management of serrated polyps of colorectum
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Management of Serrated Polyps of Colorectum. Eric YF Cheung Department of Surgery, NDH. Three messages. Serrated polyp-adenocarcinoma sequence Malignant risk of serrated polyps of colorectum Management and Surveillance: New guidelines needed. Serrated polyps—An overview. - PowerPoint PPT PresentationTRANSCRIPT
Management of Serrated Management of Serrated Polyps of ColorectumPolyps of Colorectum
Eric YF CheungEric YF Cheung
Department of Surgery, NDHDepartment of Surgery, NDH
Three messagesThree messages
Serrated polyp-adenocarcinoma Serrated polyp-adenocarcinoma sequencesequence
Malignant risk of serrated polyps of Malignant risk of serrated polyps of colorectumcolorectum
Management and Surveillance: New Management and Surveillance: New guidelines neededguidelines needed
Serrated polyps—An Serrated polyps—An overviewoverview
Colorectal polyps Colorectal polyps
AdenomaAdenoma Tubular adenomaTubular adenoma Tubulovillous adenomaTubulovillous adenoma Villous adenomaVillous adenoma
Hyperplastic polyp/Serrated polypHyperplastic polyp/Serrated polyp HarmatomaHarmatoma
Juvenile polypJuvenile polyp Peutz-Jeghers polypsPeutz-Jeghers polyps
Inflammatory polypInflammatory polyp Lymphoid aggregatesLymphoid aggregates
Traditionally viewed as innocuous
Serrated polyps (WHO)Serrated polyps (WHO)
Hyperplastic polyp (HP): Small distalHyperplastic polyp (HP): Small distal Microvesicular (MVHP)Microvesicular (MVHP) Globet-cell rich (GCHP)Globet-cell rich (GCHP) Mucin-poor Mucin-poor
Traditional serrated adenoma (TSA)Traditional serrated adenoma (TSA) DistalDistal
Sessile serrated adenoma/polyp Sessile serrated adenoma/polyp (SSA)(SSA) Proximal, largeProximal, large
Sessile serrated adenoma/polyp with Sessile serrated adenoma/polyp with dysplasia (SSA w/ dysplasia)dysplasia (SSA w/ dysplasia)Am J Gastroenterol 2012; 107:1315–1329
Incidence of Colorectal Incidence of Colorectal PolypsPolyps
Serrated polyp-Serrated polyp-Adenocarcinoma sequenceAdenocarcinoma sequence
Three pathways to CRCThree pathways to CRC
AdenomaAdenoma Adenoma-carcinoma sequenceAdenoma-carcinoma sequence: :
Chromosomal instabilityChromosomal instability Sessile Serrated Adenoma (SSA)Sessile Serrated Adenoma (SSA)
Serrated polyp-carcinoma sequence Serrated polyp-carcinoma sequence (20% CRC)(20% CRC)
Traditional Serrated Adenoma (TSA)Traditional Serrated Adenoma (TSA) Alternative/ fusion pathwayAlternative/ fusion pathway Less well characterizedLess well characterized
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Serrated polyp-Serrated polyp-Carcinoma sequenceCarcinoma sequence
Am J Gastroenterol 2012; 107:1315–1329
Initiation
Hypermethylation of promotor silencing of DNA mismatch repair gene MLH-1 Microsatellite instability
Malignant Risk of Serrate Malignant Risk of Serrate PolypsPolyps
Serrated Polyps and CRCSerrated Polyps and CRC
Genetic and pathological studyGenetic and pathological study ~ 20% CRC from serrated ~ 20% CRC from serrated pathwaypathway
Large and proximal serrated Large and proximal serrated polyps polyps more synchronous more synchronous advanced neoplasia/CRCadvanced neoplasia/CRC
Sessile serrated adenomas Sessile serrated adenomas high metachronous CRC ratehigh metachronous CRC rate
METHOD•3121 asymptomatic patients (aged 50–75 years) who had screening colonoscopies; 1371 had subsequent surveillance.
RESULTS•Patient with proximal ND-SP were more likely to have advanced neoplasia (17.3% vs 10.0%; OR, 1.90; 95% CI, 1.33-2.70). •Patients with large ND-SP were also more likely to have synchronous advanced neoplasia (OR, 3.37; 95% CI, 1.7-6.65).
During surveillance,•patients with baseline proximal ND-SP and no neoplasia were more likely to have neoplasia compared with subjects who did not have polyps (OR, 3.14; 95% CI,1.59-6.20). •Among patients with advanced neoplasia at baseline, those with proximal ND-SP were more likely to have advanced neoplasia during surveillance (OR, 2.17; 95% CI, 1.03-4.59).
Serrated polyps and Serrated polyps and metachronous tumourmetachronous tumour
•The incidence of subsequent CRCs was significantly higher in SSA patients than in control patients with HP (12.5% vs. 1.8%) and AP (12.5% vs. 1.8%). All of the subsequent CRCs or APs with HGD developed in the proximal colon. Four of the 5 CRCs demonstrated a high microsatellite instability phenotype. •We conclude that SSAs are high-risk lesions, with 15% of the SSA patients developing subsequent CRCs or APs with HGD. •support close endoscopic follow-up in patients harboring SSA
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Management and Management and SurveillanceSurveillance
TreatmentTreatmentAm J Gastroenterol Am J Gastroenterol 2012; 107:13152012; 107:1315––13291329
Complete removal of all serrated lesions Complete removal of all serrated lesions Except diminutive sigmoid/rectal lesionsExcept diminutive sigmoid/rectal lesions
Multiple diminutive (<5mm) serrated appear lesion Multiple diminutive (<5mm) serrated appear lesion should be randomly Bxshould be randomly Bx
Piecemeal resection/ possible incomplete removal Piecemeal resection/ possible incomplete removal surveillance colonoscopy 3-6 months surveillance colonoscopy 3-6 months
Surgical resection: not endoscopically ressectable, Surgical resection: not endoscopically ressectable, numerous large serrated lesion of proximal colon, numerous large serrated lesion of proximal colon, Serrated polyposis syndromeSerrated polyposis syndrome
Current Surveillance Current Surveillance strategiesstrategies
Guidelines based on observational Guidelines based on observational studies that link baseline CLN studies that link baseline CLN findings to risk of advanced findings to risk of advanced adenoma at FUadenoma at FU
For serrated lesionsFor serrated lesions USUS
After removal of HP After removal of HP 10 years interval 10 years interval No recommendation for SSA/TSANo recommendation for SSA/TSA
EuropeEurope HP: 10 yearsHP: 10 years SSA/TSA SSA/TSA consider as adenoma consider as adenoma
Why we need updated Why we need updated guidelines?guidelines?
Endoscopic detection is operator Endoscopic detection is operator dependent and variabledependent and variable SSA is hard to detect and easy to miss SSA is hard to detect and easy to miss
Serrated adenoma are likely to grow Serrated adenoma are likely to grow faster then adenomafaster then adenoma
Serrated adenomas are responsible Serrated adenomas are responsible for a large portion of interval CRCfor a large portion of interval CRC
Interval Colon CancerInterval Colon Cancer
RESULTRESULT
MSI was found in 30.4% of interval cancers MSI was found in 30.4% of interval cancers compared with 10.3% of noninterval compared with 10.3% of noninterval cancers (P = .003). After adjusting for age, cancers (P = .003). After adjusting for age, interval cancers were interval cancers were 3.7 times3.7 times more more likely to show MSI than noninterval likely to show MSI than noninterval cancers (95% CI, 1.5cancers (95% CI, 1.5––9.1).9.1).
Conceptual frameworkConceptual framework
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Take home messagesTake home messages
Some serrated polyps have Some serrated polyps have malignant potential e.g. SSA/TSAmalignant potential e.g. SSA/TSA
Grows quicker then traditional Grows quicker then traditional adenomasadenomas
All should be removed except All should be removed except diminutive HP in rectosigmoid diminutive HP in rectosigmoid regionregion
Current surveillance recommends Current surveillance recommends treating SSA/TSA as adenomatreating SSA/TSA as adenoma Modify according to size, site and Modify according to size, site and
numbersnumbers
The EndThe EndQ&AQ&A
ReferencesReferences1.1. Rex DK, Ahnen DJ, Baron JA et. al. Serrated lesions of the colorectum: Review and Rex DK, Ahnen DJ, Baron JA et. al. Serrated lesions of the colorectum: Review and
recommendations from an expert panel. recommendations from an expert panel. Am J Gastroenterol Am J Gastroenterol 2012;107:1315-13292012;107:1315-1329
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9.9. OO’’Brien MJ, Yang S, Mack C et. al. Comparison of microsatellite instability, CpG island Brien MJ, Yang S, Mack C et. al. Comparison of microsatellite instability, CpG island methylation phenotype, BRAF and KRAS status in serrated polyps and traditional methylation phenotype, BRAF and KRAS status in serrated polyps and traditional adenomas indicates separate pathways to distint colorectal carcinoma endpoints. adenomas indicates separate pathways to distint colorectal carcinoma endpoints. Am J Am J Surg Pathol Surg Pathol 2006;30:1491-15012006;30:1491-1501
10.10. Lu F, Niekerk DW, Owen D et. al. Longitudinal outcome study of sessile serrated Lu F, Niekerk DW, Owen D et. al. Longitudinal outcome study of sessile serrated adenoma of the colorectum: An increased risk of subsequent right-sided colorectal adenoma of the colorectum: An increased risk of subsequent right-sided colorectal carcinoma. Am J Surg Pathol 2010;34:927carcinoma. Am J Surg Pathol 2010;34:927––934)934)
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