Malignant colonic polyp: endoscopic treatment updatesCHAN Ka-man, FionaKwong Wah Hospital

Joint Hospital Surgical Grand Round18th April, 2015

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

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

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.

Classification

Paris Classification Japan Classification

Gastrointest Endosc 2003; 58(Suppl. 6): S3–43

Japanese Classification of Colorectal Carcinoma. 1997

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

Endoscopic treatment options

Williams. Colorectal Disease 2013;15:1–38

Exclusion of lesion for endoscopic treatment

Chromoendoscopy

Narrow band imaging

Kudo. Gastrointest Endosc 1996;44:8-14

Sano. Digest Endosc, Vol. 18.S44–51

Endoscopic treatmentSnare polypectomy

Endoscopic mucosal resection (EMR)

Endoscopic submucosal dissection(ESD)

Norman E. Upper Endoscopy, Advanced Digestive Endoscopy

Piecemeal EMR

John Hopkins colon cancer center

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

Endoscopic submucosal dissection (ESD)

Kōdansha. Understanding ESDs: A Procedure for Treating Cancer Without Major Surgery. 2011

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

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

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

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

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

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

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

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.

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

Pit pattern and histological correlation