title: Metachronous serrated neoplasia is uncommon after right colectomy in patients with methylator colon cancers with a high degree of microsatellite instability.
abstract: BACKGROUND
  Right-sided serrated polyps are precursors to sporadic microsatellite unstable colon cancers via the methylator pathway and have a high rate of synchronous and metachronous lesions. Serrated polyps also occur in Lynch syndrome, where right-sided microsatellite unstable cancers arise from germline mutations in mismatch repair genes.
  
  
  OBJECTIVE
  The aim of this study was to compare serrated neoplasia in patients with sporadic and hereditary microsatellite unstable colon cancer and to examine the effect of right colectomy on the risk of metachronous polyps and cancers.
  
  
  METHODS
  This is a retrospective, descriptive, cohort study from database and chart review.
  
  
  METHODS
  This study was conducted at a tertiary care hospital with a center for hereditary colorectal cancer.
  
  
  METHODS
  Patients who had colon cancers with a high degree of microsatellite instability, methylator cancers, and Lynch syndrome cancers, were included.
  
  
  METHODS
  Interventions included colectomy, surveillance colonoscopy, and polypectomy.
  
  
  METHODS
  The primary outcomes measured were the incidence and location of metachronous polyps and cancers.
  
  
  RESULTS
  Eighty-five patients were included: 47 with methylator cancers and 38 with Lynch syndrome. Median ages at surgery were 75 years (range, 41-90) and 48 years (range, 27-77), p < 0.0001. Forty-six (98%) patients with methylator cancers and 17 (45%) patients with Lynch syndrome underwent a right colectomy, p < 0.0001. Metachronous cancers occurred in 19/60 (32%) of patients with Lynch syndrome and no patients with methylator cancers, p < 0.0001. Thirty-four patients with methylator cancers had colonoscopic follow-up, with a median of 2 colonoscopies per patient over a 32-month follow-up (range, 1-136). Sixty-three percent of patients with Lynch syndrome had colonoscopic follow-up, median of 4 colonoscopies per patient over 102 months (range, 1-462), p < 0.0001. Four (9%) patients with methylator cancers each had 1 metachronous serrated polyp, compared with 10/37 (27%) patients with Lynch syndrome (p = 0.049), whose median number of polyps was 2 (range, 1-8). Characteristics of other associated polyps were similar between cohorts.
  
  
  CONCLUSIONS
  This study is somewhat limited by potential inherent bias from its retrospective design. Also, a high number of deaths in the CIMP+ cohort could have contributed to the low number of serrated polyps detected on colonoscopy surveillance, but given current understanding of serrated polyp growth, this may truly represent the left colon's tendency not to develop serrated polyps.
  
  
  CONCLUSIONS
  Cancers with a high degree of microsatellite instability arise through 2 different molecular mechanisms. Metachronous serrated neoplasia, benign and malignant, following right colectomy in patients with the CpG-island methylator phenotype of colorectal cancer is uncommon. However, the colons of patients with Lynch syndrome are at high risk after segmental colectomy.
authors: 1Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio 2Sanford R. Weiss, M.D., Center for Hereditary Colorectal Neoplasia, Cleveland Clinic, Cleveland, Ohio 3Department of Cancer Biology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.
authors: Craig A
authors: CA
authors: Messick
authors: Sara
authors: S
authors: Kravochuck
authors: James M
authors: JM
authors: Church
authors: Matthew F
authors: MF
authors: Kalady
mesh_terms: D018256:Adenomatous Polyps / Q000235:genetics / Q000473:pathology / Q000601:surgery; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D014408:Biomarkers, Tumor / Q000235:genetics; D003082:Colectomy / Q000379:methods; D003110:Colonic Neoplasms / Q000235:genetics / Q000473:pathology* / Q000601:surgery; D003111:Colonic Polyps / Q000235:genetics / Q000473:pathology* / Q000601:surgery; D003113:Colonoscopy; D003123:Colorectal Neoplasms, Hereditary Nonpolyposis / Q000235:genetics / Q000473:pathology* / Q000601:surgery; D018899:CpG Islands; D019175:DNA Methylation; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D053842:Microsatellite Instability; D008875:Middle Aged; D016609:Neoplasms, Second Primary / Q000235:genetics / Q000473:pathology* / Q000601:surgery; D011230:Precancerous Conditions / Q000235:genetics / Q000473:pathology; D012189:Retrospective Studies; D012306:Risk
chemical_list: D014408:Biomarkers, Tumor