POLYP COLON RECTUM ANUS

Hyperplastic Endoscopic removal of all polyps >5mm Workup: colonoscopy, CT, blood chem, albumin, CEA, tumor KRAS gene Polyp → Transanal Resection SCCA in situ/AIN2-3/, High grade SID/ Bowen’s Dse
<5mm, sessile, in distal colon, w/o atypia, Or status, bx < 30% circumference of bowel HPV 16 and 18, if high risk: pap smear q3-6mos → EUA
not premalignant total colectomy with IRA * High risk STAGE II: <3 cm in size Tx: Ablation, Resection or Imiquimod (aldara), topical 5FU
but >2cm have malignant risk Screening: T4, Poorly differentiated/ Undifferentiated histology, Grade 3 or 4, Margin clear (>3mm) Mobile, Nonfixed ANAL CANAL
Hyperplastic Polyposis Synd (HPS) * Increased risk of malignancy Angiolymphatic invasion, Close/ Indeterminate/ Positive margin of WITHIN 8cm FAV, T1 only T1/2,N0: Mitomycin/ 5FU + RT (NIGRO PROTOCOL)
#>30 polyps, any size/location resection, <12 lymph nodes examined, No lymphovascular or perineural invasion (45 Gy in 25 fractions including pelvis, anus, perineum, inguinal nodes with margin
# 5 large polyps with 1-2 being <1cm Bowel obstruction, Perforated, Young patient Well to moderately differentiated of 2.5cm around tumor)
any # with family hx of HPS* No evidence of LN on pretreatment imaging T3/4, any N: same + bilateral inguinal, low pelvic LN
Inflammatory (pseudopolyps) Occur in IBD, colitis. Not premalignant Pathologic Stage Adjuvant Chemo Polyp/CA treatment (+) Mets: Cisplatin based chemo + RT
Hamartomatous (Juvenile polyps) → rectum spared: Total colec + IRA Tis/ T1/ T2, N0M0 →NO CHEMOTHERAPY >8cm FAV → TEM/TEO ANAL MARGIN
Familial Juvenile Polyposis rectum w/ polyps: Total proctocolec + Mid → LAR, TME T1N0: local excision → margins (-): observe
- #100 polyps, autosomal dominant IPAA/end ileostomy T3, N0, M0 → OBSERVATION Upper → AR, WME → margins (+): reExcise/ RT+5FU
- rectum usually spared Screening: 10-12 years old Capecitabine vs 5FU/Leu Distal → APR (mean 2cmFAV or 0-5cm) T2-T4 or if (+) Mets: same as anal canal
Cronkite-Canada Syndrome → sx is reserved for complications of Ffup: evaluate in 8-12weeks,
- Alopecia, Cutaneous pigmentation polyposis T3, N0, M0 (high risk →CHEMOTHERAPY T1N0 → transanal excision →if progressive, locally recurrent: APR + groin LND
- Atrophy of the fingernails, toenails systemic recurrence) → margins (-) →observe →if (+) mets: Cisplatin based chemo
- Diarrhea is a prominent symptom - T4, N0, M0 → T2/high risk → transabdominal resxn →if persistent: reassess in 4weeks → reeval in 3mos
- Vomiting and Malabsorption → T1/T2,N0: observe Survelilance: q3-6mos x 5yrs (DRE, anoscopy, LNexam)
If M1, resectable primary and distant mets: → T3N0or T1/T2,N+: Annually x 3yrs (Chest, abdominal, pelvic CT)
- Protein – losing enteropathy
→ Tx based on sx 1. COLECTOMY with synchronous liver/ lung resection → CHEMO Verrucous CA/Buschke-Lowenstein/Giant Condyloma
Cowden Syndrome adjuvant tx
2. COLECTOMY with staged liver/ lung resection → CHEMO Tx: wide local exc or APR
(all three embryonal cell layers) T3/T4, any N → neoadj + Sx + chemo
3. Systemic chemotherapy usually 2 to 3 months or cycles followed by 1/2 M1 (resectable) → chemo x 2-3mos Basal Cell CA
- Facial trichilemmomas, Breast
4. COLECTOMY followed by systemic chemotherapy usually 2 to 3 → stage/sync resection Tx: wide local exc of APR (rare) or RT
Cancer Thyroid disease, GI polyps
→ sx reserved for complications months or cycles followed by metastasectomy Extrammamary Perianal Paget’s Dse
Pueutz-Jeghers Sydrome (PJS) → 5FU – RT
*for chemo – 6 months perioperative tx adenoCA in situ in apocrine glands, with GI adenoCA
- Polyposis of small intestine Screening: Baseline colonoscopy & EGD →complete chemo x6mos
- Melanin spots in buccal mucosa, lips @ 20yo followed by annual M1 (unresectable) → Asx: chemo tx: wide local excision
sigmoidoscopy → Sx: chemo, 5FU/RT, palliative Melanoma
Tx: wide local excision or APR
Neoplastic/Adenomatous Polyps Dysplasia (mild, moderate, high SURVEILLANCE/ CRITERIA FOR RESECTABILITY OF METS NEOADJUVANT Chemo: FOLFOX Attenuated FAP
24-50% >50 years old, dysplastic grade/severe/CIS/ intramucosal CA) History/ PE every 3 to 6 (lung/liver): T3/T4/N+ CapeOX - AD, APC gene, 10-100 polyps, Ca risk: 50% by 55yo
tubular adenomas 5% risk 31-40% synchronous adenomas mo for 2Y then every 6 Complete resection must be feasible for both RT: 45-50 Gy in 25- 5FU Leucovorin - Colonoscopy at 13-15yo, annually till 28yo, then q3yrs
tubulovillous 22% risk tx: polypectomy mo for a total of 5Y primary & distant mets, The primary 28fx + RT (5FU) - tx: total colectomy + IRA
villous adenomas 40% risk cx: postpolypectomy syndrome CEA (T2 or > only) every resection must be resected for cure (R0). No Or >54Gy in or: RT(5FU/Cape)+Chemo HNPCC (Lynch Syndrome)
Pedunculated → Colonoscopic snare excision 3 to 6 mo for 2Y then unresectable extrahepatic site of dse. unresectable CA *surveillance: same. + proctoscopy q6mos x - 1-3%, AD, at 40-45yo. 40% synch/metachrnous colonCA
Sessile → Saline lift, piecemeal snare exision, every 6 mo for a total of Maintenance of adequate hepatic/ + 5FU (inf) or 5yrs post LAR - assoc w/ endrometrial CA (MC), ovarian, panc, SI, HBT
endoscopic submucosal dissection 5Y pulmonary function capecitabine (oral) or *adjuvant chemo is given to px w/ - THE AMSTERDAM CRITERIA
If sessile rectal polyp (mid-distal) → transanal excision Chest/ Abdominal/ CARCINOMATOSIS: bolus 5FU Leu at first neoadjuvant chemo (St 2-4) 3 affected relatives w/ cancer of the large bowel (1 must be a first degree relative of
If large, flat, or confirmed CA → colectomy (lap) Pelvic CT annually for 3 → Chemo. But if w/ obstruction: palliative and last 5 days Carcinoid (25%, rectum, benign, but if in one of the others)
SURVEILLANCE/ FFUP to 5Y for patients at high sx, diverting ostomy, bypass, stent colon and bulky → colectomy) 2 successive generations; 1 px diagnosed before age 50 – Colonoscopy at 20-25yrs
* No polyp/small distal hyperplastic →10 year colonoscopy risk for recurrence long course: 54Gy in Carcinoid CA (like adeno) annually or 10yrs younger than youngest age of dx in family
* ≤ 2 small (<1cm) tubular adenomas → 5 – 10 year colonoscopy Colonoscopy in 1Y (If 25-28fx Lymphoma (10%, cecum, do colectomy) - TVS /endometrial aspiration biopsy annually at 25-35yo
* 3 – 10 or 1 adenoma >1cm (Villous) → 3 year colonoscopy not done pre –op due to (sx after 5-10wx) GIST (submucosal, spindle cells, imatinib - tx: total colectomy + IRA, prophylactic THBSO
* >10 adenomas → <3 year colonoscopy obstructing lesion, within (400mg/d x1yr), sunitinib) Familial Colorectal Cancer
* Sessile polyp removed piecemeal → 2 – 6 months colonoscopy ensure 3 to 6 mo) short course: - 10-15% incidence
complete excision If advanced adenoma, 25Gy in 5days - risk: no famHx: 6%, 1 1st degree member: 12%, 2:36%
Risk factors: >50yo (start screening) repeat 1Y. If no (sx after 5-10d) - colonoscopy q5yrs at 40yrs old or 10yrs before 1 st dx
environment/dietary, IBD: 2%(10yrs), 8% advanced adenoma,
(20yrs), 18% (30y) repeat 3Y, then q5Y
(+) CA: favorable histological features (+) CA: Unfavorable histologic features If M1, UNresectable primary and distant mets: INHERITED COLORECTAL CANCER APC gene testing (+): Screening at age 10 to 15 years until polyps identified
Grade I or 2 (Well to Moderately Grade 3 or 4 (Poorly/ Undifferentiated) (+) - CHEMOTHERAPY Familial adenomatous polyposis APC gene testing (-): Screening at age 50
Differentiated), No angiolymphatic angiolymphatic invasion, Positive margin: - RE EVALAUTE FOR CONVERSION EVERY 2 MONTHS IF - 1%, AD, APC gene mutation,100-1000 polyps Upper endoscopy q1-3yrs at age 25-30yo (perimapullary CA risk high)
invasion, Negative margin of resection ≤1mm from the transected margin tumor CONVERSION TO RESECTABILITY - CA risk: 100% by 50yo - Tx: total proctocolectomy + end ileostomy, total colectomy+ IRA, restorative
--> Observe/colectomy if sessile cells present →colectomy - Flexible sigmoidoscopy of 1st degree relatives of FAP patients proctocolectomy + IPAA
Haggit’s Classification: Level 2: invades neck of polyp SM1: invasion to upper 3rd of submucosa beginning age 10 to 15 years annually until age 24; *Congenital hypertrophy of retinal pigmented epithelium, Desmoid tumors,
Level 0: CA in situ Level 3: invades stalk of polyp SM2: invasion to middle 3rd of submucosa every 2 years until 34 years; every 3 years until age 44; then every 3 – Epidermoid cysts, Mandibular osteomas (Gardner’s syndrome), CNS tumors
Level 1: invades muscularis mucosa Level 4: invades submucosa of bowel wall SM3: invasion to lower 3rd of submucosa * inc risk of LN mets (only for 5 years (Turcot’s syndrome)
(head of polyp) (T1) * all sessile polyps are Level4 sessile)
COLON, RECTAL & ANAL MALIGNANCIES - AZS.2018 -