Management Of Malignant Colorectal Polyps Research Articles

Conservative management of malignant colorectal polyps in select cases is safe in long-term follow-up: An institutional review

BackgroundNon-operative management of early-stage polypectomy-identified colorectal cancer (CRC) may be a safe alternative, but limited data exist. MethodsWe compared outcomes between adults with post-polypectomy CRC who did and did not ultimately undergo resection from 2003 to 2018. Overall (OS) and recurrence-free (RFS) survival were calculated via log rank analysis using the Mantel-Cox method and plotted on Kaplan-Meier curves with significance evaluated at P < 0.05. ResultsN = 78 patients were included, most commonly with rectal/rectosigmoid CRC (45%). Almost half (47%) had resections, and the remaining 41 patients (53%) underwent organ-sparing techniques. Chemoradiation was administered to 5 of these 41 patients (12%), all with rectal cancer. At median follow-up of 52 months, 5-year OS and RFS were 78% and 100% with no significant differences when compared to resection (all P > 0.1). DiscussionUsing evidence-based patient selection and adjuvant therapy, organ-sparing management provides equal survival when compared to resection for post-polypectomy CRC.

Rectum versus colon: should malignant polyps be treated differently?

The management of malignant colorectal polyps removed at endoscopy remains controversial with patients either undergoing surgical resection or regular endoscopic surveillance. Lymph node (LN) metastases occur in 6-16% of patients with malignant polyps. This study assessed the rate of LN metastases in patients undergoing surgical resection for malignant polyps removed endoscopically to determine if there is a difference in the rate of LN metastases between colonic and rectal polyps. A retrospective review of a prospectively maintained database was performed from 2010 to 2018. All patients who underwent surgical resection following endoscopic removal of a malignant colorectal polyp were reviewed. Clinical data including patient demographics and tumour characteristics were examined. A total of 177 patients underwent surgical resection in the study period. The median age at diagnosis was 65 years (range 22-88 years) with females comprising 52% of the patient cohort (n=92/177). Polyps were located in the colon in 60.5% of cases with the remainder located in the rectum. The median number of LN harvested was 14 (range 0-44) with malignant LN (including a mesenteric tumour deposit) identified in 8.5% of resection specimens (n=15/177). Malignant LNs were retrieved in 5.5% of right-sided tumours, 5.6% of left-sided tumours and 12.9% of rectal tumours (P=0.090). A small proportion of patients with malignant polyps removed endoscopically will have LN metastases. The results of this study suggest that the tumour location might be a useful predictive marker; however, a further study with increased patient numbers is required to properly establish this finding.

Current Management of Malignant Colorectal Polyps Across a Regional United Kingdom Cancer Network.

The incidence of malignant colorectal polyps has increased secondary to the greater use of diagnostic colonoscopy and introduction of screening programs. Faced with the dilemma of whether major resection is required or whether polypectomy has been sufficient treatment, the clinician relies on high- and low-risk histological parameters to guide decision-making. The purpose of this study was to review current practice and evaluate multidisciplinary team decision-making across a United Kingdom Regional Cancer Network to establish the efficacy of previously set guidance from the Association of Coloproctology of Great Britain and Ireland (2013). This was a retrospective cohort study. The study was conducted at a United Kingdom Regional Cancer Network composed of 4 separate National Health Service Hospital Trusts, covering an overall population of 1.5 million. All patients with malignant colorectal polyps who presented to the colorectal multidisciplinary team over a 3-year period (April 1, 2012 to April 1, 2015) were included. Rate of residual disease after major resection, recurrence of cancer after polypectomy and surveillance alone, reporting of histological features, adherence to endoscopic surveillance guidelines, and outcomes of surveillance cross-sectional imaging were measured. A total of 173 patients (median age = 69 y) with a malignant colorectal polyp were identified during the study period, with a median of 2.7 years of follow-up. Thirty-seven patients (21.4%) underwent primary surgical resection with a residual disease rate of 43% (16/37). The remaining 136 patients (76.8%) were managed conservatively with recurrence in 6 cases (4.4%). Endoscopic follow-up at 3 months occurred in 61% of cases. Histological reporting was varied, with tumor differentiation and resection margin being reported in 84% of cases and lymphovascular invasion and depth of invasion in 71% and 59% of cases, respectively. This was an observational retrospective study. The residual disease rate in patients treated surgically was higher than previously reported (43.2%). Incidence of recurrence in patients treated conservatively was low (4.4%). Areas of improvements have been identified in adherence to endoscopic follow-up, histopathological reporting, and potential overuse of radiological surveillance. See Video Abstract at http://links.lww.com/DCR/B47. MANEJO ACTUAL DE PÓLIPOS COLORRECTALES MALIGNOS A TRAVÉS DE UNA RED REGIONAL DE CÁNCER DEL REINO UNIDO: La incidencia de pólipos colorrectales malignos ha aumentado secundariamente al mayor uso de la colonoscopia diagnóstica y a la introducción de programas de detección. Ante el dilema de si se requiere una resección mayor o si la polipectomía ha sido un tratamiento suficiente, el médico se basa en parámetros histológicos de alto y bajo riesgo, para guiarse en la toma de decisiones.Revisar la práctica actual y evaluar la toma de decisiones, del equipo multidisciplinario de una red regional de cáncer del Reino Unido, para establecer la eficacia de las recomendaciones previamente establecidas, por la Asociación de Coloproctología de la Gran Bretaña e Irlanda (2013).Estudio de cohorte retrospectivo.Red Regional del Cáncer del Reino Unido, que comprende cuatro Fideicomisos Hospitalarios del Servicio Nacional de Salud y que cubren una población general de 1,5 millones de personas.Todos los pacientes con pólipos colorrectales malignos presentados al equipo colorrectal multidisciplinario durante un período de 3 años (01/04/2012-01/04/2015).Tasa de enfermedad residual después de una resección mayor, recurrencia de cáncer después de polipectomía y vigilancia sola, informe de características histológicas, adherencia a directrices de vigilancia endoscópica y resultados de la vigilancia de la imagen transversal.Se identificaron un total de 173 pacientes (mediana de edad de 69 años) con pólipo colorrectal maligno durante el período de estudio, con una mediana de seguimiento de 2.7 años. 37 pacientes (21,4%) fueron sometidos a resección quirúrgica primaria con tasa de enfermedad residual del 43% (16/37). Los 136 pacientes restantes (76.8%) fueron manejados conservadoramente, con recurrencia en 6 casos (4.4%). El seguimiento endoscópico a los 3 meses, ocurrió en el 61% de los casos. El reporte histológico varió con la diferenciación tumoral. El margen de resección se informó en el 84% de los casos. La invasión linfovascular y la profundidad de la invasión fue del 71% y 59% de los casos.Estudio observacional retrospectivo.La tasa de enfermedad residual en pacientes tratados quirúrgicamente, fue más alta que la reportada previamente (43.2%). La incidencia de recurrencia en pacientes tratados de forma conservadora fue baja (4,4%). Se han identificado áreas de mejoras en cumplimiento del seguimiento endoscópico, informe histopatológico y el posible uso excesivo de la vigilancia radiológica. Vea el Resumen del Video en http://links.lww.com/DCR/B47.

Management of malignant colorectal polyps—how to decide if polypectomy is enough?

Among adults 50 years of age and older, the use of colonoscopy as a method of screening for colorectal cancer increased from 19.1% in 2000 to 60.3% in 2015 (1). Since the number of patients being screened with colonoscopy has raised, more polyps will be diagnosed and removed.

Management of malignant colorectal polyps in New Zealand.

The management of colorectal polyps containing a focus of malignancy is problematic, and the risks of under- and over-treatment must be balanced. The primary aim of this study was to describe the management and outcomes of patients with malignant polyps in the New Zealand population; the secondary aim was to investigate prognostic factors. Retrospective review of relevant clinical records at five New Zealand District Health Boards. Out of the 414 patients identified, 51 patients were excluded because of the presence of other relevant colorectal pathology, leaving 363 patients for analysis. Of these, 182 had a polypectomy, and 181 had a bowel resection as definitive treatment. The overall 5-year survival was not altered with resection but was improved with re-excision of any form (repeat polypectomy or bowel resection). There were 110 rectal lesions and 253 colonic lesions. A total of 16% of patients who had resection after polypectomy were found to have residual cancer in the resected specimen. Ischaemic heart disease, chronic obstructive pulmonary disease and metastatic disease were found to negatively impact overall survival (P < 0.001). Resection was more likely to follow polypectomy if polypectomy margins were positive, fragmentation occurred for sessile lesions and for pedunculated lesions with a higher Haggitt level. Polypectomy is oncologically safe in selected patients. Re-excision improves overall survival and should be considered in patients with low comorbidity (American Society of Anesthesiologists score 1 and 2) and where there is concern about margins (sessile lesions and positive polypectomy margins). In the majority of patients, however, no residual disease is found.

PWE-273 An international comparison of clinical practice guidelines for the management of malignant colorectal polyps

Introduction Due to the varying risks of residual disease that have been reported after removal of malignant polyps, clinicians rely on clinical practice guidelines (CPGs) to inform decision-making. This study qualitatively and quantitatively compared the internationally published guidelines on the management of malignant colorectal polyps. Method A systematic literature search was undertaken to identify malignant colorectal polyp CPGs. Quantitative comparison was based on the Appraisal of Guidelines Research and Evaluation (AGREE II), a validated CPG appraisal tool which assesses 6 domains: scope and purpose; stakeholder involvement; rigour of development; clarity and presentation; applicability; and editorial independence. Histopathological risk factor assessment and treatment recommendations were further analysed for supporting levels of evidence and scientific agreement. Results Eleven International malignant colorectal polyp guidance documents were included. The AGREE assessment demonstrated significant variation in all quality domains across the CPGs. The scope and purpose domain showed the highest level of quality (median: 91%, interquartile range (IQR): 86–97%). The Applicability domain showed the lowest level of quality (median: 43%, IQR: 35–55%). Risk was attributed dichotomously (low/high risk) to malignant polyps in 8/11 CPGs and in a graded fashion in the remainder. Importantly, there were disagreements regarding which histopathological findings carried risk. Significant variation was found for degree of risk between CPGs for resection margins, tumour budding and depth of invasion. No CPG was able to provide a comprehensive analysis when multiple histopathogical risk factors are present in an MCP. The indications for local excision also demonstrated considerable variation. Conclusion There is variation in evidence interpretation and recommendations between widely used malignant colorectal polyp CPGs. Improvements in the underlying evidence base, particularly defining accurate probabilities of residual disease in the presence of multiple histopathological risk factors, are required to allow clinicians to provide personalised care to this complex patient group. Disclosure of interest None Declared.

PTH-316 Management of colorectal polyp cancers: Abstract PTH-316 Table 1

Introduction Management of colorectal polyp cancers is variable, with no clear consensus on whether endoscopic mucosal resection (EMR) or local resection is optimal. We studied the outcome of 42 patients with colorectal polyp cancers in our hospital over a 3year period. Method 42 cases of malignant colorectal polyps between May 2012 and May2014 were identified retrospectively from the histology database. Data was collected on polyp morphology and histology including resection margin, tumour grade, lymphovascular invasion and Haggitt/Kikuchi level of invasion. All specimens were examined by a single histopathologist. Adverse oncological outcome was defined as residual tumour at the polypectomy site and/or lymph node metastases in the surgical group and local/distant recurrence in the surveillance group. Post operative morbidity and method and timing of surveillance were documented. Results 42 polyps (22 male and 20 female patients, mean age: 68 years, range: 33 to 90 years) were included. 59% of polyps appeared pedunculated at endoscopy with 27% sessile and 14% described as a “lesion.” 5 patients had radiological evidence of metastases. 43% of tumours were visible on imaging with 19% having mesorectal/presacral nodes. 13 patients underwent colonic resection. 8 of those had pedunculated polyps, 5 had sessile polyps. In 7 patients who underwent colectomy, polypectomy or EMR had been performed. Morbidity included 3 stomas (all reversed), 2 anastomotic leaks, 1 wound infection and 1 high output stoma. There were no deaths. Endoscopic resection was the sole treatment in 29 patients; 7 patients with sessile polyps, 17 patients with pedunculated polyps and 5 with “lesions.” Follow up was by imaging only in 15 patients, endoscopy only in 9 patients and a combination of imaging and endoscopy in 11 patients. 6 patients had no follow up. Conclusion This study illustrates the varied management of malignant colorectal polyps. It is clear that resection margins adversely affect outcome. A strategy is needed for managing patients with clear resection margins, including nature and timing of follow up. Disclosure of interest None Declared. References Williams J. G, et al . Managament of the Malignant colorectal polyp: ACPGBI position statement. Colorectal Dis. 2013;15:1–38 Naqvi S, et al . Management of colorectal polyp cancers. Ann R Coll Surg Engl. 2012;94:574–578

Endoscopic and surgical treatment of malignant colorectal polyps: a population-based comparative study

Long-term population-based data comparing endoscopic therapy (ET) and surgery for management of malignant colorectal polyps (MCPs) are limited. To compare colorectal cancer (CRC)-specific survival with ET and surgery. Population-based study. Patients with stage 0 and stage 1 MCPs were identified from the Surveillance Epidemiology and End Results (SEER) database (1998-2009). Demographic characteristics, tumor size, location, treatment modality, and survival were compared. Propensity-score matching and Cox proportional hazards regression models were used to evaluate the association between treatment and CRC-specific survival. ET and surgery. Mid-term (2.5 years) and long-term (5 years) CRC-free survival rates and independent predictors of CRC-specific mortality. Of 10,403 patients with MCPs, 2688 (26%) underwent ET and 7715 (74%) underwent surgery. Patientsundergoing ET were more likely to be older white men with stage 0 disease. Surgical patients had more right-sided lesions, larger MCPs, and stage 1 disease. There was no difference in the 2.5-year and 5-year CRC-free survival rates between the 2 groups in stage 0 disease. Surgical resection led to higher 2.5-year (97.8% vs 93.2%; P< .001) and 5-year (96.6% vs 89.8%; P< .001) CRC-free survival in stage 1 disease. These results were confirmed by propensity-score matching. ET was a significant predictor for CRC-specific mortality in stage 1 disease (hazard ratio 2.40; 95% confidence interval, 1.75-3.29; P< .001). Comorbidity index not available, selection bias. ET and surgery had comparable mid- and long-term CRC-free survival rates in stage 0 disease. Surgical resection is the recommended treatment modality for MCPs with submucosal invasion.

Management of Malignant Colorectal Polyps Comparing Endoscopic and Surgical Therapies: A Population-Based Comparative Study Using Propensity Score Matching

Management of Malignant Colorectal Polyps Comparing Endoscopic and Surgical Therapies: A Population-Based Comparative Study Using Propensity Score Matching

Management and short‐term outcome of malignant colorectal polyps in the north of England1

Management of malignant colorectal polyps (MCP) is contentious, with no randomized controlled trials comparing endoscopic with surgical management. This study reviews the management and outcomes of MCPs across a UK region. Patients with a malignant polyp were identified using the NORCCAG (NORthern Colorectal Cancer Audit Group) database between April 2006 and July 2010. All histopathology reports and follow-up procedures were reviewed. Of 386 patients identified, 165 (42.7%) had the polyp biopsied and 221 (57.3%) had an endoscopic local excision (37 piecemeal excision, 184 polypectomy). All patients having an endoscopic biopsy underwent surgery. 103 (46.6%) having a local excision had follow-up surgery, of whom 79 (76.7%) had no residual cancer. Of the 118 patients managed endoscopically, none had residual cancer on follow-up endoscopy. The 21 (5.4%) Dukes C cancers were associated with Kikuchi SM3/Haggitt 4 lesions (χ(2) =10.85, P=0.005) and lesions with an involved/unsure excision margin (χ(2) =7.44, P=0.017). Predictors of finding residual tumour at surgery after local excision were Kikuchi SM3/Haggitt Level 4 (χ(2) =17.07, P<0.001) and an involved/unsure excision margin (χ(2) =20.45, P<0.001). An excision margin >0 mm was associated with the finding of no residual tumour (χ(2) =25.21, P<0.001). There was no difference in survival between surgical and endoscopic management (χ(2) =0.634, P=0.426) after a mean follow-up of 25.1 months. Endoscopic management of a subgroup of MCPs appears safe. A clear resection margin (>0 mm) appears sufficient to avoid surgery, except in locally advanced lesions (Kikuchi 3/Haggitt 4) which have a greater risk of residual cancer at surgery and lymph node metastasis.

Management of colorectal polyp cancers

INTRODUCTIONManagement of malignant colorectal polyps is controversial. The options are resection or surveillance. Resection margin status is accepted as an independent predictor of adverse outcome. However, the rate of adverse outcome in polyps with a resection margin of <1mm has not been investigated.METHODSA retrospective search of the pathology database was undertaken. All polyp cancers were included. A single histopathologist reviewed all of the included polyp cancers. Polyps were divided into three groups: clear resection margin, involved resection margin and unknown resection margin. Polyps were also analysed for tumour grade, morphology, Haggitt/Kikuchi level and lymphovascular invasion. Adverse outcome was defined as residual tumour at the polypectomy site and/or lymph node metastases in the surgical group and local or distant recurrence in the surveillance group.RESULTSSixty-five polyps (34 male patients, mean age: 73 years, range: 50–94 years) were included. Forty-six had clear polyp resection margins; none had any adverse outcomes. Sixteen patients had involved polyp resection margins and twelve of these underwent surgery: seven had residual tumour and two of these patients had lymph node metastases. Four underwent surveillance, of whom two developed local recurrence. Three patients had resection margins on which the histopathologist was unable to comment. All patients with a clear resection margin had no adverse outcome regardless of other predictive factors.CONCLUSIONSPolyp cancers with clear resection margins, even those with <1mm clearance, can be treated safely with surveillance in our experience. Polyp cancers with unknown or involved resection margins should be treated surgically.

Colonoscopic polypectomy and management of malignant colorectal polyps--a review in an Irish population.

A RETROSPECTIVE analysis of 2124 colonoscopies was carried out. Most were performed as day cases under sedation. Abnormalities were detected in 59% of the colons examined; polyps were detected in 24% and almost half of these had more than one polyp. The detection rate was higher in males than females. Most polyps were left sided. Increasing size of polyp was associated with a higher proportion of villous elements and more frequent malignant change. The pattern of histological types was comparable to other large published series. Carcinoma was detected in 5% of adenomatous polyps, mainly in larger villous lesions. Twenty-nine polyps were malignant; these were also predominantly left sided. Applying the St. Mark’s criteria, no polyp with malignant change which was considered completely excised by endoscopic polypectomy has recurred or metastasized at follow up. In contrast, those polyps considered incompletely excised had a high (80%) incidence of residual tumour. The current controversies in the management of malignant colorectal polyps are discussed.