Adenoma size and number are predictive of adenoma recurrence: implications for surveillance colonoscopy

doi:10.1016/S0016-5107(00)70444-5

Gastrointestinal Endoscopy

Volume 51, Issue 4, Part 1, April 2000, Pages 433-437

https://doi.org/10.1016/S0016-5107(00)70444-5 Get rights and content

Abstract

Background: Three-year colonoscopic surveillance after initial polypectomy may not be required for all patients. Those with multiple baseline polyps and large adenomas, implicated as predictors of colon cancer, merit close observation. Conversely, patients with single small adenomas may be subjected to early endoscopic surveillance unnecessarily. Methods: From our Adenoma Registry we evaluated patient and adenoma characteristics in 697 patients. All had an adenoma recurrence within 3 years of a positive baseline colonoscopy. Potential risk factors studied were age, gender, number of adenomas, size of largest adenoma and histology. We defined a significant outcome as size of 1 cm or greater, tubulovillous or villous histology, high-grade dysplasia, carcinoma in situ, invasive cancer, or 4 or more adenomas. Results: Having 3 or more adenomas on initial colonoscopy with at least 1 measuring 1 cm or larger greatly increased the chance of a significant finding on the first surveillance colonoscopy. Conversely, patients with 1 or 2 adenomas all measuring less than 1 cm were at extremely low risk of an important outcome within 3 years. Conclusions: Patients with 1 or 2 adenomas all measuring less than 1 cm are an identified low risk group and their first surveillance examination may be delayed beyond the standard 3 years. (Gastrointest Endosc 2000;51:433-7.)

Section snippets

PATIENTS AND METHODS

The Cleveland Clinic Foundation Adenoma Registry records data from each colonoscopy involving a polypectomy into a database. From the registry we identified 697 patients seen between 1979 and 1989 who had 1 or more adenomas removed at colonoscopy and a surveillance examination within 10 to 42 months (mean 18 months). Patients with colon cancer, ulcerative colitis and familial adenomatous polyposis were excluded. Adenoma size recorded in the registry database prior to 1994 was a volume

RESULTS

Baseline patient and adenoma characteristics are shown in Table 1.

. Baseline characteristics of patients and polyps (N = 697)

Characteristic	No. of patients
Gender
Female	186
Male	511
Age (yr)
< 40	11
40-49	70
50-59	200
60-69	271
≥ 70	145
No. of adenomas
1	359
2	158
3	83
4+	97
Size of the largest adenoma (cm)
< 0.5	297
0.5-0.9	153
≥ 1.0	247
Pathology of most advanced adenoma
Tubular adenoma	531
Tubulovillous adenoma	119
Villous adenoma	12
HGD/CIS	29
Adenocarcinoma	6

At follow-up colonoscopy 63 patients (9.0%) had either histologic or size

DISCUSSION

It is estimated that the evolution from normal mucosa to adenoma to colon cancer takes from 5 to 20 years.14, 15, 16 This suggests that if all adenomas are removed at initial colonoscopy it would be safe to wait at least 5 years before repeating the examination.

However, colonoscopies performed at the currently recommended 3 years or sooner are not always normal and sometimes reveal pathologically important lesions.5, 17, 18, 19 It is not known how many lesions are true new lesions and how many

Acknowledgements

We thank Bikram Verma Ansil, MD, for data collection.

References (30)

SJ Winawer et al.
Colorectal cancer screening clinical guidelines and rationale
Gastroenterology
(1997)
SJ Stryker et al.
Natural history of untreated colonic polyps
Gastroenterology
(1987)
RJ Spencer et al.
Treatment of small colorectal polyps: a population based study of the risk of subsequent carcinoma
Mayo Clin Proc
(1984)
BC Morson
The evolution of colorectal carcinoma
Clin Radiol
(1984)
RU van Stolk et al.
Incidence of colorectal cancer during colonoscopic surveillance in a four year polyp prevention trial [abstract]
Gastroenterology
(1998)
DX Rex et al.
Colonoscopic miss rates of adenomas determined by back to back colonoscopies
Gastroenterology
(1997)
RU van Stolk et al.
Adenoma characteristics at first colonoscopy as predictors of adenoma recurrence and characteristics at follow up
Gastroenterology
(1998)
N Gopalswamy et al.
Is in vivo measurement of size of polyps during colonoscopy accurate?
Gastrointest Endosc
(1997)
RE Schoen et al.
The pathologic measurement of polyp size is preferable to the endoscopic estimate
Gastrointest Endosc
(1997)
AM Lotfi et al.
Colorectal polyps and the risk of subsequent carcinoma
Mayo Clin Proc
(1986)

SJ Winawer et al.

Prevention of colorectal cancer by colonoscopic polypectomy

N Engl J Med

(1993)

SJ Winawer et al.

Risk and surveillance of individuals with colorectal polyps

Bull World Health Organ

(1990)

R Mukakami et al.

Natural history of colorectal polyps and the effect of polypectomy on occurrence of subsequent cancer

Int J Cancer

(1990)

OD Jorgenson et al.

The Funen Adenoma Follow up Study: incidence and death from colorectal carcinoma in an adenoma surveillance program

Scand J Gastroenterol

(1993)

SJ Winawer et al.

Randomized comparison of surveillance intervals after colonoscopic removal of newly diagnosed adenomatous polyps

N Engl J Med

(1993)

Cited by (210)

Risk Factors for Metachronous Colorectal Cancer or Advanced Adenomas After Endoscopic Resection of High-risk Adenomas
2023, Clinical Gastroenterology and Hepatology
Among the characteristics of high-risk adenomas (HRAs), some may predict a higher risk of metachronous advanced lesions. Our aim was to assess which HRA characteristics are associated with high risk of metachronous colorectal cancer (CRC) or advanced adenomas (AAs).
We systematically searched Pubmed, EMBASE, and Cochrane for cohort studies and clinical trials of CRC or AA incidence at surveillance stratified by baseline lesion size, histology, and multiplicity. We calculated pooled relative risks (RRs) using a random-effects model. Heterogeneity was assessed with the I² statistic.
Fifty-five studies were included, with 936,540 patients with mean follow-up 5.4 ± 2.9 years. CRC incidence per 1000 person-years was 2.6 (2.1–3.0) for adenomas ≥20 mm, 2.7 (2.2–3.2) for high-grade dysplasia (HGD), 2.0 (1.8–2.3) for villous component, 0.8 (0.1-1.4) for ≥5 adenomas, 1.0 (0.7–1.2) for ≥3 adenomas. Metachronous CRC risk was higher in adenomas ≥20 mm vs 10 to 19 mm (RR, 2.08; 95% confidence interval [CI], 1.20–3.61), HGD vs low-grade dysplasia (RR, 2.89; 95% CI, 1.88–4.44), villous vs tubular (RR, 1.75; 95% CI, 1.33–2.31). No significant differences in CRC risk were found in ≥3 adenomas vs 1 to 2 (RR, 1.24; 95% CI, 0.84–1.83), nor in ≥5 adenomas vs 3 to 4 (RR, 0.79; 95% CI, 0.30–2.11). Compared with normal colonoscopy, RR for CRC risk was 2.61 (95% CI, 2.06–3.32) for ≥10mm, 6.62 (95% CI, 4.60–9.52) for HGD, 3.58 (95% CI, 2.24–5.73) for villous component, and 2.03 (95% CI, 1.40–2.94) for ≥3 adenomas. Similar trends were seen for metachronous AAs.
Metachronous CRC risk is highest in patients with baseline adenomas with ≥20 mm or HGD. Multiplicity does not seem to be associated with substantially higher CRC risk in the near term.
Risk Factors for Colorectal Polyps and Cancer
2022, Gastrointestinal Endoscopy Clinics of North America
Screening for Colon Cancer in Older Adults: Risks, Benefits, and When to Stop
2020, Mayo Clinic Proceedings
Citation Excerpt :
Furthermore, older men tend to have a higher prevalence of adenomatous polyps than do older women.9,10 Although the risk of adenoma and CRC is significantly affected by age, the recurrence of polyps and advanced polyps have not been associated with increased age.13-15 Only 1 study reported that older age (≥60 years) was a factor associated with recurrent polyps and advanced lesions, but this was not a substantial independent variable in a multivariate analysis.16
Colorectal cancer (CRC) is the fourth leading cause of cancer and second leading cause of mortality from cancer in the United States. As the population ages, decisions regarding the initiation and cessation of screening and surveillance for CRC are of increasing importance. In elderly patients, the risks of CRC and the presenting signs and symptoms are similar to those in younger patients. Screening and ongoing surveillance should be considered in patients who have a life expectancy of 10 years or more. Life expectancy estimates can be calculated using online calculators. If screening is deemed appropriate, the choice of which test to use first is unclear. Currently, there are a number of modalities available to screen for CRC, including both invasive modalities (eg, colonoscopy, sigmoidoscopy, capsule colonoscopy, and computed tomographic colonography) and noninvasive modalities (fecal immunochemical test, stool DNA testing, and blood testing). Colonoscopy and other invasive testing options are considered safe, but the risks of complications of the bowel preparation, the procedure, and sedation medications are all increased in older patients. In contrast, noninvasive testing provides a safe initial test; however, it is important to consider the increased false-positive rates in the elderly, and a positive test result will usually necessitate colonoscopy to establish the diagnosis. Ongoing screening and surveillance should be a shared decision-making process with the patient based on multiple factors including the patient’s morbidity and mortality risk from CRC and his or her underlying comorbidities, the patient’s functional status, and the patient’s preferences for screening. Ultimately, the decision to initiate or discontinue screening for CRC in older patients should be done based on a case-by-case individualized discussion.
High Prevalence of Adenomatous Polyps in Alaska Native People Aged 40-49 years
2019, Journal of Surgical Research
Although colorectal cancer occurs earlier in life and at twice the frequency in Alaska Native (AN) people compared with the general population, the colorectal polyp burden in this group has not been quantified. In addition, an appropriate age for initial screening in ANs has not been defined.
A retrospective chart review of 766 AN people who had screening colonoscopy from 2015 to 2016 was performed. The polyp burden in patients aged 40-49 y was compared with that in those aged 50-59 y in both the AN and the general US populations.
In total, 345 adenomas were removed: 121 (35%) from 40- to 49-year-olds and 224 (65%) from 50- to 59-year-olds. Twenty-six percent of AN people aged 40 y to 49 y and 40% of AN people aged 50 to 59 y had at least one adenoma. Low- and high-risk adenomas were significantly less frequent in the younger group (22% versus 29%, P = 0.048; 9.2% versus 15%, P = 0.035; respectively). Advanced adenomas were also less frequent in the younger group, although not statistically significant. Polyp histology, size, location, and morphology did not differ significantly between groups.
The adenoma and advanced adenoma prevalence in 40- to 49-year-old AN people is high, suggesting colorectal cancer screening should begin at age 40 y in ANs.
The effect of small or diminutive adenomas at baseline colonoscopy on the risk of developing metachronous advanced colorectal neoplasia: KASID multicenter study
2018, Digestive and Liver Disease
The clinical significance of diminutive or small adenomas remains ill defined.
We evaluated the clinical impact of diminutive or small adenomas at baseline on the risk of developing metachronous advanced colorectal neoplasia (CRN).
This multicenter, retrospective cohort study included 2252 patients with 1 or more colorectal adenomas at baseline and subsequent follow-up colonoscopy. Baseline colonoscopy findings were classified into 5 groups: 1 or 2 tubular adenomas (TAs) (<10 mm); 3–10 diminutive TAs (≤5 mm); 3–10 TAs, including 1 or 2 small adenomas (6–10 mm); 3–10 TAs, including 3 or more small adenomas; and advanced adenoma.
In multivariate analysis, after adjusting for possible confounding variables (age at baseline, sex, body mass index, smoking habits, family history of colorectal cancer, regular use of aspirin or NSAIDs, and adenoma location), 3–10 TAs including 3 or more small adenomas (hazard ratio [HR] = 2.36, p = 0.034) and advanced adenoma (HR = 2.14, p < 0.001) were independent predictors for the risk of developing metachronous advanced CRN. However, 3–10 diminutive TAs or 3–10 TAs, including 1 or 2 small adenomas, were not associated with this outcome.
Multiplicity of diminutive TAs, without advanced lesions, showed no clinical significance for risk of developing metachronous advanced CRN.
Risk of recurrent advanced colorectal neoplasia in individuals with baseline non-advanced neoplasia followed up at 5 vs 7–10 years
2023, Journal of Gastroenterology and Hepatology (Australia)

View all citing articles on Scopus

^☆: Reprint requests: Rosalind U. van Stolk, MD, Northwestern University Medical School, Searle 10-541, S-208, 303 E. Chicago Ave., Chicago, IL 60611-3008.

View full text

Original ArticlesAdenoma size and number are predictive of adenoma recurrence: implications for surveillance colonoscopy☆

Abstract

Section snippets

PATIENTS AND METHODS

RESULTS

DISCUSSION

Acknowledgements

Gastroenterology

Gastroenterology

Mayo Clin Proc

Clin Radiol

Gastroenterology

Gastroenterology

Gastroenterology

Gastrointest Endosc

Gastrointest Endosc

Mayo Clin Proc

Prevention of colorectal cancer by colonoscopic polypectomy

N Engl J Med

Risk and surveillance of individuals with colorectal polyps

Bull World Health Organ

Natural history of colorectal polyps and the effect of polypectomy on occurrence of subsequent cancer

Int J Cancer

The Funen Adenoma Follow up Study: incidence and death from colorectal carcinoma in an adenoma surveillance program

Scand J Gastroenterol

Randomized comparison of surveillance intervals after colonoscopic removal of newly diagnosed adenomatous polyps

N Engl J Med

Original Articles
Adenoma size and number are predictive of adenoma recurrence: implications for surveillance colonoscopy☆