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 Polyps Management Colonoscopic Polypectomy Transanal Excision Colorectal Resection

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

Literature Review High 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 Polyps Inter-observer Variability Kappa Statistics--a measure of observer agreement Characteristics Kappa Result Lymphovascular invasion poor Histologic grade poor Haggitt’s classification very good T stage 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 Polyp Independent Risk Factors Factor Odds ratio 95% CI p LVI Sm <0.001 Lower 1/3 R <0.001 Nascimbeni R et al DCR 2002;45:200

High Risk of LN Metastasis In T1 Low Rectum Author No. Treatment LNM (%) Nascimbeni LAR / APR 34 Goldstein APR 17 Blumberg 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 REVIEW Local Excision Ca. Rectum ( T1) Author Yr No. Loc Recur(%) FU/ M0 Madbouly Nascimbeni Paty Mellgren

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 Distant metastasis Overall survival Ca-free survival Nascimbeni R et al. DCR 2004; 47: 1773

T1 Carcinoma of Rectum Local Excision vs Radical Resection You YN, Baxter NN, Stewart A, Nelson H (ACOSOG) National Data Base Follow-up 6.3 yr Local Excision Radical Resection p Number of patient Overall Survival (5 yr) 77 % 82% 0.09 Disease Free Survival (5 yr) 93% 97% 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 Bouvet ( 68% treated ) Bailey T T2 Paty ( untreated ) ( treated )

PO Radiation After Local Excision R 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 % at 5 yr Mayo Clinic DCR 2005; 48:429 Delayed radical resection at 5 yr Cleveland Clinic DCR 2005; 48:711 Delayed radical resection at 5 yr Memorial DCR 2005; 48:1169 Delayed radical resection at 3 yr Univ Minn DCR 2000; 43:1064

Management of Malignant Polyps Summary 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 Polyps High 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 Distant metastasis Overall survival Ca-free survival 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 Match control Hahnloser D, et al. DCR 2005; 48: 429