MALIGNAN

T
COLORECT
AL POLYP
DR RAJAPANDIAN S
HOD OF COLORECTAL UNIT
GEM HOSPITAL
DEFNITION OF POLYP
An abnormal growth of tissue in the lining of the bowel.
DEFNITION refers to a colorectal polyp including
flat lesions with neoplastic invasion of
OF the submucosa without extension
into the muscularis propria.
MALIGNAN
T
COLORECTA Another term for such lesions is
Submucosally invasive polyps.
L POLYP
AJCC STAGING OF
COLORECTAL CANCER -8TH
EDITION
MALIGNANT POLYP
Vienna Classification of Gastrointestinal
Epithelial Neoplasia

MALIGNANT POLYP
ENDOSCOPIC
SURFACE
PATTERN
CLASSIFICATION
•A. Narrow Band
Imaging International
Colorectal Endoscopic
Classification
B. Japanese
Narrow Band
Imaging
Expert Team
Classification
 NICE
classification
- Kudo pit
pattern
classification.
 NICE
classification
- Kudo pit
pattern
classification.
PARIS CLASSIFICATION OF POLYP
MORPHOLOGY
 PARIS
CLASSIFICATI
ON BASED ON
POLYP
MORPHOLOGY
HISTOPATHOLOGICAL CLASSIFICATION A.HAGGITT
CLASSIFICATION.
B. KIKUCHI CLASSIFICATION.
LATERALLY SPREADING TUMOR
(Lesion)

Spreads more
Flat or sessile
>10MM laterally than
in shape
vertically
WHICH ENDOSCOPIC FEAUTRES PREDICT
SUPERFICIAL SUBMUCOSAL INVASION?

LST-NG
LST-G with a morphology with
dominant nodule sessile shape or
depression, and

Weak recommendation; moderate-quality evidence

 MALIGNANCY RISK

EVEN SIZED
NODULES <2%
GRANULAR
MIXED SIZE
LST TYPES
NODULES <20mm-7.1%
>20mm- 38%

NONGRANULAR
PSEUDODEPRESSE <20mm- 27.8%
D >20mm- 41.4%
NONGRANULAR
NONGRANULAR
<20mm- 6.4%
FLAT ELEVATED
TREATMENT RECOMMENDATION: >20mm- 10.4%
ENBLOCK ENDOSCOPIC RESECTION
INSTEAD OF PIECEMEAL REMOVAL Weak recommendation; moderate-quality evidence
Nongranular laterally spreading tumors (LST-NG).
(A, B) Smooth surface. (C, D) Pseudodepressed.
 WHICH ENDOSCOPIC FEAUTRES
PREDICT DEEP SUBMUCOSAL
INVASION?
NICE classification type 3 or Kudo classification of type V
(VN and VI).

Strong recommendation; high-quality evidence

HOW DO YOU MANAGE A SUSPICIOUS DEEP
SUBMUCOUSAL INVASIVE LESIONS?

SUSPICION OF DEEP SUBMUCOSAL CANCER

PEDUNCULATED POLYPS NON PEDUNCULATED POLYPS

BIOPSY Weak
ENDOSCOPIC recommendation;
TATTOO
POLYPECTOMY low-quality evidence
PLAN FOR SURGERY
WHICH Poor tumor differentiation,
HISTOLOGICAL
FEATURES
INCREASES Lymphovascular invasion,
LYMPHNODE
METASTASIS? Submucosal invasion depth >1 mm,

NON- Tumor involvement of the cautery margin,

or
PEDUNCULATED
POLYPS
Tumor budding.

Strong recommendation; moderate evidence

WHICH
HISTOLOGICA
Poor tumor
L FEATURES differentiation
INCREASES
LYMPHNODE
METASTASIS? Lymphovascular invasion

PEDUNCULATE
D POLYPS
Tumor within 1 mm of
the resection margin
Strong recommendation; moderate evidence
OPTIMAL
HANDLING OF
SPECIMEN
A formalin fixed specimen with steel pins
on the borders and orientation of O
(oral) and A (anal) to maintain margin
status.
What should be the pathology reporting
standards for malignant colorectal polyps?

Tumor
Grade of Mucosal margin
Histologic type extension/invasion,
differentiation status
stalk

Presence or
absence of
Specimen integrity Polyp size Polyp morphology
lymphovascular
invasion

Tumor budding

Weak recommendation; low-quality evidence

Who should be involved in the multidisciplinary
management of patients with malignant polyps?

Gastroenterologist Pathologist Oncologist

Surgeon Patient

Weak recommendation; Low-quality evidence

INDICATIONS 6 mm in size
(recommendation strong [agreement rate 100%], level of
FOR evidence B).

ENDOSCOPIC
RESECTION For Diminutive polypoid adenomas <5 mm in
size; however, follow-up observation by
WITH colonoscopy is also acceptable
(recommendation weak [agreement rate 82%], level of
RESPECT TO evidence D).

THE SIZE AND Flat and depressed neoplastic lesions even

SHAPE OF if <5 mm in size
ADENOMAS? (recommendation strong [agreement rate 100%], level of
evidence D).
How should hyperplastic polyps be
managed?

• < 5 mm detected in the rectosigmoid region – Follow up.

(recommendation weak [agreement rate 100%], level of evidence B).
What are the indications for cold snare
polypectomy?
• Nonpedunculated benign adenomas <10 mm in size
(recommendation weak [agreement rate 100%], level of evidence B).
• Diminutive lesions <5 mm in size and is acceptable for 6–9-mm lesions
(recommendation strong [agreement rate 100%], level of evidence B).

CSP should be avoided for

• ‘‘flat and depressed-type’’lesions and
• lesions suspected of being carcinoma on colonoscopy even if <5 mm in size
(recommendation weak [agreement rate 100%], level of evidence B).
How should serrated colorectal lesions
be diagnosed and treated?
Serrated lesions of the colorectum include
Have the potential to develop
into cancer, so treatment is
1. SSA/P, recommended
2. TSA,
3. HP.

• (recommendation weak [agreement rate 100%], level of evidence C).

In which colorectal tumors is it acceptable
to perform piecemeal EMR?
• Definite adenoma or
• Tis carcinoma

However, local recurrence rates are high with piecemeal resection and caution
is therefore advised.
(recommendation weak [agreement rate 100%], level of evidence C).
How should surveillance colonoscopy
be planned after endoscopic removal
of colorectal adenoma?

Within 3 years after polypectomy.

(recommendation weak [agreement rate 100%], level of evidence B).
How should surveillance be planned after
endoscopic resection of T1 (SM) colorectal cancer?

Close monitoring is
Careful follow-up for a
necessary for not only
minimum of 3 years
local recurrence but
should be performed
also lymph node
after
metastasis and distant
endoscopicresection
metastasis.
(recommendation weak [agreement rate 100%], level of
evidence C).
What is the diagnosis and management of
neuroendocrine tumors of the colorectum?

• When a rectal SMT is detected, especially in the lower rectum, a

neuroendocrine tumor (NET) is the most likely possibility.
• The strong recommendation is to confirm that the tumor surface is covered
with normal mucosa using the dye spray method and whether the tumor needs
to be resected by endoscopy or surgery depending on its size and surface
characteristics.
(recommendation strong [agreement rate 100%], level of evidence B).
MANAGEMENT OF NET

• Less than 10 mm in diameter

• No depressed surface or ulcer Endoscopic resection
• Tumor confined to T1 (SM).

Surgical resection with lymph node dissection.

• 10 mm or more in diameter
(Lymph node metastasis- 18.7- 30.4%)
How should non-neoplastic polyps be
managed?

• We recommend classifying non-neoplastic colorectal polyps as

hamartomatous, inflammatory, or hyperplastic
(recommendation strong [agreement rate 100%], level of evidence D).
• While most non-neoplastic colorectal polyps are not indicated for
endoscopic removal, we recommend removal of symptomatic polyps if they
are a source of bleeding, cause intussusception, or are suspected of being
cancer
(recommendation strong [agreement rate 100%], level of evidence D).
If dysplasia or cancer is detected in ulcerative colitis,
should be all lesions be surgical removed? Is low-grade
dysplasia an indication for surgery?

• If LGD is detected in flat mucosa, we suggest a consultation with several

experienced pathologists (recommendation weak [agreement rate 100%], level of evidence C).
• If LGD is detected in an elevated lesion and sporadic adenoma is highly probable,
the recommendation is to perform endoscopic resection and a detailed pathological
examination (recommendation strong [agreement rate 100%], level of evidence C).
• However, total proctocolectomy is recommended if cancer or high-grade dysplasia is
found and determined to be colitis-associated (recommendation strong [agreement rate
100%], level of evidence C).
 ENDOSCOPIC RESECTIONS OF
MALIGNANT POLYP
COLD SNARE
RESECTION
A: Endoscopic appearance of a small polyp
in the sigmoid colon.
B: Positioning of a specifically dedicated
snare for cold snare resection.
C: Appearance of the resection field with
mild bleeding.
D: Histopathology showing tubular
adenoma (hematoxylin/eosine,
magnification: 80-fold).
 ENDOSCOPIC
SUBMUCOSAL
DISSECTION
Endoscopic submucosal dissection. A: Endoscopic
aspect of a large sessile lesion (Paris 0-Is/0-IIa; lateral
spreading tumor, granular type) in the cecum.
B: Start of endoscopic submucosal dissection at the
proximal site.
C: Mucosal incision at the distal margin.
D: Completed resection with resection bed in the
cecum.
E: Resected specimen on corkboard.
F: Histopathology: tubulovillous adenoma with focal
high-grade intraepithelial neoplasia
(hematoxylin/eosine, magnification: 80-fold).
ENDOSCOPIC
FULL THICKNESS
RESECTION

Endoscopic full-thickness resection with the full

thickness resection device.
A: Endoscopic aspect of a recurrence after piecemeal
endoscopic mucosal resection in the ascending colon.
B: The lesion is marked and retracted into the
resection cap using a grasping forceps.
C: Resection bed with over the scope clip in situ. Note
the periluminal fat within the clip.
D: Resected specimen on corkboard.
E: Histopathology: full-thickness resection specimen
with tubulovillous adenoma/low-grade intraepithelial
neoplasia (hematoxylin/eosine, magnification 80-
fold).
Combined Endoscopic and Laparoscopic
Surgery [CELS]
TROCAR AND
MONITOR
PLACEMENT
 STEPS

Endoscopic visualization of a right colon Laparoscopic manipulation of the polyp during a snare
polyp. polypectomy
with laparoscopic delivery of the polyp into the snare.
Suture reinforcement of the colon in an area of partial-
thickness injury.
Sleeve resection of a polyp in the cecum using a
laparoscopic linear stapler.
THANK YOU