Haggitt classification of pedunculated and sessile polyps. Reprinted permission Classification of submucosal (Sm) invasion of malignant polyps. Reprinted. Looking for online definition of Haggitt classification in the Medical Dictionary? Haggitt classification explanation free. What is Haggitt classification? Meaning of . The Haggitt level is a histopathological term used for describing the degree of infiltration from a malignant Kikuchi level (sessile tumor invasion classification) .
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Colon cancer remains a significant clinical problem worldwide and in the United States it is the third most common cancer diagnosed in men and women. It is generally accepted that most malignant neoplasms of the colon arise from precursor adenomatous polyps. This stepwise progression of normal epithelium to carcinoma, often with intervening dysplasia, occurs as a result of multiple sequential, genetic mutations-some are inherited while others are acquired.
Malignant polyps are defined by the presence of cancer cells invading through the muscularis mucosa into the underlying submucosa T1. They can appear benign endoscopically but the presence of malignant invasion histologically poses a difficult and often controversial clinical scenario. Emphasis should be initially focused on the endoscopic assessment of these lesions.
Suitable polyps should be resected en-blocif possible, to facilitate thorough evaluation by pathology. In these cases, proper attention must be given to the risks of residual cancer in the bowel wall or in the surrounding lymph nodes. If resection is not feasible endoscopically, then these patients should be referred for surgical resection.
This review will discuss the important prognostic features of malignant polyps that will most profoundly affect this risk profile. Additionally, we will discuss effective strategies for their overall management. This article discusses the important prognostic features of clsasification polyps that will ultimately inform the overall management. Colorectal cancer remains a challenging clinical entity worldwide and in the United States it is the third most common cause of cancer-related mortality in both men and women.
Fortunately, classitication incidence of colorectal cancer is declining, in large part due to more prevalent educational and screening programs designed to detect early cancers and their precursor polyps[ 1 ]. This adenoma-carcinoma sequence is well described and is often an indolent process that can take many years to fully manifest after a stepwise accumulation of genetic alterations[ 23 ].
While adenomatous polyps can harbor high-grade dysplasia and other non-invasive histology, malignant polyps are defined by the invasion of adenocarcinoma through the muscularis mucosa but limited to the submucosa pT1. However, the treatment of larger lesions can be more challenging and require more advanced techniques, such as endoscopic mucosal resection EMR or endoscopic submucosal dissection ESDwhich are being used with increasing frequency in specialized centers.
These techniques afford the opportunity for complete excision rather than a piecemeal approach. This is a critical initial step in the overall management of malignant polyps because a complete excision facilitates a more comprehensive histological examination. Unfortunately, this is not the typical presentation in routine clinical practice. More commonly, a patient presents for evaluation after a resected polyp, thought to have a benign appearance at endoscopy, is found to have an invasive focus of adenocarcinoma on final pathological review.
This scenario calssification often become further complicated if the polypectomy site is not marked at the initial endoscopy. This limits endoscopic re-evaluation, if needed, and renders untrustworthy the proper identification of the involved segment of colon if definitive resection is deemed appropriate.
Analysis of the existing body of data demonstrates that this is still a controversial topic that generally requires a multidisciplinary approach. Polyps are initially characterized endoscopically by their size and morphology, which are two important features that may predict underlying malignancy and should ultimately guide how advanced polyps are managed.
Morphologically, polyps can be hagfitt classified as either pedunculated or sessile. Pedunculated polyps are those attached to the colonic mucosa by a stalk of variable length, while sessile polyps grow in a more flattened pattern over the mucosa with less separation of the cclassification epithelium from the underlying layers of the bowel wall[ 4 ].
The latter are often, understandably, more difficult to completely remove with conventional snare polypectomy, depending on their location within the colon and their size.
Using a prospective registry of colorectal polyps, Nusko et al[ 5 ] performed a multivariate analysis of adenomas detected at colonoscopy. Larger polyps between 1.
Ultimately, the endoscopic assessment of polyps can be a subjective process that can vary between endoscopists. Fortunately, as image resolution has improved, there has also been an appreciable improvement in the ability to further characterize the endoscopic appearance of these polypoid lesions.
The uses of narrow band imaging and chromoendoscopy have been shown to be effective adjuncts in this process. Narrow band imaging uses light at specific wavelengths, which enhances visualization of the mucosal surface and the associated vessels.
In conjunction with routine imaging, chromoendoscopy uses special dyes that stain the mucosa and provides contrast between normal and abnormal tissue[ 78 ].
Management of malignant colon polyps: Current status and controversies
Using these concepts, the Paris and Kudo pit classification systems further assess the degree of irregular contours, ulcerations, and pit patterns using magnifying chromoendoscopy to stratify risk of underlying malignancy[ 9 ]. While clwssification can be helpful, these classifications are still poorly standardized globally, which can lead to marked interobserver variability[ 10 ].
Histologically, polyps are classified by several factors but perhaps the most important feature is the depth of invasion. InHaggitt et al[ 11 ] put forward a classification system for pedunculated and sessile polyps based on the depth of invasion of adenocarcinoma.
According classificatlon this classiifcation system, pedunculated classifucation can be classified as levels Level 0 indicates cancer cells that are limited to the mucosa but do not penetrate through the muscularis mucosa carcinoma in situ or intramucosal carcinoma. Levels 1 through 3 pertain to pedunculated polyps only. Haggirt 1 indicates cancer cells invading through the muscularis mucosa into the submucosa but limited haggiitt the head of the polyp.
When the cancer cells invade into the level of the neck the junction of the head and the stalk of the polyp, this denotes level 2. Level 3 indicates cancer cells invading any part of the stalk and level 4 signifies cancer cells invading into the submucosa of the bowel wall below the stalk of the polyp but above the muscularis propria.
In this landmark study, they found that level 4 invasion was associated with statistically significant adverse prognostic factors[ 4611 ]. These findings were confirmed in subsequent studies. Nivatvongs et al[ 12 ] reported a series of patients undergoing colectomy for polyps with invasive carcinoma to determine the incidence of lymph node metastasis based on depth classififation invasion. Haggitt classification of pedunculated and classifiation polyps.
Reprinted permission from[ 29 ]. Sm1-invasion into the upper third of the submucosa; Sm2-invasion into the middle third of the submucosa; Sm3-invasion into the lower third of the submucosa. Classification of submucosal Sm invasion of malignant polyps. However, use of this classification system can prove challenging for pathologists if the endoscopically resected specimen does not classlfication a significant portion of the submucosa or some of the muscularis propria, which would define the deepest border of the submucosa.
Others have modified this classification system in more practical terms by measuring the degree of submucosal invasion from the muscularis mucosa[ 16 ]. The requisite margin of a polypectomy resection is still a matter of much debate due to the risk of luminal recurrence. InButte haggith al[ 18 ] reported a series of colectomies performed following classificatiin in patients hwggitt clear or suspicious submucosal invasion. In addition to the depth of invasion and margin status, invasive adenocarcinomas can also be classified by distinct histologic findings, namely tumor budding architecture, degree of differentiation, or the presence of lymphovascular invasion.
These are among the more commonly studied pathologic features, which can be of important prognostic significance that may ultimately influence management. As compared with grade 1 well-differentiated adenocarcinomas, grade 3 poorly-differentiated cancers have been shown to be associated with adverse outcomes. Similarly, the presence of lymphovascular invasion has been significantly associated with increased lymph node metastasis[ havgitt1920 ].
Tumor budding refers to small clusters of undifferentiated cancer cells ahead of the invasive front of the lesion. While this is not a routinely haggott pathologic parameter, there is increasing evidence that the quantitative assessment of tumor budding reflects clinical aggressiveness of colon cancers. This has also been shown by some to be a poor prognostic feature[ 20 – 22 ]. Although the diagnosis of invasive adenocarcinoma in polyps is ultimately based on histological examination, the overall clinical management of malignant polyps should begin with their initial assessment at the time of index endoscopy-based on the size and morphology.
Those suspicious for submucosal invasion or not deemed amenable for endoscopic removal should be referred for definitive surgical resection. It is important that the polyp site be marked to facilitate identification at the time of surgery. Larger, sessile polyps should be referred to advanced endoscopists for consideration for EMR or ESD with the ultimate goal of complete, intact resection for histological evaluation. Endoscopic mucosal resection was developed for removal of sessile polyps confined to the mucosa and submucosa and is typically used for complete excision of lesions up to 2 cm.
Resección endoscópica de cáncer colorrectal temprano como único tratamiento
This typically involves an initial submucosal injection of saline, or other suitable injectates, which elevates the identified lesion and facilitates its removal from the deeper layers with an electrocautery snare[ 2324 ]. The inability to lift a polyp with submucosal injection heralds the potential for deeper invasion by malignancy, and indicates suitability for endoscopic management.
Endoscopic submucosal dissection is generally employed for larger GI lesions but has not been widely adopted for advanced colorectal polyps. Similar to EMR, ESD initially involves the saline lift of the polyp; however, this is followed by a mucosal incision and submucosal dissection with specialized endoscopic electrosurgical knives[ 2325 ].
These techniques are more technically challenging and are associated with slightly higher risk of serious complications bleeding and perforation. Again it classificatipn paramount that the polypectomy site be marked endoscopically so that the area can be reassessed for surveillance or can be identified if surgery is needed. These patients should be referred for definitive oncologic segmental resection, if medically fit for surgery[ 26 ].
Colectomy can be carried out in the traditional open technique or with a laparoscopic approach. Laparoscopy provides the benefits of less postoperative pain, quicker recovery of bowel function postoperatively, shorter hospital stays, improved cosmesis, and earlier return to normal activities without compromising oncologic results[ 2627 ].
Low-risk polyps are characterized by the lack of these poor prognostic features and, if completely classificafion, can be managed adequately with conventional polypectomy and appropriate surveillance.
Algorithm for the management of malignant classfiication polyps. Using this risk stratification, Choi et al[ 22 ] reported a series of 87 patients that were followed prospectively after endoscopic resection of a malignant polyp. Twenty patients with high-risk features opted for surveillance or had prohibitive factors for radical surgery. There were 30 patients without risk factors, and none developed lymph node metastasis or recurrent cancer after opting for surgery or haggift 22 ].
The United States Multi-Society Task Force on colorectal cancer and other international organizations have established clear guidelines on colonoscopy surveillance after polypectomy based on the size and number of adenomatous polyps excised[ 828 ]. However, currently there is no established standard for surveillance after endoscopic removal of malignant polyps in patients that do not undergo surgery.
Most authors suggest initial follow up endoscopy in mo but the duration of subsequent surveillance varies[ 810 ]. There does not appear to be a role for routine CT imaging due to its poor sensitivity.
The management of malignant polyps can be challenging and often requires a multidisciplinary approach. Emphasis should be placed on the proper initial endoscopic assessment of these polyps and appropriate, complete resection using conventional snare polypectomy or more advanced techniques, such as endoscopic mucosal resection.
Similarly, appropriate surveillance after polypectomy is critical to mitigate the risk of recurrent or metachronous disease. By understanding the risk factors associated with lymph node metastases based on the anatomic and histologic features of polyps, we as clinicians, can help risk stratify our patients and make rational, safe and informed choices for surgery. Qi Y L- Editor: National Center for Biotechnology InformationU. Journal List World J Gastroenterol v. Published online Nov Author information Article notes Copyright and License information Disclaimer.
Management of malignant colon polyps: Current status and controversies
Aarons CB haggit the literature review, wrote and edited the review; Shanmugan S helped with the editing of the review; Bleier JIS designed the manuscript and critically analyzed and edited the review. This article has been cited by other articles in PMC. Abstract Colon cancer remains a significant clinical problem worldwide and in the United States it is the third most common cancer diagnosed in men and women.
Malignant polyp, Endoscopic mucosal resection, Submucosal invasion, Early haygitt cancer, Lymphovascular invasion, Tumor budding.