Surgical Management of Large Tubular Adenoma in the Ascending Colon

Introduction to Surgical Management

The National Comprehensive Cancer Network recommends a right hemicolectomy with en bloc removal of regional lymph nodes for a 45mm tubular adenoma in the ascending colon 1

The American Gastroenterological Association recommends endoscopic mucosal resection (EMR) for large non-pedunculated lesions ≥20mm, but lesions of this size (45mm) in the ascending colon may require surgical consideration due to high incomplete resection rates and risk of complications 2
Complete colonoscopy should be performed to rule out synchronous polyps before proceeding to surgery 6
Pathologic review is necessary if any prior biopsy was performed to assess for invasive cancer 1

The standard procedure for ascending colon lesions requiring surgical resection is right hemicolectomy with en bloc removal of regional lymph nodes, which involves excision of the primary tumor with safe margins, removal of vessels and associated mesocolon, and median laparotomy incision 1, 3, 4
Careful examination of the entire bowel is necessary during surgery, as multiple synchronous lesions may be present 5

Surveillance colonoscopy should be performed at appropriate intervals following right hemicolectomy 6
No adjuvant chemotherapy is necessary if final pathology shows stage I disease (adenoma without invasive cancer or T1 lesion) 6
Adjuvant therapy should be considered only if invasive cancer with unfavorable features is found on final pathology 1, 6

There is approximately 10-15% risk of lymph node metastases if invasive cancer is present in a 45mm lesion 1