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MALIGNANT COLORECTAL POLYP - ? GUIDELINES

Chendil Viswanathan 03 May 2011 12:34

A 65yr old female presented with acute intestinal obstruction in casualty.

Emergency CT scan(Abd & Pelvis) showed telescoping of hepatic flexure loop with mesocolon into transverse colon loop noted in the Rt hypochondrium - s/o colo-colonic intessusception. Rest Normal

Pt taken for emergency surgery. RT Hemiicolectomy & Ileo-Transverse anastomoses done.

HPR - Cauliflower like growth 5x5x1cm seen in the transverse colon. The polyp is composed of neoplastic glands showing infolding and crowding with minimal intervening stroma. The neoplastic glands are seen invading the stalk of the polyp and the superficial muscle layer. No Lymphatic or vascular emboli noted. Resection margins are free. 0/3 lymph nodes show tumor deposits.
IMP - Adenomatous polyp with malignant transformation

Is any adjuvant chemotherapy required in this case considering that the superficial muscle layer is involved or can we consider that "ADEQUATE SURGERY" is already done and kept on close observation.

Any management guidelines for "COLORECTAL MALIGNANT POLYP"

Re: MALIGNANT COLORECTAL POLYP - ? GUIDELINES

Santam Chakraborty 04 May 2011 00:18

Hi Chendil,
The two problems that I feel merit a discussion about adjuvant therapy in this patient are:

1. Inadequate LN dissection (at least 12 - 14 is recommended)
2. Superficial muscle invasion - by itself not a absolute indication.

Essentially the patient would be T2NxMx (as I dont have metastatic workup) for the patient. I presume we wont be able to get MSI and 18q deletion status as that can point to a poorer prognosis specially in the Stage II patients. If the patient is in good general conditions and agrees to the morbidity of chemotherapy and is able to afford it I would err on the side of caution and give her the chemotherapy.

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Re: MALIGNANT COLORECTAL POLYP - ? GUIDELINES

Nikhilesh Patil 04 May 2011 02:31

First thing Intussusception is uncommon in adults. It is the second most common abdominal emergency in Peads after appendicitis. If it ever happens in adults, the first differential is tumor. I agree with Santam the surgery is not complete.
Another thing, I don't know if anyone in the house has seen a 5x5cm polyp on GI path ? To me it sounds like she has a proper Colon primary. Please get a path review if possible otherwise goahead and treat with adjuvant chemo.

Re: MALIGNANT COLORECTAL POLYP - ? GUIDELINES

Santam Chakraborty 04 May 2011 03:24

Essentially when the cancer in a polyp is large enough to invade the muscle layer it no longer deserves to be called a malignant polyp. Devita makees this pretty clear actually

The management of polyps and stage I colon cancer is through surgical resection. Most cancer in polyps is not diagnosed until after the polypectomy is performed. Therefore, with respect to pedunculated lesions, care should be taken to perform the resection and the junction of the stalk and the mucosa. Invasive early stage I cancers found in a polyp managed by polypectomy do not require further resection if the margin at the stalk is free of cancer.190,191 Sessile lesions that are biopsied and shown to harbor an invasive cancer should be managed with a segmental colon resection. Large polypoid lesions may also require a segmental resection. Because the stage of the lesion will not be determined until after the resection, all colon cancer lesions managed with a segmental resection should be approached in the same manner. The type of resection will be dictated by the location of the lesion, as has been described. Following a complete resection of a stage I lesion, no further adjuvant therapy is required. Patients managed in this way can expect a more than 95% 5-year survival. Those that recur are most likely improperly classified stage II or III lesions.

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Last edited on 04 May 2011 03:25 by Santam Chakraborty Show more

Re: MALIGNANT COLORECTAL POLYP - ? GUIDELINES

Rohit Malde 04 May 2011 21:43

Interesting scenario indeed. Interesting fact Nikhilesh mentions… first differential in adults —> Malignant Tumour.
Wonder what the surgeon thought, when he opened up this 65 old female. The CT scan (pre-op) did not pick up the tumour i guess. But i agree with Nikhileshs comments as http://www.emedmag.com/html/pre/gic/consults/111504.asp

Now the surgeon has in all probability, done a reasonable job… Done Right Hemicolectomy and addressed the primary well. and as bonus got us 3 nodes which are negative.

From an oncolgists perspective, this lady has 2 adverse features:
1. Presentation as obstruction
2. Inadequate LN dissection.

Most of the members have expressed an indication for adjuvant chemo, which is a reasonable treatment strategy.
The patient should be made aware, about the modest benefit chemotherapy may offer, approximately 3-5% absolute benefit in OS at 5 years.

But i must admit the risk of relapse indeed is gonna be low, since there was no deep muscle invasion, nor was there any LVI.

Patient choice and preference may be an important deciding factor as well (in addition to her comorbid conditions).

She of course needs a Staging Baseline CT of her chest to complete the workup, again the yield will be extrememly low in this scenario.

Re: MALIGNANT COLORECTAL POLYP - ? GUIDELINES

Santam Chakraborty 11 May 2011 13:09

Hi Chendil we are having a disucssion on CRT in buccal mucosa.. what were your experiences with these tumor?

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