Management of Malignant Polyps Santhat Nivatvongs, MD Colon and Rectal Surgery Mayo Clinic Rochester Minnesota U.S.A.

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 PolypsManagement

• Colonoscopic Polypectomy

• Transanal Excision

• Colorectal Resection

Malignant Polyps

Who can have a local excision?

Who needs a radical resection?

T1 Nx Mx

Literature ReviewHigh 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 PolypsInter-observer Variability

Kappa Statistics--a measure of observer agreement

Characteristics Kappa Result

Lymphovascular invasion 0.017 poor

Histologic grade 0.163 poor

Haggitt’s classification 0.682 very good

T stage 0.725 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 < 1

Sessile & Pedunculated Level 4 12 Haggitt R, et al. Gastroent 1985; 89:328

Nivatvongs S, et al. DCR 1991; 34:323

Kyzer S, et al. Cancer 1992; 70:2044

Sessile Malignant PolypIndependent Risk Factors

Factor Odds ratio 95% CI p

LVI 3.5 1.4-8.9 0.009

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

High Risk of LN Metastasis In T1 Low Rectum

Author No. Treatment LNM (%)

Nascimbeni 2002 29 LAR / APR 34

Goldstein 1999 53 APR 17

Blumberg 1998 48 LAR / APR 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 REVIEWLocal 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 p

N=70 N=74

5 yr (%) 10 yr (%) 5 yr (%) 10 yr (%)

Local recurrence 6.6 12.2 2.8 6.2 0.26

Distant metastasis 14.2 20.5 6.9 10.2 0.13

Overall survival 72.4 44.3 90.4 72.0 0.008

Ca-free survival 66.6 39.6 83.6 69.8 0.003

Nascimbeni R et al. DCR 2004; 47: 1773

T1 Carcinoma of RectumLocal 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. Recur. (%) FU (mo)

Lamont 2000 10 0 33

Bouvet 1999 37 5 51

( 68% treated )

Bailey 1992 35 T1 10 60

18 T2

Paty 2002 67 ( untreated ) 17 120

7 ( treated ) 17 120

PO Radiation After Local ExcisionR 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 41 %

Positive margins 42 %

Recurrence at 5 yr 39 %

Disease-free survival at 5 yr 59 %

Immediate vs Salvage Resection

No Ca -free survival ( % )

Immediate radical resection 37 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 PolypsSummary

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 PolypsHigh 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 p

N=70 N=74

5 yr (%) 10 yr (%) 5 yr (%) 10 yr (%)

Local recurrence 6.6 12.2 2.8 6.2 0.26

Distant metastasis 14.2 20.5 6.9 10.2 0.13

Overall survival 72.4 44.3 90.4 72.0 0.008

Ca-free survival 66.6 39.6 83.6 69.8 0.003

Nascimbeni R et al. DCR 2004; 47: 1773

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