From the Guidelines
The recommended management for a patient with a tubular adenoma showing low-grade dysplasia is complete endoscopic removal of the polyp followed by surveillance colonoscopy in 5-10 years, with the exact timing depending on additional risk factors such as polyp size, number, and family history. After removal, patients should undergo a follow-up colonoscopy, with the timing based on other clinical factors (such as prior colonoscopy findings, family history, and the preferences of the patient and judgment of the physician) 1. If the polyp was large (≥10 mm), multiple polyps were found, or there is a family history of colorectal cancer, surveillance should occur at the 3-year mark 1. For patients with only 1-2 small (<10 mm) tubular adenomas with low-grade dysplasia, a 5-year follow-up interval is appropriate 1. Some key points to consider in the management of these patients include:
- Complete removal of the polyp is essential because tubular adenomas, even with low-grade dysplasia, represent precancerous lesions that can progress to colorectal cancer over time through the adenoma-carcinoma sequence 1.
- The risk of progression is relatively low for small tubular adenomas with low-grade dysplasia compared to villous adenomas or those with high-grade dysplasia, but regular surveillance is still necessary to detect and remove any metachronous adenomas that may develop 1.
- Patients with a history of adenomas should undergo surveillance colonoscopy and polypectomy to reduce their risk of future colorectal cancer 1. Some of the key recommendations from the guidelines include:
- Patients with one or two small (less than 1 cm) tubular adenomas, including those with only low-grade dysplasia, should have their next follow-up colonoscopy in five to 10 years 1.
- Patients with three to 10 adenomas, any adenoma 1 cm or larger, or any adenoma with villous features or high-grade dysplasia should have their next colonoscopy in three years, providing that piecemeal removal has not been done and the adenomas are completely removed 1.
From the Research
Management of Tubular Adenoma with Low-Grade Dysplasia
- The European Society of Gastrointestinal Endoscopy (ESGE) recommends that patients with complete removal of 1-4 adenomas < 10mm with low-grade dysplasia do not require endoscopic surveillance and should be returned to screening 2.
- If organized screening is not available, repetition of colonoscopy 10 years after the index procedure is recommended 2.
- The size and number of adenomas, as well as the presence of high-grade dysplasia, are major predictors of cancer risk 3.
- Patients with adenomas > 1 cm with high-grade dysplasia may be at high risk of developing further adenomas with high-grade dysplasia or carcinoma, and close follow-up is warranted 4.
Surveillance Intervals
- Surveillance colonoscopy after 3 years is recommended for patients with complete removal of at least 1 adenoma ≥ 10mm or with high-grade dysplasia, or ≥ 5 adenomas, or any serrated polyp ≥ 10mm or with dysplasia 2.
- A 3-6 month early repeat colonoscopy following piecemeal endoscopic resection of polyps ≥ 20mm is recommended, with a first surveillance colonoscopy 12 months after the repeat colonoscopy to detect late recurrence 2.
- If no polyps requiring surveillance are detected at the first surveillance colonoscopy, a second surveillance colonoscopy after 5 years is suggested 2.
Polypectomy Techniques
- Advanced resection techniques, such as endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), are effective for removing precancerous polyps 5.
- The use of viscous agents, such as Eleview, can improve the submucosal lift and reduce the total injected volume during polypectomy 5.