Treatment and follow-up of large bowel adenoma

The current clinical interest in large bowel adenoma is due to the evidence that most carcinomas arise in benign adenomas and therefore endoscopic removal of adenomas interrupts the sequence that leads to cancer. Colonoscopy is the best method for the detection and treatment of adenomas, with a diagnostic accuracy of 94% and a low incidence of complications. The majority of polyps can be resected by snare polypectomy. Regarding small polyps, snare polypectomy without current application is recommendable and hot biopsy should be avoided owing to a non negligible risk of hemorrage. Though clinical significance of small polyps is controversial, in our experience and in other studies they have a potential for malignant progression (2.4% of adenomas containing invasive carcinoma are 6 mm or less in diameter) and those located in the rectosigmoid are predictive of proximal neoplasms. If endoscopic polypectomy significantly reduces the incidence of colorectal cancer, patients submitted to adenoma removal have an increased risk for metachronous adenomas. Surveillance is therefore mandatory, once the presence of synchronous adenomas has been ruled out (clean colon). Risk factors for adenoma recurrence are family history, age, size of adenoma, multiple adenomas, dysplasia, villous histotype. Holding in due consideration compliance, risk of complications, logistic problems and costs, the following guide-lines can be proposed: total colonoscopy at the time of endoscopic polypectomy (to obtain a "clean colon") and, in the case of unsatisfactory examination, within one year. first check at 3 years and, if negative, subsequent check at 5 years. for small tubular adenomas surveillance is indicated only in the case they are multiple. The evaluation of some intermediate bio-markers might contribute to the predictive determination of adenoma recurrence, with the goal to select groups of patients with the highest risk of recurrence of adenomas.