Transcript polyps

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Final
Jeopardy
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C1 $100
Camille is doing a colonoscopy on a patient who has an average risk of colorectal
cancer with no family history. She finds two 5 mm polyps that were completely
removed and the pathology shows tubular adenomas. When should you repeat the
colonoscopy?
A. 1 year
B. 3 years
C. 5 years
D. 10 years
E. I’m a gynecologist, not an endoscopist !!!
C1 $100
Camille is doing a colonoscopy on a patient who has an average risk of colorectal
cancer with no family history. She finds two 5 mm polyps that were completely
removed and the pathology shows tubular adenomas. When should you repeat the
colonoscopy?
A. 1 year
B. 3 years
C. 5 years
D. 10 years
E. I’m a gynecologist, not an endoscopist !!!
C1 $200
Sarah is doing a colonoscopy on a patient who has an average risk of colorectal cancer
with no family history. She finds one 1.5 cm polyp in the ascending colon that was
completely removed and the pathology shows villous adenoma with high grade
dysplasia. When should you repeat the colonoscopy?
A. 1 year
B. 3 years
C. 5 years
D. 10 years
E. Do a right colectomy
Sarah is doing a colonoscopy on a patient who has an average risk of colorectal cancer
with no family history. She finds one 1.5 cm polyp in the ascending colon that was
completely removed and the pathology shows villous adenoma with high grade
dysplasia. When should you repeat the colonoscopy?
A. 1 year
B. 3 years
C. 5 years
D. 10 years
E. Do a right colectomy
Colonoscopy intervals
•
+ve family history (First degree relative with colorectal ca OR adenomatous
polyps (<60 yrs)  At least every 5 yrs
•
No polyps OR hyperplastic polyps  10 yrs
•
1-2 adenomatous polyps  5 yrs
•
3 yrs 
• 3 or more adenomatous polyps
• Polyp with HGD
• Villous histology of polyp
• Polyp >1 cm
C1 $300
A patient with a strong family history of colon cancer comes to you in clinic. His mom
had colon cancer at age 40 yrs, dad at age 35 yrs and brother at age 45 yrs. What is
your recommendation for him?
A. Start colonoscopy at age 25 yrs and repeat every 1-2 yrs
B. Start colonoscopy at age 40 yrs and repeat every 1-2 yrs
C. Start colonoscopy at age 25 yrs and repeat every 5 yrs
D. Recommend genetic counseling and total colectomy for HNPCC
E. None of the above
A patient with a strong family history of colon cancer comes to you in clinic. His mom
had colon cancer at age 40 yrs, dad at age 35 yrs and brother at age 45 yrs. What is
your recommendation for him?
A. Start colonoscopy at age 25 yrs and repeat every 1-2 yrs
B. Start colonoscopy at age 40 yrs and repeat every 1-2 yrs
C. Start colonoscopy at age 25 yrs and repeat every 5 yrs
D. Recommend genetic counseling and total colectomy for HNPCC
E. None of the above
When to start colonoscopy
•
Start at age 50 for average risk
•
If first degree relative with CRC or adenomatous polyps  10 yrs before
diagnosis in family OR at age 40 whichever is earliest
•
If CRC in distant family member  Average risk
•
If CRC in first degree relative after age 60  Average risk
C1 $400
A mother with FAP brings her 8 yo son for advice to you. She wants to know the plan
regarding screening and surgery for her son?
A. Genetic counseling, flex sig starting at age 20, surgery when polyps seen
B. Surgery now
C. Genetic counseling, followed by surgery
D. Genetic counseling, flex sig starting at puberty, surgery when polyps seen
E. Genetic counseling, flex sig starting at puberty, surgery at 15-18 yrs of age
F. None of the above
C1 $400
A mother with FAP brings her 8 yo son for advice to you. She wants to know the plan
regarding screening and surgery for her son?
A. Genetic counseling, flex sig starting at age 20, surgery when polyps seen
B. Surgery now
C. Genetic counseling, followed by surgery
D. Genetic counseling, flex sig starting at puberty, surgery when polyps seen
E. Genetic counseling, flex sig starting at puberty, surgery at 15-18 yrs of age
F. None of the above
Surveillance in FAP
1. Genetic counseling at puberty
2. Flex sig starting at puberty annually
3. If APC mutation noted, prophylactic TPC with IPAA at age 15-18 yrs
4. If FAP suspected and no mutation found, continue yearly endoscopies  once
polyps noted  TPC with IPAA
C1 final
A 35 yo male underwent his first screening colonoscopy and you found 5 adenomatous
polyps on the right. He has 3 first degree relatives with colorectal cancer, mom was
diagnosed at age 40. What’s the recommendation for him?
A. Genetic counseling, colonoscopy every 1-2 yrs
B. Colonoscopy every 5 yrs
C. Genetic counseling, Total colectomy now
D. Genetic counseling, colonoscopy every 10 yrs
E. Colonoscopy every 1-2 yrs
Timer
C1 final
A 35 yo male underwent his first screening colonoscopy and you found 5 adenomatous
polyps on the right. He has 3 first degree relatives with colorectal cancer, mom was
diagnosed at age 40. What’s the recommendation for him?
A. Genetic counseling, colonoscopy every 1-2 yrs
B. Colonoscopy every 5 yrs
C. Genetic counseling, Total colectomy now
D. Genetic counseling, colonoscopy every 10 yrs
E. Colonoscopy every 1-2 yrs
Surveillance in HNPCC
1. Genetic counseling when suspected based on clinical history (criteria)
2. Colonoscopy every 2 yrs starting at age 21 yrs
3. Colonoscopy yearly after age 40
4. Once first cancer develops  To be continued………..
C2 $100
What is the recommended screening for Ulcerative Colitis patients?
A. Colonoscopy with biopsies every 3 yrs
B. Colonoscopy starting 12-15 yrs after diagnosis of pancolitis
C. Colonoscopy starting 7-8 yrs after diagnosis of left sided colitis
D. Colonoscopy with biopsies every 1-2 yrs
E. None of the above
C2 $100
What is the recommended screening for Ulcerative Colitis patients?
A. Colonoscopy with biopsies every 3 yrs
B. Colonoscopy starting 12-15 yrs after diagnosis of pancolitis
C. Colonoscopy starting 7-8 yrs after diagnosis of left sided colitis
D. Colonoscopy with biopsies every 1-2 yrs
E. None of the above
DISCUSS
C2 $200
A patient underwent a colonoscopy which showed a large pedunculated polyp in the
right colon which was snared by Ashton Kutcher…… Michael Cox (his first scope).
Patient develops a perforation…… JK…….No perf. Pathology revealed
adenocarcinoma within a tubulovillous adenoma with >2mm margins, well
differentiated, no lymphovascular invasion. Which of these if present would lead you
to surgical resection?
A. Lymphovascular invasion
B. Poorly differentiated lesion
C. <2 mm margins
D. Haggitts level 4 (SM3)
E. Distal rectal Haggitts level 4
F. All of the above
C2 $200
A patient underwent a colonoscopy which showed a large pedunculated polyp in the
right colon which was snared by Ashton Kutcher…… Michael Cox (his first scope).
Patient develops a perforation…… JK…….No perf. Pathology revealed
adenocarcinoma within a tubulovillous adenoma with >2mm margins, well
differentiated, no lymphovascular invasion. Which of these if present would lead you
to surgical resection?
A. Lymphovascular invasion
B. Poorly differentiated lesion
C. <2 mm margins
D. Haggitts level 4 (SM3)
E. Distal rectal Haggitts level 4
F. All of the above
DISCUSS
Cancer in a polyp
•
•
If Pedunculated polyp:
• Haggitts level 1-3  >2
mm margin  Nothing
• Haggitts level 1-3  <2 mm
margin  Re-resect or
surgery
• Haggitts level 4  No LVI
and/or well diff  Nothing
• Haggitts level 4  LVI or
poor differentiation or SM3
 Resect
All Sessile lesions are level 4
•
All sessile lesions and level 4 in
distal rectum  surgery
•
Risk of LN Mets:
• <1% for Haggits 1-3
• 12-25% for Haggitts 4
Sm1
Sm2
Sm3
1%
12%
20%
C2 $300
The diagnosis of FAP is established as a result of:
A.
B.
C.
>50 polyps on colonoscopy
Genetic testing for APC gene mutation
>100 adenomatous polyps on colonoscopy
D.
Positive family history for FAP
E.
All of the above
The diagnosis of FAP is established as a result of:
A.
B.
C.
C2 $300
>50 polyps on colonoscopy
Genetic testing for APC gene mutation
>100 adenomatous polyps on colonoscopy
D.
Positive family history for FAP
E.
All of the above
DISCUSS: 1. APC gene mutation mostly seen but not needed for diagnosis (may be absent)
2. Autosomal dominant but 25% have disease due to new mutation
C2 $400
After total proctocolectomy for FAP, the major source of morbidity and mortality is
from:
A.
B.
Duodenal cancer and desmoid disease
C.
D.
E.
Osteomas
CHRPE
Thyroid cancers
Upper GI adenomas/ hyperplastic fundic gland polyps
C2 $400
After total proctocolectomy for FAP, the major source of morbidity and mortality is
from:
A.
B.
Duodenal cancer and desmoid disease
C.
D.
E.
Osteomas
CHRPE
Thyroid cancers
Upper GI adenomas/ hyperplastic fundic gland polyps
DISCUSS
C2 $500
The most common extraintestinal manifestation in FAP is:
A.
B.
Duodenal cancer and desmoid disease
C.
D.
E.
Osteomas
CHRPE
Thyroid cancers
Upper GI adenomas/ hyperplastic fundic gland polyps
C2 $500
The most common extraintestinal manifestation in FAP is:
A.
B.
Duodenal cancer and desmoid disease
C.
D.
E.
Osteomas
CHRPE
Thyroid cancers
Upper GI adenomas/ hyperplastic fundic gland polyps
DISCUSS
C3 $100
Which of the following is false for Attenuated FAP compared to FAP?
A. <100 colorectal polyps
B. No APC gene mutation
C. Greater age of onset and cancer diagnosis than FAP
D. More right sided polyps
E. Total colectomy with ileorectal anastomosis is reasonable
C3 $100
Which of the following is false for Attenuated FAP compared to FAP?
A. <100 colorectal polyps
B. No APC gene mutation
C. Greater age of onset and cancer diagnosis than FAP
D. More right sided polyps
E. Total colectomy with ileorectal anastomosis is reasonable
DISCUSS:
• Average polyps 1-50 (>100 for FAP)
• Average age for onset is 34-44 yrs (<20 yrs for FAP)
• Average age at cancer is 56 yrs (40 yrs for FAP)
C3 $200
Paula finally saw the light and switched to Colorectal Surgery and made it through
residency. Her first patient with presumed HNPCC based on clinical history undergoes
genetic testing and no mutations are found. What’s the next step?
A. He does not have HNPCC. Regular screening colonoscopy starting at age 50
B. He still has HNPCC. Continue every 1-2 yrs colonoscopy
C. He still has HNPCC. Repeat the genetic tests
D. He is at average risk for colorectal cancer
C3 $200
Paula finally saw the light and switched to Colorectal Surgery and made it through
residency. Her first patient with presumed HNPCC based on clinical history undergoes
genetic testing and no mutations are found. What’s the next step?
A. He does not have HNPCC. Regular screening colonoscopy starting at age 50
B. He still has HNPCC. Continue every 1-2 yrs colonoscopy
C. He still has HNPCC. Repeat the genetic tests
D. He is at average risk for colorectal cancer
C3 $300
Patient with FAP or HNPCC is tested and the genetic mutation is found. You test the
family members for that mutation. If it is not found in some members, what’s the next
step for them?
A. They do not have FAP/HNPCC. Regular screening colonoscopy starting at age 50
B. They still have FAP/HNPCC. Surgery for FAP and every 1-2 yrs colonoscopy for
HNPCC
C. Repeat the genetic tests
D. They are at average risk for colorectal cancer. Screening per guidelines
E. A and D
C3 $300
Patient with FAP or HNPCC is tested and the genetic mutation is found. You test the
family members for that mutation. If it is not found in some members, what’s the next
step for them?
A. They do not have FAP/HNPCC. Regular screening colonoscopy starting at age 50
B. They still have FAP/HNPCC. Surgery for FAP and every 1-2 yrs colonoscopy for
HNPCC
C. Repeat the genetic tests
D. They are at average risk for colorectal cancer. Screening per guidelines
E. A and D
Imp concept for genetic testing for FAP and HNPCC
•
•
•
If mutation found in Proband  May test relatives and if positive:
• FAP  Prophylactic TPC with IPAA at 18 yrs or later when diagnosed
• HNPCC  Screening colonoscopy 1-2 yearly
If mutation found in Proband  May test relatives and if negative:
• Average risk for relative
If no mutation found in Proband, diagnosis is already established CLINICALLY
• -ve genetic testing does not rule out either diagnosis
• Proband and families get treated or screened as they have disease
C3 $400
Which of the following is false for FAP?
A.
>1000 colonic or >20 rectal polyps is severe polyposis and should undergo
surgery NOW
B.
Flex sigs are started in relatives of FAP at age 12-15 yrs annually
C.
Once diagnosed, prophylactic total proctocolectomy with pouch should be done
at age 15-18 yrs
D.
Prophylactic Total colectomy with ileorectal anastomosis is a safe alternative in
FAP
E.
Sulindac reduces the size and number of colorectal adenomas in FAP
C3 $400
Which of the following is false for FAP?
A.
>1000 colonic or >20 rectal polyps is severe polyposis and should undergo
surgery NOW
B.
Flex sigs are started in relatives of FAP at age 12-15 yrs annually
C.
Once diagnosed, prophylactic total proctocolectomy with pouch should be done
at age 15-18 yrs
D.
Prophylactic Total colectomy with ileorectal anastomosis is a safe alternative in
FAP
E.
Sulindac reduces the size and number of colorectal adenomas in FAP
DISCUSS:
TAC/IRA is only for attenuated FAP
C3 $500
What is false for duodenal adenomas in FAP?
A.
B.
C.
D.
E.
>95% pts with FAP have duodenal adenomas
EGD surveillance should be started at age 25 yrs
Treatment is dependent on location, size and histology of polyps
Endoscopic surveillance and resection is very effective in preventing cancer
development
Whipple is usually needed for effective management of advanced polyps
C3 $500
What is false for duodenal adenomas in FAP?
A.
B.
C.
D.
E.
>95% pts with FAP have duodenal adenomas
EGD surveillance should be started at age 25 yrs
Treatment is dependent on location, size and histology of polyps
Endoscopic surveillance and resection is very effective in preventing cancer
development
Whipple is usually needed for effective management of advanced polyps
DISCUSS: Most advanced adenomas have Ca on resection
C4 $100
Which of the following is false for desmoid disease?
A. Surgery can incite rapid growth within a desmoid
B. Extra-abdominal or abdominal wall desmoids are treated with resection
C. Abdominal desmoids usually cause SB necrosis, ureteral obstructions, SBO
D. Sulindac, tamoxifen and chemotherapy may all be used for abdominal desmoids
E. Surgical resection of abdominal desmoids is usually effective
C4 $100
Which of the following is false for desmoid disease?
A. Surgery can incite rapid growth within a desmoid
B. Extra-abdominal or abdominal wall desmoids are treated with resection
C. Abdominal desmoids usually cause SB necrosis, ureteral obstructions, SBO
D. Sulindac, tamoxifen and chemotherapy may all be used for abdominal desmoids
E. Surgical resection of abdominal desmoids is usually effective
DISCUSS
C4 $200
Which of the following is not true for HNPCC associated lesions?
A.
Signet ring cell cancers
B.
C.
D.
E.
Mucinous cancers
Poorer response to 5FU
Poorer prognosis than sporadic colorectal cancer
Risk of metachronous cancer is 45% after one resection for Ca
F.
Autosomal dominant with 80% lifetime risk of cancer
C4 $200
Which of the following is not true for HNPCC associated lesions?
A.
Signet ring cell cancers
B.
C.
D.
E.
Mucinous cancers
Poorer response to 5FU
Poorer prognosis than sporadic colorectal cancer
Risk of metachronous cancer is 45% after one resection for Ca
F.
Autosomal dominant with 80% lifetime risk of cancer
DISCUSS
Poorer response to 5FU but better prognosis than sporadic overall
C4 $300
The most common extracolonic malignancy in patients with HNPCC is:
A.
Endometrial cancer
B.
Gastric cancer
C.
Ovarian cancer
D.
Urinary cancers
E.
Brain cancer
C4 $300
The most common extracolonic malignancy in patients with HNPCC is:
A.
Endometrial cancer
B.
Gastric cancer
C.
Ovarian cancer
D.
Urinary cancers
E.
Brain cancer
DISCUSS
So discuss Hysterectomy + BSO at time of colectomy
C4 $400
How frequently should a person suspected of having HNPCC undergo surveillance?
A.
B.
C.
D.
Colonoscopy yearly from age 21 yrs
Colonoscopy every two yrs from age 21, then yearly after age 40
Flex sig every two yrs from age 21, then colonoscopy yearly after age 40
Total colectomy with ileorectal anastomosis now and yearly flex sig for the
rectum
E.
Genetic testing only. No surveillance required
C4 $400
How frequently should a person suspected of having HNPCC undergo surveillance?
A.
B.
C.
D.
Colonoscopy yearly from age 21 yrs
Colonoscopy every two yrs from age 21, then yearly after age 40
Flex sig every two yrs from age 21, then colonoscopy yearly after age 40
Total colectomy with ileorectal anastomosis now and yearly flex sig for the
rectum
E.
Genetic testing only. No surveillance required
DISCUSS
C4 $500
Treatment for a patient with clinically established HNPCC with a right colon cancer is:
A.
B.
Right colectomy and yearly colonoscopies postop
C.
D.
Total colectomy with ileorectal anastomosis
Total proctocolectomy with ileoanal pouch
Consider hysterectomy for female at the same time
E.
F.
A and B
A, B and D
C4 $500
Treatment for a patient with clinically established HNPCC with a right colon cancer is:
A.
B.
Right colectomy and yearly colonoscopies postop
C.
D.
Total colectomy with ileorectal anastomosis
Total proctocolectomy with ileoanal pouch
Consider hysterectomy for female at the same time
E.
F.
A and B
A, B and D
DISCUSS
Questions 1-5
A 19 yo kid presents with anemia from GI bleeding and has mucosal pigmentation on
his lips. He also had intussusception as a kid and was diagnosed with multiple GI
polyps. What’s the diagnosis and treatment?
A. Peutz-Jeghers syndrome: Endoscopic resection of polyps (regular or intraop push
enteroscopy)
B. Peutz-Jeghers syndrome: Laparoscopic small bowel resection
C. Juvenile polyposis: Total proctocolectomy
D. FAP: Total proctocolectomy
E. None of the above
Questions 1
Diagnosis of HNPCC is based on:
A. Clinical history (Amsterdam, Bethesda criteria)
B. MSI testing (genetic testing)
C. A and B together
D. None of the above
Questions 2
Which of the following types of colonic polyps is associated with a high incidence of
malignant degeneration?
A. Tubular adenoma
B. Tubulovillous adenoma
C. Villous adenoma
D. Hamartomatous polyp
E. Hyperplastic polyp
F. Traditional serrated adenoma
Questions 3
What’s the correct incidence and age for colorectal cancer development in the
diagnosis mentioned below?
A. FAP
5-6% lifetime risk
B. Attenuated FAP
100% by age 40 yrs
C. HNPCC
<100% by age 56 yrs
D. General population
80% lifetime risk
Questions 4
Which is true for ileorectal anastomosis in the setting of FAP?
A. The risk of cancer in the retained rectum is 12-30% within 20 yrs
B. Risk of cancer in the rectum is not dependent on the severity of polyposis
C. The rectal stump should be examined every 2 yrs
D. All polyps > 10mm in the rectum should be removed endoscopically
E. Completion proctectomy is indicated for mild dysplasia in rectal polyps
Questions 5
Questions 1-5
A 19 yo kid presents with anemia from GI bleeding and has mucosal pigmentation on
his lips. He also had intussusception as a kid and was diagnosed with multiple GI
polyps. What’s the diagnosis and treatment?
A. Peutz-Jeghers syndrome: Endoscopic resection of polyps (regular or intraop push
enteroscopy)
B. Peutz-Jeghers syndrome: Laparoscopic small bowel resection
C. Juvenile polyposis: Total proctocolectomy
D. FAP: Total proctocolectomy
E. None of the above
DISCUSS
• EGD, colonoscopy, push enteroscopy with resection for small lesions
• If unable or >1.5 cm  laparotomy with push enteroscopy and polyp resection, NOT
small bowel resection
Questions 1
Diagnosis of HNPCC is based on:
A. Clinical history (Amsterdam, Bethesda criteria)
B. MSI testing (genetic testing)
C. A and B together
D. None of the above
DISCUSS
Questions 2
Which of the following types of colonic polyps is associated with a high incidence of
malignant degeneration?
A. Tubular adenoma
B. Tubulovillous adenoma
C. Villous adenoma
D. Hamartomatous polyp
E. Hyperplastic polyp
F. Traditional serrated adenoma
DISCUSS
Advanced polyps:
• Villous polyps
• Polyps with HGD
• >1 cm polyp
• SSA
Questions 3
What’s the correct incidence and age for colorectal cancer development in the
diagnosis mentioned below?
A. FAP
100% by age 40 yrs
B. Attenuated FAP
<100% by age 56 yrs
C. HNPCC
80% lifetime risk
D. General population
5-6% lifetime risk
DISCUSS
Questions 4
Which is true for ileorectal anastomosis in the setting of FAP?
A. The risk of cancer in the retained rectum is 12-30% within 20 yrs
B. Risk of cancer in the rectum is not dependent on the severity of polyposis
C. The rectal stump should be examined every 2 yrs
D. All polyps > 10mm in the rectum should be removed endoscopically
E. Completion proctectomy is indicated for mild dysplasia in rectal polyps
DISCUSS:
Examine the stump every 6-12 months and remove all polyps >5mm. If HGD or too
numerous to removed endoscopically  completion proctectomy
Questions 5