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Behemothic villous adenoma of rectum- what is the malignant potential and what is the optimal treatment? A instance and review of literature

  • Pawanindra Lali,
  • Anubhav Vindal1 &
  • Meeta Singh2

World Periodical of Surgical Oncology book 17, Article number:109 (2019) Cite this article

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Abstract

Introduction

Villous adenomas are dubiously benign lesions, which are hard to interpret because of their malignant potential. Distal villous adenomas present with bleeding or mucus discharge. Giant adenomas are not amenable for endoscopic or transanal resection. Just few isolated cases have been reported past laparoscopic resection. We nowadays our example of a circumferential giant villous adenoma of the rectum managed successfully by laparoscopic ultra-depression inductive resection with colo-anal anastomosis with a review of literature in regard to their malignant potential.

Example report

A 62-twelvemonth-old lady presented with complaints of painless bleeding per rectum and a fleshy mass protruding from the anal canal which on digital rectal examination appeared a large soft velvety flat mass with fungus discharge. Colonoscopy showed circumferential irregular, friable, edematous mucosa in rectum extending for 15 cm. Computed tomography showed a large heterogeneously enhancing polypoid mass lesion in the rectal wall involving the entire rectum. The patient underwent laparoscopic low anterior resection with colo-anal anastomosis and protecting loop ileostomy. Histopathological examination of the resected specimen revealed villous adenoma of the rectum with moderate to severe dysplasia.

Discussion

Villous adenomas are sessile growths lined by dysplastic glandular epithelium, whose adventure of malignancy is especially high up to 50% when greater than 2 cm in size. Big size, villous content, and distal location are all associated with astringent dysplasia in colorectal adenomas. Big villous rectal tumors, specially of circumferential blazon pose a great claiming for endoscopic or transanal removal. Henceforth, open or laparoscopic surgery is required for these cases.

Conclusion

Giant rectal villous polyps are usually unresectable by endoscopic methods or transanal endoscopic microsurgery and are associated with a loftier rate of unsuspected cancer which requires a formal radical oncologic resection. Equally per current data, the combined chance of dysplasia/malignancy is about 83% with 50% risk of dysplasia and frank malignancy in 33% of cases of giant rectal villous adenomas of more than eight cm in size. Laparoscopic colorectal resection is safe and constructive.

Introduction

The prevalence of adenomatous polyps of the colon and rectum was reported in approximately 25% of the population aged over 50 years [1]. A recent meta-analysis puts the pooled prevalence in average-run a risk individuals of adenomas, colorectal cancer, non-advanced adenomas, and advanced adenomas at 30.2%, 0.iii%, 17.7%, and 5.vii%, respectively [2]. The larger villous adenomas with severe dysplasia are mostly concentrated in the distal colon (left colon and rectum), in detail in the descending-sigmoid function [3]. As behemothic adenomas are difficult for endoscopic removal and cancerous potential is not known, laparoscopic colectomy offers safe and effective management of these lesions with the benefits of accelerated postoperative recovery [4]. Nosotros present a case of a circumferential giant villous adenoma of the rectum managed successfully past laparoscopic ultra-low anterior resection with colo-anal anastomosis and review of literature in terms of malignant potential and optimal treatment of such tumors.

Example summary

A 62-year-old lady presented to our outpatient department with complaints of painless haemorrhage per rectum from eight months and a fleshy mass protruding from the anal canal from 3 months. The mass was reducible on manual palpation and associated with profuse fungus discharge. The hydration condition of the patient was adequate, she had mild pallor and abdominal exam was essentially normal. On digital rectal exam, a soft velvety apartment mass was appreciated about three cm from anal verge extending from nine o' clock to 5 o' clock forth with fungus belch. The upper extent of the lesion could not be reached. The laboratory investigations revealed hemoglobin 8.iii g%, normal electrolytes with no other abnormalities; carcinoembryonic antigen (CEA) was too within normal range. Initial biopsy revealed villous adenoma with focal moderate dysplasia. A colonoscopy was washed which showed irregular, friable, edematous mucosa in rectum extending for 15 cm nearly circumferentially with no other lesions in the unabridged colon. Contrast-enhanced computed tomography showed a large heterogeneously enhancing polypoid mass lesion in the rectal wall (max thickness 2.5 cm) involving the entire rectum (Figs. one and 2). Surrounding fatty planes were normal and in that location were no enlarged lymph nodes.

Fig. i
figure 1

CECT (transverse section) showing the tumor almost involving entire circumference of rectum

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Fig. 2
figure 2

CECT (coronal section) showing the neoplasm length

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In view of the large size of the lesion with associated moderate dysplasia, a conclusion was made to perform a laparoscopic low inductive resection. The rectum and sigmoid colon were mobilized with high ligation of the inferior mesenteric avenue, total mesorectal excision with circumferential radial margin up to the dentate line and divided beyond the lesion. Colo-anal anastomosis was performed using PROXIMATE® ILS curved intraluminal stapler (25 mm) (Ethicon, Johnson, and Johnson, Cincinnati, OH, USA) and protected by a proximal loop ileostomy. The patient recovered well and was discharged on the 4th post-op twenty-four hour period. At the time of belch, digital rectal examination revealed a preserved anal sphincter tone and no troublesome mucus belch.

On test of the specimen, the lesion was seen to measure 16 × 12 cm, involving nearly whole circumference with a twenty cm proximal and i cm distal margin (Fig. 3). Histopathological test of the resected specimen revealed villous adenoma of the rectum with moderate to severe dysplasia (Figs. 4 and 5). Both the resected ends were free of tumor. Fourteen lymph nodes were isolated, all of which showed reactive changes. The patient underwent restoration of bowel continuity after five months and is healthy up to 1 year of follow-up.

Fig. 3
figure 3

Resected specimen (everted) showing the villous tumor, circumferential

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Fig. 4
figure 4

Histopathology showing villous architecture, × xl, H&E

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Fig. 5
figure 5

Dysplasia as atypical mitotic figures, × 600, H&E

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Discussion

The natural history of colorectal carcinomas has been extensively studied in correlation with the underlying accumulation of genetic alterations equally understood by the adenoma-carcinoma sequence. Adenomas are precursor lesions defined past the presence of intraepithelial neoplasia, characterized by varying degrees of nuclear stratification and loss of polarity. Polyps develop equally mucosal excrescence as a issue of accelerated catacomb fission resulting from APC factor mutation [5].

The 'villous tumor' of the rectosigmoid was commencement described by Que'nu and Landel in 1899. They described very large broad-based rectal tumors associated with secretory diarrhea [6]. The age-related prevalence of colorectal adenoma is 21–28% in l–59 years old, increasing to twoscore–45% in sixty–69 years former and ascent to 53–58% in people over the age of lxx [7]. Histologically, polyps are classified as neoplastic (adenomas) or not-neoplastic. Not-neoplastic polyps accept no malignant potential and include hyperplastic polyps, hamartomas, lymphoid aggregates, and inflammatory polyps. Neoplastic polyps or adenomas have malignant potential and are classified according to the World Health Arrangement equally tubular, tubulovillous, or villous adenomas, depending on the presence and book of villous tissue [viii]. Near of them (70% to 85%) are classified as tubular (< 25% of villous tissue), 10–25% are tubulovillous (25–75% of villous tissue), and 5% are villous adenomas (75–100% of villous tissue) [eight]. Villous adenomas are classically sessile with a velvety or hairy surface and microscopically leafage-like projections lined by dysplastic glandular epithelium. Villous architecture is defined arbitrarily by the length of the glands exceeding twice the thickness of normal colorectal mucosa [8, 9].

Giant polyps are normally defined as more than three cm on endoscopy [ten, eleven]; notwithstanding, limited literature is available about optimal management of giant villous adenomas more than x cm [12, 13]. Our case is 16 × 12 cm which was successfully managed with laparoscopic technique.

The risk of malignant degeneration is related to both the size and type of polyp [two, 9, 10]. Tubular adenomas are associated with malignancy in only 5% of cases, whereas villous adenomas may harbor cancer in upward to twoscore% [2, x]. Tubulovillous adenomas are at intermediate risk (22%). There is less than a 5% incidence of carcinoma in an adenomatous polyp less than i cm in size, whereas there is a fifty% chance that a villous adenoma greater than 2 cm in size will contain cancer [10, eleven]. The risk of malignancy is especially loftier when adenomas are big (> ten mm) and multiple, with a villous pathology [ii, 3, 9]. Not all neoplastic polyps evolve to cancer but near colorectal cancers originate as a polyp. This fact forms the basis for secondary prevention strategies to eliminate colorectal cancer by targeting the neoplastic polyps for removal before malignancy develops [2, 3].

A recent search on PubMed for keywords 'behemothic rectal villous adenoma' and 'behemothic rectal villous tumor' from 2005 to 2018 yielded 33 and 31 results respectively. The keyword 'cancerous potential of rectal villous adenoma' yielded 24 results A total of 25 behemothic villous tumors (including our case) with size range 5–31 cm were reviewed which showed carcinoma (including invasive) in eight, loftier-grade dysplasia in 6, depression- to moderate-course dysplasia in six whereas residuum negative for malignancy (Table 1). It puts the risk of dysplasia to nigh 50 % and malignancy in 33 % of cases of behemothic rectal villous adenomas. This analysis suggests that endoscopically unresectable polyps or giant polyps of villous blazon are best treated by radical oncologic resection.

Tabular array 1. Giant villous tumor of rectum in recent literature with size and cancerous potential

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In a study that analyzed 7590 adenomatous polyps to determine risk factors for loftier-grade dysplasia or invasion, the size was the strongest predictor. The percent of adenomas with high-grade dysplasia or invasive cancer based on the size of the polyp was every bit follows: <5 mm, 3.4%; 5–10 mm, thirteen.5%; and > 10 mm, 38.5% [11]. Big size, villous content and distal location are all associated with severe dysplasia in colorectal adenomas [3, viii,9,10].

Most patients with adenomas are asymptomatic, particularly when their tumour is identified by screening or surveillance [ii, 7, 9, 10]. Hematochezia and anemia are mutual presenting features due to bleeding from the tumor. Rectosigmoid lesions can present with protrusion of mass or tenesmus. Other symptoms include fever, malaise, weight loss, and abdominal pain. Villous rectal tumors may achieve a large size, and look like a "rug" involving the entire rectum, without degenerating into malignant illness [6]. An important fact is that the behemothic villous adenomas may excrete big quantities of fungus and potassium, which tin produce mucus diarrhea and electrolytic alterations. McKittrick-Wheelock syndrome, which is a disorder characterized by fluid and electrolyte depletion, is acquired past a secretory colorectal tumor [32].

Colonoscopy is the process of selection for diagnosing colorectal polyps equally it is the nigh accurate method for detecting polyps of all sizes, and information technology allows biopsy of lesions and resection of most polyps [two, 33, 34]. Endoscopic polypectomy is the mainstay of polyp management because the bulk of lesions are protuberant. Polyp size, position, and access can make this very taxing and a great challenge for endoscopic or transanal endoscopic microsurgery (TEMS) removal. Large villous tumors of the low and mid rectum can exist treated by per-anal resection with recurrence rates equivalent to transanal endoscopic microsurgery; however, the mean length of the tumor was 5.2 cm in this series [35]. TEMS can be employed in lesions upwardly to half-dozen cm in advisedly selected patients but attributable to behemothic size, location, circumferential, and diffuse villous lesion, information technology has not been indicated for such lesions. Such big lesions may approach the dentate line and pose an increased gamble of perforation with serious complications. Some other unfavorable point of endoscopic resection of circumferential rug similar mucosa is the development of stricture [36,37,38,39].

Carditello et al. treated 104 villous tumors of the rectum with a hateful size of 3 cm surgically by local or wide excision. The cancerous potential of the tumors was 30%, including 10% invasive malignancy and recurrence rate was 24 after a mean follow up of half-dozen.5 years [40]. A recent study found that the incidence of cancer in patients undergoing colectomy for an irretrievable polyp is 17.vii% [39]. Open or laparoscopic colorectal resection is the process of pick for lesions not eligible for endoscopic resection and for large sessile villous tumors [4, 23, 26, 39]. It has been demonstrated a mortality charge per unit of 0.3% with an anastomotic leak rate of 1.4% [4, 11, 39]. Consummate excision is warranted for rectal villous adenomas, equally biopsies were accurate just 50% of the time, and 1 in 8 patients had unsuspected cancer found later on excision [35, 37, 41].

Conclusion

Giant villous adenoma is a high-grade dysplastic lesion with conversion rate from adenoma to carcinoma budgeted 17–33%. Troublesome mucus discharge and bleeding may result in severe hemodynamic alterations. Every bit per current data, the combined risk of dysplasia/malignancy is about 83% with 50% take chances of dysplasia and frank malignancy in 33% of cases of giant rectal villous adenomas of more 8 cm in size. Behemothic rectal villous polyps are ordinarily unresectable by endoscopic methods or transanal endoscopic microsurgery and are associated with a high rate of unsuspected cancer which requires a formal radical oncologic resection. Laparoscopic colorectal resection is safe and effective.

Availability of data and materials

The data supporting the conclusions of this article are included in the article.

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Acknowledgements

We thank the contribution of Dr. Daljit Kaur and Varinder Singh in the preparation of this manuscript.

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Affiliations

  1. Section of Surgery, Maulana Azad Medical College, New Delhi, India

    Lovenish Bains, Pawanindra Lal & Anubhav Vindal

  2. Department of Pathology, Maulana Azad Medical College, New Delhi, Republic of india

    Meeta Singh

Contributions

LB conceived the concept. LB, PL, and AV are responsible for the blueprint. LB and PL are responsible for the definition of intellectual content. LB and PL are responsible for the literature search. LB and PL are responsible for data acquisition and analysis. LB and PL prepared the manuscript and are responsible for manuscript editing. MS provided the histopathological diagnosis. LB, PL, and AV reviewed the manuscript. All authors read and approved the final manuscript.

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Correspondence to Lovenish Bains.

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Bains, L., Lal, P., Vindal, A. et al. Behemothic villous adenoma of rectum- what is the cancerous potential and what is the optimal treatment? A example and review of literature. Earth J Surg Onc 17, 109 (2019). https://doi.org/10.1186/s12957-019-1650-4

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Keywords

  • Villous
  • Adenoma
  • Giant
  • Rectal
  • Malignant
  • Colorectal carcinoma
  • Laparoscopic
  • Colo-anal

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