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. Malignant Polyps Invasion into submucosa Early Ca T1NxMx

5. Malignant Polyps Management Colonoscopic Polypectomy Transanal Excision Colorectal Resection

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

7. 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)

9. Pathologic Assessment of Malignant Polyps Inter-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

10. 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

13. Sessile Malignant Polyp Independent 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

14. 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

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

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

19. LITERATURE REVIEW Local 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

21. 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

22. T1 Carcinoma of Rectum Local 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

23. 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

24. 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

25. 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 %

26. 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

27. 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

28. Management of Malignant Polyps High Risk Group Colon, high rectum Radical Resection Low rectum LAR / APR Loc. Exc. +/- Ch R?

29. 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

30. 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