Villous Adenoma Treatment & Management
- Author: Alnoor Ramji, MD, FRCPC; Chief Editor: Julian Katz, MD more...
See the list below:
A full colonoscopy is the accepted procedure of choice in North America for screening or investigation of possible adenomas. If possible, remove all polyps at endoscopy. Send polyps to a pathologist to assess for histological type, grade of dysplasia, and presence of carcinoma. Record the gross morphology, location, and size of each polyp.
Perform a full colonoscopy if sigmoidoscopy reveals an adenoma. Of patients with rectosigmoid adenomas, 40-50% have additional proximal polyps. From the NPS data, patients with left-sided adenomas had a 2.9-fold risk of also having right-sided polyps compared to patients with no left-sided polyps. Patients with only a hyperplastic polyp in the rectosigmoid do not require full colonoscopy.
Cautery snare is recommended for removal of larger polyps. For large sessile polyps, for which the risk of perforation is higher, injection of 1 mL or more of saline into the submucosa directly under the polyp is a useful technique. This lifts the flat polyp away from the muscular layer, creating a stalklike effect. A couple of drops of methylene blue added to the saline also allows the operator to determine if a perforation has occurred in the muscle layer, which would be seen as a break in the layer. Smaller sessile polyps should be removed or biopsied and ablated with hot-biopsy forceps or a minisnare.
After removal of a large (>2 cm) sessile polyp or if the possibility exists of incomplete removal of a large adenoma, a follow-up colonoscopy usually should be performed within 3-4 months.
In the case of malignant polyps, no further treatment is necessary if certain conditions are met, as published by the American College of Gastroenterology:
- The polyp is considered to be completely excised by the endoscopist.
- The polyp is fixed and sectioned so that it is possible to accurately determine the depth of invasion, grade of differentiation, and completeness of excision of the carcinoma.
- The cancer is not poorly differentiated.
- No evidence exists of vascular or lymphatic involvement.
- The margin of the excision is not involved.
The role for nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase-2 (COX-2) inhibitors is unclear. No evidence indicates regression in patients who already have polyps who are treated with these agents, although NSAIDS may have a role in primary prophylaxis.
See the list below:
Surgical resection of a colorectal polyp may be required, especially if the polyp is larger than 2-3 cm and is sessile (as villous adenomas often are). Also, polyps encompassing 2 colonic folds often require surgical consideration. In such situations, the colonic wall can be marked with India ink for localization of the bowel segment at surgery.
If benign, duodenal villous adenomas can be treated by local transduodenal resection, although recurrence is common and may be malignant. Consider pancreaticoduodenectomy for duodenal malignant villous adenomas and for villous tumors of the ampulla of Vater.
See the list below:
A competent endoscopist should supervise care and follow-up.
Consultation with a surgeon may be required for resection of the polyp.
Dietary recommendations have been established to prevent colorectal cancer. Given the evidence for the adenoma-to-carcinoma sequence, these recommendations likely also apply to adenomas.
Limit total fat to 25-30% of energy intake. A fatty diet may increase biliary sterols, which are damaging.
Increase fruit and fiber intake to 5 servings daily. Increased fiber dilutes luminal contents and decreases the contact between carcinogenic substances and the lumen. Fruits and vegetables also contain minerals and vitamins that may impede carcinogenesis.
Ingest 20-30 g of fiber daily. In addition to the benefits of increased fruit and fiber intake, fiber may inhibit some harmful bacteria and prevent damaging effects of bile acids.
Dietary supplementation with 3 g of calcium carbonate is suggested based upon limited data.
See the list below:
Maintain normal body weight.
Exercise daily. Exercise helps decrease transit time and, therefore, the contact of harmful substances with the lumen.
Avoid smoking and excessive consumption of alcohol.
Ferlitsch M, Reinhart K, Pramhas S, Wiener C, Gal O, Bannert C, et al. Sex-specific prevalence of adenomas, advanced adenomas, and colorectal cancer in individuals undergoing screening colonoscopy. JAMA. 2011 Sep 28. 306(12):1352-8. [Medline].
Fairley KJ, Li J, Komar M, Steigerwalt N, Erlich P. Predicting the risk of recurrent adenoma and incident colorectal cancer based on findings of the baseline colonoscopy. Clin Transl Gastroenterol. 2014 Dec 4. 5:e64. [Medline].
Wark PA, Wu K, van 't Veer P, Fuchs CF, Giovannucci EL. Family history of colorectal cancer: a determinant of advanced adenoma stage or adenoma multiplicity?. Int J Cancer. 2009 Jul 15. 125(2):413-20. [Medline].
Terhaar Sive Droste JS, Craanen ME, van der Hulst RW, Bartelsman JF, Bezemer DP, Cappendijk KR, et al. Colonoscopic yield of colorectal neoplasia in daily clinical practice. World J Gastroenterol. 2009 Mar 7. 15(9):1085-92. [Medline]. [Full Text].
Martinez ME, Baron JA, Lieberman DA, et al. A pooled analysis of advanced colorectal neoplasia diagnoses after colonoscopic polypectomy. Gastroenterology. 2009 Mar. 136(3):832-41. [Medline].
de Jonge V, Sint Nicolaas J, van Leerdam ME, Kuipers EJ, Veldhuyzen van Zanten SJ. Systematic literature review and pooled analyses of risk factors for finding adenomas at surveillance colonoscopy. Endoscopy. 2011 Jul. 43(7):560-72. [Medline].
Denis B, Peters C, Chapelain C, et al. Diagnostic accuracy of community pathologists in the interpretation of colorectal polyps. Eur J Gastroenterol Hepatol. 2009 Aug 18. epub ahead of print. [Medline].
Bokemeyer B, Bock H, Huppe D, et al. Screening colonoscopy for colorectal cancer prevention: results from a German online registry on 269000 cases. Eur J Gastroenterol Hepatol. 2009 Jun. 21(6):650-5. [Medline].
Cole BF, Logan RF, Halabi S, et al. Aspirin for the chemoprevention of colorectal adenomas: meta-analysis of the randomized trials. J Natl Cancer Inst. 2009 Feb 18. 101(4):256-66. [Medline].
Baron JA, Cole BF, Sandler RS, Haile RW, Ahnen D, Bresalier R, et al. A randomized trial of aspirin to prevent colorectal adenomas. N Engl J Med. 2003 Mar 6. 348(10):891-9. [Medline].
Bond JH. Colon polyps and cancer. Endoscopy. 2001 Jan. 33(1):46-54. [Medline].
Bond JH. Colorectal cancer update. Prevention, screening, treatment, and surveillance for high-risk groups. Med Clin North Am. 2000 Sep. 84(5):1163-82, viii. [Medline].
Bond JH. Polyp guideline: diagnosis, treatment, and surveillance for patients with colorectal polyps. Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol. 2000 Nov. 95(11):3053-63. [Medline].
Bond JH. Polyp guideline: diagnosis, treatment, and surveillance for patients with nonfamilial colorectal polyps. The Practice Parameters Committee of the American College of Gastroenterology. Ann Intern Med. 1993 Oct 15. 119(8):836-43. [Medline].
Cotton PB, Durkalski VL, Pineau BC, Palesch YY, Mauldin PD, Hoffman B, et al. Computed tomographic colonography (virtual colonoscopy): a multicenter comparison with standard colonoscopy for detection of colorectal neoplasia. JAMA. 2004 Apr 14. 291(14):1713-9. [Medline].
Day DW, Morson BC. The adenoma-carcinoma sequence. Morson BC, ed. The Pathogenesis of Colorectal Cancer. Philadelphia: WB Saunders; 1978. 58-71.
DuBois RN, Giardiello FM, Smalley WE. Nonsteroidal anti-inflammatory drugs, eicosanoids, and colorectal cancer prevention. Gastroenterol Clin North Am. 1996 Dec. 25(4):773-91. [Medline].
Farnell MB, Sakorafas GH, Sarr MG, Rowland CM, Tsiotos GG, Farley DR, et al. Villous tumors of the duodenum: reappraisal of local vs. extended resection. J Gastrointest Surg. 2000 Jan-Feb. 4(1):13-21, discussion 22-3. [Medline].
Gibbs ER, Walton GF, Kent RB 3rd, Laws HL. Villous tumors of the ampulla Vater. Am Surg. 1997 Jun. 63(6):467-71. [Medline].
Heald RJ, Bussey HJ. Clinical experiences at St. Mark's Hospital with multiple synchronous cancers of the colon and rectum. Dis Colon Rectum. 1975 Jan-Feb. 18(1):6-10. [Medline].
Itzkowitz SH, Kim YS. Colonic polyps and polyposis syndromes. Feldman M, Scharschmidt BF, Sleisenger MH. Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, and Management. 6th ed. Philadelphia, Pa: WB Saunders; 1997. 467-71.
Mandel JS, Bond JH, Church TR, Snover DC, Bradley GM, Schuman LM, et al. Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study. N Engl J Med. 1993 May 13. 328(19):1365-71. [Medline].
Morson BC, Dawson IMP. Gastrointestinal Pathology. Oxford: Blackwell Scientific; 1972.
O'Brien MJ, Winawer SJ, Zauber AG, Gottlieb LS, Sternberg SS, Diaz B, et al. The National Polyp Study. Patient and polyp characteristics associated with high-grade dysplasia in colorectal adenomas. Gastroenterology. 1990 Feb. 98(2):371-9. [Medline].
Pickhardt PJ, Choi JR, Hwang I, Butler JA, Puckett ML, Hildebrandt HA, et al. Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. N Engl J Med. 2003 Dec 4. 349(23):2191-200. [Medline].
Sandler RS, Halabi S, Baron JA, Budinger S, Paskett E, Keresztes R, et al. A randomized trial of aspirin to prevent colorectal adenomas in patients with previous colorectal cancer. N Engl J Med. 2003 Mar 6. 348(10):883-90. [Medline].
Schrock TR. Colonoscopy for colorectal cancer: too much, too little, just right. ASGE Distinguished Lecture 1993. Gastrointest Endosc. 1993 Nov-Dec. 39(6):848-51. [Medline].
Seitz U, Bohnacker S, Seewald S, Thonke F, Brand B, Braiutigam T, et al. Is endoscopic polypectomy an adequate therapy for malignant colorectal adenomas? Presentation of 114 patients and review of the literature. Dis Colon Rectum. 2004 Nov. 47(11):1789-96; discussion 1796-7. [Medline].
Stryker SJ, Wolff BG, Culp CE, Libbe SD, Ilstrup DM, MacCarty RL. Natural history of untreated colonic polyps. Gastroenterology. 1987 Nov. 93(5):1009-13. [Medline].
Winawer SJ, Zauber AG, Fletcher RH, Stillman JS, O'Brien MJ, Levin B, et al. Guidelines for colonoscopy surveillance after polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society. Gastroenterology. 2006 May. 130(6):1872-85. [Medline].
Winawer SJ, Zauber AG, Ho MN, O'Brien MJ, Gottlieb LS, Sternberg SS, et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med. 1993 Dec 30. 329(27):1977-81. [Medline].
Winawer SJ, Zauber AG, Ho MN, O'Brien MJ, Gottlieb LS, Sternberg SS, et al. The National Polyp Study. Eur J Cancer Prev. 1993 Jun. 2 Suppl 2:83-7. [Medline].
Winawer SJ, Zauber AG, O'Brien MJ, Ho MN, Gottlieb L, Sternberg SS, et al. Randomized comparison of surveillance intervals after colonoscopic removal of newly diagnosed adenomatous polyps. The National Polyp Study Workgroup. N Engl J Med. 1993 Apr 1. 328(13):901-6. [Medline].
Zauber AG, Winawer SJ. Initial management and follow-up surveillance of patients with colorectal adenomas. Gastroenterol Clin North Am. 1997 Mar. 26(1):85-101. [Medline].