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Management of Malignant Polyps

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. Invasion into submucosa Early Ca T1NxMx. Malignant Polyps. Malignant Polyps Management.

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Management of Malignant Polyps

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

  2. Management of Malignant Polyps I have no disclosure

  3. Invasion into submucosa Early Ca T1NxMx Malignant Polyps

  4. Malignant PolypsManagement • Colonoscopic Polypectomy • Transanal Excision • Colorectal Resection

  5. Malignant Polyps Who can have a local excision? Who needs a radical resection? T1 Nx Mx

  6. 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)

  7. 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

  8. 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

  9. 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

  10. High Risk of LN MetastasisIn T1 Low Rectum Author No. Treatment LNM (%) Nascimbeni 2002 29 LAR / APR 34 Goldstein 1999 53 APR 17 Blumberg 1998 48 LAR / APR 10

  11. Adequate Local Excision Colon Clear margins Clear depth > 2 mm Low rectum Clear margins Full thickness

  12. LOCAL EXCISION FOR T1 CA. RECTUM Standard Criteria Size < 3 cm Full thickness excision, 1 cm margin Not undifferenciated Ca. No lymphovascular invasion

  13. 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

  14. 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

  15. T1 Carcinoma of RectumLocal Excision vs Radical ResectionYou 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

  16. 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

  17. 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

  18. 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 %

  19. 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

  20. 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

  21. Management of Malignant PolypsHigh Risk Group • Colon, high rectum Radical Resection • Low rectum LAR / APR Loc. Exc. +/- Ch R?

  22. 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

  23. 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

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