malignant colonic polyp: endoscopic treatment updates chan ka-man, fiona kwong wah hospital joint...
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Malignant colonic polyp: endoscopic treatment updatesCHAN Ka-man, FionaKwong Wah Hospital
Joint Hospital Surgical Grand Round18th April, 2015
Prevalence Screen detected adenoma
21-58% from 50-70 years
Malignant polyps in endoscopically removed polyps 0.2-11%
Markowitz AJ. CA Cancer J Clin 1997;47:93-112Nusko G. Endoscopy 1997;29: 626-631Williams AR. Gut 1982;23:835-42
Superficial neoplastic lesionMalignant colonic polyp
Neoplasm that penetrates the muscularis mucosae into submucosa
Carcinoma in-situ/High-grade intraepithelial neoplasia Neoplasm that are confined to the epithelium or
invade the lamina propria alone and lack invasion through the muscularis mucosae
Wolff WI. Annals of Surgery 1975;182:516-525
Japanese Society for Cancer of the Colon and Rectum. 2009
World Health Organization classification of tumors. 2010. pp. 104–109
Why is endoscopic treatment feasible?Risk of lymph node metastasis in Tis is
negligible
Risk of lymph node metastasis in submucosal lesion Risk 6-12% in general Pedunculated lesions
Rate of lymph node metastasis was 0% in head invasion cases and stalk invasion cases with SM depth <3000 µm if lymphatic invasion was negative.
Non-pedunculated lesions Rate of lymph node metastasis was also 0% if
SM depth was <1000 µm.
Classification
Paris Classification Japan Classification
Gastrointest Endosc 2003; 58(Suppl. 6): S3–43
Japanese Classification of Colorectal Carcinoma. 1997
Lateral spreading tumour (LST)Neoplasm with horizontal
extending growth pattern
>10mm
Granular type (LST-G)
Non-granular type (LST-NG) High possibility of deep
submucosal invasion 14% versus 7% in glandular type (p<0.01)
30-56% have multifocal invasion
Japanese Classification of Colorectal Carcinoma. 1997
Endoscopic treatment options
Williams. Colorectal Disease 2013;15:1–38
Exclusion of lesion for endoscopic treatment
Chromoendoscopy
Narrow band imaging
Kudo. Gastrointest Endosc 1996;44:8-14
Sano. Digest Endosc, Vol. 18.S44–51
Endoscopic treatmentSnare polypectomy
Endoscopic mucosal resection (EMR)
Endoscopic submucosal dissection(ESD)
Norman E. Upper Endoscopy, Advanced Digestive Endoscopy
Piecemeal EMR
John Hopkins colon cancer center
Efficacy of EMREn bloc resection: 66.5–80% when the tumor
sizes were <20 mm
When the tumor sizes were ≥20 mm, the en bloc resection rate significantly decrease to 20-48% Local recurrence
3% en bloc resection 20% piecemeal resection
Wada. Stomach Intestine 2013;48:134–44
Walsh. Gastrointest Endosc 1992;38:303–9
Saito. Gastrointest Endosc Clin N Am 2010;20:515–24
Jin. Cancer Therapy. Vol. 7. pp. 27-30
Endoscopic submucosal dissection (ESD)
Kōdansha. Understanding ESDs: A Procedure for Treating Cancer Without Major Surgery. 2011
Efficacy of ESDMeta-analysis of ESD of 1314 large flat polyps
En-bloc resection rates 88%-90.5%
Histological R0 resection rate 76.9%-89%
Local tumor recurrence 1.9%
Tanaka S. Dig Endosc 2012; 24(Suppl 1):73–79
Saito. Gastrointest Endosc 2010;72:1217–1225
Puli SR. Ann Surg Oncol 2009;16:2147-2151
ESD vs. EMRLarger resected specimens (37 mm vs. 28mm;
p=0.0006)
Higher en-bloc resection rate(94.5% vs. 56.9%; p<0.01)
Less recurrences (2% vs. 14%; p<0.0001)
Longer procedure time (108-129 min vs. 18-29 min; p<0.0001)
Higher perforation rate (6.2% vs. 1.3%)
Nakajima. Surg Endosc 2013
Saito. Surg Endosc 2010;24:343–352
ESD versus laparoscopic colectomyLimited comparative data
Shorter procedure time (95 vs. 185 mins; p<0.001)
Shorter hospital stay (5 vs. 10days; p<0.001)
Less analgesic requirement
Early resumption of diet and mobility
The 3-year overall survival rate exceeded 99% in both the ESD and LAC groups
Kiriyama S. Endoscopy 2012; 44:1024–1030
Nakamura. Surg Endosc 2015;29:596-606
Difficulty in ESDAnatomical difficulties
Longer length, narrower lumen, extensive flexion and thinner walls
Steep learning curve Animal models 20 gastric ESD → rectal ESD → colon ESD
Complication Perforation rate 4-10% Bleeding rate 0.7-2.4%
Uroka. Journal of Gastroenterology and Hepatology (2013) 406–414
Curative endoscopic resection Lateral and vertical
margins of the specimen were free
Submucosal invasion less than 1,000 μm
No lymphovascular involvement
No poorly differentiated component
Tumor budding grade 1 (low grade)
Kitajima. J Gastroenterol 2004; 39:534–543
Endoscopic surveillanceDetection of recurrence
Metachronous adenoma and early carcinoma were detected in 54.8% and in 11.9% of surveillance endoscopy
No evidence-based consensus
First surveillance at 3-6 months, then regular surveillance in 3-5 years
Repici .Dis Colon Rectum 2009; 52: 1502–15
Conclusion Malignant colonic polyps can be managed by
endoscopic resection
ESD enables en-bloc resection of large superficial tumours
Regular surveillance aids detection of recurrence which can be managed endoscopically
Reference Wolff WI, Shinya H. Definitive treatment of “malignant” polyps of the
colon. Annals of Surgery. 1975;182(4):516-525.
Japanese Society for Cancer of the Colon and Rectum, editor. Japanese Classification of Colorectal Carcinoma. 2nd ed. Tokyo: Kanehara & Co., Ltd; 2009
Kitajima K, Fujimori T, Fujii S et al. Correlations between lymph node metastasis and depth of submucosal invasion in submucosal invasive colorectal carcinoma: a Japanese collaborative study. J. Gastroenterol. 2004; 39: 534–43.
Participants in the Paris Workshop. The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointest Endosc 2003; 58(Suppl. 6): S3–43.
Oka S, Tanaka S, Kaneko I et al. Conditions of curability after endoscopic treatment for colorectal carcinoma with submucosal invasion: Assessments of prognosis in cases with submucosal invasive carcinoma resected endoscopically. Stomach Intestine 2004; 39: 1731–43.
Polyp morphology relation to size and risk of submucosal invasion
The Paris endoscopic classification of superficial neoplastic lesions. Gastrointest Endosc 2003; 58(Suppl. 6): S3–43
Pit pattern and histological correlation
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