Management of Serrated Polyps of the Colon
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Purpose of Review
The purpose of this review is to summarize the management of serrated colorectal polyps (SPs), with a particular focus on the most common premalignant SP, sessile serrated adenoma or polyp (SSA/P). These lesions present a challenge for endoscopists with respect to detection and resection, and are also susceptible to pathologic misdiagnosis.
Patients with SSA/Ps are at an increased risk of future colorectal neoplasia, including advanced polyps and cancer. Reasonable benchmarks for SP detection rates are 5–7% for SSA/Ps and 10–12% for proximal SPs. Certain endoscopic techniques such as chromoendoscopy, narrow band imaging, water immersion, and wide-angle viewing may improve SSA/P detection. Emerging endoscopic techniques such as underwater polypectomy, suction pseudopolyp technique, and piecemeal cold snare polypectomy are helpful tools for the endoscopist’s armamentarium for removing SSA/Ps. Proper orientation of SSA/P specimens can improve the accuracy of pathology readings. Patients with confirmed SSA/Ps and proximal HPs should undergo surveillance at intervals similar to what is recommended for patients with conventional adenomas. Patients with SSA/Ps may also be able to lower their risk of future polyps by targeting modifiable risk factors including tobacco and alcohol use and high-fat diets. NSAIDs and aspirin appear to be protective agents.
SPs and SSA/Ps in particular are important colorectal cancer precursors that merit special attention to ensure adequate detection, resection, and surveillance.
KeywordsColorectal cancer prevention Colonoscopy Serrated polyps Quality metrics Polypectomy
Dr. Crockett’s effort is supported in part by a grant from the NIH (KL2TR001109).
Compliance with ethical standards
Conflict of interest
Claire Fan, Adam Younis, and Christine E. Bookhout declare no conflict of interest.
Seth D. Crockett has received research funding (Clinical trial agreements or study grants) from Exact Sciences and ColoWrap, Inc.
Human and animal rights and informed consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 3.Bosman FT, World Health Organization, International Agency for Research on Cancer. WHO classification of tumors of the digestive system. 4th ed. World Health Organization classification of tumors, vol 3. Lyon: International Agency for Research on Cancer; 2010.Google Scholar
- 4.•• Rex DK, Ahnen DJ, Baron JA, Batts KP, Burke CA, Burt RW, et al. Serrated lesions of the colorectum: review and recommendations from an expert panel. Am J Gastroenterol. 2012;107(9):1315–29. quiz 4, 30. International consensus panel document providing detailed recommendations regarding resection, interpretation and surveillance of serrated class lesions.PubMedPubMedCentralCrossRefGoogle Scholar
- 10.Lockhart-Mummery JP, Dukes C. The precancerous changes in the rectum and colon. Surg Gynecol Obstet. 1927;36:591–6.Google Scholar
- 20.•• IJspeert JE, de Wit K, van der Vlugt M, Bastiaansen BA, Fockens P, Dekker E. Prevalence, distribution and risk of sessile serrated adenomas/polyps at a center with a high adenoma detection rate and experienced pathologists. Endoscopy. 2016;48(8):740–6. Recent report from Netherlands showing relatively high rate of SSA/P detection of 8.2% among screening colonoscopies in a center with high detecting endoscopists and experienced GI pathologists.PubMedCrossRefGoogle Scholar
- 22.•• Bettington ML, Walker NI, Rosty C, Brown IS, Clouston AD, McKeone DM et al. A clinicopathological and molecular analysis of 200 traditional serrated adenomas. Mod Pathol. 2014. Largest series to date describing histopathologic and genetic features of TSAs.Google Scholar
- 26.• Payne SR, Church TR, Wandell M, Rosch T, Osborn N, Snover D, et al. Endoscopic detection of proximal serrated lesions and pathologic identification of sessile serrated adenomas/polyps vary on the basis of center. Clin Gastroenterol Hepatol. 2014;12(7):1119–26. Report from a multicenter international trial demonstrating wide inter-center variability in detection of SSA/Ps and proximal SPs.PubMedCrossRefGoogle Scholar
- 29.• Racho RG, Krishna M, Coe SG, Thomas CS, Crook JE, Diehl NN, et al. Impact of an Endoscopic Quality Improvement Program Focused on Adenoma Detection on Sessile Serrated Adenoma/Polyp Detection. Dig Dis Sci. 2017;62(6):1464–71. This study demonstrated that a quality improvement program focused on improving ADR did not impact SSA/P detection, indicating that a different skillset may be needed to detect serrated lesions.PubMedCrossRefGoogle Scholar
- 39.•• Bailie L, Loughrey MB, Coleman HG. Lifestyle Risk Factors for Serrated Colorectal Polyps: A Systematic Review and Meta-analysis. Gastroenterology. 2017;152(1):92–104. A recent systematic review and meta-analysis summarizing data on modifiable risk factors for SPs and SSA/Ps specifically.PubMedCrossRefGoogle Scholar
- 41.Anderson JC, Butterly LF, Robinson CM, Goodrich M, Impact WJE. of fair bowel preparation quality on adenoma and serrated polyp detection: data from the New Hampshire colonoscopy registry by using a standardized preparation-quality rating. Gastrointest Endosc. 2014;80(3):463–70.PubMedPubMedCentralCrossRefGoogle Scholar
- 47.•• Butterly L, Robinson CM, Anderson JC, Weiss JE, Goodrich M, Onega TL, et al. Serrated and adenomatous polyp detection increases with longer withdrawal time: results from the New Hampshire Colonoscopy Registry. Am J Gastroenterol. 2014;109(3):417–26. Multicenter study of nearly 8,000 colonoscopies demonstrating that SSA/P detection is optimized at withdrawal/inspection time of 9 minutes or longer.PubMedPubMedCentralCrossRefGoogle Scholar
- 51.Hafner S, Zolk K, Radaelli F, Otte J, Rabenstein T, Zolk O. Water infusion versus air insufflation for colonoscopy. Cochrane Database Syst Rev. 2015;5:CD009863.Google Scholar
- 52.Leung FW, Leung JW, Siao-Salera RM, Mann SK, Jackson G. The water method significantly enhances detection of diminutive lesions (adenoma and hyperplastic polyp combined) in the proximal colon in screening colonoscopy - data derived from two RCT in US veterans. J Interv Gastroenterol. 2011;1(2):48–52.PubMedPubMedCentralCrossRefGoogle Scholar
- 60.• IJspeert J, Bastiaansen BA, van Leerdam ME, Meijer GA, van Eeden S, Sanduleanu S, et al. Development and validation of the WASP classification system for optical diagnosis of adenomas, hyperplastic polyps and sessile serrated adenomas/polyps. Gut. 2016;65(6):963–70. Report detailing the WASP criteria for identification of SSA/Ps via narrow band imaging characteristics.PubMedCrossRefGoogle Scholar
- 64.•• Crockett SD, Gourevitch RA, Morris M, Carrell DS, Rose S, Shi Z, et al. Endoscopist factors that influence serrated polyp detection: A multi-center study. Endoscopy. 2018. [In press]. Multicenter study describing endoscopist characteristics associated with higher SSA/P detection rates.Google Scholar
- 66.• Anderson JC, Butterly LF, Weiss JE, Robinson CM. Providing data for serrated polyp detection rate benchmarks: an analysis of the New Hampshire Colonoscopy Registry. Gastrointest Endosc. 2017;85(6):1188–94. Multicenter study of over 45,000 colonoscopies that suggests benchmarks of 7% for detection of clinically significant SPs and 11% for proximal SPs for screening colonoscopies, based on established ADR targets.PubMedCrossRefGoogle Scholar
- 68.Crockett SD. Sessile Serrated Polyps and Colorectal Cancer. JAMA. 2017;317(9):975–6.Google Scholar
- 75.Holme O, Bretthauer M, Fretheim A, Odgaard-Jensen J, Hoff G. Flexible sigmoidoscopy versus fecal occult blood testing for colorectal cancer screening in asymptomatic individuals. Cochrane Database Syst Rev. 2013;9:CD009259.Google Scholar
- 76.Lin JS, Piper MA, Perdue LA, Rutter C, Webber EM, O’Connor E et al. Screening for Colorectal Cancer: A Systematic Review for the U.S. Preventive Services Task Force. U.S. Preventive Services Task Force Evidence Syntheses, formerly Systematic Evidence Reviews. Rockville (MD) 2016.Google Scholar
- 80.Spada C, Pasha SF, Gross SA, Leighton JA, Schnoll-Sussman F, Correale L, et al. Accuracy of First- and Second-Generation Colon Capsules in Endoscopic Detection of Colorectal Polyps: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol. 2016;14(11):1533–43 e8.PubMedCrossRefGoogle Scholar
- 88.Tutticci NJ, Hewett DG. Cold endoscopic mucosal resection of large sessile serrated polyps at colonoscopy (with video). Gastrointest Endosc. 2017.Google Scholar
- 89.• Tate DJ, Awadie H, Bahin FF, Desomer L, Lee R, Heitman SJ et al. Wide-field piecemeal cold snare polypectomy of large sessile serrated polyps without a submucosal injection is safe. Endoscopy. 2017. Report describing piecemeal cold snare polypectomy technique.Google Scholar
- 90.Grimm I, Peery AF, Kaltenbach T, Crockett SD. Quality Matters: Improving the Quality of Care for Patients With Complex Colorectal Polyps. Am J Gastroenterol. 2017.Google Scholar
- 93.Kolb JM, Morales SJ, Rouse NA, Desai J, Friedman K, Makris L, et al. Does Better Specimen Orientation and a Simplified Grading System Promote More Reliable Histologic Interpretation of Serrated Colon Polyps in the Community Practice Setting? Results of a Nationwide Study. J Clin Gastroenterol. 2016;50(3):233–8.PubMedCrossRefGoogle Scholar
- 94.• Morales SJ, Bodian CA, Kornacki S, Rouse RV, Petras R, Rouse NA, et al. A simple tissue-handling technique performed in the endoscopy suite improves histologic section quality and diagnostic accuracy for serrated polyps. Endoscopy. 2013;45(11):897–905. Study demonstrating that use of a simple technique to flatten SSA/P polypectomy specimens can improve the accuracy of pathology interpretation.PubMedCrossRefGoogle Scholar
- 97.•• Erichsen R, Baron JA, Hamilton-Dutoit SJ, Snover DC, Torlakovic EE, Pedersen L, et al. Increased Risk of Colorectal Cancer Development Among Patients with Serrated Polyps. Gastroenterology. 2016;150(4):870–8. Case control study from Denmark demonstrating that patients with SSA/Ps are at increased risk of subsequent colorectal cancer.CrossRefGoogle Scholar
- 98.Anderson JC, Butterly LF, Robinson CM, Weiss JE, Amos C, Srivastava A. Risk of Metachronous High-Risk Adenomas and Large Serrated Polyps in Individuals With Serrated Polyps on Index Colonoscopy: Data From the New Hampshire Colonoscopy Registry. Gastroenterology. 2018;154(1):117–27 e2.PubMedCrossRefGoogle Scholar
- 102.Crockett SD, Barry EL, Mott LA, Ahnen DJ, Robertson DJ, Anderson JC et al. Calcium and vitamin D supplementation and increased risk of serrated polyps: results from a randomized clinical trial. Gut. 2018;[In press].Google Scholar