1) Colonic polyps can be neoplastic or non-neoplastic, with adenomatous polyps being precursors for colon cancer. Larger and villous polyps carry higher cancer risk. 2) Management of polyps depends on size, histology, and risk factors. Low-risk polyps can be removed endoscopically, while malignant or high-risk polyps may require surgery based on factors like margins, invasion, and differentiation. 3) Studies have shown poor differentiation, vascular/lymphatic invasion, and margins less than 2mm to be histologic risk factors associated with residual disease and poorer outcomes, necessitating surgery for high-risk malignant polyps.

1. Neoplastic Colonic Polyps Dr. Saud Al-Subaie Department of Surgery Amiri Hospital Monday 17/04/2006

2. Introduction Polyp :- any protrusion arising from an epithelial surface. Precursor for carcinoma Adenomatous polyp are premalignant 2/3 of polyps are adenomatous The bigger the size, the higher the risk of Ca < 1 cm :- ~10 yrs for transformation

3. Polyp- Cancer Sequence

4. Carcinoma Adenoma Tubular Tubulovillous Villous Classification of polyps Hamartoma Hyperplastic Inflammatory (psuedopolyps) Lymphoid Neoplastic Non- Neoplastic

5. Epidemiology 10.5% (100 %) Weighted chance 40 % 10 % Villous adenoma 22% 15 % Tubulovillous 5% 75% Tubular adenoma % Malignant Prevalence TYPE

6. Size and % of Ca 54% 10% 10% Villous 45% 9% 4% Tubulo-villous 34% 10% 1 % Tubular > 2cm 1-2 cm < 1cm

7. Endoscopic appearance

9. Etiology Genetic predisposition (hereditary Vs. Sporadic) Adenomatous Polyposis Syndromes Hereditary Nonpolyposis Colorectal Cancer (HNPCC) Environmental Factors :- Diet Exposure to carcinogens Role of chemoprevention :- ASA & NSAID

10. Etiology of Ca

11. Etiology (FAP)

12. Clinical Presentation Asymptomatic: - incidental finding Symptomatic: - Usually > 1cm - Abdominal pain (intussusception) - Profuse watery diarrhea (large villous adenoma). - Bleeding PR (when ulcerated)

13. Management

14. Endoscopic Management Polypectomy is the best treatment. Cautary snare: caution !! Complete removal & retrieval of the polyp Sessile & Semisessile polyp:- Piecemeal removal. ?? tattoo with India ink

17. Adenoma With Ca Adenoma With Ca

18. What is next Options :- 1- No more intervention 2- Surgery ( Formal Resection ) What is the risk of :- 1- Residual disease 2- Local Recurrence 3- Risk of LN mets 4- Distant metastasis 5- mortality ( Cancer vs Surgery)

19. Malignant Polyp Important Factors :- 1) Depth of invasion ( Haggitt’s classification) 2) Resection margin 3) Grade of differentiation 4) Vascular invasion

20. Haggitt Highest Invasion of submucosa, not the muscularis propria, sessile polyp 4 Moderate Invasion of the (MM)& polyp stalk 3 Low Invasion of the (MM) & polyp neck 2 None Invasion of the (MM) & polyp head 1 None No invasion of the muscularis mucosa (MM), carcinoma in situ 0 Risk of LN mets Histologic description level

21. Histologic assessment Favorable ( low risk ) :- 1- Differentiation G I G II 2- Resection margin > 2mm 3- Vascular and lymphatic invasion None

22. Histological assessment Unfavorable ( high risk ) 1- Differentiation :- G III 2- Resection margin :- < 2mm 3- Vascular and lymphatic invasion :- yes

23. Cesare Hassan et al Histologic Risk Factors & Clinical Outcome A pooled- data analysis. Thirty-one studies 1,900 patients with malignant polyp. Three histologic risk factors Five unfavorable clinical outcomes Dis Colon Rectum 2005

24. Cesare Hassan et al Three histologic risk factors positive resection margin ( < 2 mm) poor differentiation of carcinoma, vascular / Lymphatic invasion Dis Colon Rectum 2005

25. Cesare Hassan et al Five unfavorable clinical outcomes residual disease recurrent disease lymph node metastasis hematogenous metastasis mortality Dis Colon Rectum 2005

26. Cesare Hassan et al CONCLUSION: All three histologic risk factors are significantly associated with the clinical outcome. Classification in low-risk and high-risk patients may be regarded as a meaningful staging procedure. Dis Colon Rectum 2005

27. Sitz et al Retrospective ( 1985 – 1996) 114 Pts with endoscopicaly removed polyps Low risk :- Complete resection G1 G 2 grade No Vascular invasion High risk :- others Dis Colon Rectum 2004

28. Sitz et al 54 low risk :- - 5  surgery  no residual disease - 33 no surgery  no adverse outcome 60 high risk : - 52 surgery  residual disease in 27% - Significantly higher risk of adverse outcome( P < 0.0001) - No surgical complications Dis Colon Rectum 2004

29. Sitz et al Conclusion:- 1- Low risk :- Endoscopic polypectomy alone is adequate 2- High risk :- The risk of adverse outcome should be weighed against the risk of surgery Dis Colon Rectum 2004

30. Volk / Fazio 47 pt 17 had favorable histology:- 16  polypectomy alone  no adverse outcome 30 pt unfavorable 21  surgery 10/30 had adverse outcome Conclusion:- Endoscopic polypectomy is adequate for polyps with favorable histology Gastroenterology 1995

31. Operative Management - Transanal excision Transcoccygeal Transabdominal Malignant rectal polyps Anatomic resection with removal of adjacent LN Malignant / incompletely excised / Suspicious polyp - Colotomy+ Polypectomy - Segmental Resection Benign polyp(>3cm can’t be managed endoscopically) Surgical options Type of polyp

32. Summary Formal surgery should be advised for Malignant polyps with the following :- Poor differentiation Vascular and lymphatic invasion < 2mm resection margins Sessile polyps Haggitts’s level 3/4

33. “ Colon cancer can only be found if looked for. And it can only be cured if found early.”

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