Case-Based Review

Colorectal Cancer: Screening and Surveillance Recommendations

Journal of Clinical Outcomes Management. 2015 March;22(3)

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1 or More Villous Adenomas

The 2006 MSTF guideline considers adenomas with villous histology to be high risk [67]. The NCI Pooling Project analyzed polyp histology as a risk factor for development of interval advanced neoplasia. Compared with patients with tubular adenomas, those with baseline polyp(s) showing adenomas with villous or tubulovillous histology (TVA) had increased risk of advanced neoplasia during follow-up (16.8% vs 9.7%; adjusted OR, 1.28; 95% CI, 1.07–1.52) [76]. Patients with one or more adenomas with villous histology were also found to have an increased risk of advanced neoplasia during surveillance compared with those with no neoplasia or small (<10 mm) tubular adenomas. Thus, the recommendation remains that repeat examination should be performed in 3 years [66].

Adenoma with High-Grade Dysplasia (HGD)

The 2006 MSTF guideline concluded that the presence of HGD in an adenoma was associated with both villous histology and larger size, which are both risk factors for advanced neoplasia during surveillance [67]. In a univariate analysis from the NCI Pooling Project, HGD was strongly associated with risk of advanced neoplasia during surveillance (OR, 1.77; 95% CI, 1.41–2.22) [76]. Thus, the recommendation remains that repeat examination should be performed in 3 years [66].

Serrated Lesions

A total of 20% to 30% of CRCs arise through a molecular pathway characterized by hypermethylation of genes, known as CgG Island Methylator Phenotype (CIMP) [77]. Precursors are believed to be serrated polyps. Tumors in this pathway have a high frequency of BRAF mutation, and up to 50% are microsatellite unstable. CIMP-positive tumors are overrepresented in interval cancers, particularly in the proximal colon. The principal precursor of hypermethylated cancers is probably the sessile serrated polyp (synonymous with sessile serrated adenoma). These polyps are difficult to detect at endoscopy. They may be the same color as surrounding colonic mucosa, have indiscrete edges, are nearly always flat or sessile, and may have a layer of adherent mucus and obscure the vascular pattern.

Recent studies show that proximal colon location or size ≥ 10 mm may be markers of risk for synchronous advanced adenomas elsewhere in the colon [78,79]. Surveillance after colonoscopy was evaluated in one study, which found that coexisting serrated polyps and high-risk adenomas (HRA; ie, size ≥ 10 mm, villous histology, or presence of HGD) is associated with a higher risk of advanced neoplasia at surveillance [78]. This study also found that if small proximal serrated polyps are the only finding at baseline, the risk of adenomas during surveillance is similar to that of patients with low-risk adenomas (LRA; ie, 1–2 small adenomas).

The current evidence suggests that size (>10 mm), histology (a sessile serrated polyp is a more significant lesion than an HP; a sessile serrated polyp with cytological dysplasia is more advanced than a sessile serrated polyp without dysplasia), and location (proximal to the sigmoid colon) are risk factors that might be associated with higher risk of CRC. A sessile serrated polyp ≥ 10 mm and a sessile serrated polyp with cytological dysplasia should be managed like a HRA with repeat colonoscopy occurring in 3 years. Serrated polyps that are <10 mm in size and do not have cytological dysplasia may have lower risk and can be managed like LRA with repeat colonoscopy occurring in 5 years [66].