What are flat polyps and why are they harder to remove?

DEAR DR. ROACH: I am a 78-year-old man who recently had a colonoscopy and had several polyps removed, but there was also a “flat polyp” that could not be removed. My doctor told me he usually recommends surgery to remove it, but due to my age, as well as my heart (stents, high blood pressure) and kidney problems (they’ve been stable for years), it wasn’t sure if surgery was the answer. Good choice.

He recommended I have another colonoscopy with another doctor who successfully removed these flat polyps. I would like your opinion on the best way to deal with this. My options are: do nothing, have surgery, or try the colonoscopy with this other doctor. I once read an article where you said that other problems could arise during colon surgery. –LF

ANSWER: This is a problem I have encountered with my own patients, and there is no right answer for everyone.

Flat polyps are more difficult to remove, but the gastroenterologist will likely have performed a biopsy of the flat polyp. Part of what is important to consider is the biopsy result of the flat polyp, which tends to show more concerning pathological findings. If the result shows severe dysplasia close to cancer, I tend to favor a more aggressive approach. But if the condition is less concerning, given your age and medical problems, it may be reasonable to have a follow-up colonoscopy.

One of my own patients required surgery because the polyp could not be removed, even by an expert, and pathology showed the polyp was dangerously close to cancer.

So, if the pathologic finding is concerning, I recommend another colonoscopy before resorting to surgery, but if it is not that concerning, I recommend a follow-up in six to 12 months. Due to your medical issues, I would be especially careful not to rush you into surgery.

DEAR DR. CAFARD: My father died of pneumonia at 76, his father of pneumonia at 46. At age 60, I received the original pneumonia vaccine and had an injection site reaction with redness and swelling. I am now a healthy 75 year old man, have had all the necessary COVID vaccines and shots, including some exotic ones when I went to Africa, and have never had a problem.

My current GP believes that because of my initial reaction to the first pneumonia injection 15 years ago, I should not receive the current two-dose injections. Given my family history with this disease, I would like to get vaccinated. –RY

ANSWER: The only pneumonia vaccine available 15 years ago was PPSV23, called Pneumovax, and I’m pretty sure that’s what you had. A reaction of redness and swelling at the injection site is common and, especially given your lack of reaction to other vaccines, would not be a reason to avoid receiving the pneumonia vaccine recommended for you, which is the PVC20 (Prevnar). I don’t think you’ll get the same reaction with this new vaccine as you did with PPSV23 15 years ago.

Currently, most healthy people should receive the PCV20 vaccine if it is available. People at higher risk (those with diabetes or chronic heart and lung diseases) should also receive PPSV23.

In my practice, I have often recommended PCV20 to those who only received PPSV23. In my opinion, the benefit outweighs the risk, given your history of a fairly mild vaccine reaction and your family history.

Dr. Roach regrets not being able to respond to individual letters, but he will incorporate them into the column as much as possible. Readers can email questions to ToYourGoodHealth@med.cornell.edu or mail to 628 Virginia Dr., Orlando, FL 32803.

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