What is the most appropriate next step in management for a 51-year-old woman with hypertension (HTN), a family history of colon cancer, and two small hyperplastic polyps removed during colonoscopy?

Colonoscopy Surveillance After Hyperplastic Polyp Removal

The most appropriate next step in management for this 51-year-old woman with two small hyperplastic polyps is colonoscopy in 10 years (option A).

Rationale for Recommendation

The US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society guidelines clearly state that patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies, and therefore the interval before subsequent colonoscopy should be 10 years 1.

Key Factors Supporting This Recommendation:

1. Polyp Characteristics:

   • The patient had only two small (8 mm) hyperplastic polyps removed
   • Hyperplastic polyps are not adenomatous lesions
   • There is no evidence that patients with small hyperplastic polyps have an increased risk for colorectal cancer 1

2. Patient Risk Profile:

   • 51-year-old woman with no colon-related symptoms
   • Family history includes mother with colon cancer at age 85 (not early-onset)
   • No personal history of colorectal neoplasia

Distinguishing Hyperplastic Polyps from Adenomas

It's important to recognize that hyperplastic polyps are fundamentally different from adenomas:

• Hyperplastic polyps are generally considered non-neoplastic
• They lack the malignant potential of adenomatous polyps
• The guidelines specifically discourage follow-up surveillance of hyperplastic polyps, except in cases of hyperplastic polyposis 1

Special Considerations

Hyperplastic Polyposis Syndrome

The patient does not meet criteria for hyperplastic polyposis syndrome, which would require:

• At least five histologically diagnosed hyperplastic polyps proximal to the sigmoid colon, of which two are greater than 1 cm in diameter; or
• Any number of hyperplastic polyps occurring proximal to the sigmoid colon in an individual who has a first-degree relative with hyperplastic polyposis; or
• Greater than 30 hyperplastic polyps of any size distributed throughout the colon 1

Family History Considerations

While the patient has a family history of colorectal cancer (mother diagnosed at age 85), this does not qualify as high-risk family history that would warrant more intensive surveillance because:

• The affected relative was diagnosed at an advanced age (85 years)
• There is no indication of hereditary non-polyposis colorectal cancer (HNPCC) or other genetic syndromes 1
• Guidelines recommend more intensive surveillance only when colorectal cancer was diagnosed in a close relative before age 55 1

Why Other Options Are Not Appropriate

• Option B (CT scan abdomen): Not indicated for routine follow-up after removal of hyperplastic polyps
• Option C (mismatch repair genetic testing): Only recommended for patients with suspected hereditary non-polyposis colorectal cancer based on family history or tumor characteristics 1
• Option D (fecal occult blood test in 6 months): The guidelines specifically discourage the use of fecal occult blood testing during surveillance after polypectomy 1, 2

Quality of Baseline Examination

The quality of the baseline colonoscopy is crucial for determining appropriate follow-up intervals. Since the patient had a complete examination with removal of only two small hyperplastic polyps, and assuming adequate bowel preparation and cecal intubation, the recommendation for a 10-year follow-up interval is appropriate 1.

In conclusion, based on the most recent and highest quality guidelines from the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society, this patient should have her next colonoscopy in 10 years.