crc, colorectal polyps
DESCRIPTION
محاضرات عين شمسTRANSCRIPT
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Colorectal Polyps
Ahmed A Abou-Zeid
Professor of Surgery
Ain Shams University
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What is a Polyp
• Any lesion that is elevated above the mucosal surface of the bowel
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Classification• Neoplastic
– Single• Adenomatous polyps• Connective tissue polyps (fibroma, lipoma, leiomyoma,
lymphoma)
– Polyposis Syndromes• FAP• HNPCC
• Non- neoplastic• Hamartomas• Metaplastic polyps• pseudopolyps
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Adenomatous polyps
• Tubular adenoma
• Tubulovillous adenoma
• Villous adenoma
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Adenomatous polyps
Tubular Adenoma Villous Adenoma
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Adenomatous Polyps Clinical Picture
• Symptomless
• Bleeding
• Discharge
• Prolapse
• Obstruction/Intussusception
• Hypokalemia/Hypoproteinemia
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Polyp - Cancer Sequence
• Circumstantial evidence– Similar anatomical distribution– Adenomas can harbour foci of carcinoma – Polyp patients are 8-10 years younger– 30% of CRC have synchronous polyps– Metachronous cancer is twice as high in
those cancers with associated polyps– Prophylactic polypectomy decrease incidence
of subsequent cancer
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Adenoma-Carcinoma Sequence
Normal
Dysplasia
Adenoma
Carcinoma
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Suspicious Polyp
• Size
• Age of polyp
• Histology
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Initial ManagementEndoscopic Procedures
Endoscopic Polypectomy
Pedunculated Sessile
Endoscopic Submucus Resection
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Initial ManagementTransanal Procedures
Endoanal Submucus Resection
Transanal Endoscopic Microsurgery (TEM)
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Initial ManagementAbdominal Procedures
• Colotomy/Colectomy• Proctotomy/Proctectomy
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The Polyp With a Malignant Focus
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Management of Malignant Polyp
• Polypectomy- Pedunculated- Well differentiated- In Head or stalk,
away from resection margin
- No vascular or lymphatic invastion
- Clear resection margins
• Radical Resection
- Sessile
- Poor differentiation
- Low in stalk
- Vascular or lymphatic invasion
- Involved resection margin
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Further Management of Malignant Polyp
Radical Resection
• Site of resection entitled by site of the polyp
• Radicality of resection entitled by extent of the polyp
• India ink injection in the era of laparoscopic surgery
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Follow Up After Polypectomy
• Benign polyp - Yearly endoscopy after positive complete clearance- Three yearly endoscopy after negative complete clearance- Five yearly therafter
• Malignant polyp - Follow guidelines of cancer management
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Metaplastic Polyps
• Also known as hyperplastic polyps• Usually minute (2-5mm), plaque like,
same colour of mucosa• Asymptomatic, do not turn malignant• Elongated tubules, scanty goblet cells,
hyperplastic cells at the base of crypts• Management depends on individual
policy
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Hamartomatous Polyps• Juvenile polyps
• Peutz-Jeghers polyps
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Juvenile Polyps• Seen in infants and children less than 10 y• Mostly situated in the rectum• Usually stalked, head covered by granulation tissue• Cut surface shows dilated cystic spaces, bulk of
polyp made up of connective tissue full of acute & chronic inflammatory cells
• Rectal bleeding, polyp prolapse• Not pre-malignant• Treatment by colonoscopy & polypectomy
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Peutz Jeghers Syndrome
• Autosomal dominant inheritance• Pigmentation• Polyps• Symptoms of rectal bleeding and recurrent
intussusception• Debate considering the malignant potential• Conservative management versus more
aggressive endoscopic management
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Peutz Jeghers Syndrome
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Inflammatory Polyps
• Accompany Chronic inflammatory process of the bowel
• Composed of oedamatous mucosal tags
• Not premalignant
• Treatment of the cause
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Inflammatory Polyps
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Connective Tissue Polyps
Submucuos Lipoma
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Connective Tissue Polyps
• Can be benign or malignant
• Size dictates symptomatology in benign lesions
• Commonly present by obstructive symptoms
• Treatment: Segmental resection
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Familial AdenomatousPolyposis
• Autosomal dominant inheritance• Mutation in APC gene• Easily recognized by its phenotypic
features– CR polyps and cancer– Extracolonic lesions
• 100% penetrance• 1 in 8,300 to 1 in 14,025 live births
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Familial AdenomatousPolyposis
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FAP/Extracolonic Lesions
• Desmoids
• CHRPE
• Duodenal adenomas
• Gastric glandular hypertrophy
• Osteomas/Neuromas
• Other tumours
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FAP/Extracolonic Lesions
CHRPE Intra-abdominal Desmoid
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FAP/Diagnosis
• Clinical diagnosis– Colonic lesions
– Extra-colonic lesions
• Sigmoidoscopy/Colonoscopy
• Genetic diagnosis
• Surveillance
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FAP/Treatment
• Prococolectomy/ Brook’s ileostomy
• Restorative proctocolectomy
• Total colectomy/ileorectal anastomosis
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HNPCC• Characterized by
– Autosomal dominant inheritance– Mutation in MMR gene– Early onset CR cancer and polyps– Extracolonic cancers
• Diagnosis: Less evident phenotypic features– Family history criteria– Pathology criteria– Genetic criteria
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Family History
• Amsterdam criteria
– CRC in 3 family members
– One member 1st degree relative to other two
– Two successive generations
– One cancer diagnosed less than 40
– FAP excluded
• Others (less strict criteria)
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Pathology Criteria
• Young age of onset
• Right sided tumors
• Multiple colonic tumors
• Extra-colonic tumors
• Aggressive histopathology features
• Good prognosis
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Genetic Criteria
• Disordered mismatch repair genes– hMLH1– hMSH2– hPMS1– hPMS2– hMSH3– hMSH6
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Extracolonic Tumours in HNPCC
• Small intestine
• Endometrium
• Urothelium
• Biliary tree
• Gastric mucosa
• Others
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Treatment of HNPCC
• Total colectomy/ileorectal anastomosis
• Restorative proctocolectomy
• Surveillance