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Colonoscopy for Small Adenomas
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IN RESPONSE:
Hurowitz and Stubbs raise the question of suitable management for patients known to have small polyps (≤ 5 mm) on flexible sigmoidoscopy. Controversy continues to surround management of patients who have a small tubular adenoma on screening flexible sigmoidoscopy and whether they should undergo colonoscopy of the proximal colon. It is not only the size of a polyp but also the underlying histologic characteristics that should determine appropriate management. Most authorities consider polyps to have advanced features if the polyps are greater than 1.0 cm or if they have a villous or tubulovillous structure. The seemingly disparate results in the studies reported by Read and colleagues (1) and Wallace and coworkers (2) can be reconciled if one examines the composition of the patient groups. Read and colleagues included patients with advanced distal polyps (that is, tubulovillous or villous adenomas); such lesions have been shown in other series to be clearly associated with a higher prevalence of advanced proximal polyps. By contrast, Wallace and colleagues did not include any patients with villous or tubulovillous lesions but restricted their study to patients with tubular lesions 1 to 5 mm or 6 to 10 mm in diameter. The results obtained by Wallace and associates are in accord with those of an earlier study by Zarchy and Ershoff (3), who found that only 1 of 124 patients (0.8%) who had polyps without advanced histologic features (<1 cm and absence of a villous or tubulovillous pattern) actually had a proximal lesion.
To summarize, the accumulated evidence indicates that patients with small tubular adenomas have a less than 1% chance of harboring a proximal lesion. On the other hand, even diminutive polyps (≤ 5 mm in diameter), if they have advanced histologic features consisting of a villous or tubulovillous pattern, are associated with a higher risk for proximal lesions.
Norton J. Greenberger, MD
University of Kansas Medical Center; Kansas City, KS 66160
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
