Quality in Endoscopy: Colonoscopy, Berlin 2012
The malignant adenoma:
when to recommend
surgery?
Evelien Dekker
AMC
Amsterdam
The Netherlands
Quality in Endoscopy: Colonoscopy, Berlin 2012
Colorectal cancer
Cancer Adenoma Normal
mucosa
Surgery
Quality in Endoscopy: Colonoscopy, Berlin 2012
Colorectal cancer
Cancer Adenoma Normal
mucosa Polypectomy
Quality in Endoscopy: Colonoscopy, Berlin 2012
Normal
mucosa
Surgery?
Cancer!
Colorectal cancer
Quality in Endoscopy: Colonoscopy, Berlin 2012
Polypectomy
Treatment
Quality in Endoscopy: Colonoscopy, Berlin 2012
Benign?
Malignant?
Treatment
Quality in Endoscopy: Colonoscopy, Berlin 2012
Malignant polyps
• After some polypectomies the polyp turns out
malignant
• Definition of malignant polyp: polypoid lesions that
appear endoscopically as adenomas but histologically
reveal invasive growth
• 0,5-8,3% of polyps turns out to be malignant1
• 10-13% residual disease (including lymph node
metastases)1
Robert, CGH 2007
Quality in Endoscopy: Colonoscopy, Berlin 2012
Malignant polyps
• Which pathologic features of a malignant polyp are
prognostic for residual disease??
Quality in Endoscopy: Colonoscopy, Berlin 2012
Prognostic features: histology
• Level of tumor invasion (Haggitt et al, 1985. Kudo et al, 1993. Kikuchi et
al, 1995)
• Lymphovascular invasion (Choi et al, 2009. Boenicke et al, 2009, Butte
et al, 2012)
• Adequacy of excisional margins (Nascimbeni et al, 2001. Boenicke
et al, 2009. Butte et al, 2012)
• Tumor histological differentiation (Choi et al, 2009. Goldstein et
al,1999)
• Histologic type of adenoma (tubular or villous)
• Morphology (sessile vs. pedunculated) (Boenicke et al, 2009)
• Location in lower third of the rectum (Nascimbeni et al, 2001)
Quality in Endoscopy: Colonoscopy, Berlin 2012
Level of tumor invasion
• Aim: which histologic features in the endoscopic
polypectomy specimen predict an adverse outcome
• Retrospective study 1964-1982 Tennessee
• Cases: patients w/ polypectomies showing cancer
• Objective: relate outcome to
• Histological classification (tubular or villous)
• Level of invasion
• Histologic grade of carcinoma (well, moderately,
poorly)
• Presence of lymphatic vessel invasion
• Status of surgical margins (negative, close-within 1
mm, positive)
Haggitt, Gastro 1985
Quality in Endoscopy: Colonoscopy, Berlin 2012
Level of tumor invasion
Haggitt, Gastro 1985
Quality in Endoscopy: Colonoscopy, Berlin 2012
Level of tumor invasion
• 129 malignant polyps
• 49% polypectomy alone, 51% some type of colectomy
Haggitt, Gastro 1985
Quality in Endoscopy: Colonoscopy, Berlin 2012
Level of tumor invasion
Haggitt, Gastro 1985
Quality in Endoscopy: Colonoscopy, Berlin 2012
Conclusion:
“The level of invasion is the major factor in determining
prognosis for the managment of carcinoma arising in an
adenoma”
“Intramucosal carcinomas have not invaded the
muscularis mucosae, and are not biologically malignant
and can be treated with endoscopic polypectomy”
Haggitt, Gastro 1985
Quality in Endoscopy: Colonoscopy, Berlin 2012
Sm1
1%
Sm2
6%
Sm3
14% % lymphnode metastases (if well-
differentiated, no lymfovascular
invasion)
Level of tumor invasion
Kudo, GI Clin N Am 1995
Quality in Endoscopy: Colonoscopy, Berlin 2012
Prognostic features: histology
• Retrospective study 1990-2007 New York
• Patients with endoscopically complete polypectomy
followed by colectomy were included (bias!)
• Aim: to determine the risk factors associated with
residual disease at colectomy following malignant
polypectomy
Butte, Dis Colon Rect 2012
Quality in Endoscopy: Colonoscopy, Berlin 2012
Prognostic features: histology
• 27 subjects (19%) had residual disease • 19 (13%) disease limited to colonic wall (16, 11% invasive)
• 10 (7%) nodal metastasis
Risks for invasive disease:
• <1 mm resection margin
• Indeterminate resection margin
• Lymphovascular invasion
Butte, Dis Colon Rect 2012
Quality in Endoscopy: Colonoscopy, Berlin 2012
Prognostic features
• We only know histology after we performed
polypectomy
• If polyp is retrieved, sent for pathology (NB DISCARD!)
and pathologist is able to assess resection margin
• Ideally: recognize polyps with invasive growth before
polypectomy, sparing risks, saving time & money
Quality in Endoscopy: Colonoscopy, Berlin 2012
Assessment of each polyp
• Location
• Size
• Shape: Paris classification
• Kudo pit pattern
• Histologic type (adenoma, SSA, HP etc)
• Signs of inavsive growth?
Quality in Endoscopy: Colonoscopy, Berlin 2012
Shape of polyp: Paris classification
Quality in Endoscopy: Colonoscopy, Berlin 2012
Chromo-endoscopy
Quality in Endoscopy: Colonoscopy, Berlin 2012
Non-invasive lesions
→ Classical adenoma-carcinoma pathway
Adenoma’s
→ Serrated pathway
Sessile Serrated Lesions: all
Hyperplastic polyps: if large, right-sided
Which lesions to resect
Quality in Endoscopy: Colonoscopy, Berlin 2012
Invasive lesions (carcinomas)
• Confined to mucosa or superficial submucosa (sm1-2)
• No lymphovascular invasion
• Well-differentiated
Which lesions to resect
Quality in Endoscopy: Colonoscopy, Berlin 2012
• Lesion is friable, indurated, ulcerated: 6-17% malignant1-4
Walsh, GIE 1992
Binmoeller, GIE 1996
Kanamori, GIE 1996
Doniec, Dis Colon Rect 2003
Endoscopic suspicion of sm-invasion
Quality in Endoscopy: Colonoscopy, Berlin 2012
Endoscopic suspicion of sm-invasion
Quality in Endoscopy: Colonoscopy, Berlin 2012
Endoscopic suspicion of sm-invasion
Quality in Endoscopy: Colonoscopy, Berlin 2012
Quality in Endoscopy: Colonoscopy, Berlin 2012
Quality in Endoscopy: Colonoscopy, Berlin 2012
Endoscopic suspicion of sm-invasion
Quality in Endoscopy: Colonoscopy, Berlin 2012
• Lesion is friable, indurated, ulcerated: 6-17% malignant1-4
• High-quality endoscopic equipment (plus chromoendoscopy, NBI/FICE/iScan): Kudo pit-pattern V, vascular pattern
Walsh, GIE 1992
Binmoeller, GIE 1996
Kanamori, GIE 1996
Doniec, Dis Colon Rect 2003
Endoscopic suspicion of sm-invasion
Quality in Endoscopy: Colonoscopy, Berlin 2012
Endoscopic suspicion of sm-invasion
Quality in Endoscopy: Colonoscopy, Berlin 2012
• Lesion is friable, indurated, ulcerated: 6-17% malignant1-4
• High-quality endoscopic equipment (plus chromoendoscopy, NBI/FICE/iScan): Kudo pit-pattern V, vascular pattern
• Non-lifting sign
Walsh, GIE 1992
Binmoeller, GIE 1996
Kanamori, GIE 1996
Doniec, Dis Colon Rect 2003
Endoscopic suspicion of sm-invasion
Quality in Endoscopy: Colonoscopy, Berlin 2012
Non-lifting sign
Quality in Endoscopy: Colonoscopy, Berlin 2012
Non-lifting sign
Quality in Endoscopy: Colonoscopy, Berlin 2012
Caused by
• Submucosal invasion
• Fibrosis by scarring (partial polypectomy, biopsies), previous injection
Walsh, GIE 1992
Binmoeller, GIE 1996
Kanamori, GIE 1996
Doniec, Dis Colon Rect 2003
Non-lifting sign
Quality in Endoscopy: Colonoscopy, Berlin 2012
• Lesion is friable, indurated, ulcerated: 6-17% malignant1-4
• High-quality endoscopic equipment (plus chromoendoscopy, NBI/FICE/iScan): Kudo pit-pattern V, vascular pattern
• Non-lifting sign
• Large adenomas: carefully inspect flat (Paris IIa or IIa+c) & non-granular lesions!
Walsh, GIE 1992
Binmoeller, GIE 1996
Kanamori, GIE 1996
Doniec, Dis Colon Rect 2003
Moss, Gastro 2011
Endoscopic suspicion of sm-invasion
Quality in Endoscopy: Colonoscopy, Berlin 2012
• Biopsies: inadequate
• Assess endoscopically
• Polypectomy = diagnostic procedure!
• Only start when you plan to finish
In case of suspicion of sm-invasion
Quality in Endoscopy: Colonoscopy, Berlin 2012
• Polypectomy scars difficult to find >10days
• Tattooing important in case of “high risk” polypectomy or a
detected cancer
• Don’t tattoo the polyp (fibrosis)
• Don’t tattoo the peritoneum (adhesions)
• Fill needle with saline, make bleb, tattoo submucosa
• Tattoo in standard fashion (e.g. 2 inj. – 3cm distal) &
decribe in report!
Tattoo
Quality in Endoscopy: Colonoscopy, Berlin 2012
Tattoo
Quality in Endoscopy: Colonoscopy, Berlin 2012
• Don’t wait for a surprise at pathology..
• Upon detection of colonic lesion: carefully assess
lesion for features of invasive growth
– friability, induration, ulceration
– Kudo V pit pattern, abnormal vascular pattern
• When suspicion for malignancy: tattoo!
In conclusion
Quality in Endoscopy: Colonoscopy, Berlin 2012
• If pathology demonstrates invasive growth,
consider surgery for
– Lesions with depth of invasion into distal third of
submucosa (sm3, >1000 μm, Haggitt level 4)
– Lesions with a positive (<1 mm) or unknown
polypectomy margin
– Lesions with lymphovascular invasion
In conclusion