Annual Colonoscopy Research Articles

Hereditary Non-polyposis Colorectal Cancer: Prevention and Therapeutic Options

Lynch syndrome (LS), also known as hereditary non-polyposis colorectal cancer (HNPCC), is the most common hereditary colorectal cancer (CRC) syndrome. The first and foremost preventive measure is to identify patients with LS among CRC patients. This requires the screening of colorectal cancer through polymerase chain reaction-based microsatellite instability (MSI) testing or immunohistochemistry to look for a loss of expression of one of the mismatch repair (MMR) proteins and the referral of selected patients to genetic counseling. In LS patients, annual or biannual complete colonoscopy with chromoendoscopy is the only validated way to significantly reduce mortality related to CRC with the greatest quality-adjusted life expectancy benefit compared with prophylactic surgery. In the case of diagnosis of colonic cancer, a subtotal colectomy with an ileo-rectal anastomosis is recommended, in order to decrease the risk of metachronous CRC. However, segmental surgery can be discussed on an individual basis. Chemoprevention with aspirin seems to be efficient in decreasing colorectal cancer risk in LS, but the minimum effective dose and potential adverse events associated with long-term use are not yet known. The option of taking low-dose aspirin might be discussed with mutated gene carriers regarding the benefit and risks of the treatment.

Colonoscopic Surveillance after Colorectal Cancer Resection: Who Needs More Intensive Follow-Up?

Background/Aims: Although there are guidelines for colonoscopic surveillance after colorectal cancer (CRC) surgery, the data evaluating the effectiveness of these guidelines are limited. We determined the risk factors for metachronous neoplasia (MN) by performing annual colonoscopy examinations after curative resection. Methods: We performed annual colonoscopic surveillance on stage I-III CRC patients after curative resection. We stratified the patients based on the advanced neoplasia risk during the surveillance. Results: Advanced MN detected was in 59 (13.1%) of 451 patients. Overall, the cumulative incidence of advanced MN was 17.3% at 5 years. By the multivariate analysis, the risk factors for advanced MN were male gender, age >65, left-sided index cancer and being in the high-risk group. The cumulative incidence of advanced MN was 38.9% at 5 years in the high-risk group. Among the patients who had advanced MN, secondary advanced MN was detected in 13 patients (22.0%) with a subsequent colonoscopy. The 2-year cumulative incidence of secondary advanced MN was 16.9%. Four (0.88%) patients had metachronous CRC during the surveillance and the interval from the index CRC was a median of 58.5 months. Conclusions: Although the current follow-up guidelines for colonoscopic surveillance after CRC are well established, the high-risk group calls for more meticulous follow-up, which should be continued for a sufficient time.

Characteristics of benign and malignant thyroid disease in familial adenomatous polyposis patients and recommendations for disease surveillance.

Familial adenomatous polyposis (FAP) is a hereditary colon cancer syndrome that involves multiple extracolonic organs, including the thyroid. Several studies have estimated the rate of thyroid cancer in FAP to occur at five times the rate of the general population, but no current consensus defines screening for thyroid cancer in this cohort. This study seeks to define the features of benign and malignant thyroid disease in FAP patients, to compare thyroid cancer cases found through screening with those found incidentally, and to propose disease surveillance recommendations. Prospective screening for early thyroid cancer detection with thyroid ultrasound (US) was performed on FAP patients at the time of annual colonoscopy since November 2008. Clinical and US data were reviewed to characterize the observed thyroid nodules. Nonscreening-detected cases (NSD) were found through review of the colon cancer registry database. Eighteen NSD were found, compared with 15 screening-detected (SD) cases, out of 205 total patients screened (Mage=42 years; 55% female). The mean tumor size was larger in the NSD group than the SD group (p=0.04), and they tended to demonstrate more positive lymph nodes and more complications than the SD group. In the screened cohort, at least one thyroid nodule was detected in 106 (51.7%) patients, with 90% of these seen on initial exam. A total of 40/106 (37.7%) patients required fine-needle aspiration biopsy of a dominant nodule (Msize=14 mm), and 28/40 (70%) of these were performed at the first US visit. Suspicious US features were present in 16/40 (40%) patients, including five sub-centimeter nodules. Cytology and/or nodule US was abnormal in 15/205 screened patients, leading to surgery and revealing 14 papillary and one medullary thyroid cancer. Given the age and sex distribution of the screened cohort, this study reveals a higher-than-expected prevalence of both benign and malignant thyroid disease in the FAP population. Additionally, SD cases seemed to consist of smaller-sized cancers that required less radical therapy compared to NSD cases. Since it was found that the initial US in the screening program accounted for the majority of detected nodules (90%) and biopsies (70%), baseline and subsequent thyroid US surveillance is recommended in all FAP patients.

Recent Advances in Understanding Colorectal Cancer and Dysplasia Related to Ulcerative Colitis

Ulcerative colitis is an idiopathic chronic inflammatory bowel disease and its incidence in Korea has rapidly increased over the past two decades. Since ulcerative colitis is associated with increased risk for colorectal cancer, annual or biannual colonoscopy with four quadrant random biopsies at every 10 cm segments has been recommended for surveillance of colitic cancer in patients with long standing left-sided or extensive colitis. Recent epidemiologic data and meta-analysis suggest that the increment of colorectal cancer risk in ulcerative colitis was not larger than that of previous studies. Moreover, in addition to the extent and duration of colitis, other risk factors such as family history of colorectal cancer, primary sclerosing cholangitis, stricture, pseudopolyps, and histologic severity of inflammation have been recognized. As a result, updated guidelines provide surveillance strategies adjusted to the individual patient's risk for colitic cancer. Regarding surveillance method, target biopsy under panchromoendoscopy is preferentially recommended rather than random biopsy.

Short-term risk of colorectal cancer in individuals with lynch syndrome: a meta-analysis.

For carriers of germline mutations in DNA mismatch repair genes, the most relevant statistic for cancer prevention is colorectal cancer (Lynch syndrome) risk, particularly in the short term. We conducted a meta-analysis of all independent published Lynch syndrome studies reporting age- and sex-dependent colorectal cancer risks. We estimated 5-year colorectal cancer risk over different age groups, separately for male and female mutation carriers, and number needed to screen to prevent one death. We pooled estimates from analyses of 1,114 Lynch syndrome families (508 with MLH1 mutations and 606 with MSH2 mutations). On average, one in 71 male and one in 102 female MLH1 or MSH2 mutation carriers in their 20s will be diagnosed with colorectal cancer in the next 5 years. These colorectal cancer risks increase with age, peaking in the 50s (one in seven males and one in 12 females), and then decrease with age (one in 13 males and one in 19 females in their 70s). Annual colonoscopy in 16 males or 25 females in their 50s would prevent one death from colorectal cancer over 5 years while resulting in almost no serious complications. In comparison, annual colonoscopy in 155 males or 217 females in their 20s would prevent one death while resulting in approximately one serious complication. For MLH1 or MSH2 mutation carriers, current guidelines recommend colonoscopy every 1 to 2 years starting in their 20s. Our findings support this regimen from age 30 years; however, it might not be justifiable for carriers who are in their 20s.

Rectocolite hémorragique : conduite diagnostique et prise en charge thérapeutique

Ulcerative colitis (UC) is a chronic inflammatory bowel disease limited to the mucosa and affecting the rectum and the colon continuously. Salicylates are the first line treatment for moderate forms. Corticosteroids are used to induce remission, but are not given as maintenance therapy. Thiopurines are indicated as maintenance therapy in case of failure of salicylates or cortico-dependence. Anti TNF alpha are indicated in cortico-resistant severe flares or if cortico- dependence. Vedolizumab (anti-integrin) is the first non anti-TNF alpha biotherapy available for the treatment of UC. Severe acute colitis is a medical emergency; diagnosis is based on Lichtiger score. An emergency colectomy for severe acute colitis is indicated in cases of surgical complication or resistance to medical therapy. UC patients with extension beyond splenic flexure are at risk of colorectal cancer, increasing with the duration of the disease, severity of mucosal inflammation, family history of colorectal cancer, and the existence of sclerosing cholangitis. Annual surveillance colonoscopy is required in patients with sclerosing cholangitis regardless of the extension of their UC.

Colorectal cancer surveillance in patients with inflammatory bowel disease and primary sclerosing cholangitis: an economic evaluation.

The cost-effectiveness of annual colonoscopy for detection of colorectal neoplasia among patients with inflammatory bowel disease (IBD) and primary sclerosing cholangitis (PSC) is uncertain. The aim of this study was to determine whether annual colonoscopy among patients with IBD-PSC is cost-effective compared with less frequent intervals from the perspective of a publicly funded health care system. A cost-utility analysis using a Markov model was used to simulate a 35-year-old patient with a 10-year history of well-controlled IBD and a recent diagnosis of concomitant PSC. The following strategies were compared: no surveillance, colonoscopy every 5 years, biennial colonoscopy, and annual colonoscopy. Outcome measures included: costs, number of cases of dysplasia found, number of cancers found and missed, deaths, quality-adjusted life-years (QALYs) gained, and the incremental cost per QALY gained. In the base-case analysis, no surveillance was the least expensive and least effective strategy. Compared with no surveillance, the cost per QALY of surveillance every 5 years was CAD $15,021. The cost per QALY of biennial surveillance compared with surveillance every 5 years was CAD $37,522. Annual surveillance was more effective than biennial surveillance, but at an incremental cost of CAD $174,650 per QALY gained compared with biennial surveillance. More frequent colonoscopy screening intervals improve effectiveness (i.e., detects more cancers and prevents additional deaths), but at higher cost. Health systems must consider the opportunity costs associated with different surveillance colonoscopy intervals when deciding which strategy to implement among patients with IBD-PSC.

How Many Annual Colonoscopies to Maintain Credentialing

Credentialing for endoscopy can be a contentious issue, particularly at a local level. Conflict often arises between gastroenterologists and surgeons or primary care physicians. These groups' professional organizations vary in the number of procedures they recommend to achieve initial credentialing. Also, data are limited as to how many procedures should be required to maintain credentialing. In the current study, investigators evaluated the records of 129 operators who each performed between 20 and 399 procedures per year in the U.K. during 2008 and 2009. …

Low Cancer Risk with Annual Surveillance in Serrated Polyposis

The genetic basis of serrated polyposis syndrome (SPS) is not yet understood, and therefore the World Health Organization definition of serrated polyposis cannot be validated. Several previous studies have suggested a high risk for colorectal cancer when patients with serrated polyposis are first recognized and during colonoscopic follow-up. The current prospective study involved 50 patients with SPS who underwent annual colonoscopy between 2007 and 2012. All polyps ≥3 mm in …

An Interesting Case of Misdiagnosed Inflammatory Bowel Disease With Immunoproliferative Small Intestine Disorder

Introduction: Inflammatory bowel disease (IBD) prevalence is increasing in Asia. Clinicians are faced with misdiagnosis for IBD even with classic symptoms. This case report shows that how a delayed diagnosis of IBD can produce significant problems for patient. Case Presentation: A 45 year-old man and known case of IPSID (Immunoproliferative small intestine disorder) was referred for follow-up to our GI (Gastrointestinal) clinic. He presented with a history of intractable watery diarrhea along with slight weight loss for the last 22 years. He was admitted with an episode of severe abdominal pain and acute peritonitis 10 years ago. At the time, laparotomy was performed due to a suspicious appendicular mass; however, the surgeon discovered a cecum mass and extended adhesion during laparotomy. According to IPSID diagnosis, he was then referred to an oncologist who treated him with chemotherapy and patient was advised to attend an annual colonoscopy checkup as follow-up. He was gradually complicated by renal stones, arthritis, hypoalbuminemia and bone disease during the follow-up. We as gastroenterologists reviewed his history again and requested a revision for all histopathology results by GI pathologist. Pathologist confirmed IBD (Crohn’s disease) from the first pathology and his treatment was started immediately. Discussion: Several diseases can mimic IBD symptoms but with careful consideration of patient’s symptoms, endoscopic findings and pathology results one should be able to diagnose IBD. Correct diagnosis of IBD can affect the quality of life of patient.

Familial risk-colorectal cancer: ESMO Clinical Practice Guidelines

J. Balmana1, F. Balaguer2, A. Cervantes3 & D. Arnold4, on behalf of the ESMO Guidelines Working Group* Department of Medical Oncology, Hospital Vall d’Hebron, Vall d’Hebron Institute of Oncology (VHIO), Universitat Autonoma de Barcelona, Barcelona; Department of Gastroenterology, Hospital Clinic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona; Department of Hematology and Medical Oncology, INCLIVA, University of Valencia, Valencia, Spain; Department of Medical Oncology, Tumor Biology Clinic, Albert Ludwigs University, Freiburg, Germany;

Young Male with Cecal Mass and Family History of Skin Tumors

Purpose: Hereditary nonpolyposis colorectal cancer (HNPCC), or Lynch syndrome, is the most common inherited colon cancer syndrome, and accounts for about 3% of all colon cancers. We present an interesting case of a young patient with family history of skin tumors presenting with mechanical obstruction due to a cecal mass. Case: A 33-year-old male with no past medical history developed intermittent abdominal cramping, constipation, and a 40-pound weight loss over the past three months. He presented to the ER with worsening abdominal pain associated with nausea and vomiting. He denied hematochezia, and his last bowel movement was two days prior to admission. The patient had a family history of Muir-Torre syndrome. His maternal grandmother died of colon cancer at a young age, and his mother had multiple sebaceous skin tumors. On exam, his abdomen was distended and diffusely tender, with hypoactive bowel sounds. Computed tomography scan showed a large obstructing cecal mass with dilated distal ileum. The patient was taken to OR for emergent fecal diversion with loop ileostomy. Colonoscopy performed two days post-op revealed an occluding ulcerated cecal mass and a colonic mass at the hepatic flexure. Repeat laparotomy demonstrated a widely metastatic tumor, and the patient underwent cytoreductive surgery with total colectomy and intra-peritoneal chemotherapy. Pathology revealed metastatic high-grade mucinous adenocarcinoma. Conclusion: HNPCC syndrome is an autosomal dominant disorder in which patients are predisposed to colon and a variety of extra-colonic cancers (endometrial, ovarian, urologic, gastrointestinal, skin). Muir-Torre syndrome is a variant of HNPCC in which there is a strong family history of colon cancers in association with sebaceous tumors. Due to early-onset colon cancer, annual screening colonoscopy is recommended starting at age 25. It is important for clinicians to identify families at risk for HNPCC syndrome to initiate timely cancer surveillance. Conclusion: HNPCC syndrome is an autosomal dominant disorder in which patients are predisposed to colon and a variety of extra-colonic cancers (endometrial, ovarian, urologic, gastrointestinal, skin). Muir-Torre syndrome is a variant of HNPCC in which there is a strong family history of colon cancers in association with sebaceous tumors. Due to early-onset colon cancer, annual screening colonoscopy is recommended starting at age 25. It is important for clinicians to identify families at risk for HNPCC syndrome to initiate timely cancer surveillance.

Dysphagia in Lynch Syndrome

Question: A 35-year-old man with Lynch syndrome presented for evaluation of progressive solid food dysphagia of 2 months’ duration. Lynch syndrome was confirmed by MSH2 mutation testing and family history of young-onset colon cancer. Annual screening colonoscopies since age 25 were normal. Upper endoscopy revealed a 1.5-cm, pedunculated polyp in the proximal esophagus just below the cricopharyngeus (Figure A). Endoscopic ultrasonography of the lesion showed it was confined to the mucosal layer without periesophageal lymphadenopathy. Computed tomography revealed an intraluminal mass at the cervical esophagus without local extension. The polyp was then removed completely using standard polypectomy techniques (Figures B and C). What is the diagnosis? Look on page 1167 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Reply

We thank Dr. Yarze for his comments on the practice guideline entitled “Long-Term Management of the Successful Adult Liver Transplant”1 from the American Association for the Study of Liver Diseases. We agree that it would be preferable for all clinical guidelines making reference to inflammatory bowel disease to use a common nomenclature. Furthermore, our intention was to indicate that for liver transplant recipients with primary sclerosing cholangitis (PSC) and colitis-associated dysplasia, colectomy should not be restricted to those with the most severe (ie, high-grade) histopathological features. As such, we will amend the guideline in its online form to read as follows: 42. Patients with PSC and inflammatory bowel disease or other established risk factors for colorectal cancer should undergo an annual screening colonoscopy with biopsies. Colectomy, including continence-preserving pouch operations, should be considered when colonic biopsy reveals dysplasia (grade 1, level B). Michael R. Lucey, M.D.1 Norah Terrault, M.D., M.P.H.2 1Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of Wisconsin School of Medicine and Public HealthMadison, WI 2Gastroenterology DivisionDepartment of MedicineUniversity of California San FranciscoSan Francisco, CA

High Rates of Metachronous Colon Cancer or Dysplasia After Segmental Resection or Subtotal Colectomy in Crohnʼs Colitis

In ulcerative colitis, total proctocolectomy is the treatment of choice for patients with colonic dysplasia or cancer because of the high risk for metachronous neoplasia. It is unknown whether patients with Crohn's disease and colon cancer or dysplasia have a similar risk. We retrospectively reviewed the charts of 75 patients treated at our center from 2001 to 2011 with Crohn's disease and colon cancer who underwent segmental resection or subtotal colectomy (STC). We then identified the presence or absence of subsequent colon cancer or dysplasia in these patients during the follow-up (0-19 years). Of the 64 patients with colon cancer, 25 had at least 1 metachronous cancer (39%). The mean time to a new cancer was 6.8 years. Eighty-five percent of patients (21/25) were undergoing annual screening colonoscopy. Of the 11 patients with dysplasia, 5 (46%) had a new dysplasia. Mean time to a new dysplastic lesion was 5.0 years. Nineteen of the 47 patients (40%) who had a segmental resection for colon cancer developed metachronous cancer and 6/17 patients (35%) with a STC had metachronous cancer. Two of the 4 patients (50%) with STC for dysplasia (50%) had a new dysplasia and 3/7 patients (43%) with segmental resection had a new dysplasia. There was no significant difference (P = 0.61) between recurrence rates in patients with segmental resection versus STC. The high rate of metachronous colon cancer after surgical resection suggests that total proctocolectomy should be considered. Larger studies are required to determine if the same is true for dysplasia.

Colonic neoplasia in young patients with inflammatory bowel disease and primary sclerosing cholangitis

Current guidelines recommend annual surveillance for colorectal cancer (CRC) in all patients with inflammatory bowel disease (IBD) and primary sclerosing cholangitis (PSC). The aim of our study was to validate the need for annual surveillance for colon neoplasia in patients ≤45 of age with a combined diagnosis of PSC and IBD. We identified patients, ≤45 years of age with a combined diagnosis of PSC and IBD, who were seen at the Mayo Clinic between 1995 and 2010. We then reviewed the medical records of the patients who developed colonic neoplasia defined as cancer, high-grade dysplasia (HGD) or dysplasia-associated lesion or mass (DALM). In the population of 784 patients ≤45 years of age with a combined diagnosis of PSC and IBD, 10 (1.3%) of 784 developed colonic neoplasia during the follow-up period. Seven patients had colon cancer, one had HGD and two had a DALM. Colonic neoplasia is uncommon in young patients (≤45 years of age) with a combined diagnosis of PSC and IBD. We suggest delaying surveillance in young patients and propose that studies should be carried out to clarify the cost-effectiveness of annual or biannual surveillance colonoscopies according to patient age.

Hereditary Nonpolyposis Colorectal Cancer (HNPCC)/Lynch Syndrome

Hereditary nonpolyposis colorectal cancer HNPCC, Lynch syndrome) is a genetic disease of autosomal dominant inheritance. It is caused by a mutation in one of four genes of the DNA mismatch repair system and confers a markedly increased risk for various types of cancer, particularly of the colon and the endometrium. Its prevalence in the general population is about 1 in 500, and it causes about 2% to 3% of all colorectal cancers. Lynch syndrome is diagnosed in two steps: If it is suspected (because a patient develops cancer at an unusually young age or because of familial clustering), the tumor tissue is analyzed for evidence of deficient mismatch repair (microsatellite instability, loss of mismatch repair protein expression). If such evidence is found, a genetic mutation is sought. The identification of a pathogenic mutation confirms the diagnosis in the patient and enables predictive testing of other family members. Diagnostic evaluations for Lynch syndrome should be carried out with appropriate genetic counseling. Selective literature review. Prospective cohort studies from Germany, Finland and the Netherlands have shown that colorectal cancers detected by systematic colonoscopic surveillance tend to be at an earlier stage than those that are discovered after the patients present with symptoms. The Finnish study also showed an overall reduction in cancer risk from colonoscopic polypectomy at regular intervals. The studies conducted so far have not yet clearly documented the putative benefit of an individualized, risk-adapted surveillance strategy. Until this is done, patients with Lynch syndrome and healthy carriers of causative mutations should be monitored with annual colonoscopy and (for women) annual gynecological examination.

A Novel Germline Mutation in Exon 15 of the APC Gene in Attenuated Familial Adenomatous Polyposis: A Report of Two Cases

Attenuated familial adenomatous polyposis (AFAP) is a variant of familial adenomatous polyposis with fewer than one hundred colorectal polyps and a later age of onset of the cancer. Here, we report two cases of AFAP within family members. Each patient demonstrated the same novel germ line mutation in exon 15 of the adenomatous polyposis coli (APC) gene and was successfully managed with sulindac after refusal to perform colectomy: a 23-year-old man with incidentally diagnosed gastric adenoma and fundic gland polyps underwent colonoscopy, and fewer than 100 colorectal polyps were found; a 48-year-old woman who happened to be the mother of the 23-year-old man also showed fewer than 100 colorectal polyps on colonoscopy. Genetic analysis revealed a novel frameshift mutation in exon 15 of the APC gene. The deletion of adenine-guanine with the insertion of thymine in c.3833-3834 resulted in the formation of stop codon 1,287 in both patients. The patients were treated with sulindac due to their refusal to undergo colectomy. The annual follow-up upper endoscopy and colonoscopy in the following 2 years revealed significant regression of the colorectal polyps in both patients.

Long-Term Follow-Up of Patients with Malignant Pedunculated Colon Polyps after Colonoscopic Polypectomy

Previously published studies have suggested that patients with resected colon cancer have an increased risk for early metachronous colon cancer. Current screening guidelines recommend intense surveillance by colonoscopy for the initial five years after the initial colon cancer has been resected. Information regarding endoscopically removed malignant polyps is limited. In the present study, 25 consecutive patients (14 male, 11 female) with malignant pedunculated colon polyps treated with snare cautery polypectomy were followed for more than one decade up to 20 years. Five patients required an additional resection to ensure that removal of the original cancer was complete. Annual colonoscopies were planned for five years. If an adenoma was detected in the fifth year, colonoscopy was performed annually until no adenomas were detected. Otherwise, colonoscopy was planned every three years after five years. In the present study, there was no mortality from colon cancer and no patient developed either recurrent colon cancer or an early metachronous colon cancer during the initial five-year period of surveillance. Two patients (one male, one female) ultimately developed late cecal cancers almost one decade after the original colon cancers were resected. One had an early stage cancer that was resected, while the other had an infiltrating mucinous carcinoma complicating a small tubulovillous adenoma with extension to a single lymph node. After surgical removal and adjuvant chemotherapy, no further neoplastic disease has been detected. Overall, patients with malignant pedunculated polyps do extremely well if appropriately managed at the time of the initial polypectomy. Short-term outcomes after removal of a malignant polyp(s) appear to be similar to those with a nonmalignant polyp. However, late metachronous colon cancer may still occur. Long-term follow-up should be considered in each patient, assuming reasonable life expectancy, because risk of additional adenomas and metachronous colon cancer persists even after the initial five years of currently recommended surveillance. Patients with resected malignant polyps may represent a special patient subgroup that requires surveillance for more extended periods than current guidelines have recommended.

Interval colon cancer in a Lynch syndrome patient under annual colonoscopic surveillance: a case for advanced imaging techniques?

BackgroundLynch syndrome confers increased risk for various malignancies, including colorectal cancer. Colonoscopic surveillance programs have led to reduced incidence of colorectal cancer and reduced mortality from colorectal cancer. Colonoscopy every 1–2 years beginning at age 20–25, or 10 years earlier than the first diagnosis of colorectal cancer in a family, with annual colonoscopy after age 40, is the recommended management for mutation carriers. Screening programs have reduced colon cancer mortality, but interval cancers may occur.Case presentationWe describe a 48-year-old woman with Lynch syndrome who was found to have an adenoma with invasive colorectal cancer within one year after a normal colonoscopy.ConclusionOur patient illustrates two current concepts about Lynch syndrome: 1) adenomas are the cancer precursor and 2) such adenomas may be “aggressive,” in the sense that the adenoma progresses more readily and more rapidly to carcinoma in this setting compared to usual colorectal adenomas. Our patient’s resected tumor invaded only into submucosa and all lymph nodes were negative; in that sense, she represents a success for annual colonoscopic surveillance. Still, this case does raise the question of whether advanced imaging techniques are advisable for surveillance colonoscopy in these high-risk patients.