A 65 y-old male undergoes a screening colonoscopy which reveals a 2cm polyp. The histopathology reveals an adenomatous polyp with no atypical cells. The most appropriate follow up for this patient is :
A) Colonoscopy at 10 yrs
B) Colonoscopy at 5 yrs and then every 5 yrs
C) Colonoscopy at 3 yrs and then every 10 yrs
D) Colonscopy at 3 yrs and then every 5 years
E) CEA every 3 months
Copy Rights: Archer USMLE Reviews
Archer USMLE Step 3 Blog 
c
Colonscopy at 3 yrs and then every 5 years
D
B
Sorry D
d
D
D
dddddddddd
D is the right Answer
D
Risk of Progression to carcinoma is related to both the size & histology of the Adenoma
Higher Risk-Size >1 cm ,Villous& High Grade dysplasia
–>Repeat Colonoscopy 5 yrs following complete removal of low risk adenomatous polyp
—>Repeat Colonoscopy 3yrs following complete removal of High risk adenomatous polyp
**If no Colonic Polyp are found at the initial examination,follow up colonoscopy at approximately 5 yrs interval is recommended(Ref-eMedicine)
DDDDDDDDDDDDDDDDDDDDDDDDDD
Answer: D
Colon polyp screening guidelines:
a) Low Risk: – 1 to 2 adenomatous polyps, both small 1cm or any adenoma with villous features or high grade dysplasia
In this group, repeat Colonoscopy in 3 years. If this is normal or shows only small polyps, repeat colonoscopy every 5 years ( remember 3, 5)
b) Intermediate Risk : 3 to 10 small adenomatous polyps or
any one adenomatous polyp >1cm or any adenoma with villous features or high grade dysplasia
In this group, repeat Colonoscopy in 3 years. If this is normal or shows only small polyps, repeat colonoscopy every 5 years ( remember 3, 5)
c) High risk:
– Greater than or equal to 10 adenomatous polyps, colonoscopy at 1 year.
– Sessile adenomatous ployp that are removed in pieces –> colonoscopy in 3 to 6 months to ensure that it is completely removed
– Polyp removed in total and has carcinoma insitu with clear margins –> colonoscopy at 1 year and then at 3 years and then, every 5 years ( Remember 1,3 and 5)
Dr Archer, did you mean, (3,10), (3,5), (1,3,5)?
Low risk single or two, small adenomatous polyp (<1cm), repeat colonoscopy in 3 years. If normal, as per average risk recommendation (i.e, every 10 years). But you said 'every 5 years' twice. (you said 3,5 twice.) Am I missing something?
If this low risk patient also had family history of colorectal cancer, (first degree relative under 60yrs or two first degree relatives have colorectal cancer), then I will repeat every 5 years instead of every 10 years.
If this patient had a previous adenomatous polyp ( 1cm), then what do you recommend? Am I right if I screen based on the previous finding? And what do you recommend if a patient has had one or two small adenomatous polyps twice?
Thank you for your help. I look forward to your response.
Dr Archer can you defend what you said about low risk group?
According to American Cancer Society, 2014, Low Risk is defined as 1 or 2 small (less than 1 cm) polyps. Adenoma has tubular features (not villous or high grade features). Adenoma has low grade dysplasia (not high grade dysplasia)
Recommendation for this group is colonoscopy started 5-10 years after polyps have been removed (all polyps that are detected are removed) and then repeat colonoscopies based on findings of last colonoscopy OR based on any new finding in family history, say for instance, patients sibling develops colon cancer.
References:
http://www.cancer.org/cancer/colonandrectumcancer/moreinformation/colonandrectumcancerearlydetection/colorectal-cancer-early-detection-acs-recommendations
http://emedicine.medscape.com/article/172674-overview
dddd
the low risk one, follow up has some problem?
very nice explanation Dr. Red
many thanks.
Update issued on 01/31/2014 (about 6 weeks ago) by American Cancer Society on recommendation for early detection of colorectal cancer. Recommendations are quite broad but comprehensive.
What is our task? In every question, we have to find the highest risk from listed risks. The corresponding guideline will be our recommendation. (Examples included in the end)
DR Archer’s classification focuses exclusively on polyp number, size and histology – findings revealed on colonoscopy. However, sometimes, even with normal colonoscopy, one must issue a high risk guideline. The American Cancer Society included such risk factors for completeness.
In order to assess risk of colorectal cancer or issue recommendation, we must look at four (4) factors:
i. Family history of colorectal cancer
ii. Whether patient has Polyps or history of polyps
iii. Whether patient has Chronic Inflammatory Bowel Disease (Ulcerative colitis or Crohn’s disease)
iv. Whether patient has Cancer (colorectal) or history of colorectal cancer (resected cancer)
Someone who had cancer, polyps, chronic inflammatory bowel disease or a family history of colorectal cancer or polyps must have a closer evaluation of their screening guidelines. I suggest this technique of systematic review:
LEVEL ONE – WE EXCLUDE HIGH RISKS. Highest Risk of Cancer is in 3 conditions. We must exclude these 3 conditions first, even in normal patients. Genetic testing may be necessary in the 1st two conditions even if the patient is normal and there is a positive family history.
Level One Formula: [10-1 or 20-1/2 or +8 – 1/2]
1. Familial Adenomatous Polyposis (FAP) – (greater than 100 polyps plus positive FAP genetic testing confirmation) – Begins at 10-12 years, then yearly colonoscopy (>90% lifetime risk) [10-1 =start at age 10 year, then every year)
2. Hereditary Non Polyposis Colon Cancer (HNPCC) – (greater than 10 polyps plus negative FAP genetic testing) – Begins at 20-25 years (or 10years before the youngest case), then 1-2 yearly colonoscopy (80% lifetime risk) [20-1/2 = start at age 20, then 1-2 years]
3. Chronic Inflammatory Bowel Disease (8 years history of Pancolitis or 12-15 years of left sided colitis) – , then start 1-2 yearly colonoscopy (60% lifetime risk) [+8-1/2 = start 8 years after diagnosis, then 1-2 yearly]
The rest is just called Increased Risk.
LEVEL TWO – EXCLUDE COLORECTAL CANCER. Colorectal cancer (diagnosed) or history of it (resected)
Level Two Formula: [0-1-3-5]
Here screening is at time of colorectal surgery (time 0), 1 year, 3year, then every 5 year – but guideline can change anytime a polyp is found or HNPPC is suspected – [0-1-3-5 ]
LEVEL THREE – ASSESS POLYPS. How to we assess polyps according to the American Cancer Society Guidelines for early detection? We look at number, size or histology of polyps to grade risk.
Level Three Formula: Bench marks are numbers 3 and 5 which represent 3-10 polyps (=intermediate risk polyps). [3-5]
Low risk – 1-2 polyps, 10 polyps on single exam – within 3 years (even 1-2 years) plus recommend genetic testing first degree relatives for HNPCC or FAP (below the 3 bench mark)
Other conditions are above or below this spectrum
Rectal Hyperplastic polyps (most benign form of colorectal polyp, histology is non-neoplastic, almost normal) – screening is just like someone with average (universal) risk. (Every 10 years from 50 years – less than low risk bar – 10 years)
Hyperplastic polyposis syndrome (>30 polyps) – no specific recommendation but some others UK authors recommend starting at age 45 year or at age of youngest relative, then every 5 years. http://familyhistorybowelcancer.wordpress.com/2012/08/31/hyperplastic-polyposis-syndrome/
Sessile polyps removed in pieces – 2 to 6 months later (above high risk bar – < 3years)
LEVEL FOUR – WE EXCLUDE FAMILY HISTORY. Family history of colorectal cancer (40-5 or 40-10)
If ONE 1st degree relatives (parents, full siblings, children) 60years old has/had colorectal cancer OR TWO or more 2nd degree relatives (grandparents, grandchildren, aunts, uncles, nieces, nephews, or half siblings) have/had colorectal cancer – screen at 40years or 10 years before diagnosis in the youngest relative, then every 10 years afterwards.
1 1st degree 60 years= 40 (x-10), 5 = [40-5]
1 1st degree > 60 years = 2 or more 2nd degree relatives any age = 40 (x-10), 10 = [40-10]
LEVEL FIVE – ALL HIGH RISK FACTORS EXCLUDED, RECOMMEND AVERAGE (UNIVERSAL) RISK GUIDELINE. Average Risk (Universal Risk) – demands screening everyone beginning at 50 years, then every 10years until age 75years (bridge to USPSTF 2008 recommendation)
HCPFA – High, Cancer, Polyp, Family, Average – ‘Hiliary Can Poll at Family Avenue’
Example 1 – If a patient has a grandfather and niece diagnosed with colorectal cancer, he is 40 years old, should he undergo colonoscopy? Given the information, he has 2 second degree relatives diagnosed with colorectal cancer so his screening should start at 40 years (now) and then every 10 years until 75 years.
Example 2 – “60 year old man was diagnosed with colorectal cancer. He has 1 known 1st degree relative that had colorectal cancer at about his age”. Your colleague is a 1st year surgical resident texting you on lifeline during a ward round. His question is ‘colorectal screening guideline, sos?’ This patient has 0-1-3-5 plan Not 40-10 family plan, because he has been diagnosed with cancer already.
New research: High Resolution Micro-Endoscopy (HRME), an optical biopsy technique can distinguish between neoplastic and non-neoplastic polyps far better than High Definition White Light Endoscopy Accuracy 95% versus 64%, Specificity 98% versus 40%, Positive Predicted Value, 92% versus 55%.
SUMMARY:
Hillary -High Risk – 10-1 or 20-1/2 or +8 – 1/2 plan
Can – Cancer – 0-1-3-5 plan
Poll – Polyp – 3-5 for intermediate risk (3-10 polyps, villous polyp, high grade dysplasia)
Low risk – > 5 (1-2 polyps, tubular polyps, low grade dysplasia)
& 10 polyps)
Family – Family Risk – 40-5 or 40- 10 plan or (x-10)
Avenue – Average Risk – 50-10 plan or (x-10)
References:
http://www.cancer.org/cancer/colonandrectumcancer/moreinformation/colonandrectumcancerearlydetection/colorectal-cancer-early-detection-acs-recommendations
http://www.medscape.com/viewarticle/819782_1
http://en.wikipedia.org/wiki/Colorectal_polyp
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2871581/
Attention! a statement was chopped out under LEVEL THREE (Polyps) explanation. Line 6 in it will sound confusing. Sorry about that.
Low risk is 1-2 polyps, tubular polyps or low grade dysplasia, here screening is after 5 years (> the 5 mark of the 3-5 intermediate risk benchmark) High risk is > 10 polyps on single exam and screening is done within 3 years (< the 3 mark of the 3-5 intermediate risk bench mark)
Thank you for your patience.
E