Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.
-
Upload
brett-patrick-mckinney -
Category
Documents
-
view
224 -
download
4
Transcript of Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.
![Page 1: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/1.jpg)
Dr KP TsuiDepartment of Surgery
Tseung Kwan O Hospital
![Page 2: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/2.jpg)
Malignant Rectal PolypPolyps with cancer cells invading the
muscularis mucosaInvasion limited to submucosa T1 lesion
![Page 3: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/3.jpg)
Incidence of malignant colorectal polyps as a proportion of all adenomas removed varies between 2.6 and 9.7%.
Average 4.7%
Sobin L, Wittekind C (eds). TNM classification of Malignant Tumours (6th Edition). Wiler-Liss: New York, 2002.
![Page 4: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/4.jpg)
Size most important determinant factor determining risk of malignant transformation within a polyp
> 1 cm: 38.5%> 42 mm: 78.9%
Tytherleigh et al. BJS 2008;95:409-423
![Page 5: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/5.jpg)
Villous adenomas have highest risk of malignancy at 29.8%
Tubular adenomas have lowest at 3.9%
Tytherleigh et al. BJS 2008;95:409-423
![Page 6: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/6.jpg)
Haggitt Classification
![Page 7: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/7.jpg)
Kikuchi Classification of Adenocarcinoma in Sessile Polyps
![Page 8: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/8.jpg)
Treatment Staging Histological Assessment
![Page 9: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/9.jpg)
Clinical Scenario 1Colonoscopy: 2 cm rectal polyp
(5 cm from anal verge)Biopsy: adenocarcinoma
![Page 10: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/10.jpg)
Endorectal ultrasound
Best method to differentiate between T1 and T2 lesion
T stage N stage Accuracy: 90 % Accuracy: 80%
Sensitivity : 85% Sensitivity: 70%Specificity: 95% Specificity: 80%
Bretagnol et al. Dis Colon Rectum 2007;50:523-533
![Page 11: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/11.jpg)
Can assess residual tumor after polypectomy
Follow up after local excision
Hernandez De Anda et al. Dis Colon Rectum 2004; 47: 818–824
![Page 12: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/12.jpg)
LimitationsOperator dependent
Upper rectal lesions
Tumor stenosis
Peritumoral fibrosis and inflammatory tissue
Effect of radiotherapy or hemorrhage after
biopsy
![Page 13: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/13.jpg)
Pelvic MRIOverall T stage accuracy 59-95%T1,2 lesion (vs ERUS)
- Similar sensitivities- Lower specificity (69%)
N stage - Comparable to EUS
Can evaluate entire pelvis
Bretagnol et al. Dis Colon Rectum 2007;50:523-533Tytherleigh et al. BJS 2008;95:409-423
![Page 14: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/14.jpg)
CT abdomen + pelvis Distant metastasesLow accuracy for T staging, 52 – 94% and N stage,
54-70%
Alexandre Jin Bok Audi Chang et al. Journal of Surgical Education; Vol 65: Number 1Bretagnol et al. Dis Colon Rectum 2007;50:523-533
![Page 15: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/15.jpg)
PETLimited role for local and regional stagingSensitivities for lymph node metastases 22-
29%
Abdel-Nabi H, Doerr RJ, Lamonica DM, et al. Radiology. 1998;206:755-760
![Page 16: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/16.jpg)
Surgical OptionsLocal excision vs Radical Surgery
Park’s per anal excision Abominoperineal
resection
TEM Total Mesorectal
Excision
Anterior
resection
![Page 17: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/17.jpg)
Local ExcisionOpportunity of cure with less detriment
Sphincter preservation
Less morbidity and mortality
Less sexual or urinary dysfunction
![Page 18: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/18.jpg)
Park’s per anal excision- Aid of anal retractors
- 6-10 cm of anal margin
- Full thickness excision
- At least 1 cm margin
- Defect usually closed with absorbable sutures
![Page 19: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/19.jpg)
Transanal endoscopic microsurgeryRectoscope
Usually below peritoneal reflection
Full thickness excision
Excision margin of 1 cm Difficult for lesions within 6 cm
![Page 20: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/20.jpg)
![Page 21: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/21.jpg)
Long-handled transanal endoscopic microsurgery instrument
![Page 22: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/22.jpg)
ComplicationsOverall rate 6-31%
Postoperative hemorrhage 1-13%
Perforation 0-9%
Suture line dehiscence
Perirectal abscess
Rectal stenoses
Hiroko Kunitake, et al. Perm J 2012 Spring;16(2):45-50
![Page 23: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/23.jpg)
Local Excision
Vs
Radical Surgery
![Page 24: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/24.jpg)
Generally accepted that local excision, by either
endoscopic polypectomy or transanal surgery is
adequate treatment for low risk ERC
Tytherleigh et al. BJS 2008;95:409-423
![Page 25: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/25.jpg)
Histopathological FeaturesLow risk early rectal cancer High risk early rectal cancer
Well or moderately differentiated Poorly differentiated
No vascular or lymphatic invasion
Vascular or lymphatic invasion
Hagitt 1-3Kikuchi Sm 1 and ?Sm2
Kikuchi Sm3 and ?Sm2Positive resection margin
![Page 26: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/26.jpg)
Poorly differentiated carcinoma: 50% risk
of lymph node metastasis
Coverlizza S, Risio M, Ferrari A, Fenoglio-Preiser CM, Rossini FP. Cancer 1989;64:1937-47
Lymphovascular invasion, sm3 invasion,
undifferentiated carcinomas have
significant risks of LN metastases.
Nascimbeni et al. Dis Colon Rectum 2002;45:200-206
![Page 27: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/27.jpg)
Des.
Depth of invasion was found to be best estimate of the probability of regional LN metastasis
Bretagnol et al. Dis Colon Rectum 2007;50:523-533
Rate of lymph node metastasis
Sm1 1-3%
Sm2 8%
Sm3 23%
Nascimbeni et al. Dis Colon Rectum 2002;45:200-206
![Page 28: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/28.jpg)
Optimal choice of surgeryThe role of local excision as a curative
procedure has been questioned due to inferior outcome in some long term follow up series.
Alexandre Jin Bok Audi, MD, et al. Journal of Surgical Education; Vol 65: Number 1 (2008)
![Page 29: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/29.jpg)
Alexandre Jin Bok Audi, MD, et al. Journal of Surgical Education; Vol 65: Number 1 (2008)
![Page 30: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/30.jpg)
Most literature data are based on case reports or small series with no standard criteria for patient selection
![Page 31: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/31.jpg)
Adjuvant chemoradiotherapyMay be beneficial Recommended for high risk T1 lesions,
assuming further surgery is not an option
Tytherleigh et al. BJS 2008;95:409-423
![Page 32: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/32.jpg)
Bretagnol et al. Dis Colon Rectum 2007; 50:523-533
![Page 33: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/33.jpg)
LimitationsMost retrospective studiesLack of controlled dataNo defined protocol for chemotherapy
![Page 34: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/34.jpg)
Salvage surgery Between 56 and 100% of recurrence suitable
for salvage surgeryMay not offer same outcomes as initial
treatmentShould not be delayed in case of recurrence
Tytherleigh et al. BJS 2008;95:409-423
![Page 35: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/35.jpg)
Clinical Scenario 2Colonoscopic polypectomy of rectal polypPathology: adenocarcinoma
![Page 36: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/36.jpg)
Radical Surgery Follow up
ERUS MRI CT
LN+
High Risks FeaturesSm3 (Sm2)Gradelymphovascular
No High Risks FeaturesHaggitt level 1,2,3 Kikuchi Sm1
Margin involvement
Yes
Local Excision
Histological assessment not
adequate
No
High Risks Features
NoYes
LN-
Pathology
![Page 37: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/37.jpg)
Follow up Digital rectal exam + Endoscopy + CEA
First 3 years: every 3 monthsNext 2 years: every 6 monthsThen annually
Endorectal ultrasound should be performed at every outpatient session
Mellgren et al. Dis Colon Rectum 2000; 43: 1064–1071NCCN guideline
![Page 38: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/38.jpg)
SummaryLocal excision
Recommended for low risk T1 Sm1 lesionRadical surgery
For high risk T1 lesion Adjuvant therapy if further surgery is not an option
![Page 39: Dr KP Tsui Department of Surgery Tseung Kwan O Hospital.](https://reader036.fdocuments.in/reader036/viewer/2022081512/56649db65503460f94aa7559/html5/thumbnails/39.jpg)
Recurrence Diagnose early for salvage surgery
Follow up Endoscopic surveillance of rectum and scar