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PubMed1992

Accuracy of colonoscopy for the detection of colorectal polyps.

The findings at colonoscopy were compared with the pathologic findings of the surgical specimen in 235 patients who underwent a colon resection for a primary colorectal neoplasm from January 1980 to December 1987 at Roswell Park Cancer Institute. Seven patients (3 percent) were found to have synchronous primary colon carcinomas, and 100 patients (43 percent) were found to have synchronous adenomatous polyps identified by colonoscopy and/or pathology. In patients with polyps 10 mm or greater in diameter, the findings on colonoscopy agreed with the pathology report 96 percent of the time. When polyps of all sizes were included, with many less than 5 mm in diameter, colonoscopy agreed with the pathology in 89 percent of patients. When only the area of the colon resected was used to determine the ability of colonoscopy to locate polyps, 58 percent of polyps of all sizes were located. The majority of the missed polyps were adjacent to a carcinoma. One cecal carcinoma was not seen by colonoscopy because of technical inabilities to reach the cecum. A second carcinoma (20 mm x 17 mm) was not seen at the splenic flexure.

Colectomy↗
PubMed1985

A conservative approach to adenomas containing invasive carcinoma removed colonoscopically.

A controversy exists as to the correct therapeutic approach to colorectal polyps that contain malignancy and are removed colonoscopically. This paper presents our experience in the management of such polyps. Between 1977 and 1983, a total of 117 patients underwent colonoscopic polypectomy for 178 adenomas. Nine adenomas from nine patients showed carcinomatous invasion across the line of muscularis mucosae. None of these carcinomas was poorly differentiated and in all but two cases there was histologic evidence of complete excision. Seven patients whose adenomas containing foci of malignant changes were treated by polypectomy alone are alive without recurrence at periods from six months to over five years (mean, 40 months). The two patients in whom endoscopic removal of cancerous adenomas was found to be either doubtfully complete or incomplete, had further surgical treatment; both are alive and well after one and five years, respectively. Nine other patients whose adenomas containing malignant changes were considered unsuitable for colonoscopic polypectomy, underwent surgical resection and in none was regional lymph node or distant metastases found at laparotomy. In conclusion, our results of local endoscopic excision for adenomas containing malignant changes suggest a conservative approach to such polyps and this policy is supported by the finding that, in none of our operated patients was there any evidence of metastatic disease.

Adult↗
PubMed1989

Management of patients with invasive carcinoma removed by colonoscopic polypectomy.

The management of patients with invasive carcinoma removed by colonoscopic polypectomy remains controversial. In order to assess the criteria for subsequent surgery after polypectomy, the histologic findings and outcome of 25 patients with invasive carcinomas treated by polypectomy were analyzed. Subsequent surgery was indicated when removed invasive carcinoma showed at least one of the following findings: 1) carcinoma near the surgical margin, 2) vessel invasion, 3) massive invasion, and 4) poorly differentiated adenocarcinoma. The authors considered those findings to be a risk factor for local residual carcinoma or lymph-node metastases, or both. Of 25 patients, 18 showed risk factors, with 16 receiving surgery. Only one had residual carcinoma in the lymphatic vessel of the surgical specimen. The remaining 15 had no carcinoma in the surgical specimens, however, one died of recurrent disease 55 months later. Two patients with risk factors received no surgery for various reasons. Local recurrent carcinoma developed in one 39 months later and the other had no recurrent carcinoma at autopsy. Seven patients without risk factors were adequately treated by polypectomy without recurrent disease 34 to 96 months later (average, 69 months). Consequently, of 18 patients with risk factors, 3 showed either residual carcinoma in the surgical specimens or recurrent carcinoma was found later. None of 7 patients without risk factors developed recurrent disease. We recommend that patients with risk factors be followed by surgery; however, patients without risk factors can be adequately treated by polypectomy alone.

Adenoma↗
PubMed1983

Colorectal schistosomiasis. Endoscopic polypectomy.

The role of colonoscopic polypectomy for schistosomal polyps was studied. The results showed that, in spite of the large number of polyps, a total of 404 polyps were removed from 20 patients. The procedure is feasible with minimal complications. A marked reduction of rectal bleeding occurred in half the patients, and the remaining half had minimal symptoms. Colonoscopic polypectomy gives equal results to colonic excision for schistosomal polyps.

Adolescent↗
PubMed1987

The role of colonoscopy and flexible sigmoidoscopy in screening for colorectal carcinoma.

Six hundred thirty-two patients were referred to the Colorectal Clinic from February 1983 to February 1986 for screening with the Pentax 65 cm flexible sigmoidoscope. Forty-nine of these patients (8 percent) had adenomatous polyps. There were 27 males and 22 females. The mean distance examined by the 65 cm flexible sigmoidoscope was 55 cm. Five patients were excluded from analysis, leaving 44 patients who underwent colonoscopy to the cecum. At the time of colonoscopy, 15 of the 44 patients (34 percent) had one or more adenomatous polyps beyond reach of the 65 cm flexible sigmoidoscope. The remaining 29 patients who underwent colonoscopy had no polyps beyond reach of the 65 cm flexible sigmoidoscope. Thirty adenomatous polyps, one invasive carcinoma of the ascending colon, and one hyperplastic polyp were found in these 15 patients. In summary, 34 percent of patients found to have adenomatous polyps within reach of the 65 cm flexible sigmoidoscope harbored one or more adenomatous polyps in the proximal colon at the time of colonoscopy. A positive 65 cm flexible sigmoidoscope examination requires colonoscopy to identify and remove proximal premalignant lesions, thereby aborting the polyp-cancer sequence.

Colonic Neoplasms↗
PubMed2000

Endoscopic management of polypoid early colon cancer.

Endoscopic management of polypoid early colonic cancer (malignant polyps and polypoid carcinomas) is no longer controversial. When the endoscopist is satisfied that excision is complete and histology is "favorable" (a resection margin of 2 mm and well or moderately well differentiated tumor), surgery is unnecessary. When histology show "unfavorable" characteristics (which a few histologists still take to include invasion into lymphatics), surgical or laparoscopic resection may be indicated, providing the patient is considered at suitable risk. Surgery kills some patients without finding residual cancer and cannot save others with metastases, so it should be recommended only with due clinical consideration. Sessile or broad-based polyps, especially those in the rectum, are more likely to be "high risk" and merit specialist management if local removal is to be attempted and to allow proper histologic assessment. Endoscopic approaches such as saline injection polypectomy, india-ink tattooing, and use of the argon beam coagulator are applicable in some cases. New approaches that still require trials include ultrasonographic probes, which occasionally clarify the degree of invasion, and prototype stapling devices to allow full-thickness histologic specimens to be obtained.

Colonic Polyps↗
PubMed1985

Prognostic factors in colorectal carcinomas arising in adenomas: implications for lesions removed by endoscopic polypectomy.

Endoscopic polypectomy has become the preferred technique for the removal of most colorectal adenomas. Whether polypectomy alone or segmental colectomy is the appropriate management of the patient whose adenoma contains carcinoma is a controversial issue. We studied 129 colorectal carcinomas that arose in adenomas and in which invasion was no deeper than the submucosa of the underlying colonic wall. The following factors were evaluated: location; gross appearance (sessile versus pedunculated); histologic type of adenoma (tubular, villous, mixed); grade of carcinoma; level of invasion (0--carcinoma confined to the mucosa, 1--head, 2--neck, 3--stalk, 4--submucosa of underlying colonic wall); vascular invasion; and adequacy of excisional margins. Patients were divided into two groups with respect to outcome: adverse (dead from colorectal carcinoma, alive with colorectal carcinoma or positive nodes on colectomy), and favorable (absence of above). Sixty-three patients were treated by polypectomy alone and 66 by colectomy (21 preceded by polypectomy); there were no operative deaths. Mean follow-up was 81 mo. None of 65 patients with carcinoma confined to the mucosa had an adverse outcome, but 8 of 64 patients with invasive carcinoma did. Level 4 invasion (p less than 0.001) and rectal location (p = 0.025) were the only statistically significant adverse prognostic factors. Seven of 28 level 4 lesions and six of 42 rectal lesions had an adverse outcome; level 4 lesions were overrepresented in the rectum (14 of 42; p = 0.032). We conclude that the level of invasion should be the major factor in determining prognosis for the management of carcinoma arising in an adenoma.

Adenocarcinoma↗
PubMed1991

Pseudomalignant ulcerative change of the gastrointestinal tract.

The occurrence of pseudomalignant ulcerative change in seven specimens from the colon and rectum of six patients is described. In all cases, there was surface ulceration of a polypoid lesion which contained granulation tissue and acute and chronic inflammation. There was an underlying inflammatory pseudopolyp in four lesions, a juvenile polyp in one lesion, an adenomatous polyp in one lesion, and a benign retention polyp in one lesion. Within the stroma of all cases were numerous atypical cells that mimicked a malignant neoplasm. The atypical cells expressed vimentin in immunohistochemical studies; no expression of keratins, leukocyte common antigen, factor VIII, Ulex europaeus, carcinoembryonic antigen, actin, or desmin was found. Recognition of this lesion is important, as confusion with carcinoma, lymphoma, sarcoma, or a viral infection may easily occur.

Adolescent↗
PubMed1993

Management of malignant colorectal polyps.

The optimal management of patients with adenomatous polyps that contain invasive adenocarcinoma remains controversial. The independent factors of margins of resection, level of invasion, differentiation, grade, and vascular invasion are examined as prognostic indicators for outcome. The literature is reviewed with regard to the management of patients with polyp-containing invasive adenocarcinoma with standard operative resection versus endoscopic treatment alone.

Carcinoma↗
PubMed1994

Stereological assessment of architectural changes in dysplastic epithelium of colorectal adenomas.

BACKGROUND: Against the background of developing quantitative prognostic indicators for the future risk of colorectal cancer in adenoma bearing-patients, the possibilities of stereological measuring techniques for providing objective measures of architectural changes in colorectal adenomas were examined. MATERIAL AND METHODS: The haematoxylin-eosin stained tissue sections of 59 adenomas, of which 20 showed mild dysplasia, 20 moderate dysplasis, and 19 severe dysplasia, were assessed. Using a projection microscope equipped with a coherent test system that was specifically designed to analyze anisotropic tissue, the volume density of stroma, epithelium and lumen, the outer and the inner gland surface density, and the length density lumen were determined. RESULTS: With respect to grading, significant differences in the means of the inner gland surface density and the length density lumen were found mainly between mild and severe dysplasia as well as between moderate and severe dysplasia. This was especially evident when considering the subgroup of tubular adenomas. Stepwise discriminant analysis resulted in an overall correct jackknifed classification of 81.3% when mild and moderate dysplasia cases were taken as one group, and were compared with the group of severe dysplasia cases. With respect to histological type, the volume density lumen and the outer surface density glands, were most favourable. These two features allowed for an 87.5% overall correct jackknifed classification of tubular adenomas, versus adenomas with villous components. The analysis time was roughly 30 minutes per polyp. Intra-observer reproducibility was satisfying, with CE-values < or = 5% for all variables. Inter-observer reproducibility tests were encouraging. CONCLUSIONS: The application of stereological techniques can be worthwhile in assisting in the classification of colorectal adenomatous polyps. Such techniques could therefore be a useful tool to estimate the prognostic value of adenoma morphology with respect to the development of metachronous colorectal tumours.

Adenomatous Polyps↗
PubMed1997

Colorectal polyps and their relationship to cancer.

Autosomal dominant, familial forms of colorectal adenocarcinoma are recognized, but more than 90% of cases are sporadic. Most familial and sporadic cases arise through malignant transformation of benign adenomas in a process known as the adenoma-to-carcinoma sequence. Adenomas are classified histologically as tubular, tubulovillous, or villous. As a neoplasm, adenomas all manifest mild, moderate, or severe dysplasia. The majority (> 90%) of adenomas are small (< 1 cm in diameter) and do not progress. Risk factors for carcinomatous progression include the presence of multiple adenomas, size greater than or equal to 1 cm, and villous histology or severe dysplasia in adenomas of any size. The adenoma-to-carcinoma sequence advances through the accumulation of lesions involving multiple genes. It appears that similar molecular genetic mechanisms are involved in familial and sporadic forms of colorectal neoplasia.

Colonic Polyps↗
PubMed1987

Jejunitis cystica profunda in a hamartomatous polyp. Report of a case.

A patient with a history of abdominal discomfort and rectal bleeding was discovered to have two hamartomatous polyps, one of the jejunum and one of the colon. The former was associated with mucinous cysts at its base. The findings were similar to those described for colitis cystica profunda. This case is a rare example of cystica profunda disease of the small bowel. Uniquely, it was associated with a hamartomatous polyp.

Adult↗