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Crc, colorectal polyps (2)
- 1. Colorectal Polyps Ahmed A Abou-Zeid Professor of Surgery Ain Shams University
- 2. What is a Polyp • Any lesion that is elevated above the mucosal surface of the bowel
- 3. Classification • Neoplastic – Single • Adenomatous polyps • Connective tissue polyps (fibroma, lipoma, leiomyoma, lymphoma) – Polyposis Syndromes • FAP • HNPCC • Non- neoplastic • Hamartomas • Metaplastic polyps • pseudopolyps
- 4. Adenomatous polyps • Tubular adenoma • Tubulovillous adenoma • Villous adenoma
- 5. Adenomatous polyps Tubular Adenoma Villous Adenoma
- 6. Adenomatous Polyps Clinical Picture • Symptomless • Bleeding • Discharge • Prolapse • Obstruction/Intussusception • Hypokalemia/Hypoproteinemia
- 7. Polyp - Cancer Sequence • Circumstantial evidence – Similar anatomical distribution – Adenomas can harbour foci of carcinoma – Polyp patients are 8-10 years younger – 30% of CRC have synchronous polyps – Metachronous cancer is twice as high in those cancers with associated polyps – Prophylactic polypectomy decrease incidence of subsequent cancer
- 9. Suspicious Polyp • Size • Age of polyp • Histology
- 10. Initial Management Endoscopic Procedures Endoscopic Polypectomy Pedunculated Sessile Endoscopic Submucus Resection
- 11. Initial Management Transanal Procedures Endoanal Submucus Resection Transanal Endoscopic Microsurgery (TEM)
- 12. Initial Management Abdominal Procedures • Colotomy/Colectomy • Proctotomy/Proctectomy
- 13. The Polyp With a Malignant Focus
- 14. Management of Malignant Polyp • Polypectomy - Pedunculated - Well differentiated - In Head or stalk, away from resection margin - No vascular or lymphatic invastion - Clear resection margins • Radical Resection - Sessile - Poor differentiation - Low in stalk - Vascular or lymphatic invasion - Involved resection margin
- 15. Further Management of Malignant Polyp Radical Resection • Site of resection entitled by site of the polyp • Radicality of resection entitled by extent of the polyp • India ink injection in the era of laparoscopic surgery
- 16. Follow Up After Polypectomy • Benign polyp - Yearly endoscopy after positive complete clearance - Three yearly endoscopy after negative complete clearance - Five yearly therafter • Malignant polyp - Follow guidelines of cancer management
- 17. Metaplastic Polyps • Also known as hyperplastic polyps • Usually minute (2-5mm), plaque like, same colour of mucosa • Asymptomatic, do not turn malignant • Elongated tubules, scanty goblet cells, hyperplastic cells at the base of crypts • Management depends on individual policy
- 18. Hamartomatous Polyps • Juvenile polyps • Peutz-Jeghers polyps
- 19. Juvenile Polyps • Seen in infants and children less than 10 y • Mostly situated in the rectum • Usually stalked, head covered by granulation tissue • Cut surface shows dilated cystic spaces, bulk of polyp made up of connective tissue full of acute & chronic inflammatory cells • Rectal bleeding, polyp prolapse • Not pre-malignant • Treatment by colonoscopy & polypectomy
- 20. Peutz Jeghers Syndrome • Autosomal dominant inheritance • Pigmentation • Polyps • Symptoms of rectal bleeding and recurrent intussusception • Debate considering the malignant potential • Conservative management versus more aggressive endoscopic management
- 22. Inflammatory Polyps • Accompany Chronic inflammatory process of the bowel • Composed of oedamatous mucosal tags • Not premalignant • Treatment of the cause
- 24. Connective Tissue Polyps Submucuos Lipoma
- 25. Connective Tissue Polyps • Can be benign or malignant • Size dictates symptomatology in benign lesions • Commonly present by obstructive symptoms • Treatment: Segmental resection
- 26. Familial Adenomatous Polyposis • Autosomal dominant inheritance • Mutation in APC gene • Easily recognized by its phenotypic features – CR polyps and cancer – Extracolonic lesions • 100% penetrance • 1 in 8,300 to 1 in 14,025 live births
- 28. FAP/Extracolonic Lesions • Desmoids • CHRPE • Duodenal adenomas • Gastric glandular hypertrophy • Osteomas/Neuromas • Other tumours
- 30. FAP/Diagnosis • Clinical diagnosis –Colonic lesions –Extra-colonic lesions • Sigmoidoscopy/Colonoscopy • Genetic diagnosis • Surveillance
- 31. FAP/Treatment • Prococolectomy/ Brook’s ileostomy • Restorative proctocolectomy • Total colectomy/ileorectal anastomosis
- 32. HNPCC • Characterized by –Autosomal dominant inheritance –Mutation in MMR gene –Early onset CR cancer and polyps –Extracolonic cancers • Diagnosis: Less evident phenotypic features –Family history criteria –Pathology criteria –Genetic criteria
- 33. Family History • Amsterdam criteria –CRC in 3 family members –One member 1st degree relative to other two –Two successive generations –One cancer diagnosed less than 40 –FAP excluded • Others (less strict criteria)
- 34. Pathology Criteria • Young age of onset • Right sided tumors • Multiple colonic tumors • Extra-colonic tumors • Aggressive histopathology features • Good prognosis
- 35. Genetic Criteria • Disordered mismatch repair genes –hMLH1 –hMSH2 –hPMS1 –hPMS2 –hMSH3 –hMSH6
- 36. Extracolonic Tumours in HNPCC • Small intestine • Endometrium • Urothelium • Biliary tree • Gastric mucosa • Others
- 37. Treatment of HNPCC • Total colectomy/ileorectal anastomosis • Restorative proctocolectomy • Surveillance