Original article 81

Some diminutive colorectal polyps can be removed

and discarded without pathological examination

Authors B. Denis1,2, J. Bottlaender1, A. M. Weiss1, A. Peter1, G. Breysacher1, P. Chiappa1, P. Perrin2

1
Institutions Médecine A, Hôpital Pasteur, Colmar, France
2
ADECA Alsace, Colmar, France

submitted
15 September 2009
accepted after revision
28 September 2010
Bibliography
DOI http://dx.doi.org/
10.1055/s-0030-1255952
Published online
24 November 2010
Endoscopy 2011; 43:
81–86 © Georg Thieme
Verlag KG Stuttgart · New York
ISSN 0013-726X
Corresponding author
B. Denis, MD
Médecine A
Hôpital Pasteur
39 avenue de la Liberté
68024 Colmar
France
Fax: +33-3-89124533
bernard.denis@ch-colmar.fr
Background and study aims: Pathological exam-
ination of colorectal polyps is useful if clinical
management is affected (i. e. when invasive carci-
noma is detected or postpolypectomy surveil-
lance interval is guided). Our aim was to assess
whether the pathological examination of some
diminutive (measuring ≤ 5 mm) polyps can be
omitted.
Patients and methods: Consecutive patients un-
dergoing a colonoscopy at Pasteur Hospital (Col-
mar, France) between January and August 2008
were included in this prospective study. Six senior
gastroenterologists predicted the future surveil-
lance interval without referring to the result of
pathological examination.
Results: In all, 350 polyps from 175 patients
were removed and analyzed. The endoscopist
was able to predict the correct surveillance inter-
val without referring to the result of pathological
examination in 118 patients (67.4 %; 95 % confi-
dence interval [CI] 60.5 – 74.4). The pathological
examination of 18.4 % (95 % CI 13.7 – 23.1) of di-
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minutive polyps either associated with a cancer
or a polyp measuring ≥ 10 mm or removed in
very old or frail patients could be omitted without
any consequence for the patient. If diminutive
polyps one or two in number were discarded
without pathological examination in patients
with a personal history of colorectal neoplasm,
three patients out of 43 would have a 5-year in-
stead of a 3-year surveillance interval. As a whole,
if 44.1 % (95 % CI 38.0 – 50.1) of diminutive polyps
were discarded, the surveillance interval would
remain identical in 98.3 % (95 % CI 96.4 – 100) of
patients.
Conclusions: The pathological examination of up
to 44 % of diminutive polyps (i. e. 33 % of all
polyps), can be safely omitted. The pathological
examination would be required only for those
with suspicious gross appearance, those three or
more in number, and those isolated one or two
in number that are removed from people without
personal history of colorectal neoplasm.

Introduction sis. The pathological examination however is of

! value only if clinical management is affected (i. e.
Colorectal cancer (CRC) can be prevented by re-
moving colorectal neoplasia. Several studies have
demonstrated that CRC incidence is reduced after
polypectomy [1 – 3]. After polypectomy, decisions
regarding surveillance intervals are based on pa-
thology findings of the removed specimens. For
example, colonoscopic surveillance is required
when polyps are adenomatous but generally not
when they are nonadenomatous. A 3-year surveil-
lance interval is warranted for advanced adeno-
mas, whereas a 5-year interval is recommended
for nonadvanced adenomas. Decisions regarding
surgical resection after endoscopic removal of ma-
lignant polyps are based on pathological features
and adequacy of endoscopic resection. It is usually
recommended that every effort should be made to
retrieve all resected tissue for pathological analy-
when invasive carcinoma is detected or when the
postpolypectomy surveillance interval is guided).
Moreover it places a huge burden on pathologists
and its cost is not negligible, even though it is nota-
bly lower than that of the colonoscopy itself. Some
authors have suggested that the pathological ex-
amination of some small (6 – 9 mm) and/or di-
minutive (≤ 5 mm) polyps could be omitted [4 –
7]. For example, Külling et al. found that the patho-
logical examination of a right-sided diminutive
polyp in a patient < 60 years might not always be
necessary because it was associated with a low
risk (3.8 %) of advanced pathologic features [4].
The aim of our study was to ascertain whether the
pathological examination of some diminutive
polyps could be omitted without undue risk to
the patient.

Denis B et al. Pathological examination of diminutive polyps … Endoscopy 2011; 43: 81 – 86

82 Original article

Groups of patients Number Total number Number Table 1 Distribution

of DPs, (%) of polyps of patients of diminutive polyps.

No DP 0 (0) 43 32
Any DP in very old or frail patient 7 (2.7) 7 4
Any DP associated with cancer or polyp(s) ≥ 10 mm 41 (15.7) 71 27
Any DP among three or more polyps < 10 mm 106 (40.6) 116 32
Any DP among two or less polyps < 10 mm
One DP associated with one polyp 6 – 9 mm 6 (2.3) 12 6
One or two DPs isolated with history* 61 (23.4) 61 43
One or two DPs isolated without history* 40 (15.3) 40 31
Total 261 (100) 350 175
DP: diminutive polyp. History*: personal history of colorectal neoplasm.

Patients and methods

Discard without

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! Pathological examination
pathological examination
All colonoscopic procedures performed between January and Au-
gust 2008 in the endoscopy unit of the Pasteur Hospital in Colmar
were prospectively recorded. They were performed by six senior Polyps

gastroenterologists. The endoscopist completed a form for each

Polyps > 5 mm
colonoscopy that displayed polyp(s) and specified before the pro-
cedure whether the colonoscopic procedure was the first for the
patient, whether there was a history of CRC or adenoma, and Polyps ≤ 5 mm
whether there was a first-degree family history of CRC. People
with a history of inflammatory bowel disease, of adenomatous Suspicious gross
polyposis coli or of hereditary nonpolyposis colorectal cancer Very old or
appearance
were excluded. At the end of the procedure, the endoscopist reg- frail people
istered the details of all polyps removed: number, shape, loca-
tion, and size. The polyp size was measured in vitro with a ruler Associated with cancer
in the endoscopy suite immediately after retrieval and before or polyp(s) ≥ 10 mm
3 or more polyps
fixation. Finally, the endoscopist specified whether or not colo- < 10 mm
noscopic surveillance was necessary, the proposed surveillance 1 polyp ≤ 5 mm associated
interval, and the reason(s) for the proposed surveillance. with 1 polyp 6–9 mm
The pathological examination of polyps was performed as usual
1 or 2 polyps
by four senior general pathologists. After the pathological exam- ≤ 5 mm
ination, the endoscopist completed the form with the details of
each polyp (histological type and degree of dysplasia) and speci-
History* no history*
fied the final surveillance interval recommended when taking
into account the results of the pathological examination. Finally,
the endoscopist specified the number of polyps for which the
pathological examination had been useful. Fig. 1 Proposed algorithm for the management of polyps.
The surveillance intervals after polypectomy described in the *History refers to personal history of colorectal neoplasm.
French guidelines [8] were considered appropriate: briefly, a
3-year interval was recommended for patients with any advanced
adenoma, three or more adenomas or any adenoma and a family and villous (> 80 %). Serrated polyps were classified as hyperplas-
history of CRC; a 5-year interval was recommended in all other pa- tic polyp or serrated adenoma (including sessile serrated adeno-
tients with adenoma, either classical or serrated. ma, traditional serrated adenoma, and mixed serrated polyp) ac-
cording to the terminology published in the review of Snover et
Classification of diminutive polyps al. [10]. Dysplasia was classified according to the revised Vienna
The diminutive polyps were classified into different groups tak- classification of gastrointestinal epithelial neoplasia [11, 12]. In
ing into account the criteria used for the determination of the situ and intramucosal carcinomas (categories 4.2 and 4.4 in the
surveillance intervals (● " Table 1; ●
" Fig. 1). Very old or frail pa- revised Vienna classification and Tis in the tumor-node-metasta-
tients included persons with advanced age or co-morbidities sis [TNM] classification) were classified as high grade neoplasia
leading to < 10 years’ life expectancy according to the judgement [11 – 13]. Cancer was defined as carcinoma invading at least the
of the endoscopist. submucosa across the muscularis mucosae (category 5 in the re-
vised Vienna classification) [11, 12]. Advanced adenoma was de-
Pathological classification fined as an adenoma measuring ≥ 10 mm or with a villous com-
Polyps were classified as hyperplastic polyps or adenomas ac- ponent > 20 % or with high grade dysplasia or invasive carcinoma.
cording to the World Health Organization classification [9]. Ade-
nomas were further classified as serrated or classical. According
to percentage of villous elements, classical adenomas were classi-
fied as tubular (< 20 % villous elements), tubulovillous (20 – 80 %),

Denis B et al. Pathological examination of diminutive polyps … Endoscopy 2011; 43: 81 – 86

 Original article 83

Statistical methods
Table 2 Distribution of polyps according to size.
The chi-squared test was used to test for statistical significance by
comparison of proportions. The significance threshold was set at Polyp type Polyp size All
0.05.
≤ 5 mm 6 – 9 mm ≥ 10 mm
Number, 261 (74.6) 35 (10.0) 54 (15.4) 350 (100)
n (%)
Results
Adenoma- 180 (69.0) 29 (82.9) 51 (94.4) 260 (74.3)
!
tous polyp,
A total of 355 polyps were removed during 175 colonoscopic pro- n (%)*
cedures in 68 women and 107 men with a mean age of 64.8 years Advanced 22 (12.2) 13 (44.8) 51 (100) 86 (33.1)
(range 36 – 86 years). Among the colonoscopies, 47.4 % were a adenoma,
first procedure and 46.5 % a surveillance procedure after polypec- n (%) †
tomy or surgery for CRC. A first-degree family history of CRC was Invasive 0 (0) 0 (0) 2 (3.9) 2 (0.8)
carcinoma,
present in 13.9 % of cases. The pathological examination had not
n (%) †
been performed in five polyps, leaving 350 polyps to be assessed.
*As % of polyps. †As % of adenomas.
Their distribution according to size is presented in ●

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" Table 2. In

all, 261 diminutive polyps were removed in 143 people. They

accounted for 74.6 % of the polyps. Of these, 15.7 % were associat-
ed with either a CRC or a polyp ≥ 10 mm in size and 38.7 % were
isolated one or two in number (● " Table 1). There was no invasive
carcinoma among them and 22 (12.2 %) were advanced adeno-
mas: 11 displayed high grade dysplasia, nine villous features,
and two both.
If the 48 diminutive polyps that were either associated with a
CRC or a polyp ≥ 10 mm in size or removed in very old or frail pa-
tients had been discarded without pathological examination, the
surveillance interval would have remained correct in all these 31
patients (●" Table 3). If the six diminutive polyps that were asso-

The pathological examination was estimated to be useful by the
endoscopist for 146 polyps (41.7 %). This rate of useful examina-
tions varied according to the size of polyp (26.1 % for polyps
measuring ≤ 5 mm, 80.0 % for 6 – 9 mm, and 92.6 % for ≥ 10 mm;
P < 0.001) and the context (53.6 % in case of a first procedure and
29.8 % in case of a surveillance procedure; P < 0.001). At the end of
the colonoscopy, the endoscopist could specify for 133 patients
(76.0 %) whether or not colonoscopic surveillance was necessary
and propose a surveillance interval. This rate varied from 60.0 %
in 65 patients without family history of CRC having a first proce-
dure, to 91.2 % in 80 patients having a surveillance procedure for
CRC or adenoma. The surveillance proposed by the endoscopist
ciated with a polyp 6 – 9 mm in size had been discarded, the sur-
veillance interval would have remained correct in all six patients.
If the 61 diminutive polyps that were isolated one or two in num-
ber had been discarded in patients with a personal history of
colorectal neoplasm, three of 43 patients would have had a sur-
veillance interval of 5 years instead of 3 years. Overall, depending
on the kind of diminutive polyps discarded without pathological
examination, their number would vary from 18.4 % (95 % CI 13.7 –
23.1) to 44.1 % (95 % CI 38.0 – 50.1), and the related rate of correct
surveillance intervals in the whole cohort would vary respective-
ly from 100 % to 98.3 % (172/175; 95 % CI 96.4 – 100) for both
French and US guidelines (● " Table 3). If a 3-year surveillance in-

was confirmed by the result of pathological examination in 118
patients (88.7 %) and modified in 15 patients (11.3 %): the surveil-
lance interval was shortened in 11 cases, lengthened in two, and
the surveillance was cancelled in two cases. As a whole, the en-
doscopist was able to predict the correct surveillance interval
without the result of pathological examination in 118 patients
(67.4 %) (95 % CI 60.5 – 74.4). This rate was respectively 50.8 % in
patients without family history of CRC having a first procedure
and 82.5 % in patients having a surveillance procedure.
terval had been proposed for the 32 patients with three or more
polyps measuring < 10 mm without pathological examination of
diminutive polyps, surveillance would have been either too early
or unnecessary in 19 patients (59.4 %).
Using the French pathology fees, the total cost for histopathology
for 175 patients was € 10 192. Depending on the kind of diminu-
tive polyps discarded without pathological examination, the cost
reduction would vary from € 1058 to € 3511 (10.4 % to 34.5 %)
(●" Table 3).

Diminutive polyps Number Number of patients with Savings, € Table 3 Accuracy of the sur-
discarded without of polyps (%) correct surveillance interval/ veillance intervals determined
without pathological examina-
pathological examination number of patients (%)
tion of some diminutive polyps,
[95 % CI] [95 % CI]
and generated savings in re-
Any number associated with cancer 48 (18.4) 31/31 (100) 1058.4 duced pathology costs (accord-
or polyp(s) ≥ 10 mm [13.7 – 23.1] [100 – 100] ing to French and US guide-
or in very old or frail patient lines).
One associated with a polyp 6 – 9 mm 6 (2.3) 6/6 (100) 252.0
[0.5 – 4.1] [100 – 100]
One or two isolated with history* 61 (23.4) 40/43 (93.0) 2200.8
[18.2 – 28.5] [85.4 – 100]
Total 115 (44.1) 77/80 (96.3) 3511.2
[38.0 – 50.1] [92.1 – 100]
*Personal history of colorectal neoplasm.

Denis B et al. Pathological examination of diminutive polyps … Endoscopy 2011; 43: 81 – 86

84 Original article
Discussion
!
Our study suggests that the pathological examination of some di-
minutive polyps can be safely omitted. Their number varies from
18 % to 44 % depending on the level of risk one accepts for the sur-
veillance interval. The pathological examination of diminutive
polyps that are either associated with a CRC or a polyp ≥ 10 mm
in size or removed in very old or frail people (i. e. 18 % of them),
can be omitted without any risk. If those associated with a polyp
6 – 9 mm in size were discarded (i. e. 2 % of them), the surveillance
interval would remain correct in all six patients. If those isolated
one or two in number were discarded in people having a perso-
nal history of colorectal neoplasm (i. e. 23 % of them), three of 43
patients would have a 5-year surveillance interval instead of a 3-
year interval. This rate of misclassification seems minor and
acceptable in current practice.
The benefit of not examining diminutive polyps is a cost reduc-
tion, but what are the actual risks of such a policy? After polypec-
tomy, the endoscopist has two questions to answer: 1) Is there
any invasive carcinoma and, if yes, what is the appropriate treat-
ment? 2) Is surveillance necessary and, if yes, what is the appro-
priate surveillance interval?
The pathologist is indispensable in answering the first question.
The pathologist has to determine whether the submucosa has
been invaded and assess the prognostic factors that determine
whether polypectomy is sufficient or whether a colectomy would
be necessary. The risk of invasive carcinoma is related to the ade-
noma size [14 – 16] and can be considered as negligible within di-
minutive adenomas. It varies between 0 [16 – 19] and 0.1 % [20] in
the literature and is estimated at 0.03 % when pooling the largest
published series [5, 16 – 24] (● " Table 4). Moreover, these very
small carcinomas should be generally recognized by the endos-
copist on their macroscopic features, as they almost invariably oc-
cur in lesions with a depressed morphology [25].
To determine the postpolypectomy surveillance interval, the en-
doscopist has two questions to answer: 1) Is surveillance neces-
sary (or is the polyp neoplastic), and if it is 2) What is the appro-
priate surveillance interval (or is the adenoma advanced)? Cur-
rently, the pathological examination is the “gold standard” for
distinguishing between adenomatous polyps that require colo-
noscopic surveillance and nonadenomatous polyps, which usual-
ly do not. Using conventional endoscopy, the endoscopist is not
accurate enough to differentiate a hyperplastic from an adeno-
matous polyp [26, 27]. By contrast, imaging technologies such as
optical magnification, chromoendoscopy, narrow-band imaging,
confocal endomicroscopy, and autofluorescence imaging en-
hance the accuracy of the endoscopist. Some authors have pro-
posed to replace the pathological examination by in vivo charac-
terization between neoplastic and non-neoplastic polyps using
these techniques. In this way only suspected invasive lesions are
sent for pathological examination, whereas nondepressed polyps
<10 mm in size could be left in situ if non-neoplastic, or resected
and disposed of if assessed as adenomatous, without the need for
formal histology [6, 7, 27]. However, the accuracy of these tech-
niques is far from 100 % and most of them are expensive, increase
the colonoscopic procedure time, require special training, have
been assessed in expert hands only, and have yet to be compared
one with another [28].
Our approach is different and original. It is mainly founded on the
fact that the discrimination between neoplastic and non-neo-
plastic polyps, either by the pathologist or by the endoscopist,
has strictly no impact on the management in diminutive polyps
Denis B et al. Pathological examination of diminutive polyps … Endoscopy 2011; 43: 81 – 86
Table 4 Rate of invasive carcinoma within diminutive adenomas.
Author [ref.] Number of Carcinoma,
diminutive n (%)
adenomas
Matek et al. 1985 [17] 2214 0 (0)
Weston & Campbell 1995 [18] 919 0 (0)
Nusko et al. 1997 [16] 5027 0 (0)
Gschwantler et al. 2002 [19] 3016 0 (0)
Church 2004 [20] 2066 2 (0.1)
Odom et al. 2005 [5] 2851 1 (0.03)
Butterly et al. 2006 [21] 1305 1 (0.08)
Yoo et al. 2007 [22] 3303 1 (0.03)
Lieberman et al. 2008 [23] 3744 1 (0.03)
Rex et al. 2009 [24] 4326 4 (0.09)
Total 28 771 10 (0.03)
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associated with either a CRC or a polyp measuring ≥ 10 mm be-
cause whatever their histology, the surveillance interval will be
3 years. Likewise, it has strictly no impact in those removed in
very old or frail people as there is no need for surveillance what-
ever the diminutive polyp histology. Moreover, it has only a
minute impact on the management in those isolated one or two
in number that are removed in people having a personal history
of colorectal neoplasm, as they will need a surveillance colonos-
copy at least every 5 – 10 years whatever the kind of polyp re-
moved [8, 29]. Our results are somewhat lower than those ob-
tained with narrow-band imaging: we could predict a surveil-
lance interval without pathological examination of diminutive
polyps in 45.7 % (80 of 175) of our patients, which was correct in
96 % (77 of 80) of cases (●
" Table 3), whereas Ignjatovic et al. could
predict in 63.1 % (82 of 130) of their patients, correct in 95 – 98 %
of cases [27]. The two approaches might however be complemen-
tary, the endoscopic characterization being particularly useful for
diminutive polyps three or more in number, those isolated one or
two in number in people without history of colorectal neoplasm,
and for small polyps. Both approaches however share the same
drawback as they do not take into account advanced pathological
features.
We believe, with others, that the role attributed today to the pa-
thology results for distinguishing between a 3- and a 5-year sur-
veillance interval is excessive and should be reduced [30 – 32]. As
there is no standard definition of villous architecture and high
grade dysplasia and considering the lack of reproducibility, the
length of surveillance interval cannot reliably depend on these
pathological features [30 – 32]. The accuracy of pathologists for
the diagnosis of villous histology and high grade dysplasia is
poor-to-moderate, so that, in our opinion, these advanced patho-
logical features should be abandoned for clinical use [32 – 38].
The definition of the advanced adenoma should be simplified
and restricted to adenomas measuring ≥ 10 mm. It should be pos-
sible in most cases to determine the surveillance interval with
only clinical and macroscopic criteria such as polyp size and
number, these criteria being those most strongly correlated with
advanced adenoma recurrence [29, 39, 40]. Guidelines remain to
be elaborated. They should be close to the British guidelines,
which do not take into account advanced pathological features
in adenomas ≤ 10 mm in size for the determination of the surveil-
lance interval [41]. In our study, the endoscopist was able to pre-
dict the correct surveillance interval at the end of the colonosco-
py in 67.4 % of cases, without the results of pathological examina-

tion. This rate was even higher at 82.5 % in people with a personal
or a family history of colorectal neoplasm. Besides, we propose
another original approach mainly founded on the fact that ad-
vanced histology is related to polyp size [14, 19, 21 – 23]. We pro-
pose to remove and discard the smallest polyp(s) that are asso-
ciated with a larger polyp. This approach relies on the hypothesis
that the histology of the largest polyp is more advanced than that
of smaller polyp(s). This was true in all six patients with a di-
minutive polyp associated with a small polyp and, of course, in
all 33 patients with diminutive polyp(s) associated with large
polyp(s). The risk of misclassification was thus negligible (mark-
edly lower than that obtained by pathologists when assessing vil-
lous histology and high grade dysplasia), and considered accept-
able [32 – 38].
Our study underlines the importance of measuring the polyp
size. Two size cut-offs are clinically important: 5 mm because
polyps measuring > 5 mm will need pathological examination
whereas some of those ≤ 5 mm in size will not, and 10 mm be-
cause polyps ≥ 10 mm will need a 3-year surveillance colonosco-
py. As in vivo measurement of polyp size is not accurate enough,
we measure it with a ruler in vitro immediately after retrieval
[42]. This measurement is easy and quick to perform and should
be done in current practice, especially for sizes close to the two
cut-offs of 5 and 10 mm.
Our study has several limitations. The main one is its small size
along with its single-center design. Our results should be verified
with a larger scale multicenter trial before the proposed policy
could be introduced to current practice. One could consider that
our conclusions are only valid in France; however, this is not the
case because our results remain similar when using other guide-
lines, such as US guidelines. Owing to the differences between
national surveillance guidelines, it is almost impossible to con-
struct a universal algorithm; however, we propose an algorithm
on the management of diminutive polyps (● " Fig. 1) that could be
adapted to different guidelines. Moreover, a universal message
can be drawn from our study: it is possible, as of today and in all
countries and facilities without the introduction of any new tech-
nology, to discard safely some diminutive polyps without patho-
logical examination – at least around 18 % of them without any
risk to the patient.
Another limitation is that the discard policy of diminutive polyps
is valid only when the number of polyps < 10 mm in size is one or
two. When their number is three or more, they all have to be
examined because a number of three or more adenomas leads
to a 3-year surveillance interval [8, 29]. Indeed, when proposing
a 3-year interval to patients with three or more polyps < 10 mm
in size without pathological examination of diminutive ones, we
calculated a 59.4 % rate of over-surveillance owing to the high
proportion of nonadenomatous polyps within those polyps.
However, is it really necessary to perform a surveillance colonos-
copy within a 3-year interval for people having three or more
adenomas < 10 mm in size? Some authors have shown that a
number of three or more nonadvanced adenomas was not an
independent risk factor for recurrent advanced adenoma within
4 years [43].
Another question remains unanswered: What is the actual risk of
a 5-year surveillance interval for an isolated diminutive adenoma
with advanced pathologic features? Is it really necessary to per-
form surveillance colonoscopy at 3-year intervals as recommen-
ded by French and US guidelines [8, 29]? Some studies have sug-
gested that a 5-year interval might be sufficient even after
removal of high risk adenomas [44]. Our opinion is that a 5-year
Denis B et al. Pathological examination of diminutive polyps … Endoscopy 2011; 43: 81 – 86
Original article 85
interval is enough, as recommended by British guidelines [41].
There is no evidence that an isolated adenoma measuring
< 10 mm with villous features or high grade dysplasia requires 3-
year instead of 5-year surveillance [30, 31, 45].
Another question remains unanswered: What should we do with
diminutive polyps detected on colonoscopy? To date it is usually
recommended to report, remove, and analyze all raised mucosal
colorectal lesions irrespective of size and appearance. This cur-
rently accepted practice will probably have to change in the set-
ting of mass CRC screening as it is expensive and has a low level of
evidence if the goal of colonoscopy is cancer prevention. All in all,
the same arguments that lead radiologists to ignore diminutive
polyps detected on computed tomographic colonography can be
used to omit the pathological examination of those removed dur-
ing colonoscopy [45, 46]. Many experienced endoscopists simi-
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larly do not report distal diminutive polyps that they consider to
be hyperplastic, and instead leave them in situ provided a sur-
veillance colonoscopy is planned. Our study suggests that all di-
minutive polyps should be removed because of the non-negligi-
ble risk of advanced adenoma. In all, 12.2 % of our diminutive ade-
nomas were advanced, which is by far higher than the range of
0.2 – 8.5 % reported in previous studies [4, 20 – 24]. The high CRC
incidence in Alsace is probably not enough to explain such a dif-
ference. Data from the European cancer registries show that the
incidence of CRC in Alsace is one of the highest in Europe [47].
Another probable explanation is the double tendency of our pa-
thologists to over-read villous histology and high grade dysplasia
[32]. However, the natural history of diminutive adenomas is not
fully known. Is it really necessary to remove them to prevent
CRC? At the present time while we await better knowledge on
their natural history, all neoplastic diminutive polyps should
probably be removed during colonoscopy. Overall, the natural
history of colorectal adenomas, including diminutive, small, and
advanced adenomas, is still incompletely understood and should
be the field of future research, especially to assess their real risk
of becoming invasive CRC.
In summary, 18 – 44 % of diminutive polyps (i. e. 14 – 33 % of all
polyps), can be removed and safely discarded without pathologi-
cal examination with, respectively, 100 % to 98.3 % of patients
having the same surveillance interval as with pathological exam-
ination. A pathological examination would still be required for
some diminutive polyps: those with an unusual gross appearance
such as ulceration or depression that could reflect malignancy,
those three or more in number, and those isolated one or two in
number removed from persons without personal history of colo-
rectal neoplasm (● " Fig. 1). If such a policy was adopted, the
pathological examination could be spared in up to 33 % of all
polyps, lightening the burden for overloaded pathologists and
generating significant cost savings.
Acknowledgments
!
The authors thank all the staff of the Endoscopy Unit and the pa-
thologists of the Pasteur Hospital of Colmar for their contribu-
tions.
Competing interests: None
86 Original article
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