Surveillance for « Hyperplastic polyps »

Robert Benamouzig Avicenne Hospital, University Paris 13

Bobigny France

Hyperplastic polyps

Hyperplastic polyps (HPs) are usually small, located in the end-portion of the colon (the rectum and sigmoid colon), have no potential to become malignant, and are not worrisome.

HPs are small and frequent • HPs accounted for :

– 50% of polyps 1–5 mm

– 28% of polyps 6–9 mm

– 14% of polyps 10 mm

• Distal HPs are frequent (8 to 40%)

• Proximal HPs – 1 to 4%

Imperiale TF et al, N Engl J Med 2000 Lieberman DA et al, N Engl J Med 2000 Regula J et al, N Engl J Med 2006 Lieberman DA et al, Gastroenterology 2008 Forsberg AM et al, Scand J Gastroenterol 2012

Distal HPs and adenoma « Guidelines »

• « Several reports suggest that a hyperplastic polyp found in the left colon may predict the presence of an adenoma in the proximal colon »

• « Other large, prospective, controlled studies, some performed in asymptomatic persons, have failed to confirm this association »

• The balance of evidence supports the recommendation that a hyperplastic polyp found during flexible sigmoidoscopy is not, by itself, an indication for subsequent colonoscopy

Bond H et al, ASGE & AGA endorsed guidelines

All distal HPs and proximal neoplasia (vs no distal polyp)

Lin et al, Arch Intern Med 2005

All distal HPs and proximal neoplasia

Dodou et al, 2012

All HPs and adenomas

Forsberg et al, Scand J Gastroenterol 2012

Non-diminutive HPs and neoplasia

• 2,482 asymptomatic patients with screening colonoscopies

• Non-diminutive HP (> 5 mm) associated with an increased risk of advanced neoplasm

• No difference proximal vs. distal colon – OR = 5.95 vs. 5.36

Lim et al, Digestion 2011

Guidelines

U.S. Multi-Society Task Force on Colorectal Cancer and the American Cancer

Society 2006, revised 2012

Guidelines

• The management of patients with hyperplastic polyps only was omitted from prior guidelines

• There is no evidence that patients with small distally located hyperplastic polyps have an increased risk for colorectal cancer and therefore they should be prescreened as appropriate for average-risk patients

• The present guidelines state this explicitly

Are Guidelines followed ? declaration

Tanaka et al, Kobe J Med Sci 2011

Are Guidelines followed observation

25%

Ransohoff et al, Dig Dis Sci 2012

HPs and adenoma recurrence

Benson et al,

Lancet 1999.

HPs and adenoma recurrence

• 99 patients only hyperplastic polyps (group I). • Patients paired according to age and sex with no

polyps (group II) and adenomas (group III). • New polyps were found in 46.4% in group I versus

15.5% in group II (p < 0.001) and 50% in group III (NS).

• Patients with hyperplastic polyps were 2.4 times more likely to have further adenomas than were those without polyps.

Croizet O, Gastrointest Endosc. 1997

HPs and adenoma recurrence

• 42 patients for whom hyperplastic polyps were the only colorectal neoplasms found on the index examination, in contrast to 362 control patients who had a "clean" index examination.

• Mean follow-up time was 4.3 years.

• Patients found to have only hyperplastic polyps on initial examination had a rate of subsequent adenoma diagnoses (42%) twice that of patients with a clean initial colonoscopy (21%), RR 2.0 (95% CI, 1.2-3.4).

Huang EH, Surg Endosc. 2001

Adenoma + HPs and adenoma recurrence

• 1637 participants in the Polyp Prevention Trial • 27% had hyperplastic polyps coexisting with

adenomas at baseline.

• No association between the presence of baseline hyperplastic polyps and recurrence of – any adenoma (OR, 1.19; 95% CI, 0.94-1.51) – advanced adenoma (OR, 1.25; 95% CI, 0.78-2.03).

Laiyemo AO, Clin Gastroenterol Hepatol. 2009

Microvesicular, Globet cell, Mucinous

Are HPs, HPs ?

• Significant proportion of recently reported right-sided HPs are SSAs – 4096 pathology reports by 25 pathologists

– 17% of right-sided previously reported HPs and 20% of those >5 mm were reclassified as SSAs

Singh et al, Gastrointest Endosc 2012

HPs and SSA shares molecular abnormalities

Rex et al, Am J Gastroenterol 2012

Biomarker predictive of colonic neoplasia outcome in patienst with HPs

• High expression of progastrin in HPs associated with risk for metachronous adenomas

Do et al, Cancer Prev Res 2012

Guidelines

• What HPs ? – Pathological and Molecular features – Proximal site – Size : 5 to 10 mm, > 10 mm – Number

– New studies – More precise guidelines ?

Distal HPs and proximal neoplasia

Dave et al , J Gen Intern Med 2003

All distal HPs and proximal neoplasia (vs distal denoma)

Lin et al, Arch Intern Med 2005