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Recommended Procedure for Large Polyp Removal
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Recommended Procedure for Large Polyp Removal

Hello,

My mom went for a colonoscopy recently and they found a large polyp (2-3cm) just where the rectum ends and the colon starts (at "4th valve").  The doctor who performed the procedure told us she had cancer as my mom came out of anesthesia.  We scheduled an appointment with a reputable colorectal surgeon/surgical oncologist and got the biopsy results back during our visit with the surgeon.  Four biopsy samples were taken during the original colonscopy and the results were tubular adenoma.  The surgeon reviewed the information/symptoms/photos/results and preliminarily diagnosed it as a large adenoma polyp. He indicated that this particular spot in the colon was common for large non-cancerous polyps to form. As anyone would, he warned there was still a chance of a carcinoma being within the polyp.

The surgeon indicated he might be able to remove the entire polyp transanally.  He is going to do a colonscopy himself this week to review the polyp/location further.  If he can remove it transanally, he recommended doing so as an inital step and having the entire polyp biopsied to determine the future course of action.  If he can't, he recommended laproscopic surgery to remove the polyp.  

Now that you have the background, my questions are:

1.  Is going transanally/biopsy/determine future course an acceptable first course of action or is it too passive?  I've read conflicting information.  Some say it's fine so long as the entire polyp is removed, others say even if it is benign a piece of the colon must come out along with some nodes just to be safe.  Note the surgeon did say if carcinoma was found in the polyp she'd have to go back in for surgery...

2.  We recently had a CT scan done to be safe.  Haven't seen the results but could they tell enough information to potentially change the course of action?  For example, if there was carcinoma would the CT scan be able to tell if it penetrated the colon wall?

3.  I keep reading about transanal endoscopic microsurgery (TEM).  Seems to be a good technique (more thorough/involved than traditional transanal "polyechtomy") but very few do it.  Any suggestions on how to find a physician that does this in the NYC area?

Thanks in advance.  

Ken

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To answer your questions:
1) It is difficult to give personal recommendations without reviewing the chart.  The decision for a surgical vs endoscopic approach would depend on the position, size and microscopic characteristics of the polyp.  

If there is conflicting opinions, I would continue to consider additional surgical options - preferably at a major academic medical center.  

2) The CT scan will help in determining the best treatment option.  Normally the scan in conjunction with colonoscopy is needed to determine the best treatment approach.

3) I am not a surgeon, so I cannot comment on this approach.  I do not practice in NYC, so I cannot make any specific physician recommendations.  I would start at one of the major academic medical centers there (NYU, Mt. Sinai, Columbia, or Cornell).

These options can be discussed with your personal physician.

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Kevin, M.D.
kevinmd_b
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Looking for any additional thoughts...This has been an emotional saga as follows:

Mid-January - First Colonoscopy, prelim diagnosis CA.
Late January - Follow up with Surgeon/biopsy results, his prelim diagnosis, large non-CA polyp.
Early February - Second Colonscopy/comprehensive biopsy.  Surgeon felt there was no CA based on look/feel/mobility.
Late February - Biopsy results come back as moderately differentiated adenocarcinoma associated with a tubular-villous adenoma.  Surgeon recommends neoadjuvant chemo/radiation followed by resection without doing further staging.
Late February - We went to a renowned surgeon at Sloan-Kettering in NYC for a second opinion.  Ultrasound indicated a T1 lesion (early).  He recommended resection only because it was so early.  Surgery date set for March 31.
Early March - The surgeon calls back and indicates his pathology department has reviewed the biopsy slides and believes it is not CA.  His recommendation is to have a gastroent remove the lesion so the entire thing can be biopsied (March 14 date).

Additional info, the lesion is at 12 cm and is 3 cm dia.

Questions are:

1)  How can the diagnosis of CA be so varied by different institutions (based on pathology)?  Seems to me the "cells" would be cut and dry, it is or it isn't.  I have to say I trust Sloan-Kettering most since this is all that they deal with.

2)  Is there any risk of "making things worse" by removing the polyp through conventional means if it does come back as CA?  Or does it not matter since we have surgery scheduled for March 31 anyway?

3)  If it comes back as "pre-cancerous" only but they cannot remove the full polyp through conventional means, I presume she should go in for surgery to ensure removal of all of the pre-cancer cells?

4)  Finally, we're a little scared about doctors now.  If it does come back as pre-cancer and we went with the first surgeon, she would have gone through chemo/radiation and radical surgery for no reason!  Conversely, I don't want to be to passive if it really is CA.  Do you think it is worthwhile to get a 3rd opinion?  I have to say everything I've read on our current NYC surgeon indicates he is world renowned and probably the best we're going to get.

Thanks again.
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