The malignant Adenoma

Quality in Endoscopy: Colonoscopy, Berlin 2012

The malignant adenoma:

when to recommend

surgery?

Evelien Dekker

AMC

Amsterdam

The Netherlands


Colorectal cancer

Cancer Adenoma Normal

mucosa

Surgery


Colorectal cancer

Cancer Adenoma Normal

mucosa Polypectomy


Normal

mucosa

Surgery?

Cancer!

Colorectal cancer


Polypectomy

Treatment


Benign?

Malignant?

Treatment


Malignant polyps

• After some polypectomies the polyp turns out

malignant

• Definition of malignant polyp: polypoid lesions that

appear endoscopically as adenomas but histologically

reveal invasive growth

• 0,5-8,3% of polyps turns out to be malignant1

• 10-13% residual disease (including lymph node

metastases)1

Robert, CGH 2007


Malignant polyps

• Which pathologic features of a malignant polyp are

prognostic for residual disease??


Prognostic features: histology

• Level of tumor invasion (Haggitt et al, 1985. Kudo et al, 1993. Kikuchi et

al, 1995)

• Lymphovascular invasion (Choi et al, 2009. Boenicke et al, 2009, Butte

et al, 2012)

• Adequacy of excisional margins (Nascimbeni et al, 2001. Boenicke

et al, 2009. Butte et al, 2012)

• Tumor histological differentiation (Choi et al, 2009. Goldstein et

al,1999)

• Histologic type of adenoma (tubular or villous)

• Morphology (sessile vs. pedunculated) (Boenicke et al, 2009)

• Location in lower third of the rectum (Nascimbeni et al, 2001)


Level of tumor invasion

• Aim: which histologic features in the endoscopic

polypectomy specimen predict an adverse outcome

• Retrospective study 1964-1982 Tennessee

• Cases: patients w/ polypectomies showing cancer

• Objective: relate outcome to

• Histological classification (tubular or villous)

• Level of invasion

• Histologic grade of carcinoma (well, moderately,

poorly)

• Presence of lymphatic vessel invasion

• Status of surgical margins (negative, close-within 1

mm, positive)

Haggitt, Gastro 1985



• 129 malignant polyps

• 49% polypectomy alone, 51% some type of colectomy



Conclusion:

“The level of invasion is the major factor in determining

prognosis for the managment of carcinoma arising in an

adenoma”

“Intramucosal carcinomas have not invaded the

muscularis mucosae, and are not biologically malignant

and can be treated with endoscopic polypectomy”



Sm1

1%

Sm2

6%

Sm3

14% % lymphnode metastases (if well-

differentiated, no lymfovascular

invasion)


Kudo, GI Clin N Am 1995



• Retrospective study 1990-2007 New York

• Patients with endoscopically complete polypectomy

followed by colectomy were included (bias!)

• Aim: to determine the risk factors associated with

residual disease at colectomy following malignant

polypectomy

Butte, Dis Colon Rect 2012



• 27 subjects (19%) had residual disease • 19 (13%) disease limited to colonic wall (16, 11% invasive)

• 10 (7%) nodal metastasis

Risks for invasive disease:

• <1 mm resection margin

• Indeterminate resection margin

• Lymphovascular invasion

Butte, Dis Colon Rect 2012


Prognostic features

• We only know histology after we performed

polypectomy

• If polyp is retrieved, sent for pathology (NB DISCARD!)

and pathologist is able to assess resection margin

• Ideally: recognize polyps with invasive growth before

polypectomy, sparing risks, saving time & money


Assessment of each polyp

• Location

• Size

• Shape: Paris classification

• Kudo pit pattern

• Histologic type (adenoma, SSA, HP etc)

• Signs of inavsive growth?


Shape of polyp: Paris classification


Chromo-endoscopy


Non-invasive lesions

→ Classical adenoma-carcinoma pathway

Adenoma’s

→ Serrated pathway

Sessile Serrated Lesions: all

Hyperplastic polyps: if large, right-sided

Which lesions to resect


Invasive lesions (carcinomas)

• Confined to mucosa or superficial submucosa (sm1-2)

• No lymphovascular invasion

• Well-differentiated

Which lesions to resect


• Lesion is friable, indurated, ulcerated: 6-17% malignant1-4

Walsh, GIE 1992

Binmoeller, GIE 1996

Kanamori, GIE 1996

Doniec, Dis Colon Rect 2003

Endoscopic suspicion of sm-invasion



• High-quality endoscopic equipment (plus chromoendoscopy, NBI/FICE/iScan): Kudo pit-pattern V, vascular pattern

Walsh, GIE 1992


Kanamori, GIE 1996






• Non-lifting sign

Walsh, GIE 1992


Kanamori, GIE 1996




Non-lifting sign


Caused by

• Submucosal invasion

• Fibrosis by scarring (partial polypectomy, biopsies), previous injection

Walsh, GIE 1992


Kanamori, GIE 1996


Non-lifting sign




• Non-lifting sign

• Large adenomas: carefully inspect flat (Paris IIa or IIa+c) & non-granular lesions!

Walsh, GIE 1992


Kanamori, GIE 1996


Moss, Gastro 2011



• Biopsies: inadequate

• Assess endoscopically

• Polypectomy = diagnostic procedure!

• Only start when you plan to finish

In case of suspicion of sm-invasion


• Polypectomy scars difficult to find >10days

• Tattooing important in case of “high risk” polypectomy or a

detected cancer

• Don’t tattoo the polyp (fibrosis)

• Don’t tattoo the peritoneum (adhesions)

• Fill needle with saline, make bleb, tattoo submucosa

• Tattoo in standard fashion (e.g. 2 inj. – 3cm distal) &

decribe in report!

Tattoo


Tattoo


• Don’t wait for a surprise at pathology..

• Upon detection of colonic lesion: carefully assess

lesion for features of invasive growth

– friability, induration, ulceration

– Kudo V pit pattern, abnormal vascular pattern

• When suspicion for malignancy: tattoo!

In conclusion


• If pathology demonstrates invasive growth,

consider surgery for

– Lesions with depth of invasion into distal third of

submucosa (sm3, >1000 μm, Haggitt level 4)

– Lesions with a positive (<1 mm) or unknown

polypectomy margin

– Lesions with lymphovascular invasion

In conclusion

The malignant Adenoma

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