Definitive Treatment of “Malignant” Polyps of the Colon
Definitive Treatment of “Malignant” Polyps of the Colon
复制标题
“恶性”结肠息肉的根治性治疗
作者：
W. Wolff;H. Shinya
在这个国家，结肠癌的发病率一直在持续上升，最近治愈率没有提高。因此，随着越来越多的证据表明常见的肿瘤性息肉是恶性肿瘤的前兆，结肠直肠癌的演变一直是人们关注的焦点。“肿瘤性”息肉包括“腺瘤性息肉”、“绒毛状腺瘤”和最近认识到的“绒毛腺性息肉”。内镜下切除2,000多个结肠息肉（无死亡）的经验向外科医生提出了两个主要关注的问题：（1）息肉中的临床恶性肿瘤是什么？以及，（2）什么时候应该用腹腔镜手术取代或在内窥镜手术后进行？分析了892例连续腺瘤性（管状）、绒毛状、绒毛腺性（绒毛管状）和“息肉样癌”息肉，其中855例随访6个月至4年。支持绒毛和管状的生长模式仅仅是一个类似的基础干扰细胞更新的变种的概念。浅表癌（原位癌）发生在6.6%的肿瘤性息肉中，如果息肉被完全切除，则没有威胁。只有当癌细胞穿透粘膜肌层时才被认为是“侵袭性的”。““恶性息肉”一词应保留用于这种形式。在这一系列的肿瘤性息肉中，5.0%发现了浸润性癌。只有在这一组中才需要提出进一步手术干预的问题。影响决定后续剖腹手术的主要考虑因素是息肉大小和大体形态（即无蒂或有蒂），组织学类型（息肉和癌症本身），浸润深度和息肉切除平面之间的间隙是否充分，以及患者的年龄和一般状况。这些都进行了分析。46例“恶性息肉”患者中有25例接受了腹部探查：17例显示无残留癌，而8例（5例内镜下切除不完全）肠壁有肿瘤。在剩下的21例患者中，单独内镜息肉切除术被认为是合适的，没有一个在临床和内镜随访中显示出残留或复发的癌症。结肠镜检查似乎是一个最有前途的方法在癌症计划的目标，提供预防和治疗的机会，在一个有利的阶段的疾病。
There has been an unremitting rise in incidence of colonic cancer in this country with no recent improvement in cure rate. As a result the evolution of colorectal cancer has been the focus of considerable attention with an enlarging body of evidence pointing to the common neoplastic polyp as a precursor to malignancy. "Neoplastic" polyps include "adenomatous polyps," "villous adenomas" and, lately recognized, "villo-glandular polyps." Experience with endoscopic removal of over 2,000 colonic polyps (with no mortality) has introduced two questions of prime concern to the surgeon: (1) What constitutes clinical malignancy in a polyp? AND, (2) When should laparatomy supplant or follow endoscopic removal? Eight hundred and ninety-two consecutive adenomatous (tubular), villous, villoglandular (villo-tubular) and "polypoid cancer" polyps are analyzed, 855 of which have been followed for 6 months to 4 years. Support is offered to the concept that villous and tubular growth patterns are merely variants of a similar base disturbance in cell renewal. Superficial cancer (carcinoma-in-situ) occurred in 6.6% of neoplastic polyps and represents no threat if the polyp is completely removed. Only when the cancer penetrates the muscularis mucosae should it be regarded as "invasive." The term "malignant polyp" should be reserved for this form. Invasive cancer was found in 5.0% of neoplastic polyps in this series. Only in this group need the question of further surgical intervention be raised. Major considerations influencing a decision for subsequent laparotomy are polyp size and gross morphology (i.e. sessile or pedunculated), histologic type (of the polyp and of the cancer itself), adequacy of clearance between depth of invasion and plane of polyp resection, and the patient's age and general condition. These are analyzed. Twenty-five of 46 patients with "malignant polyps" were subjected to abdominal exploration: 17 showed no residual cancer, whereas 8 (5 with recognized incomplete endoscopic removal) had tumor in the bowel wall. Of the remaining 21 patients, for whom endoscopic polypectomy alone was deemed appropriate, none have shown residual or recurrent cancer on clinical and endoscopic followup. Colonoscopy appears to be a most promising approach in terms of the goals of cancer programs, offering both prophylaxis and opportunity for treatment at a favorable stage of disease.