A 50-year-old woman comes to the office for a preventive examination. She feels well and has no ongoing symptoms. Medical and family histories are unremarkable. The patient does not use tobacco or alcohol. Blood pressure is 132/76 mm Hg and pulse is 72/min. BMI is 25 kg/m². Physical examination is normal. The patient is up to date on breast and cervical screening but has not undergone colon cancer screening. She is referred for colonoscopy, during which a single colon polyp is discovered. The polyp is removed and sent for histologic analysis. Which of the following pathologic findings is associated with the greatest risk of malignant transformation in this patient?

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11ec160b_3939_9974_9249_abb4d738a5af_MD0001_00 Colonic polyps may be differentiated as non-neoplastic and neoplastic. Most are non-neoplastic and do not increase the risk of colon adenocarcinoma; such types include: Neoplastic polyps include adenomatous polyps (ie, tubular, villous, tubulovillous) and serrated polyps (ie, sessile serrated polyp, traditional serrated adenoma). These polyps have the potential to transform into colonic adenocarcinoma. Increasing polyp size is the most important characteristic that correlates with malignancy risk; the risk is increased in polyps >10 mm and is greatest in those >4 cm. Other risk factors include degree of dysplasia and histologic pattern. Villous adenomas are more likely to undergo malignant transformation than tubular adenomas (Choice C). (Choice E) Hamartomatous polyps consist of disorganized mucosal glands, smooth muscle, and connective tissue. Sporadic juvenile polyps are solitary hamartomatous lesions that are not associated with increased risk of colon cancer. Multiple hamartomatous polyps frequently occur in Peutz-Jeghers and juvenile polyposis syndromes, both of which confer an increased risk of malignancy. Educational objective: Adenomatous and serrated polyps (ie, sessile serrated polyp, traditional serrated adenoma) are neoplastic polyps that have malignancy potential. Increasing polyp size is the most important risk factor for cancer; villous histology and high-grade dysplasia are additional risk factors.

A 50-Year-Old Woman Comes to the Office for a Preventive