a 55 yrs old woman with a past history of colon cancer that underwent left hemicolectomy ,T2N0 well diff adenocarcinoma, in follow up colonoscopy one year after operation shows a 1*1 cm cessile polyp that removed endoscopically . pathology showed hi grade dysplasia .
what is your recommendation?
Dear DR HAbibollah
I think the very important part of this decision is familial history and previus oncological history of patients. In familial ocurrence of GI cancers, especiually fullyfilled the Lynch syndrome (HNPCC) criteria the right hemicolectomy = colectomy with ileo-rectal anastomosis is indicated to avoid of further malignancies.
Dear professor Mahmoudzade
I hope you forgive me for being insolent...According to NCCN guidelines,do you think if this patient doesn't have any specific risk factors,follow up with colonoscopy one year later would be appropriate?
Is a really difficult answer because a high grade dysplasia is the same that cancer, so you tell that es a polyp but the question is. The polyp is flat or no? because with that size if the polyp is flat i thing that the most effective treatment y surgery.
Dear Dr Tomasz
our patients familial history is unremarkable.
Dear Dr Ignacio
Thanks for your replay,polyp was sessile and completely removed by colonoscope.
Dear Dr Negar
Thanks for your attention. according NCCN ver 2,2016 for sessile polyp ,two option was recommended but regard to patient history of cancer i am keen to surgery.
The patient is young with a previous cancer. A further polyp with high grade dysplasia is concerning. There maybe a field change within the colon. I would be inclined to offer surgery in the form of a completion colectomy with ileorectal anastomosis. The rectum can be easily surveyed endoscopically. There should be adequate rectum remaining to ensure reasonable function.
If no genetic links with colon cancer have been found, for a sessile adenoma with the reported size and histology the best follow-up would be a check at 3 months to conferm complete resection. Further follow-up depends on findings, according to guidelines (ESGE, ASGE...) Total colectomy imposes major burdens on patients in terms of quality of life.
If the family history is negative right hemicolectomy & ileorectal anastomosis
If margins of polyp excision uncertain, repeat flexible sigmoidoscopy of polyp site which can be tattooed, if ok, by BSg guidelines intermediate risk based n size more than 1 cm, hence colonoscopy at 3 years. Grade of dysphasia in completely excised polyp is not a criteria for early surveillance
Colonoscopy at 3 months to check polypectomy site would be fine if the patient had not had a previous cancer. With her age (
A carefully evaluation of removed polyp and merges to discard an unmissed cancer. Follow up with colonoscopy at 3 month. Later the standard routine in the follow up.
Repeat colonoscopy at 6 month with re biopsy of the polyp site, then such patient need surveillance colonoscopy
Dear Dr. Mahmoodzadeh, after all these suggestions and comments, what have you decided to do?
Dear Dr Candol
I talked with the patient in detail regarding that she has two option ,first to observe carefully second total abdominal colectomy that i was for it.
finally she accept surgery and we operated her.
Ideally should be removed by ESD. If it was resected by EMR then a careful colonoscopy in 4-6 months. I believe this patient would have a CT as part of post CRC protocol.
Dear Dr Rameshshanker
Thanks for your nice comment. At that time ct scan was normal and CEA at normal range also
according NCCN guideline for sessile polyp, colon resection (segmental at least) is preferred
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