Intestinal Polypoid Adenomas Treatment & Management

Updated: Feb 05, 2018
  • Author: Swati G Patel, MD, MS; Chief Editor: BS Anand, MD  more...
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Treatment

Medical Care

Excision and complete removal of adenomatous tissue during colonoscopy is considered the treatment of choice, and the goal of therapy is to decrease the risk for the development of colorectal cancer (CRC). Several techniques for polyp removal are used, including biopsy forceps and snare excision (with and without electrocautery), as well as simple fulguration and piecemeal excision of large polyps.

Chemoprevention—with sulindac, a nonsteroidal anti-inflammatory drug (NSAID)—has been shown to significantly reduce the number and size of adenomas in patients with familial adenomatous polyposis (FAP). [49, 50] The selective cyclooxygenase-2 (COX-2) inhibitor celecoxib has also been shown to cause modest regression of colonic adenomas in patients with FAP. [51] Although widely used, neither of these drugs is approved by the US Food and Drug Administration (FDA) for polyp prevention in FAP.

There has been a case report of chemoprevention with curcumin followed by silibinin significantly reducing the number of recurrent polyps in a middle-aged patient with multiple colorectal adenomatous polyps but without germline adenomatous polyposis coli (APC) or MYH gene mutations. [52]  Another case report indicated a possible chemopreventive role for tacrolimus and mycophenolate mofetil; investigators noted complete reversion of FAP in a teenager carrier with a germline mutation in the APC gene who received a kidney transplant, followed by treatment with tacrolimus and  mycophenolate mofetil. [53]

Several case-control and cohort studies indicate that the regular use of aspirin or other NSAIDs is associated with a lower rate of CRC and mortality. Several controlled trials have shown that aspirin and selective COX-2 inhibitors can decrease the rate of metachronous adenomas. [54] Owing to concerns about their adverse effects, NSAIDs are not currently recommended for either treatment or prevention of sporadic colonic adenomas in average-risk patients.

Flexible sigmoidoscopy and colonoscopy generally are outpatient procedures. Inpatient care rarely is required for the diagnosis and treatment of adenomas.

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Surgical Care

Surgical intervention is usually not required in the management of adenomatous polyps. Rarely, a large (>2 cm) sessile adenoma may not be amenable to endoscopic resection and may require surgery. Large rectal adenomas can be removed via intraoperative transanal resection. More proximal lesions may require laparoscopy or laparotomy with segmental colonic resection and evaluation of lymph nodes. For these lesions, it is important that the endoscopist mark the location of the polyp with a tattoo during colonoscopy prior to surgery.

In a retrospective study (2000-2014) that used data from the Healthcare Cost and Utilization Project National Inpatient Sample to evaluate rates of surgical resection for nonmalignant colorectal polyps in the age of endoscopy, Peery et al found an increased incidence from 5.9 per 100,000 adults in 2000 to 9.4 per 100,000 adults in 2014, in men and women across all races and ethnicities aged 20-79 years. [55]  However, over the same period, the incidence of surgery for colorectal cancer decreased significantly (31.5 to 24.7 surgeries per 100,000 adults).

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Consultations

Most colonoscopy and polyp treatment is performed by gastroenterologists or colorectal surgeons who work closely with primary care physicians and pathologists to coordinate the diagnosis, treatment, and follow-up of adenomas.

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Diet

Observational studies have suggested a link between dietary measures such as avoidance of red meat and alcohol or diets high in fruits and vegetables as measures to protect against the development of colorectal adenomas. These measures, however, have not been shown to prevent new adenomas in prospective randomized trials. The US Preventive Services Task Force (USPSTF) guidelines [7] acknowledge these data and do not recommend specific dietary measures for the prevention of colorectal adenomas. In contrast, the American Cancer Society has prudent lifestyle and dietary recommendations for cancer prevention.

The American Cancer Society (ACS) makes the following lifestyle and nutrition recommendations for general cancer prevention [24] :

  • Achieve and maintain a healthy weight throughout life.
  • Be as lean as possible throughout life without being underweight.
  • Avoid excess weight gain at all ages. For those who are currently overweight or obese, losing even a small amount of weight has health benefits and is a good place to start.
  • Engage in regular physical activity and limit the consumption of high-calorie foods and beverages as key strategies for maintaining a healthy weight.
  • Adopt a physically active lifestyle.
  • Adults should engage in at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity activity each week, or an equivalent combination, preferably spread throughout the week.
  • Children and adolescents should engage in at least 1 hour of moderate or vigorous intensity activity each day, with vigorous intensity activity occurring at least 3 days each week.
  • Limit sedentary behavior such as sitting, lying down, watching television, or other forms of screen-based entertainment.
  • Doing some physical activity above the usual activities, no matter what one’s level of activity, can have many health benefits.
  • Consume a healthy diet, with an emphasis on plant foods.
  • Choose foods and beverages in amounts that help achieve and maintain a healthy weight.
  • Limit consumption of processed meat and red meat.
  • Eat at least 2.5 cups of vegetables and fruits each day.
  • Choose whole grains instead of refined grain products.
  • If you drink alcoholic beverages, limit consumption.
  • Drink no more than 1 drink per day for women or 2 per day for men.
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Activity

Multiple epidemiologic studies suggest that obesity increases and regular physical activity decreases colorectal cancer (CRC) risk. No intervention studies have yet directly evaluated the relationship between obesity, physical activity, and adenoma or carcinoma risk, but avoiding obesity and maintaining regular physical activity are prudent recommendations for good health and they may affect CRC risk.

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Prevention

Observational epidemiologic studies have implicated several dietary factors as potentially modulating the prevalence of adenomas. Red meat has been associated with an increased risk, whereas consumption of fruits/vegetables and diets high in fiber has been associated with a decreased risk in some observational studies. These dietary factors have not been shown to alter the risk of adenomas in prospective studies. Thus, at this time, the US Preventive Services Task Force (USPSTF) does not recommend specific dietary measures in the prevention of colorectal adenomas, but prudent lifestyle and dietary recommendations have been made by the American Cancer Society (ACS) (see Diet).

Antioxidant supplements do not have a significant beneficial effect on the primary or secondary prevention of adenoma.

Growing evidence suggests a protective role for aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) against the development of colorectal cancer; however, there is ongoing concern about the risk of these medications. At this time, chemoprevention is not recommended for individuals without hereditary cancer syndromes. There is a role for the use of sulindac and celecoxib in the management of familial adenomatous polyposis (FAP).

Smoking tobacco increases the risk of adenomatous polyps and colorectal cancer (CRC). Patients should be encouraged to quit smoking.

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Long-Term Monitoring

The interval between colonoscopy depends on the size, number, and histological type of polyp, as well as the patient's family history. Polyp recurrence rates are approximately 20% at 5 years and around 50% at 15 years, with even higher recurrence rates in patients with multiple index polyps. Polyps may be missed at the index colonoscopy, and the presence of a polyp when colonoscopy is repeated at 1 year is about 33%.

For those with no adenomas on colonoscopy, repeat screening is recommended in 10 years. For those with 1-2 small adenomas (≤9 mm), repeat colonoscopy is recommended in 5-10 years. For those with an adenoma larger than 1 cm, 3 or more adenomas of any size, or an adenoma with advanced histology (villous features, high-grade dysplasia), colonoscopy should be repeated in 3 years.

In a multicenter, longitudinal, observational study in 15 colorectal cancer (CRC) high-risk clinics in Spain, investigators studied the risk of developing CRC or the need for surgery during endoscopic surveillance in a cohort of patients with multiple (10-100) colorectal polyps. A total of 265 patients were followed for a median of 3.8 years, and patients underwent a median of 5 colonoscopies. More than 10% of patients required colorectal surgery within 4 years, more than half of which was for incident CRC. [56]

Colonoscopy should be repeated within 6 months if the mucosa was not adequately visualized (poor bowel preparation, incomplete colonoscopy) or if a high-risk lesion was removed (large polyp, piecemeal resection) to ensure that the entire polyp has been removed.

In a retrospective study (2002-2007) of outpatient screening and surveillance colonoscopies over a span of 5 years, Murphy et al compared next-day versus any other day ("non-next-day") repeat colonoscopy outcomes. They found a substantial increase in adenoma detection on follow-up, confirming the need for repeat examination after a colonoscopy with inadequate bowel preparation. Investigators found no differences in outcomes between next-day and non-next-day colonoscopy, supporting the view that inadequate colonoscopy should be repeated within 1 year as convenient for the patient and physician. [57]

In another retrospective study (1982-2014), investigators evaluated severity scoring for surveillance and treatment in 437 patients with duodenal polyposis who underwent 1912 upper gastrointestinal endoscopies and found that not only did over 20% of patients develop high-grade dysplasia after 10 years but surgical remained necessary in 12% of patients despite iterative endoscopic resections, with many occurring too late (20% who underwent surgery had developed duodenal or ampulary adenocarcinoma and 8% displayed malignancy with lymph node involvement). [58]  The investigators indicated that in high-risk patients, more accurate predictive scoring by accounting for ampullary anomalies may increase compliance with closer endoscopic surveillance.

Patients diagnosed with adenomas who are not properly followed with surveillance of a repeat colonoscopy have an increased risk of developing metachronous adenomas and/or colorectal cancer. Whatever the interval recommended for repeat colonoscopy, the patient must be cautioned to report any new bowel symptoms or bleeding, because of the concern that new pathology may have developed in the interim.

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