EJ Jr. Endoscopic brush cytology in esophageal cancer. JAMA1975;232:1358.

11. Mandard AM, Tourneaux J, Gignois M, et al. In-situ carcinomaof the oesophagus. Macroscopic study with particular referenceto the Lugol test. Endoscopy 1980;12:51-7.

12. Jass JR, Morson BC. Epithelial dysplasia in the gastrointestinaltract. In: Sherlock P, Jerzy-Glass G, eds. Progress in gastroen­terology, vol. 4. New York: Grune & Stratton, 1983:345-71.

13. Jessen K, Paolucci P, Classen M. Endoscopic vital staining of

An approach to malignant polypsJerome D. Wave, MD

Current medical opmIOn holds that most coldnicand rectal carcinomas develop via malignant changesthat occur in previously benign colon adenomas. Theincidence of cancer rises with the increasing size ofthe polyp and is dependent on its histology.! The riskof carcinoma is 0.1% in polyps less than 6 mm indiameter, increases to 1% when an adenoma is 1 cmin diameter, and may reach 20 to 40% in tumors over3 cm in size.2 The larger polyps (over 1 cm) andadenocarcinoma both appear to be most prominent inthe rectum and sigmoid portions of the colon. Recentstudies, however, show that the location of coloniccarcinoma is changing, so that there is an increasing .incidence of malignancy in the right colon and thetransverse colon, whereas the actual number of suchtumors in the distal bowel is diminishing in fre­quency.3

Because of the risk of carcinoma in polyps, all thoseover 1 cm in diameter should be removed by polypec­tomy and submitted for histologic review. The adventof colonoscopy has rendered the removal of polypsrelatively easy and risk free. 4 As there is a low risk ofcarcinoma in polyps less than 6 mm in diameter, theirfinding on a double contrast barium enema examina­tion should not be the impetus for colonoscopic resec­tion; however, if they are encountered during colon­oscopy, they should be removed by biopsy and fulgur­ation. Small polyps are rarely the cause of colonicbleeding, but if bleeding (visible or occult) is persis­tent, colonoscopy should be performed to determinethe cause of bleeding. Although most lesions presentwithin the colon will be diagnosed by x-ray, a normalbarium enema (or one that is interpreted as showingdiverticulosis as the only abnormality) in the patientwith persistent bleeding does not mean that the colonis free of significant lesions. In this particular groupof patients, colonoscopy has demonstrated polyps over5 mm in diameter in 15% and infiltrating carcinomain 10%.5

From the Division of Gastroenterology, Department of Medicine, Mt.Sinai School of Medicine, New York, New York.

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the oesophagus in high risk patients: detection of dysplasia andearly. carcinoma. In: Sherlock P, Morson BC, Barbara L, Ve­ronesi V, eds. Precancerous lesions of the gastrointestinal tract.New York: Raven Press, 1983:65-70.

14. Sjogren RW Jr, Johnson LF. Barrett's esophagus. a review. AmJ Med 1983;74:313-21.

15. Witt TR, Bains MS, Zaman MB, Martini N. Adenocarcinomain Barrett's esophagus. J Thorac Cardiovasc Surg 1983;85:337­45.

If malignant cells are present in the head of anadenoma, whether pedunculated or sessile, but do notinvade the stroma, colonoscopic excision is sufficient.This entity is called carcinoma in situ, or severedysplasia by pathologists. The term is based on thestrict criterion of absence of malignant cells crossingthe muscularis mucosae within the polyp. After resec­tion, further follow-up should be performed as if theoriginal lesions were benign.5

Any degree of invasion into the stroma of the ade­noma (i.e., carcinoma cells crossing the muscularismucosae) places the patient at risk for metastasessince lymphatics are present within the stroma. Evi­dence is accumulating that any degree of invasion,whether in a pedunculated or sessile adenoma, is as­sociated with a risk of spread to lymph nodes regard­less of whether carcinoma does or does not reach theline of resection.6 Simple polypectomy and observa­tion of the site for subsequent healing are no longerconsidered adequate since the polypectomy site mayheal and endoscopy is inadequate to ascertain whetherextraluminal metastases are present. Therefore, allpatients with any degree of invasive carcinoma in aresected adenoma should undergo laparotomy and sur­gical resection. Decision for bowel surgery may bealtered in patients who are elderly or infirm or inthose patients in whom the carcinoma-within-an-ad­enoma is located near the rectum, and abdominoperi­neal resection would be required.

Pedunculated adenomas (tubular or villous) re­moved in toto by severing the stalk endoscopically arecured and do not recur. Total excision of sessile ade­nomatous polyps provides the same results, but deter­mination of total removal may be difficult at the timeof polypectomy. In sessile lesions, the site ofresectionshould be reinspected in 6 to 12 months, and furthersurveillance should be the same as that of any highrisk patient. If several adenomas are removed at thetime of original endoscopic examination, there is ahigh chance of discovering more polyps on follow-upexamination, some having newly grown and othershaving been missed at colonoscopy. The follow-upinterval for a patient with a single benign adenoma,totally removed, in whom the entire colon was endos-

GASTROINTESTINAL ENDOSCOPY

copically inspected, is approximately 3 years. If mul­tiple polyps are removed or if sessile adenoma(s) arepresent, a shorter follow-up interval is recommended.7

Follow-up ofthe patient following surgical resectionof a portion of the large bowel for cancer is designedto detect synchronous or metachronous tumors, recur­rent carcinoma at the suture line, or metastatic dis­ease. The patient who has had one carcinoma of thelarge bowel has an increased probability of developinganother carcinoma within that portion of the colonand has a tendency for the occurrence of furthercolonic adenomas.8 In this very high risk patient, theentire colon should be inspected for synchronous tu­mors, either before or after surgical resection of car­cinoma. Most recurrent carcinomas of the colon donot occur at the suture line but are manifested asmetastatic disease.9

The suture line should be visualized 6 to 9 monthspostoperatively since most suture line metastases, ifthey occur, become manifest within 1 year after resec­tion. lO At the time of suture line inspection, a totalexamination of the entire colon may be performed. Ifno synchronous adenomas are seen, the patient neednot be re-examined for 2 to 3 years since the intent of

YAG laser therapy of gastrointestinaltumors

Victor W. Groisser, MD

Gastrointestinal applications of neodymium:YAGlaser (Nd:YAG) therapy are still in an evolutionaryprocess. One area of interest is the treatment of in­operable neoplasms of the esophagus, stomach, duo­denum, and colon. Palliative therapy with Nd:YAGlaser is indicated for obstructing symptoms, bleedingfrom the malignancy, and tumor bulk. The first twoindications offer obvious improvements. Debulking ofa tumor mayor may not be of value.

The principle indication for therapy of esophagealneoplasms is control of dysphagia. This has beensuccessfully accomplished by Nd:YAG laser therapy.lMultiple applications of Nd:YAG laser photocoagula­tion and photodestruction are generally involved, re­quiring four to six treatments. Fewer or more sessionsmay be needed depending on the extent and the com­plexity of the lesion. Using Nd:YAG laser, an effectivelumen can be established, with the patient able to eatsoft or regular food. Lesions near the cricopharyngeusmay be technically difficult to effectively treat. Be­cause of the nature of esophageal neoplasm, patientsgenerally live only 3 to 9 months. Most, however, can

From the Division of Gastroenterology, Department of Medicine,Mountainside Hospital, Montclair, New Jersey.

VOLUME 30, NO.5, 1984

subsequent examination is to discover metachronouspolyps.

REFERENCES1. Morson BC. Evolution of cancer of the colon and rectum.

Cancer 1974;34:845-9.2. Day DW, Morson BC. The adenoma-carcinoma sequence. In:

Morson BC, ed. The pathogenesis of colorectal cancer. Phila­delphia: WB Saunders, 1978:58-71.

3. Abrams JS, Reines HD. Increasing incidence of right sidedlesions in colorectal cancer. Am J Surg 1979;137:522-6.

4. Wolff WI, Shinya H, Geffen A, et al. Comparison ofcolonoscopyand the contrast enema in five hundred patients with colorectaldisease. Am J Surg 1975;129:181-6.

5. Enterline HT. Significance of adenomatous polyps in coloncarcinogenesis. In: Grundmann E, ed. Colon cancer. Stuttgart:Gustav Fischer, 1978:57-65.

6. Colacchio TA, Forde KA, Scantlebury VP. Endoscopic polypec­tomy: inadequate treatment for invasive colorectal carcinoma.Ann Surg 1981;194:704-7.

7. Waye JD, Braunfeld S. Surveillance intervals after colonscopicpolypectomy. Endoscopy 1982;14:79-81.

8. Shinya HR, Wolff WI. Morphology, anatomic distribution andcancer potential of colonic polyps. Ann Surg 1979;190:679-82.

9. Winawer SJ, Sherlock P. Malignant neoplasms of the smalland large intestine. In: Schleisinger M, Fortran J, eds. Gastroin­testinal disease. Philadelphia: WB Saunders, 1983:1220--49.

10. Rao AR, Kagan AR, Chan PM, Gilbert HA, Nussau H, HintzBC. Patterns of recurrence following curative resection alonefor adenocarcinoma of the rectum and sigmoid colon. Cancer1981;48:1492-5.

be palliated during this time. Nd:YAG laser therapyof esophageal carcinoma can be performed as an out­patient, after initially establishing the treatmentschedule.

From October 1982 through September 1983 wetreated 17 patients with carcinoma using Nd:YAGlaser. Of these, six patients had esophageal carcinoma.The carcinoma in one patient was at the cricophary­geus and was essentially inaccessible for effective ther­apy. In the other five patients, therapy was successfulin maintaining an open lumen and allowing the pa­tients to eat. Two of the six are living and one returnson an outpatient basis for recurrent therapy.

Three patients in our series were treated for gastricmalignancy. One patient had a leiomyosarcoma in thebody of the stomach extending to the esophagus. Re­current oozing from the tumor required 2 to 4 units ofblood per month. Two patients had carcinomas ob­structing either the cardioesophageal junction or thepylorus. Nd:YAG laser therapy to reduce gastrointes­tinal bleeding was successful in the first patient, andobstructive symptoms were reduced in the other twopatients. In one of the patients with obstruction aconsiderable portion of the tumor was debulked witha polypectomy snare prior to laser therapy.

There are several reports of experiences usingNd:YAG laser treatment to reduce obstruction orbleeding in colorectal tumors.2

-4 In our one-year series,

eight patients were treated for rectal carcinoma. One

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