Episode 3 UL CRS

Welcome back to another episode of Clinical Challenges in Colorectal Surgery with Bulszynski, and Simon. Today we'll be discussing several cases surrounding the management of advanced and malignant polyps. But before we begin, I think it's first important to remind all the listeners that the U. S. Multi Society Task Force on Colorectal Cancer, with representatives from multiple GI societies, Last issued colonoscopy surveillance recommendations in early 2020.

The American Society for Gastrointestinal Endoscopy provides guidelines on how to remove polyps. As well as recommendations for follow up after colonoscopy and polypectomy. And these have been included in our show notes for your future use. But it really is important to remember that these are only guidelines.

And the frequency of colonoscopy is influenced by many factors. Some as simple as the quality of bowel preparation at the time of your scope. And this should be mentioned in every report. So you have to remain up to date. And remember

there are things like the Boston bowel prep score that you really should know.

For Before we start talking about advanced malignant polyps, I think it's worth repeating to everybody so that we know in the past 10 to 15 years they have lowered the screening age from 50 to 45. So the answer on your abscite score is 45 for average risk patients for their first colonoscopy. And Coligard is a stool based test, and it detects three things.

It picks up on hemoglobin, and then it also picks up on two other separate DNA mutations that are related to colorectal cancer. This is a good option for patients who just refuse to have a colonoscopy, or if they're at a poor risk to have a screening colonoscopy, or they don't have access to a colonoscopy.

However, keep in mind, if somebody comes in with rectal bleeding, Coligard's already immediately positive because it does detect hemoglobin. Coligard is approved for average risk patients. Not high risk patients. So people with a history of polyps

or family history are also not candidates for a Coligard.

The sensitivity for Coligard picking up cancer is very high. It's around 92 percent. But detecting advanced adenomas or serrated polyps is only 40 percent. So it's also something that you should talk to your patients about. I think another point to highlight is that in patients with no identified risk factors, the cumulative lifetime risk of colorectal cancer is still very significant at about one in 20.

And colonoscopy is really the only truly preventative intervention. Dr. Cavalugas mentioned about Cologuard and the like, and of course they have a role, but most of the time they seem to be detecting an early stage cancer rather than a advanced disease. And arguably at some of these situations, the horse has already bolted.

And so, colonoscopy does prevent us from being in that position. Yeah, I could not agree more. If patients

are on the fence, I really try to push for colonoscopy from the preventive aspect. When we had talked about this, even as a group the other day, we had. mentioned the point to reiterate about the increasing rate of early onset colorectal cancer, especially rectal cancer in patients under 50, because oftentimes younger people aren't undergoing those colonoscopies.

However I think it's an important thing to note that younger folks will be found to have polyps, the majority on the left side. So they could be picked up on a flexible sigmoidoscopy if you can't get the colonoscopy approved by insurance. And just, you know, a side note to mention, but today we're discussing the subset of advanced malignant polyp management without getting into the tedious surveillance interval recommendations referenced previously.

All right, so let's talk about through a few cases. Let's say it's a 53 year old female who comes for a screening colonoscopy. And in the CECM, you find a 25 millimeter sessile polyp that's completely

resected on block using a saline lift. It was a sessile polyp, which is why you had to saline lift it, and the PATH demonstrates a moderately differentiated adenocarcinoma arising within the polyp, extending to within 0.

2 millimeters of the cauterized margin. Now we're telling you that because obviously that's important so there's no other evidence of pathologic high risk features. So what are the next steps to consider in this patient? First, the term malignant polyp refers to a colorectal polyp, including flat, sessile, and pedunculated ones, with neoplastic invasion of the submucosa without extension into the muscularis propria.

Another term for these lesions is submucosally invasive polyps. Morphologically, pedunculated polyps are classified by Haggit levels 0 through 4. And the polyp in this scenario is sessile, which automatically classifies it as a haggit level 4 and therefore puts it at

high risk, an unacceptably high risk of lymph node involvement and therefore I would offer this patient a right colectomy.

So what if the polyp was pedunculated? As I alluded to before, Haggit Level is a classification system for depth of cancer invasion in the polyps. This system is mostly useful for pedunculated polyps, and again classified 0 4, where Level 1 Plastic elements limited to the mucosa, and then one through four have submucosal invasion based on their invasion.

Invasion into the head, neck, and stalk of the pedunculated polyp. Level one denotes cancer invasion into the submucosa, but is limited to the head. Level two denotes cancer cells reaching into the neck, and then level three invades the stalk level four. As we said before, in invades the submucosa below the stalk.

But not into the muscular is propria, and all malignant non

pedunculated polyps are therefore defined as a haggit level 4. Simply put, haggit 1 and 2 means there's likely an adequate margin. Level 3 into the stock has typically has a deeper margin and therefore increases its risk of lymph node invasion and prompts a further discussion for surgical resection.

Going back to the original 20 millimeter flat polyp in the right colon in our case, of course, it was saline lifted and removed on block. But it's important to flag that there are other management options. We can, of course, just biopsy it. We can lift it. And attempt to remove it on block as was the case, or we can leave it alone and come back to fight another day with either better equipment or a better or more advanced endoscopist, someone who can perform an EMR, ESD, or even arrange a combined lap assisted endoscopic resection which would potentially reduce the morbidity of a patient.

collectomy and anastomosis.

Anyhow, I guess, with this patient the patient underwent an uneventful right hemicolectomy. The sessile polyp was identified. The final pathology excluded lymph node involvement, as such it was considered a stage one colon cancer. And so, what is our surveillance for this?

The patient should have a repeat colonoscopy in one year and I like to glamorize it for my patients and tell them I'll see them back for scope on our one year anniversary together. So, Dr. Glendak, do you want to give us another case presentation? Of course, I was referred a patient for a second opinion regarding what was termed a superficial rectal cancer that was identified in a pedunculated polyp that was removed during colonoscopy, and the patient was absolutely distraught and had already been sent, referred to a medical oncologist who was actually the doctor who referred her to me.

The pathology report read minimally invasive adenocarcinoma invading into the

submucosa with inter mucosal adenocarcinoma arising within a tubo vill adenoma. No lymphovascular space invasion was seen. There was an important comment in the pathology report that described stock margin vocally involved by adenoma.

in a well or in well oriented sections. Now this is important because if the specimen isn't oriented properly, the pathologist really can't give you a good report. And in cases like this, I think the most important thing to do is to calm the patient. And get another pathology read to confirm first that the specimen was in fact well oriented and that the polyp was pedunculated and not sessile, and secondly to make sure that this was indeed a minimally invasive cancer.

As haggit is not used by many pathologists, an actual measurement in millimeters of depth of invasion of the submucosa is often easiest when describing these submucosal cancers

and measurement of invasive cancer to the stock margin. In this case, there was less than one millimeter of submucosal invasion present, and six millimeters distance from the invasive cancer to the margin of the pedunculated polyp stalk.

And re review showed a tubulovilus adenoma with high grade dysplasia and focal areas invasion into the superficial, and again that's less than one millimeter of submucosa, with desmoplastic stromal response. The stalk margin was negative for high grade dysplasia. Or invasive adenocarcinoma. She was dis presented at the MDT and only surveillance recommended.

So before we move on, I'm gonna ask another of my junior questions that I always fire at Dr. Glandy with some of these cases. is I commonly get colonoscopy reports that just say polyp. So if you don't know if it's pedunculated or sessile, what how would you proceed with this case that you're

talking about?

Well, again, the accurate measurement of the depth of invasion in malignant polyps really requires specific handling of the pathology report. Specimen. And this is really important because for larger polyps, this involves pinning the specimen to a stiff material before it's put into formal and to maintain its proper orientation and pinning of the specimen actually allows the specimen to be properly oriented for evaluation by the pathologist.

Dr. Bulszynski, can you tell us a little bit more about the importance of submucosal invasion? Yes. So, I still see the term haggard quite often, although I'm in a sort of obviously a different country. And as I think Hilary mentioned, a haggard fall by definition is a flat polyp, or sorry, a flat polyp is by definition a haggard fall.

So having said that I think the challenge with submucosal advation is of

course knowing how deep is it because unless one has muscle within the biopsy, in my mind, it's very difficult to measure, you know, what is one third, what is two thirds, what is three thirds. And I do think what Dr.

Galandiak mentioned about kind of identifying you know, what is an invasion of less than one millimeter. And that being called superficial submucosal invasion, rather than something deeper being deep submucosal invasion is very useful. And this then correlates to risk of metastases, of course.

So, something which is less than one millimeter it has about a 0 to 4 percent risk of kind of an advanced cancer, whereas something which has a depth of greater than one millimeter is associated with a risk of residual disease in the bowel or lymph nodes at about 10 to almost 20%, and so therefore is an indication for surgical resection in a far greater cohort of patients.

And then I think here it really is important to know

where pathology reports are coming for. There are some really very good quality pathology labs, and there are some pathology labs that are, for example, run by in house, by large GI group practices, where the quality of the reads may not be as known a quantity.

It's never wrong to get a second opinion. I can't tell you how often in my career this has resulted in really a big change in the diagnosis. This is especially true if you're receiving referrals from areas with smaller populations and resources. It's really important to know an expert either at the institution where you're working or where you did your training at where you can send slides for re review.

Okay, so let's move on to our third case of the day. Okay. Dr. Bulszynski, you have an obese 60 year old male who's a smoker, who underwent his first ever screening colonoscopy and was found to have a 15 millimeter sessile serrated

adenoma that was biopsied but not removed entirely from the cecum. He otherwise was noted to have two 8 millimeter tubular adenomas removed by cold snare in the descending colon.

How do you prepare to call this patient to discuss this? His pathology results and what are your recommendations? So, patients with SSAs are at an increased risk of future colorectal neoplasia. And this may include both advanced polyps and cancer. Reasonable benchmarks for Detection of such polyps is about five to ten percent.

Certain endoscopic techniques such as chromoendoscopy, narrowband imaging, water immersion wide angle viewing may help with detection of flat polyps. And sort of more emerging techniques like underwater polypectomy and sort of more. piecemeal resections of these polyps are helpful tools for endoscopists.

As Dr. Glendick sort of labored on the point of both ensuring that the polyp is well preserved and also well analyzed is is incredibly important. So, you know, when I prepare to talk to the patient, I discuss all these. I also, you know, but I certainly have a far greater threshold of repeating endoscopy on someone with flat polyps because I do worry that we miss them because our pattern of recognition, these polyps are less and also I'm very careful to analyze what the quality of the bowel prep was because that is an elephant of the room when it comes to determining how frequently we scope people.

Thank you. Yeah, I think it's a, it's interesting. They've recently changed the nomenclature to be SSLs now, which is a Sessile Serrated Lesion because they're not necessarily polyps as Dr. Bulszynski talked about. They have very irregular margins. I've, I have biopsied a few things just because they looked weird or the granular pattern of the ileocecal valve just didn't look right to

me and it came back as a Sessile Serrated you know, change.

And so I think that they shouldn't. Technically, they are to undergo surveillance at intervals similar to what's recommended for the conventional adenomas, but the AGA also has kind of shortened the guideline where if you have tubular adenomas, they'll say 7 to 10 years, but if you have sessile serrated lesions, they'll say 5 to 10 years because I, you know, they don't go through the typical Vogelstein pathway of adenoma to carcinoma, and they kind of evolved through the CPG methylation pathway an MLH1 mutation to their carcinoma, and nobody has really studied how long this takes.

So I agree with Dr. Volshinsky, I kind of would keep them at a little bit higher level of alert, just because, They're difficult to see. They don't have distinct borders. They have a different pathway to carcinoma than other adenomas that we have historically studied. The patients with SESS oscillatory lesions may be able to lower their risk factors by, you know,

limiting their smoking and alcohol use high fat diets NSAIDs and aspirin appear to be protective agents in some correlational studies, though there's been no actual scientific studies showing this.

We have seen in, throughout the literature, that endoscopists, Endoscopists that are better at removing the right sided cess ulcerated lesions do have lower colorectal cancer incidences in those studies, and there's a recommendation by the AGA that a second look, whether that be forward view or with retroflexion, should be made in the right colon to help increase the detection, since these are so common on the right side.

This is why many endoscopists will only scope with pediatric scopes. And Dr Bolton see, I know you had brought to up earlier in an earlier discussion about other ways to potentially increase right sided detection of polyps that aren't necessarily commented on any guidelines. Do you want to tell us a little bit about your thoughts there?

Yeah, a few interesting points. I

actually, first of all, really like paediatric scopes but what I've noticed, and this is a change in culture, in Australia, people are typically a lot more heavily sedated and so adult scopes are preferred because I think it is easier to scope with an adult scope, but it causes patients to have more discomfort and with an adult scope, the risk I think of retroflexing in the cecum, at least anecdotally, is greater.

And so I do I am reluctant to do that personally, but I think sort of multiple intubations of the right colon are very important to Sandy's point. Now, I guess. I sort of think that it's important to recalibrate one's vision for hyperplastic polyps, and we sort of all been taught that classically they hide behind the mucous cap, but also, I think all of us have done colonoscopies in a short succession after someone else, and have found fairly large, Flat polyps and it's hard for me to imagine that those polyps grow that rapidly,

but rather I think they have been probably missed because they don't fly.

They don't follow the visual pattern that we look for. Now, interestingly, with the rapid gains in AI. I think it's a very interesting field to see how technology may augment polub detection and whether, even if that does so, whether that translates to any real world benefits in one of the scope hospitals where I scope at the moment, we the hospital has purchased this AI gizmo.

And so I do turn it on when I do colonoscopies. And I personally feel it's kind of like maybe having a. role monitor in a classroom looking behind me to make sure that I keep focus and I don't copy anyone else's work. So I, I'm not certain if if the polyp guide itself helps or whether it's a Hawthorne effect and I do actively look further and more more actively.

The other thing that I'd like to say, which I have adopted is a paper which has been put

published by James Church about 10 years ago in DCR called Keeping the Cecum Clean. And he advocates giving Imodium one hour after the last bowel movement in an attempt to prevent bile leaking into the right colon and making it a lot harder to visualize that area.

And so particularly for patients who I scope in the afternoon, I do prescribe Imodium and I think it helps me perhaps this is a role for some more research within the now AI space. In the advent of A. I., do you feel it, do you, are you able to see the parameters that the A. I. program picks up? Like, does it pick up the same as or more polyps than you would?

And the second question is, do you feel like in the future it might be, do your bowel prep at home, swallow this capsule, and we'll see if this capsule can find polyps before we have to sedate you and put an I. V. in you and make you take the day off of work? Oh, very interesting questions. I,

so again, I'm not an expert at AI.

I love, you know, a stick shift car and an analog watch. So, so it doesn't come naturally to me but what I've noticed is when you do scope, there's a target sign that appears and you can make it more or less sensitive. But I do find that it's quite a lot of noise and the polyps that we agree upon.

I think. that I tend to see anyway, and the polymorphs that the AI picks up versus me, I'm not sure the significance of that. There's a lot of three millimetre little things and whether that's a little bit of debris or not, I don't know. But I do think it, it helps you slow down and look more actively. And that's probably its biggest role at present.

Your concept of, you know, a pill cam type idea is fantastic. And I do believe there are some colonic pill cams now, but of course I think they're up against a very proficient tool in a colonoscopy. And the limiting

factor, of course, is you take the prep, yet you don't get an intervention out of it.

So you still have to then take the prep again if there's a problem which is hard to sell to some patients. In regards to keeping the cecum clean in Dr. Church's paper, he used two tablets, so four milligrams of Imodium one hour after completed the prep. Is that your standard as well?

Yeah I've I'm openly biased to adopting a lot of his ideas. I was fortunate enough to train under him. And so a lot of what I do. Has been influenced by him. Yeah. I mean, I read the paper. It was randomized. It was prospective and there was pretty good results of actually having better detection in the right colon afterward.

So, I'm kind of biased into maybe adopting the practice too, but with the blinded. Yes. Good. Yeah. Okay. So, okay. The challenge is it was one endoscopist. And so I think that there is a question of how how translatable it would be to,

to both other institutions and other practitioners and also the endoscopist himself has a incredible experience in endoscopy.

So, I think his eye of caliber being calibrated to, you know, flat polyps would be far ahead of mine. All right. Well, let's move on to our fourth and last case. Dr. Cavalucos, you have a 45 year old male who you're performing a first time screening colonoscopy for, and you find a 35 millimeter semi pedunculated mid rectal polyp.

What are your thoughts and next steps in addressing this lesion? So the first thing that is really important is to recognize that rectal cancer is not the same as colon cancer. They're treated differently. The importance of staging up front is every bit as important, if not more important than colon cancer.

Certainly, we always want to know if a patient has metastatic disease. But for colon cancer, the lymph nodes and, you know, positive lymph nodes that may appear on the CT scan don't necessarily change

your surgical treatment, whereas for rectal cancer, it most certainly needs in this day and age, usually indicates total neoadjuvant treatment.

So the first thing that I do when I look at it is, how much do I think that this may be a cancer or not? The gross characteristics of malignancy are obvious things like depression, ulcerations. If I try to go to a resected or a saline injected, if it won't lift, meaning that it may be invasive to the underlying layers that is something that is a big warning sign to tell me to sort of get away.

There's also pit patterns Kudo explained in his paper over several different reports that there's, you know, there's five levels of pit patterns, level four and five, really irregular and can oftentimes it's just the surface of the polyp and how it looks can tip you off that the irregularity of the glands on the surface may indicate malignancy.

There's no other endoscopic signs with that can tell you really how invasive it is. Obviously, that's at the bottom of the

polyp, but the things that do portend a higher risk of superficial invasion into the submucosa are typically size over two centimeters or non granular lateral spreading lesions.

Some of these lesions with these features should be considered either for End block endoscopic resection because this may, you know, obviously optimize the pathologic assessment of any lesion if you need to do full thickness versus whether or not and Dr. Glendick I'm sure will talk a little bit more about, you know, if you're able to palpate it and in general how this feels.

So how does everyone do their saline lift since it's been mentioned? Do you have any tips or tricks for the listeners? I mean, I think it's really important to always start in a normal area when you do your saline lift. And then Dr. Kavloukis has taught me as well to maybe start more proximal to the polyp and inject it there to bring the polyp towards you rather than push it away.

Dr. Wolshensky, do you have any? Tips or

tricks? Not really. I sometimes find that saline lift is absorbs quite quickly. And so I do want to make sure that the equipment I need to remove the polyp is in the room. Nothing drives me more. Crazy than sort of preparing something and then realizing that I don't have the right snare.

So it's a practical thing, but that's probably something which is very important. When I started scoping, we used to use jelly fusion, which is a colloid solution. I don't really use it anymore. It's actually quite hard to get in the hospital. I don't think it's stocked as readily as it used to be, but that may be an option because obviously the call load would not absorb as quickly.

I mean, the colored solutions that are available, I think I honestly don't think they make it any easier than just using saline. And then it all also must might be worthwhile for some of the younger listeners to know that, you know, there's, cold versus hot snare. Cold usually has is less likely

to bleed and, you know, to consider if you're taking a polyp from the right side of the colon where it might be a little thinner versus the left or the rectum, which is, you know, extra peritoneal.

And that, you know, part of the AGA's best practices that use a cold snare for all Cecel polyps, three to nine millimeters. So, okay, moving along, Dr. Bulszynski, what are your thoughts on tattooing this area of the mid rectum? Ah, yeah it's an interesting question. Thank you. So obviously tattooing is very useful in confirming the location of a cancer in general, and this would enable precise surgical excision, particularly MIS.

However, both the cecum and the rectum I believe are exceptions to this because they can both be confidently and accurately identified without needing tattoo, both endoscopically and then minimally invasively for surgery. So for polyps identified outside the rectum, I guess the I think it,

it significantly improves things.

And I think it's important to know that the technique of tattooing is important and that you want to be injecting in an oblique. Manna and I think Dr Hyman's recommendations were a four quadrant circumferential tattooing technique to improve circumferential visualization and that technique involves about 0.

2 to 0. 5 mils of Indian ink raised in a bleb about one centimeter distal to the tumor or lesion. Now, of course, there are, however, downsides of tattooing, and this brings us back to the question about the tattooing in the mid rectum, and so I think the plane of dissection may be obscured if transmural injection and spillage of the dye occurs it may also cause submucosal fibrosis, and therefore, a delayed lift would be far more challenging, and also, if you are to then perform a TME there is a query whether The tattoo would cause inflammation in the mesorectum and also cause that dissection to be more challenging.

So, it's certainly it's not a free intervention. There are costs. Do you have a comment? I typically I think that in the advent of, Watch and wait depending on where the certainly you would think that it should be pretty easy to be able to at least see a scar that you're going to surveillance in certain cases.

I think that it may be important to put. the tiniest bit of ink just so that you're certain which wall it's on or if it's, especially if it's somewhere in the second or third rectal valve area where you're not necessarily going to be able to feel the scar either. I've had, you know, at least three cases now where I have scoped them after they got their chemo radiation and It's like, you know, wow, thank goodness.

There was a tattoo there because you really could not tell where the tumor was. It might just be useful for photographic surveillance and documentation as you follow it and I mean, I agree. I don't think that

it's necessarily, you know, when I do my. I don't say, okay, there's the tattoo. I see it.

Thank goodness. Now I just need to get a distal margin. I just put a very tiny bit around the cancer. If I think that watch and wait is hopefully an option that this patient is going to go after. Or also, I think if you have a rectal polyp that looks suspicious, particularly the pedunculated polyps, where once you excise it, you might not be able to identify it anymore.

If you think there, you might not need to resect it or do a local excision afterwards. I think they're tattooing the site of the excision also within a small amount of a tattoo. I think it's useful. And regardless of where tattoos are placed. to document exactly what your thought process was, where you put the tattoo relative to the lesion is always helpful for you or whoever the next person is who's going to help this patient, which is not always the case.

So it's always

good. to have a reminder. Yeah, I can't agree more with this because you may be surveying this patient for the next 20 years. And reproducibility is incredibly important. It's almost, I think this component of surgery is like playing chess. You want to think, you know, four moves ahead of what you're going to be faced with.

And if you tattoo each patient differently you know, come there fifth or 10th scope. you have no idea what was the original idea that you had and good luck finding the notes at that point. Sure. I think it's also, I'm a little bit leery. I don't disagree with you. The CECM has definite landmarks that should make you aware that you're there.

However, I have seen the CECM confused time and time again. So if I oftentimes will get a polyp that has been excised that has some sort of carcinoma at the margin. I will scope them the day before I operate on them to make sure that I sort of agree that they were

at the cecum and not the hepatic flexure.

I agree with you and that brings up a different debate whether One should trust anyone else's scope entirely before you operate on them, because I certainly, if I scope someone and identify the secum, I'm confident that that's the secum. And if someone tells me that they identified the secum, I'm sadly far less confident.

Yeah. The case that I had described earlier was tattooed and the entire upper half of the rectum was blue. So a case of a bit inappropriate tattooing . But I guess, I mean, these are real world things that happen. I mean, as surgeons who I think are largely the listening audience of this podcast, I mean, we're, we are out there most days doing colonic resections and doing colonoscopies, you know, 10 to 20% of that time.

So. I think it's a lot of you know, you don't want to subject patients to ongoing repeat colonoscopies. And a lot of these things are kind

of out of your hands, but sort of figuring out how you're going to deal with it is something that you will adapt to as you go through your practice and you learn who kind of refers you lesions and how they've been treating them.

Well, I think today's been a really great discussion and we've all learned a little something new. But we've got to wrap it up with our five quick hits of the day. The first being remember that the screening age for first colonoscopy for average risk patients is 45 years old, and ColoGuard is another option for those special cases that we mentioned.

A malignant polyp is defined as neoplastic invasion of the submucosa without extension into the muscular asopria. Cess ulcerated lesions progress to carcinoma along the CPG methylation pathway and carry malignant potential. Large polyps should be orientated on a rigid surface before sending to pathology and formalin.

And always consider pathology re review prior to proceeding with resection.

So, thank you all for your attention, and until next time, dominate the day!