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Research Article | DOI: https://doi.org/10.31579/2690-1919/488
1Department of Gastroenterology, West China Xiamen Hospital, Sichuan University, Xiamen, China.
2Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.
*Corresponding Author: Zeng Yan Xue. Department of Gastroenterology, West China Xiamen Hospital, Sichuan University, Xiamen, China
Citation: Jinkun Guoea, Jinyan Guob, Jianxiong Dengea, Ming Zhangea, Meng Queae, (2025), Profile of Colorectal Polyps in Young Patients: A Retrospective Study., J Clinical Research and Reports, 19(3); DOI:10.31579/2690-1919/488
Copyright: © 2025, Zeng Yan Xue. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 21 January 2025 | Accepted: 15 February 2025 | Published: 31 March 2025
Keywords: colorectal polyps; young; advanced histology
Background and objectives: There is an increased incidence of colorectal cancer in young patients, however, the relationship between polyp characteristics and histology is not clearly understood. This study aimed to investigate the prevalence of different histological types of polyps in young patients and risk factors associated with advanced histology.
Methods: Young patients (aged < 45 years) who underwent polypectomy at Sir Run Run Shaw Hospital (2015-2017, Zhejiang, China) and West China Xiamen Hospital (2023, Xiamen, China) were included. A database of endoscopes was accessed to classify polyps according to endoscopic features. The distribution of polyps and the risk factors associated with advanced histology were reported.
Results: The detection rate of polyps among the youth was 20%. Hyperplastic polyps were second only to tubularadenomas in frequency. Of the 2776 polyps, nearly 85% were sessile, 29.4% were located in the sigmoid colon, and 25.4% were located in the rectum. Among polyps, 87.3% were < 10 mm in diameter. Histological features of advanced adenoma were found in 5.3% of patients. Of these, 30.4% occurred in polyps < 10 mm. Furthermore, 69.6% were distributed in the distal colorectum. Multivariate logistic regression analysis demonstrated that polyp size and morphology were independent predictors of advanced adenomas.
Conclusions: Large size and pedunculated morphology were independent predictors of advanced polyp histology in young patients. Nearly one-third of the advanced histology cases were associated with small polyps. It is recommended that endoscopists resect all polyps found during colonoscopy, especially pedunculated polyps, and submit them for histology.
The vast majority of colorectal polyps are incidentally detected during colonoscopy. A polyp is defined as a proliferative or neoplastic lesion of the intestinal mucosal layer [1], increased in detection with the widespread use of colonoscopy. Most lesions were small (<2>
A great deal of effort has been done on depicting the clinical and advanced histological aspects of colorectal polyps [3-7], but the disease spectrum is variable in different populations, and the association between the endoscopic characteristics and histology of colorectal polyps is not fully understood. It has been reported that 5.6% of polyps present with advanced histopathological features [8]. The low prevalence of advanced histopathology for some polyps suggests that not all polyps require endoscopic resection or continuous endoscopic surveillance. Given the increasing incidence of colorectal cancer (CRC) in young patients, it is significant to identify the correlation between polyp characteristics and histopathology in such populations. This study aimed to analyze the prevalence of different types of colorectal polyps in a young cohort utilizing retrospective data and to explore the relationship between the endoscopic characteristics of polyps and histopathology.
Patients
This retrospective and descriptive study was approved by the Ethics Committees of the Sir Run Run Shaw Hospital (Zhejiang University School of Medicine, SRRSH), and West China Xiamen Hospital (Sichuan University, WCXMH). The records of young patients (aged 18-44) who underwent endoscopic polypectomy at SRRSH (2015-2017) and WCXMH (2023) were analyzed. Data, including basic demographics, polyp size, location, morphology, endoscopic diagnosis and pathology, were retrieved from electronic medical records. The approach at our institution was to prepare patients with a polyethylene glycol electrolyte solution for standard colonoscopy by endoscopists. A senior endoscopist was defined by performing more than 3,000 examinations with more than 10 years of experience in endoscopic procedures. Informed consent was obtained from all patients before colonoscopy.
Polyp characteristics.
The polyps were graded by size as follows: 1–5 mm, 6–9 mm, 10–19 mm, 20-49 mm, and ≥50 mm. The polyp were ranked by location as follows: cecum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum. The proximal colon was defined as being located from the cecum to the transverse colon, whereas the distal colorectum was classified as being located from the splenic flexure to the rectum. The polyps were stratified by morphology as follows: pedunculated and sessile. Polyps were further stratified by histopathology into inflammatory polyp (IP), hamartomatous polyp (HMP)，hyperplastic polyp（HP）, traditional serrated adenoma (TSA), tubular adenoma (TA), tubulovillous adenoma (TVA), villous adenoma (VA), TA with high-grade dysplasia (TA-HG), sessile serrated adenoma/polyp (SSA/P), carcinoma, and others (including intestinal mucosa, lymphoid polyps, carcinoid tumors, and neuroendocrine tumors, etc.). Any polyp exhibiting histologic features of TVA, VA, TA-HG, SSA/P, or carcinoma is referred to as a “advanced adenoma”.
Data processing and analysis were performed using R version 4.4.0, along with Zstats 1.0 (www.zstats.net). Descriptive statistics were performed for all variables, including means and standard deviations for continuous variables, and frequencies for categorical variables. T-test or chi-square test was used to analyze the differences between variables. Identification of factors influencing advanced adenoma were performed using binary logistic regression analysis. For the multivariate analysis model, only factors with P <0>
Baseline characteristics of the patients and the histological features of colorectal polyps.
During the study period, a total of 10250 young patients（aged 18-44）underwent colonoscopy at both hospitals, among whom 2,050 (20%) underwent polypectomy. Finally, 207 patients were excluded because of incomplete pathology or endoscopy reports, and the remaining 1843 young patients (2776 polyps) were included for analysis. Their mean age was 37.6 ± 5.4, with 1249 (67.8%) male. 50 endoscopists were involved in the colonoscopy of 1843 patients, of which 21 (42.9%) senior endoscopists were involved in the colonoscopy of 1023 (55.5%) patients. The distribution of different histological types of colorectal polyps was shown in Table 1. A total of 2776 polyps were detected, including 1455 (52.4%) non-neoplastic polyps and 1321 (47.6%) colorectal adenomas (neoplastic polyps). Among the colorectal adenomas, there were 1170 TA, 97 TVA, 11 VA, 16 SSA/P, and 14 carcinomas. Details in demographic and endoscopic parameters and the logistic regression analysis of colorectal adenomas were shown in Table 2. The average age of young patients with colorectal adenomas was 38.3± 5.1. There was no significant difference in age (P=0.210) or gender (P=0.086) between patients with advanced adenomas and those with nonadvanced adenomas. Among male patients, 90 (10.2%) were advanced adenomas, and the remaining 89.8% were nonadvanced adenomas (8.8-fold difference), compared to 13.3% of female patients with advanced adenomas and 86.7% with nonadvanced adenomas (6.5-fold difference).
Size of polyps.
There were 2776 polyps, of which 2710 had definite sizes. Of the 2710 polyps, 2367 (87.3%) were <10>
Location of polyps.
Of 2776 polyps, 817 (29.4%) were found in the sigmoid colon, followed by 706 (25.4%) in the rectum. As shown in Table 1, the frequency of advanced adenomas in each part of the colon was 24/289 (8.3%) in the ascending colon, 62/817 (7.6%) in the sigmoid colon, 11/318 (3.5%) in the descending colon, 24/706 (3.4%) in the rectum, 16/527 (3.0%) in the transverse colon, and 7/242 (2.9%) in the cecum. Of the advanced adenomas (n=148), 45 (30.4%) were distributed in the proximal colon and 103 (69.6%) polyps were distributed in the distal colorectum (Table 2, P =0.053).
Morphology of polyps.
Of the 2776 polyps, nearly 85% were sessile. Of the 148 advanced adenoma, 76 (51.3%) were pedunculated polyps and 72 (48.7%) were sessile ones. The frequency of advanced adenoma was 76/412 (18.4%) in pedunculated polyps and 72/2364 (3.0%) in sessile ones. As presented in Table 2, the distributions of advanced adenoma and nonadvanced adenoma were different in both morphology groups (pedunculated vs sessile: 51.3% vs 48.7%, 17.9% vs 82.1%, respectively, P < 0>
Risk factors for advanced adenomas.
Logistic regression models were performed to explore the potential factors associated with advanced adenomas (Table 2). On univariate logistic regression analysis, size and morphology of polyps correlated with advanced adenoma (P <0 OR=8.99, xss=removed OR=27.12, OR =0.50, P =0.001).>0.05) (Table 2). Details of the parameters of colorectal adenomas from the two hospitals were shown in Table 3. Significant differences were observed between the two hospitals regarding the size, location, and morphology of colorectal adenomas (P < 0>
The present study, conducted in two comprehensive tertiary hospitals, provided a profile of colorectal polyps in young patients. The frequency of advanced adenomas of the colon is approximately 5%, which increases with increasing polyp size. Advanced histology was more prevalent in larger pedunculated colorectal polyps, but nearly one third of advanced adenomas were discovered in polyps less than 10 mm.
International guidelines recommend CRC screening in average-risk adults over 45 years of age for early detection of CRC and adenomatous polyps [8]. Recently, physicians have called for increased awareness of CRC in young populations because of the increased incidence of CRC in young populations [10]. The reported prevalence of colonic polyps varies widely, possibly due to differences in the structure of studies, screening methods, and even genetic and environmental factors. Data on the prevalence and distribution of polyps in young Asians are limited. It was estimated that 30% of the Western population suffers from colon polyps, while lower rates (10-15%) have been recorded in Asia and Africa [11]. In our study, the colorectal polyp detection rate is 20% in youth (average age 37.6 ± 5.4), compared with 17.5% in Chinese patients under age 50 (average age 41.0 ± 6.8 years) [12]and 16.3% in the asymptomatic Chinese (average age 56.6±10.7 years) [13]. The adenoma detection rate (ADR) has been regarded as a primary benchmark for colonoscopy [14, 15]. In a multinational Asian study, the ADR for patients aged 20-39 years and patients aged 40-49 years were 4.7% and 13.9%, respectively [16]. Aging is a risk factor for colorectal adenomas and is associated with the development of high-grade dysplasia in adenomas, irrespective of the size and histology of the adenoma [17]. In the 40-49 years and 50-59 years groups, Leshno et al. noted significant disparities in Western and East Asian populations regarding total and advanced ADR [18]. There was also a tendency for ADR to increase with age in our study population. We found a higher ADR in men than in women, and the ratio of ADR in men to women was 2.0 (men vs female, 886 vs 435), which is consistent with other studies in Asian population studies [19-22] (odds ratios ranged from 1.7 to 2.4). Our findings support the conclusion that optimal the ADR targets should be stratified according to gender and age. Several studies have confirmed that gender and age are risk factors for advanced adenoma or CRC [23-27], which was not found in our youth cohort study.
Clinicians make judgments regarding particular polyps based on histology. The proportion of each polyp type appeared to provide the most visually and clinically meaningful information. Our study and others have shown that the histological features of advanced adenomas become more prevalent as the polyp size increases [7, 8]. Martínez et al. demonstrated that patients with baseline adenomas of 10-19 mm and ≥20 mm have a substantially higher risk of developing advanced neoplasms than those with adenomas of < 5>10 mm). Some small polyps may regress or grow slowly [29], and overdiagnosis of tiny polyps appears to incease the cost of colonoscopic surveillance. However, since the majority of all polyps were tiny, a substantial proportion of all polyps with characteristics of advanced adenoma were observed in polyps less than 10 mm. The trend was analogous to the results of a large national database study [7]. We then recommended the removal of all polyps, regardless of polyp size, whether the patient is young or old [4, 5, 30].
The malignant potential of adenomas is generally considered to correlate with their size, location, and morphology. Our findings indicate that the polyp location is closely, but not independently, associated with abnormal developmental changes in colorectal adenomas. Adenomas detected by screening colonoscopy were more frequent in the distal colon than in the proximal colon, especially advanced adenomas [12, 31, 32], which was in line with our study. Studies [12, 33, 34] also focused on the status of the proximal colon based on findings in the distal colon. They found that the relative risk of proximal colorectal adenomas was higher in patients with distal colorectal adenomas than in those without. Right-sided CRC increases in older adults, and Yamaji et al. [35] have revealed a right-side shift in the location of new colorectal adenomas with age. In our study, together with that of Saudi Arabia [36], the majority of neoplastic polyps were located in the left colon. That seems to support the development of an adenoma-carcinoma sequence. Furthermore, multivariate logistic regression analysis showed that pedunculated polyp was an independent predictor of advanced histology (OR=1.5, p=0.001). In short, we emphasized the necessity of biopsy and colonoscopic surveillance in young populations with pedunculated polyps.
This was a retrospective study with some limitations. First, the inclusion cohort included patients from two endoscopic centers who underwent polypectomy, therefore, a selection bias exists. Second, it was not a population-based screening study, and the current data cannot permit the establishment of the absolute prevalence of colorectal polyps in the young population. Measurements by endoscopists are generally used for clinical decision making. The proportion of polyps shown here may not be sufficient to establish a benchmark for clinical practice, but we provide some indicative value for designing effective population-based CRC screening. Prospective studies in more centers and with larger sample sizes are needed in the future. Finally, our study relied on polyp size reported by the endoscopist, the accuracy of which may be affected by individual differences. However, there are no standards on how to measure the size of polyps, so such a limitation probably applies to most studies concerning polyp size measurement.
In summary, our study demonstrated that specific characteristics of colorectal polyps, such as large and pedunculated, are associated with advanced histology in young patients, highlighting the importance of excision. In addition, owing to the large proportion of advanced histopathology related to small polyps, it is recommended that endoscopists resected all polyps detected during colonoscopy and submit them for histology.
This study was supported by grants (no. 2021KY749 to Meng Que Xu) from the Medical Health Technology Project of Zhejiang and (no. 3502Z202374037 to Zeng Yan Xue) from the Xiamen Natural Science Foundation. We thank all the doctors, nurses and pathologists who helped to manage the patients during the study.
The authors declare no conflict of interest.
Data Availability Statement
The raw data supporting the conclusions of this study will be made available by the authors upon request.
Author Contributions
Conceptualization and funding acquisition: Meng Que Xu and Zeng Yan Xue; Acquisition, analysis, and interpretation of the data: Yu Qin Shen, Ming Yong Di and Yi Fang Deng; Writing – original draft: Yu Qin Shen; Writing – review & editing: Meng Que Xu and Zeng Yan Xue.
Ethics approval
This study was conducted with the approval of the Ethics Committees of Sir Run Run Shaw Hospital, Zhejiang University and West China Xiamen Hospital, Sichuan University.
Funding: This study was supported by the grants (no. 2021KY749 to Meng Que Xu) from the Medical Health Technology Project of Zhejiang and (no. 3502Z202374037 to Zeng Yan Xue) from the Xiamen Natural Science Foundation.
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