Malignant polyp, stalk invaded

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Dom1991
Posts: 7
Joined: Sun Sep 03, 2017 5:18 am

Malignant polyp, stalk invaded

Postby Dom1991 » Sun Sep 03, 2017 7:22 am

A young relative has recently been diagnosed with a large malignant predunculated adenoma in the sigmoid colon. The polyp was completely excised in one clean cut during the colonoscopy which discovered it, and the colon lining was tattoed. The pathology report showed that the cancer had invaded into the bottom half of the polyp stalk, but showed there was a clear margin between the boundary of the cancer and the colon wall lining where the polyp was excised. Would this mean the polyp is a level 3 on the haggitt level? Presumably if it was level 4 then there would be no margin at the bottom of the stalk since the cancer would have passed through the submucosa line of the bowel wall, so would be found at the very bottom of the stalk?

The pathology report was shown to the top pathologist in the hospital and the first thing he said was that they will not die from this. I know nothing in medicine is 100% but i suppose i should take some comfort in this as i doubt the pathologist would make a statement like that unless they were fairly confident.

If there is a margin at the bottom of the stalk but the cancer has still invaded into the stalk, how likely do you think it is that the cancer would invade the lymphovascular system? Would the cancer not have to pass the clear margin at the bottom of the stalk to reach the lymph nodes?

The relative is having a CT and MRI scan next week as a matter of course, and then the doctor has agreed to do a small surgical resection to be absolutely sure that there will be no recurrence. We know the hospital team personally so I suspect that we are being given ultra conservative treatment options.

Any advice much appreciated.

Andrea1976
Posts: 380
Joined: Sun Jan 03, 2016 10:32 am

Re: Malignant polyp, stalk invaded

Postby Andrea1976 » Sun Sep 03, 2017 11:54 am

Sorry to hear. I had the same type of polyp. But my invasion was level 1 haggit - limited to the head of the polyp. I was considering surgery / colon resesction but cancer center surgical GI oncologist met with me several times and said no / refused. So I put my life in his hands and hope for the best.
I would recommend to send the pathology for 2nd opinion to a cancer center if you want to be sure. I am in touch with young female who also had level 3 haggit and didn't have surgery. Level 4 is considered to have surgery. Everything above is questionable based on the pathology. What does the pathology say excactly? I am almost 2 years out.

From what you said. Yes, it's Haggit level 3. You can look at NCCN guidelines for malignant polyps. There are other factors. Personally I would not be happy with less than 2 mm clear margins. Your question if this could still spread? Yes, it could. Generally the chances are about 10% but even with surgery and no lymphnodes it could still spread. There were several cases here. With Haggit level 1 it's listed as 1-6% chance so still not 0.
Stage I
pedunculate polyp in descending colon
moderately diff adenocarcinoma 0.6 cm
Tumor confined to the head of the polyp
Stalk margin 2 cm negative for dysplasia and malignancy
Polyp removed during colonoscopy 1/15/16
No lymphovascular involved
No surgery
CEA after polyp removal 0.3
Genetic testing negative for colon and breast cancer
39 year old female. I am not celebrating my 40th but waiting for my big 50 birthday party!!!

veckon
Posts: 131
Joined: Thu Jul 27, 2017 7:44 am

Re: Malignant polyp, stalk invaded

Postby veckon » Sun Sep 03, 2017 12:04 pm

Dom1991 wrote:A young relative has recently been diagnosed with a large malignant predunculated adenoma in the sigmoid colon. The polyp was completely excised in one clean cut during the colonoscopy which discovered it, and the colon lining was tattoed. The pathology report showed that the cancer had invaded into the bottom half of the polyp stalk, but showed there was a clear margin between the boundary of the cancer and the colon wall lining where the polyp was excised. Would this mean the polyp is a level 3 on the haggitt level? Presumably if it was level 4 then there would be no margin at the bottom of the stalk since the cancer would have passed through the submucosa line of the bowel wall, so would be found at the very bottom of the stalk?

The pathology report was shown to the top pathologist in the hospital and the first thing he said was that they will not die from this. I know nothing in medicine is 100% but i suppose i should take some comfort in this as i doubt the pathologist would make a statement like that unless they were fairly confident.

If there is a margin at the bottom of the stalk but the cancer has still invaded into the stalk, how likely do you think it is that the cancer would invade the lymphovascular system? Would the cancer not have to pass the clear margin at the bottom of the stalk to reach the lymph nodes?

The relative is having a CT and MRI scan next week as a matter of course, and then the doctor has agreed to do a small surgical resection to be absolutely sure that there will be no recurrence. We know the hospital team personally so I suspect that we are being given ultra conservative treatment options.

Any advice much appreciated.


A "malignant adenoma" is called adenocarcinoma. Does the pathology report actually say adenocarcinoma? If not, it is not cancer yet.

The term cancer is unfortunately overloaded in many medical contexts. I suspect what you are confused about on the pathology is alternatively called "carcinoma in situ", "pre-cancer", and sometimes "non-invasive cancer". At the end of the day, this type of neoplasm can be removed before it becomes adenocarcinoma. As long as it is removed, it will not become cancer.

Regardless, I would advise genetic testing to make sure he/she doesn't have a pathological mutation, like Lynch Syndrome.

Also, the term lymphovascular implies both the lymphatic system and the vascular system. Tumor circulating cells in your blood can spread to distant organs purely through blood circulation, so lymph node invasion is not a hard requirement. It can be either or both or neither. Some metastasis has no known explanation.

In fact, I have liver metastases from rectal adenocarcinoma and no visible lymphatic invasion. Cancer metastasis is complex and a subject of research. It isn't as well understood as Google may indicate.
27 yo male
Metastatic rectal cancer diagnosed 12/16
Liver metastases and peritoneal carcinomatosis
Lynch syndrome, MSI-H
Failed liver resection 3/17
FOLFOX6 12/16 - 05/17
Keytruda 5/17 - present
@Memorial Sloan Kettering

Andrea1976
Posts: 380
Joined: Sun Jan 03, 2016 10:32 am

Re: Malignant polyp, stalk invaded

Postby Andrea1976 » Sun Sep 03, 2017 1:08 pm

From the original post. Yes, it is adenocarcinoma haggit level 3 / stage 1 colon cancer. Haggit level 0 is non invasive - precancerous. Level 1 is head, level 2 neck, level 3 stalk and level 4 colon wall invasion. Most pedunculated adenocarcinomas don't require surgery. But it is all individual case type of decision. I agree with genetic testing. I had all the genetic testing done.

Also lymphovascular invasion should be noted in the pathology and also grade etc.
Stage I
pedunculate polyp in descending colon
moderately diff adenocarcinoma 0.6 cm
Tumor confined to the head of the polyp
Stalk margin 2 cm negative for dysplasia and malignancy
Polyp removed during colonoscopy 1/15/16
No lymphovascular involved
No surgery
CEA after polyp removal 0.3
Genetic testing negative for colon and breast cancer
39 year old female. I am not celebrating my 40th but waiting for my big 50 birthday party!!!

Dom1991
Posts: 7
Joined: Sun Sep 03, 2017 5:18 am

Re: Malignant polyp, stalk invaded

Postby Dom1991 » Mon Sep 04, 2017 2:51 pm

Hi guys,

thanks so much for your replies it's much appreciated. I need to get hold of the pathology report as i believe i now have a solid base of understanding to read it. One thing which is confusing me is the distinction between the sub mucosa of the predunculated polyp, and the submucosa of the colon wall. Are these separate or the same thing. I guess I don't really understand what the stalk of a polyp really is biologically, and if there is any actual barrier at the bottom of the stalk where the colon wall is. If there is a clear margin of no cancer at the bottom of the excised stalk, then i don't understand how the cancer jumps past this margin? I am guessing it's through lymp vessels or blood vessels which must presumably come into the stalk? Is there a lower chance of the cancer spreading through the vessels inside the stalk, as opposed to say, the vessels below the colon wall.

Thanks again for all advice.

veckon
Posts: 131
Joined: Thu Jul 27, 2017 7:44 am

Re: Malignant polyp, stalk invaded

Postby veckon » Mon Sep 04, 2017 4:55 pm

Dom1991 wrote:Hi guys,

thanks so much for your replies it's much appreciated. I need to get hold of the pathology report as i believe i now have a solid base of understanding to read it. One thing which is confusing me is the distinction between the sub mucosa of the predunculated polyp, and the submucosa of the colon wall. Are these separate or the same thing. I guess I don't really understand what the stalk of a polyp really is biologically, and if there is any actual barrier at the bottom of the stalk where the colon wall is. If there is a clear margin of no cancer at the bottom of the excised stalk, then i don't understand how the cancer jumps past this margin? I am guessing it's through lymp vessels or blood vessels which must presumably come into the stalk? Is there a lower chance of the cancer spreading through the vessels inside the stalk, as opposed to say, the vessels below the colon wall.

Thanks again for all advice.


I think what you are asking about is called tumor angiogenesis. I can't do the subject justice here, but https://en.wikipedia.org/wiki/Angiogene ... giogenesis might be a good starting point.

(Like everything else about cancer, keep in mind it's a reflection of what the writer(s) think we know now and not necessarily reflective of the objective, and complex, biological reality, which is the subject of ongoing research.)
27 yo male
Metastatic rectal cancer diagnosed 12/16
Liver metastases and peritoneal carcinomatosis
Lynch syndrome, MSI-H
Failed liver resection 3/17
FOLFOX6 12/16 - 05/17
Keytruda 5/17 - present
@Memorial Sloan Kettering

Dom1991
Posts: 7
Joined: Sun Sep 03, 2017 5:18 am

Re: Malignant polyp, stalk invaded

Postby Dom1991 » Tue Sep 05, 2017 4:05 pm

Thanks again for all your replies everyone, I can already see what a supportive community this is. GREAT NEWS - the MRI (3 Tesla) and CT results came back today and it was all completely normal, no sign of metastasis and no sign of any lymph node enlargement or missed polyps in the colon.

Of course we are far from out the woods yet, but it's great news going into my relatives surgery next month. I haven't been able to talk with the doctor but I presume that these scans make it fairly sure that there is no distant metastasis, and the clear MRI scan showing no enlarged nodes is a positive indicator in terms of the risk of lymph node metastasis. I do, however, understand that these are only indicators and nothing is guaranteed in medicine, but I feel like these clear scans are a great sign for a haggitt level 3 polyp.

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susie0915
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Facebook Username: Susan DeGrazia Hostetter
Location: Michigan

Re: Malignant polyp, stalk invaded

Postby susie0915 » Tue Sep 05, 2017 5:48 pm

That is good news.
58 yrs old Dx @ 55
5/15 DX T3N0MO
6/15 5 wks chemo/rad
7/15 sigmoid/scar tissue left
8/15 Pet scan NED
9/15 LAR
0/24 nodes
10/15 Bowel blockage. surgery,early ileo rev, c-diff inf :(
12/15 6 rds of xelox
5/16 Clear CT lung scarring/inflammation
9/16 clear colonoscopy
4/17 CT 4mm lung nod
7/17 no change lung nod
10/17 Clear pel/abd CT
11/17 CEA<.5
1/18 CT/Lung no change in 4mm nodule
5/18 CEA<.5, clear CT pel/abd/lung nod no change

Andrea1976
Posts: 380
Joined: Sun Jan 03, 2016 10:32 am

Re: Malignant polyp, stalk invaded

Postby Andrea1976 » Tue Sep 05, 2017 9:38 pm

Great news! So she/he will have colon resection?
Stage I
pedunculate polyp in descending colon
moderately diff adenocarcinoma 0.6 cm
Tumor confined to the head of the polyp
Stalk margin 2 cm negative for dysplasia and malignancy
Polyp removed during colonoscopy 1/15/16
No lymphovascular involved
No surgery
CEA after polyp removal 0.3
Genetic testing negative for colon and breast cancer
39 year old female. I am not celebrating my 40th but waiting for my big 50 birthday party!!!

Dom1991
Posts: 7
Joined: Sun Sep 03, 2017 5:18 am

Re: Malignant polyp, stalk invaded

Postby Dom1991 » Wed Sep 06, 2017 7:35 am

Yes he will have the colon resection surgery, the doctor performing it is very experienced and it will be robotic surgery with no need for a bag. I know surgery is debated for haggitt level 3 polyps with clear resection margins, but given his young age (reduced chance of surgery issues) and the strong chance of quick recovery from surgery, it's felt it's much better to be safe than sorry.

DarknessEmbraced
Posts: 3128
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Facebook Username: Riann Fletcher
Location: New Brunswick, Canada

Re: Malignant polyp, stalk invaded

Postby DarknessEmbraced » Wed Sep 06, 2017 2:18 pm

I hope your surgery goes well!*hugs*
Diagnosed 10/28/14, age 36
Colon Resection 11/20/14, LAR (no illeo)
Stage 2a colon cancer, T3NOMO
Lymph-vascular invasion undetermined
0/22 lymph nodes
No chemo, no radiation
Clear Colonoscopy 04/29/15
NED 10/20/15
Ischemic Colitis 01/21/16
NED 11/10/16
CT Scan moved up due to high CEA 08/21/17
NED 09/25/17

Dom1991
Posts: 7
Joined: Sun Sep 03, 2017 5:18 am

Re: Malignant polyp, stalk invaded

Postby Dom1991 » Mon Sep 25, 2017 11:35 am

Hi guys,

Just seen some information on the histology report, and the following summary was given.

Histology showed a TVA with low grade dysplasia, however there was a focus of moderately differentiated adenocarcinoma. There was also an element of perineural invasion, however no other bad features were seen. Follow up staging scan including CT abdo/pelvis of the chest and MRI pelvis which has not shown any worrying abnormalities. Options of management were either intensive follow up with endoscopy and serial MRI scans versus an anterior re-section.

I'm a little confused as I thought a TVA with low grade dysplasia meant it wasn't cancer. I also find the terminology a little confusing, such as a 'focus' of moderately differentiated adenocarcinoma, and an 'element' of perineural invasion. Any ideas?

Thanks :)

Andrea1976
Posts: 380
Joined: Sun Jan 03, 2016 10:32 am

Re: Malignant polyp, stalk invaded

Postby Andrea1976 » Wed Sep 27, 2017 3:51 pm

TVA - tubuvillious adenoma would be my guess? My whole polyp stalk was just regular adenoma. Head of the polyp was high grade adenoma with 0.6 cm invasive cancer / adenocarcinoma. Often times with large polyps if part are high grade adenoma than a small section / focus of invasive cancer could be found. Do you know how big was the actual invasive component? perineural invasion - I didn't have one. My pathology says no perineural invasion. I wish my pathology reports how deep in mm my invasive cancer went into submucosa of the head. It only states superficial invasion.
Stage I
pedunculate polyp in descending colon
moderately diff adenocarcinoma 0.6 cm
Tumor confined to the head of the polyp
Stalk margin 2 cm negative for dysplasia and malignancy
Polyp removed during colonoscopy 1/15/16
No lymphovascular involved
No surgery
CEA after polyp removal 0.3
Genetic testing negative for colon and breast cancer
39 year old female. I am not celebrating my 40th but waiting for my big 50 birthday party!!!

Dom1991
Posts: 7
Joined: Sun Sep 03, 2017 5:18 am

Re: Malignant polyp, stalk invaded

Postby Dom1991 » Wed Sep 27, 2017 4:15 pm

Yes that's what it is. I don't actually know to be honest, I know the cancer was confined to the head and was only small, but I know it did penetrate into the submucosa of the head. I also know there was a clear resection margin and the whole polyp was taken off cleanly at the stalk.

It was the wording of an element of perineural invasion that threw me, as not sure what this means.

Andrea1976
Posts: 380
Joined: Sun Jan 03, 2016 10:32 am

Re: Malignant polyp, stalk invaded

Postby Andrea1976 » Wed Sep 27, 2017 4:52 pm

If it was only in the head than no stalk invasion. Than it's Haggit 1. Stalk invasion - cancer in the stalk is Haggit 3.
Stage I
pedunculate polyp in descending colon
moderately diff adenocarcinoma 0.6 cm
Tumor confined to the head of the polyp
Stalk margin 2 cm negative for dysplasia and malignancy
Polyp removed during colonoscopy 1/15/16
No lymphovascular involved
No surgery
CEA after polyp removal 0.3
Genetic testing negative for colon and breast cancer
39 year old female. I am not celebrating my 40th but waiting for my big 50 birthday party!!!


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