*Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK, †Torbay Hospital, Torquay, UK, ‡Department of General Surgery, Manchester Royal Infirmary, Manchester, UK, §Royal Infirmary, Glasgow, UK, ¶Department of Histopathology, Royal Bolton NHS Foundation Trust, Bolton, UK, **Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK, ††The Royal Marsden Hospital, London, UK, ‡‡Salisbury NHS Foundation Trust, Salisbury, UK and §§Department of Histopathology, University Hospital of South Manchester, Manchester, UK

https://onlinelibrary.wiley.com/doi/pdf/10.1111/codi.12262

Management of the malignant colorectal polyp: ACPGBI position statement

In this article, the underlying nature of the adenoma is defined and evidence in support of the adenoma-carcinoma sequence is presented. Emphasis is placed on recent findings from the field of molecular biology which fortify the concept of the adenoma as a step in the evolution of large bowel cancer. Despite the considerable body of indirect evidence in support of the adenoma-carcinoma sequence, the de novo theory still has some support. Although differences between the de novo and adenoma carcinoma concept are largely semantic, the fact that infiltrating carcinoma can arise within small, flat foci of severely dysplastic epithelium (indistinguishable from carcinoma in situ) may be of considerable clinical importance. Other routes of morphogenesis exist also, but these make a relatively small contribution to the overall incidence of colorectal cancer. Even if it is accepted that the majority of colorectal cancers develop in a preexisting adenoma, the systematic removal of adenomas would pose a number of practical difficulties. First, adenomas are extremely common, particularly in populations at high risk of colorectal cancer. A second factor is the recently recognized existence of flat or depressed adenomas which may be small and difficult to visualize endoscopically. A simple screening program based on our knowledge of the evolution of colorectal cancer is outlined.

Do all colorectal carcinomas arise in preexisting adenomas

31. Cannon-Albright LA, Skolnick MH, Bishop DT, et al: Common inheritance of susceptibility to colonic adenomatous polyps and associated colorectal cancers. N Engl J Med 1988;319:533-537. 32. Guillem JG, Forde KA, Treat MR, et al: Colonoscopic screening for neoplasms in asymptomatic first-degree relatives of colon cancer patients. Dis Colon Rectum 1992;35:523-529. 33. Winawer SJ, Zauber AG, Gerdes H, et al: Risk of colorectal cancer in the families of patients with adenomatous polyps: National Polyp Study Workgroup. N Engl J Med 1996;334:82-87. 34. St. John DJB, McDermott FT, Hopper JL, et al: Cancer risk in relatives of patients with common colorectal cancer. Ann Intern Med 1993;118:785-

https://onlinelibrary.wiley.com/doi/pdf/10.3322/canjclin.47.2.93

Management of colorectal polyps

Invasive carcinomas in polyps removed during endoscopy are described. Most of them can be treated adequately by polypectomy alone, but some need additional surgical treatment. Incomplete excision, poorly-differentiated carcinoma, and lymphatic invasion are associated with increased risk of residual carcinoma and lymph node metastases, making colorectal resection more attractive; however, in elderly patients and poor-risk patients, the risks of surgery should be balanced against the possible advantage of curative surgery. Rectal polyps may be large but sphincter preservation can usually be achieved by different types of local excision. Recently described flat adenomas may contain carcinoma, but may also be treated by polypectomy using snare or hot biopsy.

Treatment of carcinoma in adenomas

The fundamental aspects of optical coherence tomography and a brief description of its applications in medicine and biology are presented The impact of multiple scattering in tissues on OCT imaging performance, and developments in reducing the overwhelming multiple scattering effects and improving imaging capabilities by the use of immersion technique are discussed A novel technique based on the use of biocompatible and hyperosmotic chemical agents to impregnate the tissue and to enhance the OCT images is described The mechanisms for improvements in imaging depth and contrast are discussed, primarily through the experimental examples

Optical Coherence Tomography: Light Scattering and Imaging Enhancement 16

World experience now overwhelmingly supports the policy of conservative management by endoscopic snare polypectomy of "focal" cancer in polyps (malignancy in adenomas and polypoid carcinomas), providing that the polyp is pedunculated and that endoscopic and histological criteria are favorable. Invasion to within 2-3 mm of the snare-resection line is acceptable, providing that the advancing tumour margin is well-circumscribed. Unfavourable characteristics include poorly differential tumour, involvement of stalk vessels, and sessile configuration. This management policy applied to 90 patients between 1971 and 1981 resulted in successful 5-year follow-up of the 74 patients treated by polypectomy alone. Among the 16 patients managed surgically, no local lymph nodes were involved in any case, although 4 patients were found to have residual local tumour at the polypectomy site.

Practical aspects of endoscopic management of malignant polyps.

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Practical aspects of endoscopic management of malignant polyps.