7. Polyp - Cancer Sequence
• Circumstantial evidence
– Similar anatomical distribution
– Adenomas can harbour foci of carcinoma
– Polyp patients are 8-10 years younger
– 30% of CRC have synchronous polyps
– Metachronous cancer is twice as high in
those cancers with associated polyps
– Prophylactic polypectomy decrease
incidence of subsequent cancer
14. Management of Malignant
Polyp
• Polypectomy
- Pedunculated
- Well differentiated
- In Head or stalk,
away from resection
margin
- No vascular or
lymphatic invastion
- Clear resection
margins
• Radical Resection
- Sessile
- Poor differentiation
- Low in stalk
- Vascular or lymphatic
invasion
- Involved resection
margin
15. Further Management of
Malignant Polyp
Radical Resection
• Site of resection entitled by site of
the polyp
• Radicality of resection entitled by
extent of the polyp
• India ink injection in the era of
laparoscopic surgery
16. Follow Up After
Polypectomy
• Benign polyp
- Yearly endoscopy after positive complete
clearance
- Three yearly endoscopy after negative
complete clearance
- Five yearly therafter
• Malignant polyp
- Follow guidelines of cancer management
17. Metaplastic Polyps
• Also known as hyperplastic polyps
• Usually minute (2-5mm), plaque like,
same colour of mucosa
• Asymptomatic, do not turn malignant
• Elongated tubules, scanty goblet cells,
hyperplastic cells at the base of crypts
• Management depends on individual
policy
19. Juvenile Polyps
• Seen in infants and children less than 10 y
• Mostly situated in the rectum
• Usually stalked, head covered by
granulation tissue
• Cut surface shows dilated cystic spaces,
bulk of polyp made up of connective tissue
full of acute & chronic inflammatory cells
• Rectal bleeding, polyp prolapse
• Not pre-malignant
• Treatment by colonoscopy & polypectomy
20. Peutz Jeghers Syndrome
• Autosomal dominant inheritance
• Pigmentation
• Polyps
• Symptoms of rectal bleeding and
recurrent intussusception
• Debate considering the malignant
potential
• Conservative management versus more
aggressive endoscopic management
22. Inflammatory Polyps
• Accompany Chronic inflammatory
process of the bowel
• Composed of oedamatous mucosal
tags
• Not premalignant
• Treatment of the cause
25. Connective Tissue Polyps
• Can be benign or malignant
• Size dictates symptomatology in
benign lesions
• Commonly present by obstructive
symptoms
• Treatment: Segmental resection
26. Familial Adenomatous
Polyposis
• Autosomal dominant inheritance
• Mutation in APC gene
• Easily recognized by its phenotypic
features
– CR polyps and cancer
– Extracolonic lesions
• 100% penetrance
• 1 in 8,300 to 1 in 14,025 live births
32. HNPCC
• Characterized by
–Autosomal dominant inheritance
–Mutation in MMR gene
–Early onset CR cancer and polyps
–Extracolonic cancers
• Diagnosis: Less evident phenotypic
features
–Family history criteria
–Pathology criteria
–Genetic criteria
33. Family History
• Amsterdam criteria
–CRC in 3 family members
–One member 1st degree relative to other two
–Two successive generations
–One cancer diagnosed less than 40
–FAP excluded
• Others (less strict criteria)
34. Pathology Criteria
• Young age of onset
• Right sided tumors
• Multiple colonic tumors
• Extra-colonic tumors
• Aggressive histopathology features
• Good prognosis
