Correspondence
Risk of lymph node metastasis in malignant colorectal polyps
C. Beaton*†, B. M. Stephenson*† and G. L. Williams*†
doi:10.1111/codi.12404
*North Devon District Hospital, Barnstaple, UK and †Royal Gwent Hospital, Newport, UK E-mail: [email protected]
Dear Sir, We enjoyed the comprehensive ACPGBI Position Statement on the Management of the Malignant Colorectal Polyp, published as a supplement in Colorectal Disease [1]. Along with many other members of colorectal cancer multidisciplinary teams, we welcome this publication on what is a controversial topic for both clinician and patient. The real question after endoscopic resection of a malignant polyp is the ‘absolute’ risk of lymph node metastasis on an individual basis. This is indeed difficult to predict. We have very recently published the only specific meta-analysis of histopathological factors influencing the risk of lymph node metastasis in early colorectal cancer [2]. Data were taken from 4510 patients in 23 cohort studies, none of which was randomized. This scrutiny of the current literature confirmed a statistically significant increased risk of lymph node metastasis with poor differentiation, lymphovascular invasion, submucosal invasion > 1 mm and tumour budding. In patients fit enough for resectional surgery an informed discussion, based on these factors, can be had with regard to lymph node metastasis risk. Some multidisciplinary teams are over-zealous with regard to the ‘need for surgery’, citing the dread of potential metastatic risk, and there is a wide variation in practice amongst teams dealing with malignant polyps [3]. Indeed, a critical review from Germany, of 114 ‘low-risk’ cases, suggested that endoscopic polypectomy alone was quite satisfactory [4]. These two most recent publications will update clinicians on the evidence with which best to inform the management of their patients and will hopefully help to eradicate disparities in the management of malignant colorectal polyps. The ideal would be to conduct a multicentre randomized control trial to evaluate the impact of management strategies, but this would be an enormous task and is unlikely to occur. All clinicians therefore need to scrutinize regional nonrandomized comparative audits carefully, especially with the increasing detection of these malignant polyps via the national screening programmes.
Received 9 August 2013; accepted 17 August 2013; Accepted Article online 27 August 2013
References 1 Williams JG, Pullan RD, Hill J et al. Management of the malignant colorectal polyp: ACPGBI position statement. Colorectal Dis 2013; 15(Suppl. 2): 1–38. 2 Beaton C, Twine CP, Williams GL, Radcliffe AG. Systematic review and meta-analysis of histopathological factors influencing the risk of lymph node metastasis in early colorectal cancer. Colorectal Dis 2013; 15: 788–97. 3 Gill MD, Rutter MD, Holtham SJ. Management and short term outcome of malignant colorectal polyps in the north of England. Colorectal Dis 2013; 15: 169–76. 4 Seitz U, Bohnacker S, Seewald S, Thonke F et al. Is endoscopic polypectomy an adequate therapy for malignant colorectal adenomas? Presentation of 114 patients and review of the literature. DCR 2004; 47: 1789–96.
Reply to Beaton et al. doi:10.1111/codi.12447
Dear Sir, We are grateful to Beaton et al. [1] for their comments on our Position Statement [2]. Both studies highlight factors that predict the risk of lymph node involvement in a malignant colonic polyp. Beaton et al. are to be commended on the rigorous scientific approach they applied to their analysis of the available literature. The risk of lymph node metastasis in a malignant polyp is fundamental to decision making following polypectomy. However, the risk is difficult to estimate as more than one adverse factor may be present and it is hard to assess how multiple factors combine to influence the absolute risk of lymph node involvement. It is for this reason that we concluded our Position Statement with an overview of how different factors combine to influence the likelihood of lymph node involvement. We accept that this is an estimate only and the chart will evolve as more information becomes available.
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, 67–72
67
Correspondence
The second issue to be considered when managing a patient with a malignant polyp with adverse histology is what is the risk to the patient of surgical resection of the relevant part of the colon or rectum from which the polyp arose? Whilst agreeing with Beaton et al. that a randomized trial of management strategies would the ideal, this would be a Herculean task which would present major difficulties in obtaining consent for inclusion in a trial. What would be much more likely to succeed and produce valuable information to guide future management of this challenging problem is a malignant polyp registry, which would include endoscopic and histological information about the polyp, information about the patient, decision making and follow-up information. Properly resourced and with accurate data submission and follow-up, a large number of polyps could be collated fairly quickly as these lesions are not rare and most multidisciplinary teams regularly discuss the management of these lesions. Such information would add considerably to our understanding of how to manage patients with a malignant polyp.
J. G. Williams*, J. Hill† and N. Haboubi‡ *Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, WV10 0QP, UK; †Manchester Royal Infirmary, Manchester, M13 9WL, UK and ‡University Hospital of South Manchester, Manchester, M23 9LT, UK E-mail: [email protected] Received 6 September 2013; accepted 15 September 2013; Accepted Article online 8 October 2013
Reference 1 Beaton C, Stephenson BM, Williams GL Risk of lymph node metastasis in malignant colorectal polyps. Colorectal Dis 2014; 16: 67. 2 Williams JG, Pullan RD, Hill J et al. Management of the malignant colorectal polyp: ACPGBI position statement. Colorectal Dis 2013; 15(Suppl 2): 1–38.
Sacral transcutaneous stimulation for faecal incontinence may have a different mechanism of action to sacral nerve stimulation
over the entire sacrum for faecal incontinence [3]. tSNS appears to be cheaper and safer than sacral nerve stimulation (SNS). The mechanism of action for both techniques of sacral stimulation is uncertain. When SNS is performed under general anaesthetic, the correct position of an SNS electrode lead is confirmed by external anal sphincter (EAS) activity. Fowler et al. have suggested that this activity is likely to be a reflex response mediated by afferent spinal pathways, rather than direct efferent stimulation [4]. We attempted to see if tSNS has a similar effect upon the EAS. If so, it could be theorized that tSNS has a similar mechanism of action to SNS. Approval was given by the local Ethics Committee, and informed consent was obtained. Five patients with faecal incontinence underwent SNS under general anaesthetic. All underwent tSNS just prior to SNS lead placement. Two active 90 9 50 mm electrode pads were placed over the sacrum and two ground pads were positioned lateral to these. Stimulation of the entire sacrum was performed using a Neurotrac Continence machine (Verity Medical Ltd., Braishfield, Hampshire, UK). Continuous stimulation was applied with a pulse width of 210 ls, a frequency of 14 Hz and an amplitude of 60 mA. EAS activity was assessed by visual inspection and by electromyography (EMG), performed using a needle electrode. Buttock contractions were seen during tSNS in all patients. However, no visible activity of the EAS was observed. No compound muscle action potentials of the EAS were observed on EMG. Visible contraction of the EAS was observed in all patients during the subsequent test phase of SNS. We suggest that tSNS may have a different mechanism of action to SNS, although a significant placebo effect cannot be disregarded. Larger studies are needed to investigate tSNS further.
G. P. Thomas, C. Norton, R. J. Nicholls and C. J. Vaizey The Sir Alan Parks Department of Physiology, St Mark’s Hospital and Academic Institute, Watford Road, Harrow, HA1 3UJ, UK E-mail: [email protected] Received 6 June 2013; accepted 12 June 2013; Accepted Article online 8 August 2013
doi:10.1111/codi.12376
References Dear Sir, Several small studies have suggested that transcutaneous sacral nerve stimulation (tSNS) may be an effective treatment for faecal incontinence in the short term [1–3]. We recently reported the outcome of 10 patients who had undergone bilateral transcutaneous stimulation
68
1 Chew SS, Sundaraj R, Adams W. Sacral transcutaneous electrical nerve stimulation in the treatment of idiopathic faecal incontinence. Colorectal Dis 2011; 13: 567–71. 2 Leung E, Francombe J. Preliminary results of sacral transcutaneous electrical nerve stimulation for fecal incontinence. Dis Colon Rectum 2013; 56: 348–53.
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, 67–72
Copyright of Colorectal Disease is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Risk of lymph node metastasis in malignant colorectal polyps
C. Beaton*†, B. M. Stephenson*† and G. L. Williams*†
doi:10.1111/codi.12404
*North Devon District Hospital, Barnstaple, UK and †Royal Gwent Hospital, Newport, UK E-mail: [email protected]
Dear Sir, We enjoyed the comprehensive ACPGBI Position Statement on the Management of the Malignant Colorectal Polyp, published as a supplement in Colorectal Disease [1]. Along with many other members of colorectal cancer multidisciplinary teams, we welcome this publication on what is a controversial topic for both clinician and patient. The real question after endoscopic resection of a malignant polyp is the ‘absolute’ risk of lymph node metastasis on an individual basis. This is indeed difficult to predict. We have very recently published the only specific meta-analysis of histopathological factors influencing the risk of lymph node metastasis in early colorectal cancer [2]. Data were taken from 4510 patients in 23 cohort studies, none of which was randomized. This scrutiny of the current literature confirmed a statistically significant increased risk of lymph node metastasis with poor differentiation, lymphovascular invasion, submucosal invasion > 1 mm and tumour budding. In patients fit enough for resectional surgery an informed discussion, based on these factors, can be had with regard to lymph node metastasis risk. Some multidisciplinary teams are over-zealous with regard to the ‘need for surgery’, citing the dread of potential metastatic risk, and there is a wide variation in practice amongst teams dealing with malignant polyps [3]. Indeed, a critical review from Germany, of 114 ‘low-risk’ cases, suggested that endoscopic polypectomy alone was quite satisfactory [4]. These two most recent publications will update clinicians on the evidence with which best to inform the management of their patients and will hopefully help to eradicate disparities in the management of malignant colorectal polyps. The ideal would be to conduct a multicentre randomized control trial to evaluate the impact of management strategies, but this would be an enormous task and is unlikely to occur. All clinicians therefore need to scrutinize regional nonrandomized comparative audits carefully, especially with the increasing detection of these malignant polyps via the national screening programmes.
Received 9 August 2013; accepted 17 August 2013; Accepted Article online 27 August 2013
References 1 Williams JG, Pullan RD, Hill J et al. Management of the malignant colorectal polyp: ACPGBI position statement. Colorectal Dis 2013; 15(Suppl. 2): 1–38. 2 Beaton C, Twine CP, Williams GL, Radcliffe AG. Systematic review and meta-analysis of histopathological factors influencing the risk of lymph node metastasis in early colorectal cancer. Colorectal Dis 2013; 15: 788–97. 3 Gill MD, Rutter MD, Holtham SJ. Management and short term outcome of malignant colorectal polyps in the north of England. Colorectal Dis 2013; 15: 169–76. 4 Seitz U, Bohnacker S, Seewald S, Thonke F et al. Is endoscopic polypectomy an adequate therapy for malignant colorectal adenomas? Presentation of 114 patients and review of the literature. DCR 2004; 47: 1789–96.
Reply to Beaton et al. doi:10.1111/codi.12447
Dear Sir, We are grateful to Beaton et al. [1] for their comments on our Position Statement [2]. Both studies highlight factors that predict the risk of lymph node involvement in a malignant colonic polyp. Beaton et al. are to be commended on the rigorous scientific approach they applied to their analysis of the available literature. The risk of lymph node metastasis in a malignant polyp is fundamental to decision making following polypectomy. However, the risk is difficult to estimate as more than one adverse factor may be present and it is hard to assess how multiple factors combine to influence the absolute risk of lymph node involvement. It is for this reason that we concluded our Position Statement with an overview of how different factors combine to influence the likelihood of lymph node involvement. We accept that this is an estimate only and the chart will evolve as more information becomes available.
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, 67–72
67
Correspondence
The second issue to be considered when managing a patient with a malignant polyp with adverse histology is what is the risk to the patient of surgical resection of the relevant part of the colon or rectum from which the polyp arose? Whilst agreeing with Beaton et al. that a randomized trial of management strategies would the ideal, this would be a Herculean task which would present major difficulties in obtaining consent for inclusion in a trial. What would be much more likely to succeed and produce valuable information to guide future management of this challenging problem is a malignant polyp registry, which would include endoscopic and histological information about the polyp, information about the patient, decision making and follow-up information. Properly resourced and with accurate data submission and follow-up, a large number of polyps could be collated fairly quickly as these lesions are not rare and most multidisciplinary teams regularly discuss the management of these lesions. Such information would add considerably to our understanding of how to manage patients with a malignant polyp.
J. G. Williams*, J. Hill† and N. Haboubi‡ *Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, WV10 0QP, UK; †Manchester Royal Infirmary, Manchester, M13 9WL, UK and ‡University Hospital of South Manchester, Manchester, M23 9LT, UK E-mail: [email protected] Received 6 September 2013; accepted 15 September 2013; Accepted Article online 8 October 2013
Reference 1 Beaton C, Stephenson BM, Williams GL Risk of lymph node metastasis in malignant colorectal polyps. Colorectal Dis 2014; 16: 67. 2 Williams JG, Pullan RD, Hill J et al. Management of the malignant colorectal polyp: ACPGBI position statement. Colorectal Dis 2013; 15(Suppl 2): 1–38.
Sacral transcutaneous stimulation for faecal incontinence may have a different mechanism of action to sacral nerve stimulation
over the entire sacrum for faecal incontinence [3]. tSNS appears to be cheaper and safer than sacral nerve stimulation (SNS). The mechanism of action for both techniques of sacral stimulation is uncertain. When SNS is performed under general anaesthetic, the correct position of an SNS electrode lead is confirmed by external anal sphincter (EAS) activity. Fowler et al. have suggested that this activity is likely to be a reflex response mediated by afferent spinal pathways, rather than direct efferent stimulation [4]. We attempted to see if tSNS has a similar effect upon the EAS. If so, it could be theorized that tSNS has a similar mechanism of action to SNS. Approval was given by the local Ethics Committee, and informed consent was obtained. Five patients with faecal incontinence underwent SNS under general anaesthetic. All underwent tSNS just prior to SNS lead placement. Two active 90 9 50 mm electrode pads were placed over the sacrum and two ground pads were positioned lateral to these. Stimulation of the entire sacrum was performed using a Neurotrac Continence machine (Verity Medical Ltd., Braishfield, Hampshire, UK). Continuous stimulation was applied with a pulse width of 210 ls, a frequency of 14 Hz and an amplitude of 60 mA. EAS activity was assessed by visual inspection and by electromyography (EMG), performed using a needle electrode. Buttock contractions were seen during tSNS in all patients. However, no visible activity of the EAS was observed. No compound muscle action potentials of the EAS were observed on EMG. Visible contraction of the EAS was observed in all patients during the subsequent test phase of SNS. We suggest that tSNS may have a different mechanism of action to SNS, although a significant placebo effect cannot be disregarded. Larger studies are needed to investigate tSNS further.
G. P. Thomas, C. Norton, R. J. Nicholls and C. J. Vaizey The Sir Alan Parks Department of Physiology, St Mark’s Hospital and Academic Institute, Watford Road, Harrow, HA1 3UJ, UK E-mail: [email protected] Received 6 June 2013; accepted 12 June 2013; Accepted Article online 8 August 2013
doi:10.1111/codi.12376
References Dear Sir, Several small studies have suggested that transcutaneous sacral nerve stimulation (tSNS) may be an effective treatment for faecal incontinence in the short term [1–3]. We recently reported the outcome of 10 patients who had undergone bilateral transcutaneous stimulation
68
1 Chew SS, Sundaraj R, Adams W. Sacral transcutaneous electrical nerve stimulation in the treatment of idiopathic faecal incontinence. Colorectal Dis 2011; 13: 567–71. 2 Leung E, Francombe J. Preliminary results of sacral transcutaneous electrical nerve stimulation for fecal incontinence. Dis Colon Rectum 2013; 56: 348–53.
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, 67–72
Copyright of Colorectal Disease is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
