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Aust. N.Z. J . Surg.

(1994) 64, 242-246

MANAGEMENT OF THE MALIGNANT COLORECTAL POLYP: THE


IMPORTANCE OF CLINICOPATHOLOGICALCORRELATION
JAMES W. E. MOORE,*
DESMOND
C. HOFFMANN*
AND ROBERTROW LAND^
*Colorectal Surgical Unit, Royal Adelaide Hospital and tDepartment of Pathology, Institute of Medical and
Veterinary Science, Adelaide, South Australia, Australia
The results of management of colorectal adenomas removed endoscopically and found to contain invasive cancer seen in a
single institution over a 10 year period are presented. Clinical data were obtained retrospectively from patient case notes
and all specimens were reviewed by one pathologist. Fifty-four patients with malignant polyps were studied after exclusion
of others with polypoid carcinomas, epithelial misplacement and cases managed by primary segmental resection. Of the
various considered predictors of adverse outcome, only histologically incomplete excision proved significant. However,
when excision was considered macroscopically complete there was no significant association between incomplete
histological excision and adverse outcome. Consideration should be given to conservative managementof such cases.
Key words: colonoscopy, colorectal carcinoma, colorectal polyp, polypectomy.

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.

to the invasive tumour were termed polypoid carcinomas


and were excluded. Patient case notes were reviewed and
data regarding age, sex and date of polypectomy were
obtained. The site of the polyp within the colon was taken
from the procedure report, and its size and morphology
(sessile vs pedunculated) were determined from the
procedure report or from the gross description of the
pathology specimen, or both. If the patient proceeded to
a completion resection (i.e. segmental colectomy, anterior
resection or abdominoperineal resection after polypectomy), the pattern of residual disease was recorded (none,
bowel wall, nodal, distal or a combination of these).
Follow up was obtained by review of case notes, and by
general practitioner and patient interview. This was recorded as total and disease-free follow up in months postpolypectomy. Disease-free status was determined by a
combination of clinical and endoscopic criteria, at last
review. If recurrence had occurred, the pattern and timing
of recurrence (local, regional or distal) was recorded.
Mortality was classified as cancer related or unrelated.
Patients were also assigned to one of two groups:
(1) Adverse outcome, where either recurrence occurred
after polypectomy alone or when residual or metastatic
disease was found at completion resection.
(2) Favourable outcome, where no recurrence had been
documented after endoscopic polypectomy alone or when
completion resection revealed no evidence of residual
malignant disease (implying that polypectomy alone
would have produced a favourable outcome).
All pathology specimens were reviewed by a single
pathologist (R. Rowland). Details regarding the type of
polyp involved (tubular, comprising greater than 2/3
tubular architecture; villous, greater than 2/3 villous
architecture; and tubulovillous, neither of these) were
recorded. The carcinoma was graded as well, moderately
or poorly differentiatedaccording to previously described

MANAGEMENT OF MALIGNANT COLORECTALPOLYP

riter ria.'^*'^ The depth of invasion was recorded according


to the method described by Haggitt (Table l). The
margin of clearance of invasive malignancy was measured on both lateral and deep margins in millimetres and
correlated with the endoscopic assessment of macroscopic clearance of the lesion. The presence or absence
of vessel invasion (defined as tumour within endothelial
lined spaces) was recorded but no attempt was made to
differentiate between lymphatic and venous invasion.

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

Invasive tumour (through muscularis mucosae)


confined to head of polyp
Invasive tumour to the junction of head and stalk
(i.e. to the neck of polyp)
Invasive tumour into part of the stalk of the polyp
Invasive tumour invading beyond the stalk, into the
submucosa of the bowel wall below the polyp but
not into the muscularis propria

A carcinoma arising in a pedunculated polyp may be classified as


Haggitt level 1-4 depending on the level of invasion seen, but a
carcinoma arising in a sessile polyp is by definition level 4 as it involves
the submucosa of the underlying bowel.

243

polypectomy, without clinical evidence of recurrent


disease.
Tables 2 to 4 describe the association between Haggitt
level and the site, histological type and grade of polyp.
Ninety-six per cent of polyps were located distal to the
splenic flexure (Table 2). There was no significant difference in level of invasion between polyp types (Table 3).
Although only one poorly differentiated lesion was seen,
there was no association between Haggitt level and grade
of polyp (Table4). Vascular invasion occurred in four
cases (Table 5) but no patient with vascular invasion
suffered an adverse outcome. Haggitt level 4 invasion,
polyp morphology and grade were not statisticallysignificant predictors of adverse outcome (Table 6).
Outcome after polypectomy by completeness of excision is shown in Table7. In the 49 cases where the
endoscopist assessed the excision to be complete, only
two suffered an adverse outcome, despite tumour extending to the resection margins in 10 specimens. When cases
considered to be macroscopically completely excised by
the endoscopist were subdivided by completeness of
histological excision, there was no statistically significant
difference in outcome at last follow up (two-tailedFishers
Exact test, P = 0.4). Histologically incomplete excision
was a significant predictor of adverse outcome (Tables 7,
8; two-tailed Fishers Exact test, P = 0.01). However,
within the group with histologically incomplete excision,
adverse outcome was significantly less common when the
polyp was macroscopically completely excised compared
to those in which part of the polyp remained after removal
(P = 0.01).
Twenty-nine patients were managed conservatively
following polypectomy with two adverse outcomes, and
25 patients underwent completion resection with three
adverse outcomes (Table 6). The indications for completion resection were incomplete excision (14 cases), vascular invasion (one case) and stalk invasion (10 cases).
Haggitt level 4 predicted three of five adverse outcomes
(sensitivity of 60% and specificity of 64%; Table 8).
Following conservative management, the two adverse
outcomes (cases 1, 4; Table 6) were manifest as small
mural recurrences at the polypectomy site detected 3 and
4 months post-polypectomy, respectively. Both were
treated by segmental resection (no nodal involvement)
and are alive and well at 8 and 52 months, respectively.
Two cases with adverse outcome after completion resection (cases 2, 5; Table6) were found to have a single
node involved by tumour, but neither case had evidence

Table 2. Location of polyps


Haggit level

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

of residual mural disease and are alive and well at 6 and


32 months. The third case underwent piecemeal resection
of a large sessile rectal lesion and subsequent completion
resection revealed no evidence of residual tumour. Multiple hepatic metastases developed at 12 months and this
patient died 15 months post-polypectomy.

Table 3. Histopathological type of polyp


Haggitt level
1

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

Exact P value =NS for all comparisons (Pearson Chi-squared test)


comparing polyp type by Haggitt level.

Table 4. Grade of polyps


Haggitt level

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

Table 5. Vascular invasion


Haggitt level
1

2
3
4 (pedunculated)
4 (sessile)

Total

Present

Absent

Total

15

16

12
7
12

12
9
13

50

54

Table 6. Details of cases with adverse outcome

Local
recurrence

Case number and pattern of failure*


2
3
4
Nodal on
Metastasis
Local
resection
12/12
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)

MANAGEMENT OF MALIGNANT COLORJXTAL POLYP

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

Two cases were lost to follow up; *Excision grossly complete/


incomplete, endoscopists assessment; ?Margins positive, carcinoma at
polypectomy resection margin on histology.

Table 8. Sensitivity and specificity of Haggitt level 4 invasion


for prediction of adverse outcome

245

documented and in this context may warrant further


study.26
The frequency of vessel invasion in malignant polyps
varies widely between series, ranging from 1.6 to
37~0.2.3.11.12.14.26The reason for this is unclear and cannot
be explained by differences of tumour grade or type of
study (polypectomy vs resectional series). The presence
of tumour within endothelial lined spaces, especially with
surrounding smooth muscle, may be easily recognized,
but significant difficultiesexist in distinguishing between
the effects of tissue retraction around the tumour and
involvement of small lymphatics or veins.I4The authors
believe this is a major source of potential error and chose
to report only unequivocal vessel invasion and not distinguish between venous and lymphatic involvement. This
no doubt helps to account for the low incidence of vessel
invasion reported.
The presence of vessel invasion is widely considered
to be of adverse prognostic significance and is used as an
indication for completion resection.I
This has recently been challenged in a study from St Marks Hospital, in which there was only one adverse outcome in 61
endoscopically completely resected malignant polyps,
20 of which had venous invasion detected.14 This is in
accordance with previous work, from that institution,
demonstrating no prognostic importance of intramural
venous invasion in Dukes A carcinomas resected at open
surgery.21Similar findings have been reported in Dukes
B colorectal lesions with respect to lymphatic invasion.
Agrez et al. found no influence of either intramural or
extramural lymph vessel involvement on age adjusted
survival following re~ection.~
Nivatvongs ef al. found
that vessel invasion is only of importance when related to
depth of invasion (by Haggitt
Vascular invasion
was not associated with any adverse outcome in the
present series.
The lack of significant numbers of poorly differentiated
tumours in the present study prevents any useful assessment of the importance of this variable in determining
outcome after polypectomy. There is, however, agreement in the literature that poorly differentiated lesions
should undergo completion resection.2+8*1.13*14
This is despite the same lack of numbers in many series, the only
exception being the series by Nivatvongs et al. who
reported three cases with lymph node involvement in 23
poorly differentiated lesions.26
The issue of polyp size does not seem to be of
significance as a predictor of adverse outcome but rather
as a limiting technical factor when considering endoscopic management of the index polyp. The importance
of providing the pathologist with a complete excision
biopsy rather than an unassessable series of tissue fragments has been discussed by many a ~ t h o r s . ~ .This
~*~*~*~~
has led to proposed guidelines for endoscopic polypectomy based on the size of the lesion, namely 35mm
for pedunculated and 15 mm for sessile lesions.14 The
practice of piecemeal polypectomy, particularly of sessile
tumours, should be discouraged. This technique entails
increased risk to the patient and prevents accurate pathological assessment of the clearance and depth of invasion.
1312*20*23

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%.

figure as none of the recurrences in the present study


occurred later than 24 months, despite a mean follow up
of almost 40 months.
The series reported here is of particular interest because
it identifies the value of the endoscopists assessment of
whether or not polypectomy is complete. Tumour at or
close to the margins of resection has been widely accepted
as an important prognostic factor predicting local residual
disease or nodal metastasis following endoscopic removal
of a malignant polyp.7.3*20-22
The present authors experience supports that of others,3*5*11.23
indicating that a significant number of polyps macroscopically completely
removed but with positive histologic margins do not
suffer an adverse outcome. If the reason for offering
completion resection to patients with histologically positive margins is the risk of residual mural disease, it may
be reasonable to extend conservative management of
malignant polyps to include a period of observation
followed by re-endoscopy and re-biopsy after 6 weeks.
Completion resection would then be reserved for those
with residual or recurrent malignant disease. The risk of
nodal involvement has been suggested as further reason
for resection but in this series it was low (3.3%) and
approaches the operative mortality for elective resection
in patients over the age of 70 year^.^^**^ The reason for
the failure to find residual or recurrent disease in many
cases with positive margins is not clear but may relate to
the destruction of tumour cells by diathermy current at
the base of the polyp, beyond the line of endoscopic
resection. The exact magnitude of this effect is poorly

MOORE ET AL.

246

It should be reserved for patients where the risks of open


surgical management are deemed prohibitive and no
practical alternative exists.

14.

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