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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
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
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
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
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 ?