Villous adenoma in 108 patients

Villous SAMUEL

Adenoma M.D. AND RICHARD

II. PORTER,

Prom the Department o_f Surgery, Hospitals, Iowa City. Iowa 52240.

University

of Iowa

FTf3R continued follow-up of A tients with vilfous adenoma

sixty-nine papreviously reported [I], as well as an additional thirty-nine we have found the conservative patients. therapeutic approach to be both prudent and effective. For years the question of local excision or radical resection has confronted the surgeon encountering a clinically benign villous adenoma. Turell [.!?I, Dreese et al. [3], Hayes [F], Ramirez et al. [C] and others have also advocated the conservative approach, primarily because most lesions are benign, the patients are elderly and thus poor operative risks, and because there is little evidence that benign villous adenomas undergo malignant degeneration. This study reaffirms our original advocacy of total biopsy in the initial management of villous adenomas of the large bowel. If the biopsy reveals invasive cancer, then the lesion must be treated as a cancerous one. CLINICALMATERIAL

The patients in this study include sixty-nine patients with villous adenomas seen at the University of Iowa Hospitals from 19.52 through 1961. A summary of experience with these patients was published in 1963 [I 1. I&ye have continued to observe these sixty-nine patients and have added thirty-nine more, who were treated from lY(i:! through 1963. The villous adenoma is a soft, mobile, mucouscovered, exophytic, papillary lesion of the large bowel. We excluded from this study tumors in which lixation, induration, or ulceration indicated invasion. The villous adenoma has numerous synonyms: villous tumor, villous polyp, papillary adenoma, glandular papilloma. papillomatous polyp, and colonic papilloma. The difficulty in determining the invasive qualities of a villous adenoma is emphasized by comparing the gross features of the lesions in Figures 1 and 2. They are similar in appearance; both are soft, non-

in 108 Patients D. LIECHTY,

M.D., Iowl

City, lawc~

ulcerated, and clinically without induration. Histologically the lesion in Figure 1 shows typical papillar? growth, but without invasion (Fig. 3). The lesion in Figure 2 is identical grossly to the other tumor but there is greater cellular atypia and invasion into the muscularis mucosa (Fig. 1). Six of the 10X patients refused excision, though five had incisional biopsy. All specimens were benign histologically. Three of these patients have been followed up. One is dead of unknown cause. one is asymptomatic after two years, and in the other obstruction developed and the patient required colostomy but has refused definitive therapy on the rectal lesion. RESULTS

One hundred eight patients with 1 I 1 tumors, clinically benign, were reviewed. There were fifty-six male and fifty-two female patients whose average age was 65.2 years. Histologically benign tumors comprised 79 per cent and malignant tumors represented 21 per cent of the lesions. Operative mortality for all methods of treatment was 5.5 per cent. Of the 111 tumors, 105 were located in the rectum or lower part of the sigmoid colon. Two were in the cecum, tbvo in the hepatic flexure, and one each in the transverse and descending colon. (Fig. 5.) Other primary malignant neoplasms occurred in seventeen of the 1OS patients (13.7 per cent). The location of these lesions was as follows: gastrointestinal tract, eight patients; bronchus, two; prostate, two; gallbladder. one; skin and oral cavity, three; uterus, one. Treatment has been classified as local resection or extensive resection. Local methods include simple cauterization, transanal excision, or colotomy with excision of the tumor and posterior rectotomy with excision. Extensive resection includes segmental or colonic resecresection, and pulltion, abdominoperineal through procedures. Treatment was attempted

14

1 1. Benign villous adenoma;

” note the glistening,

soft surface without

FIG. 2. Malignant villous adenoma with gross characteristics in Figure 1. Clinically there was no induration.

identical

ulceration.

to those shown

FIG. 3. The microscopic picture of the villous adenoma seen in Figure 1. There is orderly papillary growth without invasion.

in 102 instances. Seventy-two local resections were carried out for sixty-three benign lesions and nine malignant ones. Extensive resections were performed for seventeen benign and thirteen malignant tumors. Over-all operative mortality was 5.5 per cent. Three deaths occurred in the first group of sixty-nine patients. All three deaths were in patients with benign lesions. Two were in patients who underwent extensive resections. In the second group three patients also died in the postoperative period. Two of these patients were being treated for malignant tumors. One had peritonitis after a small bowel obstruction

and one died of sepsis after a wound dehiscence. The third died of a colotomy leak and perotonitis after excision of a benign lesion. All three patients were aged, being seventy-one, eighty-two, and eighty-five years old, respectively. Follow-up study of the patients treated from 1952 through 1961 substantiated our previous conclusion that patients with villous adenomas are usually elderly and poor operative risks. Of the sixty-nine patients treated in the first group, thirty-eight have died and one cannot be found, and thus is presumed dead (57 per cent). Twenty-one died of cardiovascular causes and two of cerebral vascular disease. Fifteen died of The

American

Journal

of Surgery

Villous

cancer, five of which I\-ere primary

in the colon or rectum. Of the patients treated between 1961 and 1965, three died in the postoperative period and two died later. secondary to cardiovascular disease. Thus the over-all mortality in the patients with tjro to five year follow-up study is 13 per cent. Total recurrence in the 102 treated patients was ten, or 93 per cent. In the first group of patients, the sixty-nine treated between 1952 and 1961, three benign and three malignant tumors recurred. In the second group of patients, the thirty-nine treated between 1962 and 1965, two benign and two malignant tumors recurred. Benign recurrent lesions in the first group all followed transanal excision. In group two, one recurrence of a benign lesion followed transanal excision and the other followed colotomy and excision. In no patient was the original tumor benign and the recurrent tumor malignant.

Adenoma

section or a lo\\-anterior resection with an accompanying precarious anastomosis. We believe that most of these tumors can be treated by local excision with significantly less mortality and morbidity. Of the grossly benign villous adenomas approximately one fifth are malignant histologically. They commonly occur in old people who have a high incidence of severe associated systemic disease. This is substantiated by this study which revealed that thirty-eight of the originally treated sixty-nine patients were dead. Most died of cardiac disease, although fifteen had cancer, only five cases of which were in the colon. This reaffirms our earlier conclu-

COMMENTS

In the past surgeons have had difficulty deciding what surgical therapy is indicated when confronted with a large papillary tumor which resembles cancer. Some have treated these primarily as malignant neoplasms. Since most occur in the rectum and low part of the sigmoid colon, this often means abdominoperineal re-

FIG. 5. Location patients).

of villous adenomas

(111 tumors in 10%

Porter and Liechty

16 STEP

1

GROSS

-----------.

DIAGNOSIS

“BENIGN”

VILLOUS

HISTOLOGIC

Stops--------__

TUMORS

DIAGNOSIS

(FRACTIONAL

BIOPSIES)

BenigYYhlignm+ STEP 3 ___

LOCAL

(FROZEN

/ RESECTION

AND/OR

SERIAL

\ CANCER

OPERATION

SECTIONS)

Benign /\lignon+

\

Age

I STEP4-------

CANCER

OPERATION LOCAL

FIG. 6. Scheme for planning

treatment

sions that associated malignant disease is frequent in patients with villous adenoma. The length of the follow-up period assumed special importance in evaluation of recurrences. The over-all recurrence rate in 102 patients was 9.3 per cent. Of the sixty-nine patients in the first group there were three benign and three malignant recurrent lesions; of the thirty-nine patients in the second group, there were two benign and two malignant recurrent tumors. Of the total of five benign recurrent lesions, four occurred after transanal excision. Re-excision of recurrent rectal tumors has been simple and safe in our experience. The fifth benign recurrent tumor occurred after transabdominal colotomy. Special care should be taken to insure complete excision of upper colonic tumors. Transabdominal operations are, of course, more formidable than anorectal procedures. There were five malignant recurrent lesions. Each patient had the appropriate operation for cancer and had recurrence in spite of this, or they had a limited operation because of operative risk. In either instance little will be done to change the recurrence rate in this group. No benign lesion recurred as a malignant one. With these facts in mind, we recommend again the scheme illustrated in Figure 6 for surgical treatment. Grossly benign villous adenomas should be excised locally and totally. If a malignant lesion is present and the risk of a big operation is not too great, an operation for cancer should be performed. If the risk is overwhelming, then local excision or cauterization are the alternatives. If the lesion is benign, periodic

Risk

/

1 I

RESECTION

of grossly benign villous tumors.

re-examinations will detect recurrences which the patients are treated accordingly.

for

SUMMARY

One hundred eight patients with grossly benign villous adenomas of the large bowel are reviewed. Approximately 20 per cent of the clinically benign tumors show malignant characteristics histologically. These lesions occur in elderly people with other concurrent disease. About 16 per cent of the patients have other primary cancerous lesions. Recurrence rate in all patients was 9.3 per cent, whereas the operative mortality was 5.5 per cent. In no instance was a recurrent lesion malignant, when the original lesion was histologically benign. We, therefore, urge a conservative approach in therapy; total local excision of the tumor, followed by histologic examination. If it is malignant, an operation for cancer should be performed. If the lesion is benign, the patient should be periodically re-examined. REFERENCES

1. LIECHTY, R. D. and RATERMAN, L. Villous adenoma, a surgical dilemma. Arck. Surg., 87: 107, 1963. 2. TURELL, R. The cancer potential of colorectal adenomas. Am. J. Surg., 103: 529, 1962. 3. DREESE, W. C., GRADINGER, B. C., HELLWIG, C. A., WELCH, J. W., and MCCUSKER, E. N. Villous tumors of the rectum and sigmoid. Surg. Gynec. & Obst., 115: 182, 1962. 4. HAYES, M. A. Panel discussion: adenomas of the large intestine and their malignant potential. Am. J. Surg., 101: 91, 1961. 5. RAMIREZ, R., CULP, C. E., JACKMAN, R. J., and DOCKERTY, M. B. Villous tumors of the lower part of the large bowel. J.A .M .A., 194: 863, 1965. The American

Journal

of Surgevy