
Takes 10 years to become invasive cancerTakes 10 years to become invasive cancer
Interruption of adenoma-carcinoma Interruption of adenoma-carcinoma sequence sequence
Do all colorectal adenomatous Do all colorectal adenomatous polyps have high malignant polyps have high malignant
potential?potential?
Small (<1cm) simple tubular adenomas Small (<1cm) simple tubular adenomas are found in 30-50% of older adults (>60) are found in 30-50% of older adults (>60)
Correa P. Gastroenterology 1979Correa P. Gastroenterology 1979
Do all colorectal adenomatous polyps Do all colorectal adenomatous polyps have high malignant potential?have high malignant potential?
Tubular adenoma have low malignant potential Tubular adenoma have low malignant potential
Most of them remain static or regressMost of them remain static or regress
Few will increase in size, develop villous Few will increase in size, develop villous changes, high grade dysplasia and invasive changes, high grade dysplasia and invasive carcinoma carcinoma
Hoff G. Scand J Gastroenterology 1986Hoff G. Scand J Gastroenterology 1986
Advanced adenoma ConceptAdvanced adenoma Concept
>1cm, villous change, high grade >1cm, villous change, high grade dysplasia, invasive carcinomadysplasia, invasive carcinoma
US National Polyp StudyUS National Polyp Study
Natural history of untreated colonic polypsNatural history of untreated colonic polyps
Total 226 patients with polyps >1cmTotal 226 patients with polyps >1cm
Mean 68 monthsMean 68 months
mean 5.2 surveillance barium enemamean 5.2 surveillance barium enema
83 (37%) polyps enlarged83 (37%) polyps enlarged
21 (9%) cancers21 (9%) cancers
Stryker SJ. Gastroenterology 1987Stryker SJ. Gastroenterology 1987
Natural history of untreated colonic polypsNatural history of untreated colonic polyps
Cumulative risk of malignancy with polyp Cumulative risk of malignancy with polyp >1cm at 5, 10, and 20 years was 2.5%, >1cm at 5, 10, and 20 years was 2.5%, 8% and 24%8% and 24%
Stryker SJ. Gastroenterology 1987Stryker SJ. Gastroenterology 1987
Management Management of colorectal polypof colorectal polyp
PathologicalDiagnosis and risks
stratification
Diagnosis and
EndoscopicPolypectomy
Follow up surveillance
Diagnosis and Surveillance ToolsDiagnosis and Surveillance Tools
Colonoscopy Vs Double contrast barium enemaColonoscopy Vs Double contrast barium enema
Colonoscopy more accurate with sensitivity of Colonoscopy more accurate with sensitivity of 94%94%
Barium enema 67%Barium enema 67%
Hogan et al. Gastrointest Endosc 1977Hogan et al. Gastrointest Endosc 1977
Effect of PolypectomyEffect of Polypectomy
Several Case control studies from US, Norway Several Case control studies from US, Norway and Italy demonstrated that and Italy demonstrated that Endoscopic Endoscopic polypectomypolypectomy decreased in incidence and decreased in incidence and mortality of colorectal cancermortality of colorectal cancer
Winawer SJ. N Engl J Med 1995Winawer SJ. N Engl J Med 1995
This-Evensen E. Scnd J Gastroenterol 1999This-Evensen E. Scnd J Gastroenterol 1999
Zauber AG. Gastroenterology 2000Zauber AG. Gastroenterology 2000
Initial Management of PolypsInitial Management of Polyps
Endoscopic polypectomyEndoscopic polypectomy Complete colonoscopy to remove all the Complete colonoscopy to remove all the
synchronous adenomasynchronous adenoma
Achieve detailed histological diagnosis Achieve detailed histological diagnosis
Treatment of Small benign polypsTreatment of Small benign polyps
Endoscopic polypectomyEndoscopic polypectomy
Electro-cauteryElectro-cauterySnaringSnaring
Hot biopsyHot biopsy
Treatment of Large sessile polypsTreatment of Large sessile polyps
Large sessile polyp (>2cm) contains Large sessile polyp (>2cm) contains villous tissuevillous tissue high malignant potentialhigh malignant potential High local recurrenceHigh local recurrence
Follow up colonoscopy 3-6 monthsFollow up colonoscopy 3-6 months
SurgerySurgery
Long term results of endoscopic removal Long term results of endoscopic removal of large colorectal adenomasof large colorectal adenomas
288 patients with total 302 polyps larger 288 patients with total 302 polyps larger than 3cm removed endoscopically in 12 than 3cm removed endoscopically in 12 yearsyears244 sessile and 78 pedunculated244 sessile and 78 pedunculatedRecurrence rate 17%Recurrence rate 17%2 patients developed malignant recurrence2 patients developed malignant recurrence
U. Seitz. Endoscopy 2003U. Seitz. Endoscopy 2003
Treatment of Malignant Colonic Treatment of Malignant Colonic PolypPolyp
Risk of local recurrence and lymph node Risk of local recurrence and lymph node metastasis vs Risk of Surgerymetastasis vs Risk of Surgery
Malignant Polyp with High recurrence risk vs Malignant Polyp with High recurrence risk vs Low recurrence risk Low recurrence risk
High surgical risk patient vs Low surgical risk High surgical risk patient vs Low surgical risk patientpatient
Unfavorable criteria for malignant polypUnfavorable criteria for malignant polyp
with high recurrence risk with high recurrence risk
Positive margin involvement of resected polypPositive margin involvement of resected polyp
Poorly differentiated Poorly differentiated
Presence of vascular or lymphatic invasionPresence of vascular or lymphatic invasion
Coutsoftides T. Ann Surg1978Coutsoftides T. Ann Surg1978
Unfavorable criteria for malignant Unfavorable criteria for malignant polyp with high recurrence riskpolyp with high recurrence risk
Cleveland clinicCleveland clinic Without unfavorable criteriaWithout unfavorable criteria
Cranley JP. Gastroenterology 1986Cranley JP. Gastroenterology 1986
pedunculatedpedunculated sessilesessile
Incidence of Incidence of residual cancerresidual cancer
0.3%0.3% 1.5%1.5%
Unfavorable criteria for malignant Unfavorable criteria for malignant polyp with high recurrence riskpolyp with high recurrence risk
Italian studyItalian study Cases with one or more unfavorable criteria Cases with one or more unfavorable criteria
Coverlizza S. Cancer 1989Coverlizza S. Cancer 1989
Pedunculated Pedunculated Sessile Sessile
Incidence Incidence of residual of residual
cancercancer
8.5%8.5% 14.4%14.4%
Management Of Malignant PolypManagement Of Malignant Polyp
High recurrent High recurrent risk malignant risk malignant
polyppolyp
Low recurrent Low recurrent risk malignant risk malignant
polyppolyp
Low surgical Low surgical risk patientrisk patient
SurgerySurgery SurgerySurgery
oror
FU surveillanceFU surveillance
High surgical High surgical risk patientrisk patient
Endoscopic polypEndoscopic polypectomy and FU sectomy and FU s
urveillanceurveillance
Endoscopic Endoscopic polypectomy and polypectomy and FU surveillanceFU surveillance
Post polypectomy SurveillancePost polypectomy Surveillance
When?When?
Relative risk of developing colorectal cancer after Relative risk of developing colorectal cancer after polypectomy in polypectomy in Mayo clinicMayo clinic
Mayo Clin Proc 1986Mayo Clin Proc 1986
RR RR
<1cm<1cm 11
>1cm>1cm 2.72.7
No =3 / >3No =3 / >3 55
1618 patients in 1618 patients in St Mark Hospital, LondonSt Mark Hospital, London
Atkin WS. N Engl J Med 1992Atkin WS. N Engl J Med 1992
RRRR
If resected polyp <1cmIf resected polyp <1cm 11
>1cm or presence of villous tissue>1cm or presence of villous tissue 3.63.6
If number of polyps> 3If number of polyps> 3 6.66.6
US National Polyp Study US National Polyp Study
7-center trial7-center trial
1418 patients with at least one newly diagnosed 1418 patients with at least one newly diagnosed colorectal adenoma after colonoscopy and colorectal adenoma after colonoscopy and polypectomy polypectomy
FU colonoscopy at 1 year then 3 years Vs every FU colonoscopy at 1 year then 3 years Vs every 3 years3 years
US National Polyp StudyUS National Polyp Study
FU colonoscopy FU colonoscopy at 1 years and at 1 years and then 3 yearsthen 3 years
FU colonoscopy FU colonoscopy at 3 yearsat 3 years
““Recurrent” Recurrent” adenomaadenoma
41.7%41.7% 32-42%32-42%
Large Large advanced advanced adenomaadenoma
3.3%3.3% 3.3%3.3%
Winawer SJ, N Eng J Med 1993Winawer SJ, N Eng J Med 1993
Predictive factorsPredictive factors - - Increase chance of Increase chance of
having advanced adenomahaving advanced adenoma
if n >/= 3if n >/= 3 large adenoma >/= 1cm large adenoma >/= 1cm Family history of Colorectal cancer (1st Family history of Colorectal cancer (1st
degree relative)degree relative)
US National Polyp Prevention Study US National Polyp Prevention Study
479 patients479 patientsPredictors for advanced metachronous adenomaPredictors for advanced metachronous adenoma
Multiple adenoma >/=3Multiple adenoma >/=3 Presence of villous histologyPresence of villous histology
Van Stolk RU. Gastroenterology 1998Van Stolk RU. Gastroenterology 1998
Very low risk of recurrent advanced Very low risk of recurrent advanced adenoma at 3 yearsadenoma at 3 years
Only one or two small tubular adenomaOnly one or two small tubular adenoma No family history of colorectal cancerNo family history of colorectal cancer
Post Polypectomy surveillance Post Polypectomy surveillance recommendationsrecommendations
Complete colonoscopy to clear all polypsComplete colonoscopy to clear all polyps
Additional clearing exam after resection of a large sessile Additional clearing exam after resection of a large sessile adenoma or uncertainty of complete resectionadenoma or uncertainty of complete resection
High risk patients (n>/=3 , >/=1cm, villous histology, High risk patients (n>/=3 , >/=1cm, villous histology, high grade dysplasia, Family Hx of CR cancer) high grade dysplasia, Family Hx of CR cancer) FU colonoscopy at 3 yearsFU colonoscopy at 3 years
Low risk patientLow risk patient FU colonoscopy at 5 yearsFU colonoscopy at 5 years
Post Polypectomy surveillance Post Polypectomy surveillance recommendationsrecommendations
Selected low risk patients may not require follow–up Selected low risk patients may not require follow–up surveillance colonoscopy for advanced age or co-surveillance colonoscopy for advanced age or co-morbiditymorbidity
After one negative follow-up surveillance colonoscopy, After one negative follow-up surveillance colonoscopy, subsequent surveillance interval increase to 5 yearssubsequent surveillance interval increase to 5 years
Surveillance should be discontinued for advanced age or Surveillance should be discontinued for advanced age or co-morbidity co-morbidity
Winawer SJ. Gastroenterology 2003Winawer SJ. Gastroenterology 2003
SummarySummaryColorectal polyps
Endoscopic polypectomy
Benign Malignant
Risk stratificationLow risk High risk
FU Colonoscopy 3 years
Fu colonoscopy5 year
High risk High risk malignant malignant
polyppolyp
Low risk Low risk malignant malignant
polyppolyp
Low Low surgical surgical
risk patientrisk patient
SurgerySurgery SurgerySurgery
OrOr
SurveillanceSurveillance
High High surgical surgical
risk patientrisk patient
Endoscopic Endoscopic polypectomypolypectomy
Endoscopic Endoscopic polypectomypolypectomy
Normal FUColonoscopy
Surgery
Thank YouThank You