Endoscopic surveillance in patients with multiple (10–100) colorectal polyps

Background and study aims: Endoscopic surveillance in patients with multiple colorectal polyps aims to reduce colorectal cancer (CRC) incidence and mortality, as well as the need for colorectal surgery. The aim of this study was to determine the risk of developing CRC or the need for surgery during endoscopic surveillance in a cohort of patients with multiple (10 – 100) colorectal polyps.

Patients and methods: This was a multicentrer, longitudinal, observational study in 15 CRC high risk clinics in Spain, carried out between January 2009 and December 2010. Patients who were included in the EPIPOLIP trial and had at least 1 year of follow-up were included in the study. The primary outcome of interest was the incidence of CRC at least 1 year following the initial colonoscopy. The secondary outcome was the need for colorectal surgery.

Results: A total of 265 patients were followed for a median of 3.8 years. Patients underwent a median of 5 colonoscopies, and 17 patients (6.4 %) were diagnosed with CRC. A total of 32 patients (12.1 %) underwent surgery, including 15 (5.7 %) for prophylaxis without a diagnosis of CRC. The corresponding incidence density rates for CRC and colorectal surgery were 1.4 (95 % confidence interval [CI] 0.7 to 2.1) and 2.7 (95 %CI 1.7 to 3.6) per 100 patient-years, respectively. Only the presence of symptoms at first colonoscopy was independently associated with CRC diagnosis (hazard ratio [HR] 7.7, 95 %CI 1.1 to 59.3) and colorectal surgery (HR 4.6, 95 %CI 1.02 to 20.6).

Conclusions: Patients with more than 10 neoplastic polyps required frequent colonoscopies within a short follow-up period. More than 10 % of patients required colorectal surgery within 4 years, more than half for incident CRC.

• References

• 1 Alvarez C, Andreu M, Castells A et al. Relationship of colonoscopy-detected serrated polyps with synchronous advanced neoplasia in average-risk individuals. Gastrointest Endosc 2013; 8: 1-10
• 2 Chow E, Lipton L, Lynch E et al. Hyperplastic polyposis syndrome: phenotypic presentations and the role of MBD4 and MYH. Gastroenterology 2006; 131: 30-39
• 3 Boparai KS, Mathus-Vliegen EMH, Koornstra JJ et al. Increased colorectal cancer risk during follow-up in patients with hyperplastic polyposis syndrome: a multicentre cohort study. Gut 2010; 59: 1094-1100
• 4 Rosty C, Hewett DG, Brown IS et al. Serrated polyps of the large intestine: current understanding of diagnosis, pathogenesis, and clinical management. J Gastroenterol 2013; 48: 287-302
• 5 Zauber AG, Winawer SJ, O’Brien MJ et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med 2012; 366: 687-696
• 6 Winawer SJ, Zauber AG, Ho MN et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med 1993; 329: 1977-1981
• 7 Elmunzer BJ, Hayward RA, Schoenfeld PS et al. Effect of flexible sigmoidoscopy-based screening on incidence and mortality of colorectal cancer: a systematic review and meta-analysis of randomized controlled trials. PLoS Med 2012; 9: e1001352
• 8 Pohl H, Srivastava A, Bensen SP et al. Incomplete polyp resection during colonoscopy – results of the complete adenoma resection (CARE) study. Gastroenterology 2013; 144: 74-80.e1
• 9 Knudsen AL, Bülow S, Tomlinson I et al. Attenuated familial adenomatous polyposis: results from an international collaborative study. Colorectal Dis 2010; 12: e243-e249
• 10 Boparai KS, van den Broek FJC, van Eeden S et al. Increased polyp detection using narrow band imaging compared with high resolution endoscopy in patients with hyperplastic polyposis syndrome. Endoscopy 2011; 43: 676-682
• 11 Bouguen G, Manfredi S, Blayau M et al. Colorectal adenomatous polyposis Associated with MYH mutations: genotype and phenotype characteristics. Dis Colon Rectum 2007; 50: 1612-1617
• 12 Bresalier RS. Management of high-risk colonoscopy patients. Gastrointest Endosc Clin N Am 2010; 20: 629-640
• 13 Ellis C. Colonic adenomatous polyposis syndromes: clinical management. Clin Colon Rectal Surg 2008; 1: 256-262
• 14 Thirlwell C, Howarth KM, Segditsas S et al. Investigation of pathogenic mechanisms in multiple colorectal adenoma patients without germline APC or MYH/MUTYH mutations. Br J Cancer 2007; 96: 1729-1734
• 15 Knudsen AL, Bisgaard ML, Bülow S. Attenuated familial adenomatous polyposis (AFAP). A review of the literature. Fam Cancer 2003; 2: 43-55
• 16 Hazewinkel Y, Tytgat KM, van Eeden S et al. Incidence of colonic neoplasia in patients with serrated polyposis syndrome who undergo annual endoscopic surveillance. Gastroenterology 2014; 147: 88-95
• 17 Atkin WS, Valori R, Kuipers EJ et al. European guidelines for quality assurance in colorectal cancer screening and diagnosis. First edition – Colonoscopic surveillance following adenoma removal. Endoscopy 2012; 44: SE151-SE163
• 18 Lieberman DA, Rex DK, Winawer SJ et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2012; 143: 844-857
• 19 Vasen HF, Möslein G, Alonso A et al. Guidelines for the clinical management of familial adenomatous polyposis (FAP). Gut 2008; 57: 704-713
• 20 Jasperson KW, Tuohy TM, Neklason DW et al. Hereditary and familial colon cancer. Gastroenterology 2010; 138: 2044-2058
• 21 Guarinos C, Sánchez-Fortún C, Rodríguez-Soler M et al. Clinical subtypes and molecular characteristics of serrated polyposis syndrome. Clin Gastroenterol Hepatol 2013; 11: 705-711
• 22 East JE, Saunders BP, Jass JR. Sporadic and syndromic hyperplastic polyps and serrated adenomas of the colon: classification, molecular genetics, natural history, and clinical management. Gastroenterol Clin North Am 2008; 37: 25-46
• 23 Guarinos C, Juárez M, Egoavil C et al. Prevalence and characteristics of MUTYH-associated polyposis in patients with multiple adenomatous and serrated polyps. Clin Cancer Res 2014; 20: 1158-1168
• 24 Snover DC, Ahnen DJ, Burt RW, Odze RD. Serrated polyps of the colon and rectum and serrated (“hyperplastic”) polyposis. In: Bosman FT, Carneiro F, Hruban RH, et al., eds. WHO Classification of tumours of the digestive system. Berlin: Springer-Verlag; 2010
• 25 Grupo de trabajo de la guía de práctica clínica de prevención del cáncer colorrectal. Actualización 2009. Prevencion del Cáncer Colorrectal. Guía de práctica clínica. Programa de Elaboración de Guías de Práctica. Barcelona: Asociación Española de Gastroenterología, Sociedad Española de Medicina de Familia y Comunitaria, y Centro Cochrane Iberoamericano; 2009 Available from: www.guiasgastro.net
• 26 Lynch HT, de la Chapelle A. Hereditary colorectal cancer. N Engl J Med 2003; 348: 919-932
• 27 Lucci-Cordisco E, Risio M, Venesio T et al. The growing complexity of the intestinal polyposis syndromes. Am J Med Genet A 2013; 161A: 2777-2787
• 28 Moreira L, Pellisé M, Carballal S et al. High prevalence of serrated polyposis syndrome in FIT-based colorectal cancer screening programmes. Gut 2013; 62: 476-477
• 29 Nielsen M, Hes FJ, Nagengast FM et al. Germline mutations in APC and MUTYH are responsible for the majority of families with attenuated familial adenomatous polyposis. Clin Genet 2007; 71: 427-433
• 30 Filipe B, Baltazar C, Albuquerque C et al. APC or MUTYH mutations account for the majority of clinically well-characterized families with FAP and AFAP phenotype and patients with more than 30 adenomas. Clin Genet 2009; 76: 242-255
• 31 Burt RW, Leppert MF, Slattery ML et al. Genetic testing and phenotype in a large kindred with attenuated familial adenomatous polyposis. Gastroenterology 2004; 127: 444-451