A 69-year-old man comes to the office for a follow-up visit. During a recent screening colonoscopy, he underwent complete excision of an 18-mm pedunculated polyp found in the ascending colon. Biopsy showed a high-grade dysplastic villous adenoma without involvement of the stalk or its margins There was no vascular or lymphatic invasion or other features of adenocarcinoma. The patient reports no symptoms and has no family history of colon polyps or colorectal cancer. He is otherwise in good health and has no other medical conditions. No abnormalities are noted on physical examination. Which of the following is the most appropriate next step in management of this patient?

Question

A 69-year-old man comes to the office for a follow-up visit.  During a recent screening colonoscopy, he underwent complete excision of an 18-mm pedunculated polyp found in the ascending colon.  Biopsy showed a high-grade dysplastic villous adenoma without involvement of the stalk or its margins  There was no vascular or lymphatic invasion or other features of adenocarcinoma.  The patient reports no symptoms and has no family history of colon polyps or colorectal cancer.  He is otherwise in good health and has no other medical conditions.  No abnormalities are noted on physical examination.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf2a_db16_8f63_8db926c6a7e6_MD0005_00 Adenomatous polyps are the most common type of neoplastic colon polyp and are associated with an increased risk for future colorectal adenocarcinoma. Whereas average-risk patients with normal findings on screening colonoscopy may be rescreened at 10-year intervals, those with adenomatous polyps require more frequent colonoscopic surveillance (Choice D). Furthermore, the following findings in adenomatous polyps are associated with an additional increase in risk: Villous or tubulovillous histology High-grade dysplasia Size ≥10 mm High number (eg, ≥3 adenomas) regardless of histology This patient had a pedunculated adenomatous polyp that was completely excised. It had features that place the patient at increased risk, including size ≥10 mm, villous morphology, and high-grade dysplasia. He therefore requires enhanced surveillance with repeat colonoscopy in 3 years. (Choice A) Annual colonoscopy is recommended for patients with familial adenomatous polyposis, a genetic disorder associated with a very high risk of colorectal adenocarcinoma, who have not undergone prophylactic colectomy. It is not needed for patients with sporadic polyps that have been completely excised. (Choice B) Patients with large polyps >20 mm that are removed piecemeal have a significant short-term risk due to possible incomplete polyp removal. Such a patient should undergo a second-look colonoscopy within 6 months to verify that the polyp was completely removed and that no polyps were missed. (Choice E) Colectomy is recommended for patients who have polyps with high-risk features of invasive malignancy (eg, lymphovascular involvement, cancer extending to specimen margin). It is not needed for patients with uncomplicated adenomatous polyps. Educational objective: Patients with adenomatous colon polyps are at increased risk for colorectal adenocarcinoma and require an increased frequency of colonoscopic surveillance. In addition, adenomatous polyps with villous or tubulovillous histology, high-grade dysplasia, or size ≥10 mm are associated with an additional increase in risk and generally warrant repeat colonoscopy in 3 years. References: Screening for colorectal cancer: US Preventive Services Task Force recommendation statement. (http://www.ncbi.nlm.nih.gov/pubmed/34003218) Baseline colonoscopy findings associated with 10-year outcomes in a screening cohort undergoing colonoscopy surveillance. (http://www.ncbi.nlm.nih.gov/pubmed/31376388)

A 69-Year-Old Man Comes to the Office for a Follow-Up