The clinical relevance and in-vivo growth rates of small (6—9 mm) colorectal polyps are not well established. We aimed to assess the behaviour of such polyps with CT colonography assessments.
In this longitudinal study, we enrolled asymptomatic adults undergoing routine colorectal cancer screening with CT colonography at two medical centres in the USA. Experienced investigators (PJP, DHK, JLH) measured volumes and maximum linear sizes of polyps in vivo with CT colonography scans at baseline and surveillance follow-up. We defined progression, stability, and regression on the basis of a 20% volumetric change per year from baseline (20% or more growth classed as progression, 20% growth to −20% reduction classed as stable, and −20% or more reduction classed as regression). We compared findings with histological subgroups confirmed after colonoscopy when indicated. This study is registered withClinicalTrials.gov, number NCT00204867.
Between April, 2004, and June, 2012, we screened 22 006 asymptomatic adults and included 243 adults (mean age 57·4 years [SD 7·1] and median age 56 years [IQR 52—61]; 106 [37%] women), with 306 small colorectal polyps. The mean surveillance interval was 2·3 years (SD 1·4; range 1—7 years; median 2·0 years [IQR 1·1—2·3]). 68 (22%) of 306 polyps progressed, 153 (50%) were stable, and 85 (28%) regressed, including an apparent resolution in 32 (10%) polyps. We established immediate histology in 131 lesions on colonoscopy after final CT colonography. 21 (91%) of 23 proven advanced adenomas progressed, compared with 31 (37%) of 84 proven non-advanced adenomas, and 15 (8%) of 198 other lesions (p<0·0001). The odds ratio for a growing polyp at CT colonography surveillance to become an advanced adenoma was 15·6 (95% CI 7·6—31·7) compared with 6—9 mm polyps detected and removed at initial CT colonography screening (without surveillance). Mean polyp volume change was a 77% increase per year for 23 proven advanced adenomas and a 16% increase per year for 84 proven non-advanced adenomas, but a 13% decrease per year for all proven non-neoplastic or unresected polyps (p<0·0001). An absolute polyp volume of more than 180 mm3 at surveillance CT colonography identified proven advanced neoplasia (including one delayed cancer) with a sensitivity of 92% (22 of 24 polyps), specificity of 94% (266 of 282 polyps), positive-predictive value of 58% (22 of 38 polyps), and negative-predictive value of 99% (266 of 268 polyps). Only 16 (6%) of the 6—9 mm polyps exceeded 10 mm at follow-up.
Volumetric growth assessment of small colorectal polyps could be a useful biomarker for determination of clinical importance. Advanced adenomas show more rapid growth than non-advanced adenomas, whereas most other small polyps remain stable or regress. Our findings might allow for less invasive surveillance strategies, reserving polypectomy for lesions that show substantial growth. Further research is needed to provide more information regarding the ultimate fate of unresected small polyps without significant growth.
Cancer can still occur after successful eradication of dysplasia with radiofrequency ablation.
Radiofrequency ablation (RFA) for patients with Barrett esophagus with high-grade dysplasia (HGD) has been clearly established as an acceptable and preferred treatment option for the majority of these patients. In the initial multicenter trial, RFA completely eradicated dysplasia in 91% of patients with HGD (JW Gastroenterol May 27 2009) and in 95% who were followed up for 2 years. Repeat RFA was performed in 55% of patients after the 1-year primary end point — mostly based on the discretion of the endoscopist rather than biopsy indication (JW Gastroenterol Nov 4 2011). No cancers were reported. The inference by some clinicians is that patients who have had successful ablative therapy can be considered cured and can be discontinued from surveillance. However, a new case report provides contrary evidence.
Three patients underwent successful RFA treatment of Barrett esophagus with HGD at tertiary academic centers; procedures were performed by nationally recognized experts in RFA. Two patients underwent endoscopic mucosal resection before RFA. The first patient had five post-RFA surveillance endoscopies during 2 years before subsquamous HGD was detected. The second patient had normal neosquamous epithelium at 3 months but subsquamous esophageal adenocarcinoma detected at 6 months. The third patient underwent two endoscopies at 3-month intervals, and at 9 months, a nodular area was noted and a subsquamous esophageal adenocarcinoma was detected.
Comment: This report emphasizes the ongoing risk for cancer following successful RFA treatment in patients with Barrett esophagus and HGD. These cases clearly demonstrate the need for meticulous surveillance. However, until the optimal surveillance schedule after ablative therapy is defined in national guidelines, experts currently recommend surveillance intervals of 3 months in year 1, 6 months in year 2, and 1 year thereafter. Quadrant biopsies should be taken every 1 cm in addition to separate biopsies of any visible lesions. Although RFA poses less risk than surgery, it is far from a cure.
Source: Journal Watch Gastroenterology
Physicians who treat patients with thyroid cancer as part of a multidisciplinary treatment team need specific perioperative information, including results from clinical examination, biochemical testing, and cross-sectional and functional imaging tests, among other sources.
Communication between disciplines is critical, but the American Thyroid Association recognized that there was no universally accepted model for effectively sharing this data among the various care providers. The association’s Surgical Affairs Committee was tasked with identifying critical information that should be readily available to each member of the multidisciplinary team. The goal was to help physicians develop a management plan for each patient that will lead to a rational, risk-based approach to initial therapy, adjuvant therapy and follow-up studies.
The committee identified three distinct types of data that must be shared: preoperative evaluations, intraoperative findings and postoperative data, events and plans. The committee provided several data points in each category such as comorbid conditions and abnormal laboratory values that could influence decisions about adjuvant radioiodine ablation therapy in the preoperative category, extent of surgery and description of gross extrathyroidal extension from the intraoperative findings and vocal cord dysfunction and anticipated after-care plan from the postoperative findings.
“Accurate communication of the important findings of thyroidectomy is critical to individualized risk stratification, as well as to the short-term follow-up issues of thyroid cancer care that are often jointly managed in the postoperative setting,” committee member R. Michael Tuttle, MD, of the Memorial Sloan-Kettering Cancer Center, and colleagues wrote. “Moreover, true multidisciplinary communication is essential to providing optimal adjuvant care and surveillance