Positive fecal occult blood tests performed during digital rectal examination are not as specific for adenomas as are samples obtained after defecation. In general, the risk of harboring a colonic adenoma is highest in men of advanced age. Hyperplastic polyps, while the most common, have no malignant potential. Only Peutz-Jeghers and adenomatous polyps have malignant potential. Although the risk of malignant transformation is low for individual adenomatous polyps, the incidence of malignancy increases with the size of the adenoma and the age of the patient.
Villous adenomas are more likely to progress to cancer than are tubular adenomas.
Most colonic polyps can be removed via the colonoscope using electrocautery techniques. Surgical removal is indicated only when an experienced endoscopist cannot remove the polyp safely or if the polyp contains an invasive malignancy. Most pedunculated polyps are amenable to electrocautery snare polypectomy. Sessile polyps larger than 2 cm usually contain villous features, have a high malignant potential, and tend to recur following colonoscopic polypectomy. If complete or safe colonoscopic resection is not possible for technical reasons, the lesion should be biopsied and the patient referred for primary surgical therapy.