title: Advanced colorectal adenomas in patients under 45 years of age are mostly sporadic.
abstract: BACKGROUND
  The presence of advanced adenomas in younger individuals is a criterion for Lynch syndrome (LS). However, the utility of screening advanced adenomas for loss of mismatch repair (MMR) protein expression to identify suspected LS remains unclear.
  
  
  OBJECTIVE
  Determine the prevalence of MMR defects to understand whether these patients harbor a defined genetic risk for CRC.
  
  
  METHODS
  The study cohort included adult patients ≤45 years of age with advanced adenomas (villous histology, ≥1 cm in diameter, ≥3 polyps of any size) endoscopically removed between 2001 and 2011. Clinical records were reviewed along with detailed pathological review and immunohistochemical MMR analysis.
  
  
  RESULTS
  A total of 76 (40.1 % male, age 40.6 ± 5.4 years) patients met inclusion and exclusion criteria. Indications for colonoscopy were gastrointestinal (GI) bleeding 39 (51.3 %), CRC in a first-degree relative 17 (22.4 %) and somatic GI symptoms 20 (26.3 %). Index colonoscopy revealed a median of 1 adenoma (range 1-4), mean diameter of 12.9 ± 7.1 mm, 40 (52.6 %) with villous histology. The mean follow-up duration was 3.3 ± 2 years. Recurrent adenomas developed in 24 (31.6 %), of which 8 (10.5 %) were advanced adenomas; none of these patients developed CRC. One of 66 (1.5 %) adenomas available for immunohistochemical (IHC) testing revealed loss of MLH1 and PMS2.
  
  
  CONCLUSIONS
  IHC screening of advanced adenomas from patients younger than 45 years of age identified potential LS in one of 64 patients. The low yield of IHC screening in this population suggests that universal IHC screening of advanced adenomas from patients younger than 45 years of age for MMR defects is not an efficient strategy for identifying LS subjects.
authors.affiliation: Division of Gastroenterology, Washington University School of Medicine, 660 South Euclid Ave, Campus Box 8124, St Louis, MO, 63110, USA, vkushnir@wustl.edu.
authors.forename: Vladimir M
authors.initials: VM
authors.lastname: Kushnir
authors.forename: Ilke
authors.initials: I
authors.lastname: Nalbantoglu
authors.forename: Rao
authors.initials: R
authors.lastname: Watson
authors.forename: Jonathan
authors.initials: J
authors.lastname: Goodwin
authors.forename: Elyas
authors.initials: E
authors.lastname: Safar
authors.forename: Reena V
authors.initials: RV
authors.lastname: Chokshi
authors.forename: Riad R
authors.initials: RR
authors.lastname: Azar
authors.forename: Nicholas O
authors.initials: NO
authors.lastname: Davidson
mesh_terms: D000236:Adenoma / Q000453:epidemiology / Q000473:pathology*; D000293:Adolescent; D000328:Adult; D015179:Colorectal Neoplasms / Q000453:epidemiology / Q000473:pathology*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000209:etiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D055815:Young Adult