Haggitt classification of pedunculated and sessile polyps. Reprinted permission Classification of submucosal (Sm) invasion of malignant polyps. Reprinted. Looking for online definition of Haggitt classification in the Medical Dictionary? Haggitt classification explanation free. What is Haggitt classification? Meaning of . The Haggitt level is a histopathological term used for describing the degree of infiltration from a malignant Kikuchi level (sessile tumor invasion classification) .
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The management of the malignant polyp continues to be challenging. Endoscopic resection by polypectomy has been shown to be sufficient for management of certain polyps containing cancer; however, it is important to keep in mind that polypectomy does not remove the lymph node drainage basin and may be an inadequate resection for some adenocarcinoma containing polyps that have specific histologic features.
Depth of invasion has been shown to correlate with the risk of lymph node metastasis. For these patients formal oncologic surgical resection is indicated. Traditional open or laparoscopic procedures are routinely used for colectomy in these patients. Following polypectomy or segmental colectomy, surveillance of these patients is critical, and can lead to excellent long-term outcomes. Polyps are simply defined as a macroscopic protrusion of the colonic mucosa into the bowel lumen.
Polyps include adenomatous, inflammatory, hamartomatous, and hyperplastic lesions.
Adenomatous polyps are by definition benign, but the subsequent development of malignancy makes them particularly important to the endoscopist and surgeon. These polyps consist of epithelial growths of abnormal glands accompanied by a varying amount of villous component tubular, tubulovillous, and villous adenomas.
Polyps can be classified by their macroscopic structural configuration, such as sessile broad base habgitt pedunculated, and by their histologic appearance including villous component and degree of dysplasia.
Malignant colorectal polyps
Although these polyps are benign, varying degrees of dysplasia may be seen within them. Severe dysplasia, high-grade dysplasia, and carcinoma in situ are all synonymous and denote the high risk of malignant transformation over time. Other factors affecting risk of malignancy include polyp size, extent of villous component, and patient age. Mark’s Hospital, the degree of dysplasia was clearly associated with risk of the polyp harboring malignancy.
The investigators showed that only 5. Furthermore, the size of the polyp is associated with risk of malignancy, with studies showing the presence of cancer in 1. The muscularis mucosa must be breached to be defined as malignant. Polypectomy is usually performed during colonoscopy using snare polypectomy techniques. High-quality polypectomy is the classification excision of the polyp, which should include the entire stalk to its base. The submucosa of the bowel wall should be included to allow optimal histologic evaluation of the margins.
Classificatin level of invasion into the polyp is a critical factor and dictates whether the endoscopic management of a malignant polyp claxsification adequate. This depth of invasion has been shown claseification correlate with the risk of lymph node metastasis.
Haggitt et al 11 described a classification system for pedunculated polyps with levels of invasion ranging from 0 to 4 Fig. Level 0 indicates carcinoma in situ or intramucosal carcinoma.
Management of the Malignant Polyp
These lesions are not invasive, and therefore behave as benign adenomas due to an absence of lymphatics in the mucosal layer. Level 1 lesions have adenocarcinoma invading through the muscularis mucosa into the submucosa, and are strictly limited to the head of the polyp. Carcinomas invading to the neck of the polyp are considered level 2 lesions.
Invasion of the carcinoma into the stalk of the polyp is level 3 invasion. Level 4 lesions signify invasion of the adenocarcinoma into the bowel wall below the polyp stalk, and is limited to the submucosa. Sessile polyps do not contain stalks, and are considered to be equivalent to a level 4 pedunculated polyp with respect to their incidence of lymph node metastasis. Due to a lack of characterization of sessile lesions in the Haggitt classification and the recognition that the risk of lymph node metastasis in each level 4 lesion is not the same, Kudo 12 classified these lesions into three levels Fig.
Submucosal invasion was classified into thirds with Sm 1 lesions exhibiting invasion into the upper third of the submucosa, Sm 2 invasion into the middle third of the submucosa, and Sm 3 invasion into the lower third of the submucosa.
Anatomic landmarks of pedunculated and sessile malignant polyps with respect to Haggitt level. Adapted from Haggitt et al. Depth of submucosal invasion in sessile malignant polyps. Sm 1invasion into upper third; Sm 2invasion into middle third; Sm 3invasion into lower third. The adequacy of endoscopic resection is dependent on the risk of nodal metastasis, as endoscopic resection does not remove or sample the lymph node drainage basin.
Haggitt level | Radiology Reference Article |
Interestingly, the incidence of lymph node metastasis did haghitt reach statistical significance when considering margin of resection. Removal of a polyp via piecemeal technique will complicate the histologic interpretation of the margin, and should be avoided.
Oncologic segmental resection is indicated for the following polyps and histologic features This can be done in the traditional open approach or via laparoscopic techniques.
The laparoscopic approach has potential benefits of less postoperative pain, faster return of postoperative bowel function, improved cosmesis, classifictaion return to work, less operative blood loss, shorter hospitalization, reduced overall costs, fewer postoperative bowel obstructions, and a lower incidence of ventral hernia when compared with the open approach. Recent reports show enthusiasm for laparoscopic-assisted colonoscopic polypectomy, which is a combined procedure that involves the laparoscopic mobilization of the colon to facilitate traditional endoscopic polypectomy techniques.
The use of frozen section allows for the determination of malignant invasion after which a segmental resection can then be performed if pathology indicates. This may allow for management of larger lesions previously felt to be colonoscopically unresectable or lesions that are in anatomically unfavorable locations. The procedure provides a recovery time that approximates colonoscopy alone and the morbidity of resection is avoided completely.
Conversely, insufflation of the colon for colonoscopy during hggitt decreases the usable peritoneal space for pneumoperitoneum making the procedure more technically challenging.
A comment must be made regarding management of rectal lesions, specifically lesions of the distal third as they have been shown to have a higher incidence of lymph node metastasis compared with proximal and middle rectal lesions that behave similarly to the colon.
An alternative approach of transanal full classificatin excision or transanal endoscopic microsurgery TEMS plus chemoradiation can also be considered. Close endoscopic follow-up is required to detect local recurrence in the setting of an endoscopically managed malignant polyp. A complete surveillance colonoscopy should be performed within 3 years of the initial polypectomy and then every 3 years thereafter pending any additional finding.
For the patient who has received formal, oncologic resection, they should receive a postprocedure baseline classifidation at 1 year and then after 3 years.
Further colonoscopic surveillance is performed every 5 years thereafter unless findings dictate more frequent examinations. Adenomatous polyps harboring a focus of adenocarcinoma are a complex problem.
Management is dependent on risk of lymph node metastasis, and therefore, risk of recurrence and spread. Endoscopic polypectomy is sufficient for these malignant polyps provided they exhibit favorable histology, limited depth of invasion, and a minimum of 2 mm margin.
In contrast, poor histology or more extensive invasion warrants formal oncologic bowel resection, assuming that the patient is an acceptable operative candidate. National Center for Biotechnology InformationU. Clin Colon Rectal Surg.
Marcela RamirezM. Scott ThomasM. Haggitg information Copyright and License information Disclaimer. Address for correspondence and reprint requests: This article has been cited by other articles in PMC. Malignant polyp, adenocarcinoma, adenomatous polyp, endoscopic polypectomy, segmental colectomy, Haggitt level.
When Is Endoscopic Resection Adequate? Open in a separate window. Haggitt level 4 lesions with distal third submucosa invasion. RECTAL LESIONS A comment must be made regarding management of rectal lesions, specifically lesions of the distal third as they have been shown to have a higher incidence of lymph node metastasis compared with proximal and middle rectal lesions that behave similarly to the colon.
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