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INTRODUCTION
The introduction of colonoscopic polypectomy in 1969I
revolutionized the management of colorectal polyps and
has become the accepted practice in cases with lesions
proximal to the distal rectum. There is continued debate
regarding management of the endoscopically removed
polyp that contains invasive carcinoma, despite almost 2
decades of discussion in the literature.*-14It is clear that
there has been a significant shift towards conservative
management and yet doubt still exists over the indications
for completion resection. This study presents the 10 year
experience of one Australian institution in the management of malignant colorectal polyps, to determine the
prognostic significance of previously described clinical
and histopathological indicators of adverse outcome after
treatment by polypectomy alone.
METHODS
A record of all colorectal polyps containing invasive
malignancy seen at the Institute of Medical and Veterinary Science (IMVS)from January 1982 to April 1992
was obtained by review of histopathology reports coded
by the SystemizedNomenclatureof Medicine (SNOMED)
number. I5 Only polyps removed by colonoscopic snare
excision were included. Invasive malignancy was defined
as invasion by malignant cells through the muscularis
mucosae. Cases of carcinoma in situ, intramucosal carcinoma and epithelial misplacement (pseudocarcinomatous invasion 16.17) were excluded. Cases in which there
was no adenomatous component in the mucosa adjacent
Correspondence:J. Moore,Colorectal Surgical Unit, Royal Adelaide
Hospital, Adelaide. SA SOOO, Australia.
Accepted for publication 30 September 1993.
RESULTS
One hundred and twenty-nine pathology reports describing adenomatous polyps containing a focus of invasive
carcinoma were obtained after review of the records of
the IMVS. Thirty-two patients who underwent primary
resection were excluded. Other exclusions were patients
with prior or synchronous bowel cancer (six cases),
polypoid carcinoma with no associated adenoma (five
cases), incomplete medical records (1 1 cases) and those
with severe dysplasia (10 cases). An additional 11 cases
were reclassified after pathological review as having
mucosal misplacement and excluded. This left a study
group of 54 patients who had colorectal polyps with
invasive carcinoma. The mean age of the group was 66.7
years. The mean size of pedunculated polyps was 18.6mm
(range 10-30) and 21.3 mm (range 15-120) for sessile
lesions. Median follow up was 34.5 months (range 4-1 10;
mean 39.5) with two patients lost to follow up. Overall
70% of patients had follow up of greater than 24 months.
There was one cancer-related death and four patients
died of other causes at 5, 23, 24 and 62 months postTable 1. Haggitt classification of depth of invasion
Level 1
Level 2
Level 3
Level 4
243
Ascending
Transverse
1
2
3
4 (pedunculated)
4 (sessile)
Total
Descending
Sigmoid
Rectum
Total
12
3
7
8
1
3
1
3
1
16
4
12
9
11
13
31
19
54
1
1
MOORE ET AL..
244
DISCUSSION
Endoscopic polypectomy was introduced in 1969 by
Wolff and Shinya' and is now the preferred management
option for large bowel polyps proximal to the distal
rectum, but the management of the polyp containing
invasive malignancy remains controversial.Seriesreported
in the literature are often difficult to compare because
'invasive cancer' is not always clearly defined. In this
series, carcinoma was only diagnosed when there was
invasion beyond the muscularis mucosae. Cases of carcinoma in situ or intramucosal carcinoma were excluded
because of their apparent lack of metastasizing potential. " Eleven adenomas initially reported as invasive
lesions were found, after review, to represent cases of
epithelial misplacement and were excluded. This highlights the difficulty in distinguishing misplacement from
invasive tumour. l6 It also emphasizes the need for careful
review of histology both in the individual patient in
whom a decision regarding resection is pending and when
assessing the published literature. By excluding patients
with polypoid carcinoma, the authors hope to avoid a
possible source of error (i.e. including cases that may not
have been suitable for endoscopic polypectomy in the
first instance).
Pathology reporting may have other influences on
published outcomes following endoscopic removal of
malignant polyps. The extent of excision, particularly of a
pedunculated lesion, can only be assessed by a combined
clinical and histopathological assessment, an issue often
not stressed in the literature. The endoscopist must be
sure that no residual polyp remains and that this is
conveyed to the pathologist. Otherwise, a pedunculated
polyp may be reported as sessile because little stalk has
been taken. Likewise, vessel invasion in the stalk of a
pedunculated polyp may be missed if only the head of
the polyp has been excised. The well-defined histologic
staging system of Haggitt2 allows the stratification of
cases by depth of invasion and, when combined with the
endoscopist's report, overcomes these difficulties.
Almost all series have used similar outcome criteria to
those the present authors have used (i.e. recurrence on
follow up or residual disease on completion resection).
Wilcox has suggested that status after follow up be
reported only after 5 or preferably 10 years to overcome
the problem of late rec~rrence.'~
This is a conservative
2
3
4 (pedunculated)
4 (sessile)
Total
Tubular
Tubdovillous
Villous
9
3
10
6
3
1
1
1
2
5
31
10
13
1
1
5
Well
Moderate
12
3
4 (pedunculated)
4 (sessile)
3
3
4
1
7
5
10
26
27
Total
Poor
Total
16
4
12
9
13
54
2
3
4 (pedunculated)
4 (sessile)
Total
Present
Absent
Total
15
16
12
7
12
12
9
13
50
54
Local
recurrence
5
Nodal on
resection
1
Ped
Yes
2
Ped
No
3
Sess
No
4
Sess
No
4
Ped
No
NS
NS
P =0.01
Moderate
No
Well
No
Moderate
No
Well
No
Moderate
No
NS
Haggitt level
Morphology
Complete excision
(histologically)
Grade
Vessel invasion
*See text for details; tFisher's exact test; Ped.pedunculated, Sess, sessile.
Predictive
valuet (adverse
outcome)
Table 7. Outcome after polypectomy by completeness of excision assessed by combined clinical and histological assessment
Excision Excision grossly Excision grossly
complete
complete*
incomplete*
but margins
and margins
positive?
positive?
Outcome
favourable
Outcome
unfavourable
37
10
245
Level 4 invasion
Present
Absent
Total
Adverse outcome
Present
Absent
3
2
5
17
30
47
Total
20
32
52
Two cases were lost to follow up; sensitivity=60%; specificity =63.8%;positive predictive value = 15%.
MOORE ET AL.
246
14.
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