Malignant colorectal polyps: venous invasion and successful treatment by endoscopic polypectomy

We reviewed the pathology of 81 malignant colorectal polyps in 80 patients treated by endoscopic polypectomy and assessed the importance of carcinomatous invasion of veins in the stalk (submucosa). All the patients were followed up for at least five years. Venous invasion was present in 30 of the polyps (37%). The histological features of lymphatic invasion were considered too subjective to be of value. Most of the tumours were well or moderately differentiated adenocarcinomas, one was poorly differentiated, and one was a signet ring cell carcinoma. Seventy one patients were treated by polypectomy alone, and 58 of these were alive and well five years later, with no evidence of recurrence. Nine died of unrelated causes within five years, but four died of carcinomatosis: one with recurrent tumour, one with a possible metachronous caecal cancer, and in two patients there was late development of malignancy of uncertain nature. The remaining nine patients underwent surgical resection after initial endoscopic polypectomy because of incompleteness of excision, poor differentiation of the tumour, or a decision by the surgeon. Tumour was not present in the resection specimens apart from a single lymph node deposit in the patient with signet ring cell carcinoma. These nine patients were alive and well without evidence of recurrence five years later. The results reemphasize the necessity of good cooperation between endoscopist and pathologist, meticulous laboratory technique, strict histopathological criteria including examination of resection margins and degree of differentiation of the tumour, and regular endoscopic follow up. Endoscopic polypectomy of pedunculated and sessile malignant polyps is adequate treatment if the lesion can be removed in one piece, the tumour is well or moderately differentiated, and local excision is judged complete by endoscopic and histological criteria. Patients with histologically incompletely excised polyps, containing well or moderately differentiated carcinoma, can be safely managed by conservative treatment provided the endoscopist is certain there is no residual tumour. Venous invasion by tumour is a common finding in malignant colorectal polyps and seems to have no prognostic importance.