Profile of Colorectal Polyps : a Retrospective Study from King Fahad Hospital , Madinah , Saudi Arabia

Colorectal cancer (CRC) is one of the most commonly diagnosed cancers in the West, after Lung and breast cancers and is responsible for significant mortality and morbidity (Rim et al., 2009; Jemal et al., 2010; American Cancer Society, 2011). Although previously, rest of world had low incidence rates for CRC, is now showing an increasing trend in some regions (Jemal et al., 2010) with some demographic differences from Western patients (Goh et al., 2005). The Kingdom of Saudi Arabia (KSA) is considered a low-incidence area, however one group in their analysis predicted asignificant fourfold increase in the burden of CRC in KSA, in the coming decades (Ibrahim et al., 2008) and a more recent report demonstrated continued increase (Mosli and Al-Ahwal, 2012). According to the Saudi Cancer Incidence Report (2012), CRC is second only to breast cancer in the local population of KSA. The progression of adenoma to adenocarcinoma is a well-accepted concept and basis of screening programs for colorectal carcinomas by colonoscopy (Neri et al., 2010; Aldestein et al., 2011) These screening programs have lead to significant decrease in the incidences of


Introduction
Colorectal cancer (CRC) is one of the most commonly diagnosed cancers in the West, after Lung and breast cancers and is responsible for significant mortality and morbidity (Rim et al., 2009;Jemal et al., 2010;American Cancer Society, 2011).Although previously, rest of world had low incidence rates for CRC, is now showing an increasing trend in some regions (Jemal et al., 2010) with some demographic differences from Western patients (Goh et al., 2005).The Kingdom of Saudi Arabia (KSA) is considered a low-incidence area, however one group in their analysis predicted asignificant fourfold increase in the burden of CRC in KSA, in the coming decades (Ibrahim et al., 2008) and a more recent report demonstrated continued increase (Mosli and Al-Ahwal, 2012).According to the Saudi Cancer Incidence Report (2012), CRC is second only to breast cancer in the local population of KSA.
The progression of adenoma to adenocarcinoma is a well-accepted concept and basis of screening programs for colorectal carcinomas by colonoscopy (Neri et al., 2010;Aldestein et al., 2011) These screening programs have lead to significant decrease in the incidences of

Profile of Colorectal Polyps: a Retrospective Study from King Fahad Hospital, Madinah, Saudi Arabia
Abdulkader Albasri 1 *, Hala Yosef 1 , Akbar Hussainy 1 , Saud Bukhari 1 , Ahmed Alhujaily 2 CRC (Levin et al., 2008).The main focus of CRC control relies on methods to detect and remove adenomas, before they become malignant (Consolo et al., 2010).A number of surveillance guidelines are being followed in the West (Brooks et al., 2008;Health Quality Ontario, 2009).However in a recent excellent mini-review on CRC Screening of Asian Americans, Hwang (2013) has concluded that the individual Asian subgroups were underserved by CRC screening and recommended further studies to focus on each individual Asian subgroup, so that more proficient CRC screening and intervention programs could be developed for each subgroup.
The prevalence of Colorectal polyps/adenomas is high (Heitman et al., 2009) and comparable between the two sexes (Ferlitsch et al., 2011).The prevalence of colorectal polyps varies from one country to another.Among asymptomatic patients, the prevalence is approximately 10% in sigmoidoscopy studies and more than 25% in colonoscopy studies (Giacosa et al., 2004).Further reviewing the literature regarding colorectal polyps, we find a number of recent publications from the West Africa (Lee et al., 2012;Veruttipong et al., 2012;Onyekwere et al., 2013;Patil et al., 2013) and remaining Asia (Bashir et al., 2012), especially Iran (Geramizadeh and Keshtkar-Jahromi, 2013) however there is a dearth of any research on this pathology in the region except for a recent paper from Kuwait (Al-Enezi et al., 2010).
From the KSA, only one detailed study on colorectal polyps could be retrieved, which was done almost twenty years back at King Khalid University Hospital, Riyadh (Al-Rashed and Al-Amri, 1996).Recently a group from King Abdul Aziz University Hospital (KAAUH), Jeddah; only briefly mentions colorectal polyps, while reporting the profile of all the colonic biopsies in their hospital (Qayyum and Sawan, 2009).In the same year, Bokhary (2009), has studied and reviewed only the Serrated Colonic Polyps in one of the Teaching Hospital of KSA.
Our study is first of its kind in the region of Al-Madinah Al-Munawwarah, KSA, giving detail analysis of the colorectal polyps as diagnosed in the histopathology laboratory of King Fahad Hospital, Al-Madinah Al-Munawwarah.

Materials and Methods
Two hundred and twenty-four patients who underwent polypectomy for colorectal polypsbetween January 2006 and December 2013 in King Fahad Hospital, Madinah, Saudi Arabia were retrospectively analyzed.All the demographic data such as the age and sex of the patients and information about size of polyps, histological type, locationof polyps and grade of dysplasia were collected from pathology reports and analyzed by software program SPSS 17. Association of dysplasia with the patient's age and the site, size, histological type of polyps was assessed using the chi-squared test.The p value <0.05 was considered as statistically significant.
Of all adenomatous polyps only 33 (19.9%) were greater than 20mm in diameter and 55 (33.1%) were 10-20 mm size and 78 (47%) were less than 10 mm in size.The relative frequency of adenoma and relation of histologic type to size is shown in Table 3.In these adenomatous polyps, 59 cases (35.5%) had low grade dysplasia and 107 cases (64.5%) had high grade dysplasia.
Table 4 shows the association of dysplasia with the gender, age, histological type, location and size of polyps.High grade dysplasia is significantly associated with female patients more than male patients (p=0.001).Villous and tubulovillous types are associated with higher rate of dysplasia as compared to tubular type (p<0.001).In addition, large polyps (>1cm) are associated with   high grade of dysplasia more than small polyps (<1 cm, p<0.001).High grade dysplasia is seen in polyps located at the left side colon more common than right side colonic polyps (p=0.004).

Discussion
Colorectal cancer (CRC) is quite common in the West (Jemalet al., 2010;American Cancer Society, 2011).Although Asia and KSA are considered as low incidence zones (Goh et al., 2005), however in one of the recent research; the incidence of CRC in the KSA was predicted to increase four folds in the coming decade (Ibrahim et al., 2008).CRC is preventable cancer by changing the dietary habits and through screening programmes.As the colorectal polyps are well precursors of CRC, their endoscopic removal during bowel screening programs, have significantly decreased the CRC incidence in the West (Levin et al., 2008;Consolo et al., 2010).Through previous and recent researches in screening endoscopy, colorectal polyps have been found to be quite common in the asymptomatic populations of the Western world (Patil et al., 2013) however the literature is quite insufficient in Africa (Veruttipong et al., 2012;Onyekwere et al., 2013) and Asia (Bashir et al., 2012;Geramizadeh and Keshtkar-Jahromi, 2013) especially the Middle East (Al-Enezi et al., 2010).
However one scientist group from Romania have reported slight female preponderance (56.6%) in their study of 795 colonoscopies having 183 cases of colorectal polyps (Munteanu et al., 2009).Similarly another group from Iran, although gave a male predominance figures in the total count of polyps, further qualifies that neoplastic polyps were more frequent in women; and non-neoplastic polyps were more common in males (Zahir et al., 2010).
In our study, the average age of the colorectal polyp patients was 49 years.In the recent literature of colorectal polyps from the region and Asia, Al-Rashed and Al-Amri (1996) from KSA (Bafandah et al., 2005;2008) from Iran have reported minimum age results of about 42 years, with wide standard deviations.From Kuwait a very close figure of 45 years has been quoted (Al-Enezi et al., 2010).On the other side of spectrum; mean age has been reported as above 50 years (Wisedopas et al., 2005;Tony et al., 2007), reaching up to maximum of 58 years (Bafandeh et al., 2005).One group from Hong Kong studying advanced polyps and CRC, found the mean age of 69.2 in the advanced polyps (Lam et al,. 2007).
Regarding the histological subtypes of 166 adenomatous polyps; in our study, there were 61.4% tubulovillous adenoma, followed by 24.7% tubular adenoma and 13.8% villous adenoma.The literature review from recent publications, however report that tubular adenoma is more common than tubulovillous adenoma.74% tubular adenoma followed by 20% tubulovillous adenoma have been reported from Kuwait (Al-Enezi et al., 2010); while from Iran, tubulovillous adenoma was reported as infrequent i.e.only 3.3% as compared to 78.9% tubular adenoma (Zahir et al., 2010).Al-Rashed and Al-Amri (1996) from KSA in their 2772 colonoscopy study, reported 188 polyps, they did not separate the two subtypes and reported them together as a total 89.5% were tubular and tubulovillous adenomas.
We followed the anatomic distribution of these polyps at the level of the colon and found 36.6% of polyps in sigmoid colon, followed by 21% in rectum.From Iran also, a group have reported highest number of polyps in Sigmoid colon (27.2%) followed by 21.24% in caecum and ascending colon (Eshghi et al., 2011).Similar were the observations from Romanian scientists, who report 39.85% polyps in sigmoid colon (Munteanu et al., 2009).Finally Al-Rashed and Al-Amri (1996) from KSA also found majority of polyps (82%) in the left side of the colon.
In our study, 35.5% adenomatous polyps had low grade dysplasia and 64.5% had high grade dysplasia.High grade dysplasia is significantly associated with female patients more than male patients (p=0.001).Villous and tubulovillous types are associated with higher rate of dysplasia as compared to tubular type (p<0.001).In addition, large polyps (>1cm) are associated with high grade of dysplasia more than small polyps (<1 cm, p<0.001).High grade dysplasia is seen in polyps located at the left side colon more common than right side colonic polyps (p=0.004).Similar observation was made by a group in Iran; who studied 240 polyps in 211 cases; and concluded that size of polyp and amount of villous component were strongly associated with high grade dysplasia (Zare-Mirzaie et al., 2013).In a recent study from India (Tony et al., 2007), in which 99 adenomatous polyps were found; 56.56% were less than 1cm, 22.22% were between 1 and 2 cm and 21.21% were greater than 2cm.Dysplasia was severe in large (>2 cm) polyps compared to small (<1 cm) ones (p<0.001).A group from Turkey; while studying malignancy risk in small polyps, evaluated 1369 polyps <10 mm in 680 patients.67.2% of polyps <10 mm were of neoplastic nature, although they did not mention the grading of dysplastic change (Unal et al., 2007).
Summarizing the discussion, our observations are consistent with most of the recent studies from across the globe and region regarding demographic data of colorectal polyps i.e. age, sex, and location of polyps.However tubulo-villous adenoma was the commonest histological subtype in our study; while tubular adenoma has been reported as most common subtype in the recent and remote literature.We found a significant correlation of presence of high grade dysplasia with size of polyps, tubulo-villous/ villous subtypes of adenomata and left sided polyps as reported in previous and present literature; however our observation of significant correlation of high grade dysplasia with female gender had not been reported in the present literature.
We conclude that our study reveal similar type and distribution of colorectal polyps in the region of Al Madinah Al Munawwarah, as that in previous and recent studies from the West and regional countries, with minor differences.We recommend screening programs such as stool occult blood testing and endoscopies for early detection of the colorectal polyps, which are the precursor lesions of CRC, which has been predicted to increase in coming years.