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
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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
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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
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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.
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Classification
Paris Classification Japan Classification
Gastrointest Endosc 2003; 58(Suppl. 6): S3–43
Japanese Classification of Colorectal Carcinoma. 1997
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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
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Endoscopic treatment options
Williams. Colorectal Disease 2013;15:1–38
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Exclusion of lesion for endoscopic treatment
Chromoendoscopy
Narrow band imaging
Kudo. Gastrointest Endosc 1996;44:8-14
Sano. Digest Endosc, Vol. 18.S44–51
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Endoscopic treatmentSnare polypectomy
Endoscopic mucosal resection (EMR)
Endoscopic submucosal dissection(ESD)
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Norman E. Upper Endoscopy, Advanced Digestive Endoscopy
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Piecemeal EMR
John Hopkins colon cancer center
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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
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Endoscopic submucosal dissection (ESD)
Kōdansha. Understanding ESDs: A Procedure for Treating Cancer Without Major Surgery. 2011
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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
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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
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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
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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
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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
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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
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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
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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.
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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
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Pit pattern and histological correlation