Endoscopic red flags for the detection of high-risk serrated polyps: an observational study

Background and study aims: In routine practice, colonoscopy may fail to prevent colorectal cancer (CRC), especially in the proximal colon. A better endoscopic recognition of serrated polyps is important, as this pathway may explain some of the post-colonoscopy cancers. In this study, the endoscopic characteristics of serrated polyps were examined.

Patient and methods: This was a cross-sectional, single-center study of all consecutive patients referred for elective colonoscopy during 1 year. The endoscopists were familiarized with the detection and treatment of nonpolypoid colorectal lesions. Serrated polyps were classified into high risk serrated polyps, defined as dysplastic or large ( ≥ 6 mm) proximal nondysplastic serrated polyps, and low risk serrated polyps including the remaining nondysplastic serrated polyps. Advanced colorectal neoplasms were defined as multiple (at least three), ≥ 10 mm in size, high grade dysplastic adenomas or CRC.

Results: A total of 2309 patients were included (46.1 % men, mean age 58.4 years), of whom 2.5 % (57) had at least one high risk serrated polyp and 13.9 % (322) had at least one advanced neoplasm. Overall, serrated polyps were more often nonpolypoid than adenomas (16.2 % vs. 11.1 %; P = 0.002). In total, 65 high risk serrated polyps were found, of which 43.1 % (28) displayed a nonpolypoid endoscopic appearance. Patients with advanced neoplasms were more likely to have synchronous high risk serrated polyps than patients without advanced neoplasms: OR 3.66 (95 % CI 2.03 – 6.61, P < 0.001).

Conclusions: High risk serrated polyps are frequently nonpolypoid and are associated with synchronous advanced colorectal neoplasms. Advanced colorectal neoplasms may therefore be considered red flags for the presence of high risk serrated polyps. Detection, diagnosis, and treatment of high risk serrated lesions may be important targets to improve the quality of colonoscopic cancer prevention.

• References

• 1 Baxter NN, Goldwasser MA, Paszat LF et al Association of colonoscopy and death from colorectal cancer. Ann Intern Med 2009; 150: 1-8
• 2 Singh H, Nugent Z, Demers AA, Bernstein CN. Rate and predictors of early/missed colorectal cancers after colonoscopy in Manitoba: a population-based study. Am J Gastroenterol 2010; 105: 2588-2596
• 3 Brenner H, Hoffmeister M, Arndt V et al Protection from right- and left-sided colorectal neoplasms after colonoscopy: population-based study. J Natl Cancer Inst 2010; 102: 89-95
• 4 Arain MA, Sawhney M, Sheikh S et al CIMP status of interval colon cancers: another piece to the puzzle. Am J Gastroenterol 2009; 105: 1189-1195
• 5 Iino H, Jass JR, Simms LA et al DNA microsatellite instability in hyperplastic polyps, serrated adenomas, and mixed polyps: a mild mutator pathway for colorectal cancer?. J Clin Pathol 1999; 52: 5-9
• 6 Yang S, Farraye FA, Mack C et al BRAF and KRAS mutations in hyperplastic polyps and serrated adenomas of the colorectum: relationship to histology and CpG island methylation status. Am J Surg Pathol 2004; 28: 1452-1459
• 7 Kambara T, Simms LA, Whitehall VL et al BRAF mutation is associated with DNA methylation in serrated polyps and cancers of the colorectum. Gut 2004; 53: 1137-1144
• 8 Park SJ, Rashid A, Lee JH et al Frequent CpG island methylation in serrated adenomas of the colorectum. Am J Pathol 2003; 162: 815-822
• 9 Makinen MJ. Colorectal serrated adenocarcinoma. Histopathology 2007; 50: 131-150
• 10 East JE, Saunders BP, Jass JR. Sporadic and syndromic hyperplastic polyps and serrated adenomas of the colon: classification, molecular genetics, natural history, and clinical management. Gastroenterol Clin North Am 2008; 37: 25-46
• 11 Jass JR. Classification of colorectal cancer based on correlation of clinical, morphological and molecular features. Histopathology 2007; 50: 113-130
• 12 Torlakovic E, Skovlund E, Snover DC et al Morphologic reappraisal of serrated colorectal polyps. Am J Surg Pathol 2003; 27: 65-81
• 13 Lash RH, Genta RM, Schuler CM. Sessile serrated adenomas: prevalence of dysplasia and carcinoma in 2139 patients. J Clin Pathol 2010; 63: 681-686
• 14 Goldstein NS. Small colonic microsatellite unstable adenocarcinomas and high-grade epithelial dysplasias in sessile serrated adenoma polypectomy specimens: a study of eight cases. Am J Clin Pathol 2006; 125: 132-145
• 15 Bouwens M, Rondagh E, Winkens B et al Are hyperplastic polyps precursors of colorectal cancer? A long-term, retrospective study.. Gastroenterology 2009; 136: A97
• 16 Lu FI, van Niekerk de W, Owen D et al Longitudinal outcome study of sessile serrated adenomas of the colorectum: an increased risk for subsequent right-sided colorectal carcinoma. Am J Surg Pathol 2010; 34: 927-934
• 17 Hawkins NJ, Ward RL. Sporadic colorectal cancers with microsatellite instability and their possible origin in hyperplastic polyps and serrated adenomas. J Natl Cancer Inst 2001; 93: 1307-1313
• 18 Jaramillo E, Watanabe M, Slezak P, Rubio C. Flat neoplastic lesions of the colon and rectum detected by high-resolution video endoscopy and chromoscopy. Gastrointest Endosc 1995; 42: 114-122
• 19 Li D, Jin C, McCulloch C et al Association of large serrated polyps with synchronous advanced colorectal neoplasia. Am J Gastroenterol 2009; 104: 695-702
• 20 Hiraoka S, Kato J, Fujiki S et al The presence of large serrated polyps increases risk for colorectal cancer. Gastroenterology 2010; 139: 1503-1510
• 21 Schreiner MA, Weiss DG, Lieberman DA. Proximal and large hyperplastic and nondysplastic serrated polyps detected by colonoscopy are associated with neoplasia. Gastroenterology 2010; 139: 1497-1502
• 22 Harrison M, Singh N, Rex DK. Impact of proximal colon retroflexion on adenoma miss rates. Am J Gastroenterol 2004; 99: 519-522
• 23 Rex DK, Cutler CS, Lemmel GT et al Colonoscopic miss rates of adenomas determined by back-to-back colonoscopies. Gastroenterology 1997; 112: 24-28
• 24 Hetzel JT, Huang CS, Coukos JA et al Variation in the detection of serrated polyps in an average risk colorectal cancer screening cohort. Am J Gastroenterol 2010; 105: 2656-2664
• 25 Kahi CJ, Hewett DG, Norton DL et al Prevalence and variable detection of proximal colon serrated polyps during screening colonoscopy. Clin Gastroenterol Hepatol 2011; 9: 42-46
• 26 Church JM, Muto T, Appau K. Flat lesions of the colorectal mucosa: differences in recognition between Japanese and American endoscopists. Dis Colon Rectum 2004; 47: 1462-1466
• 27 Sanduleanu S, Rondagh EJA, Masclee AA. Development of expertise in the detection and classification of non-polypoid colorectal neoplasia: experience-based data at an academic GI unit. Gastrointest Endosc Clin N Am 2010; 20: 449-460
• 28 Soetikno RM, Barro J, Friedland S et al. Diagnosis of flat and depressed colorectal neoplasms. ASGE Endoscopic Learning Library 2006. Available at: http://www.asge.org/ell_list.aspx (Last accessed 26 July 2011)
• 29 Rex DK. Colonoscopic polypectomy. ASGE Endoscopic Learning Library 2007. Available at: http://www.asge.org/ell_list.aspx (Last accessed 26 July 2011)
• 30 Soetikno R, Friedland S, Kaltenbach T et al Nonpolypoid (flat and depressed) colorectal neoplasms. Gastroenterology 2006; 130: 566-576
• 31 The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointest Endosc 2003; 58: 3-43 (Suppl December)
• 32 Bosman FT, Carneiro F, Hruban RH, Theise ND. WHO classification of tumours of the digestive system. Lyon, France: IARC Press; 2010
• 33 Farris AB, Misdraji J, Srivastava A et al Sessile serrated adenoma: challenging discrimination from other serrated colonic polyps. Am J Surg Pathol 2008; 32: 30-35
• 34 Baker K, Zhang Y, Jin C, Jass JR. Proximal versus distal hyperplastic polyps of the colorectum: different lesions or a biological spectrum?. J Clin Pathol 2004; 57: 1089-1093
• 35 Spring KJ, Zhao ZZ, Karamatic R et al High prevalence of sessile serrated adenomas with BRAF mutations: a prospective study of patients undergoing colonoscopy. Gastroenterology 2006; 131: 1400-1407
• 36 Winawer S, Fletcher R, Rex D et al Colorectal cancer screening and surveillance: clinical guidelines and rationale-Update based on new evidence. Gastroenterology 2003; 124: 544-560
• 37 Costantini M, Sciallero S, Giannini A et al Interobserver agreement in the histologic diagnosis of colorectal polyps. The experience of the multicenter adenoma colorectal study (SMAC). J Clin Epidemiol 2003; 56: 209-214
• 38 Terry MB, Neugut AI, Bostick RM et al Reliability in the classification of advanced colorectal adenomas. Cancer Epidemiol Biomarkers Prev 2002; 11: 660-663
• 39 Li D, Jin C, McCulloch C et al Association of large hyperplastic polyps with synchronous advanced colorectal neoplasia. Gastroenterology 2008; 134: A-181
• 40 Iacopetta B. Are there two sides to colorectal cancer?. Int J Cancer 2002; 101: 403-408
• 41 Rex DK. Preventing colorectal cancer and cancer mortality with colonoscopy: what we know and what we don’t know. Endoscopy 2010; 42: 320-323
• 42 Brooker JC, Saunders BP, Shah SG et al Total colonic dye-spray increases the detection of diminutive adenomas during routine colonoscopy: a randomized controlled trial. Gastrointest Endosc 2002; 56: 333-338
• 43 LeRhun M, Coron E, Parlier D et al High resolution colonoscopy with chromoscopy versus standard colonoscopy for the detection of colonic neoplasia: a randomized study. Clin Gastroenterol Hepatol 2006; 4: 349-354
• 44 Boparai KS, Mathus-Vliegen EM, Koornstra JJ et al Increased colorectal cancer risk during follow-up in patients with hyperplastic polyposis syndrome: a multicentre cohort study. Gut 2010; 59: 1094-1100
• 45 Levin B, Lieberman DA, McFarland B et al Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology 2008; 134: 1570-1595
• 46 Nagengast FM, Kaandorp CJ. Revised CBO guideline ‘Follow-up after polypectomy’. Ned Tijdschr Geneeskd 2001; 145: 2022-2025
• 47 Terdiman JP, McQuaid KR. Surveillance guidelines should be updated to recognize the importance of serrated polyps. Gastroenterology 2010; 139: 1444-1447
• 48 Martinez ME, McPherson RS, Levin B, Glober GA. A case-control study of dietary intake and other lifestyle risk factors for hyperplastic polyps. Gastroenterology 1997; 113: 423-429
• 49 Wallace K, Grau MV, Ahnen D et al The association of lifestyle and dietary factors with the risk for serrated polyps of the colorectum. Cancer Epidemiol Biomarkers Prev 2009; 18: 2310-2317
• 50 Morimoto LM, Newcomb PA, Ulrich CM et al Risk factors for hyperplastic and adenomatous polyps: evidence for malignant potential?. Cancer Epidemiol Biomarkers Prev 2002; 11: 1012-1018
• 51 Shrubsole MJ, Wu H, Ness RM et al Alcohol drinking, cigarette smoking, and risk of colorectal adenomatous and hyperplastic polyps. Am J Epidemiol 2008; 167: 1050-1058
• 52 Khalid O, Radaideh S, Cummings OW et al Reinterpretation of histology of proximal colon polyps called hyperplastic in 2001. World J Gastroenterol 2009; 15: 3767-3770
• 53 Glatz K, Pritt B, Glatz D et al A multinational, internet-based assessment of observer variability in the diagnosis of serrated colorectal polyps. Am J Clin Pathol 2007; 127: 938-945
• 54 Rex DK, Kahi C, O’Brien M et al The American Society for Gastrointestinal Endoscopy PIVI (Preservation and Incorporation of Valuable Endoscopic Innovations) on real-time endoscopic assessment of the histology of diminutive colorectal polyps. Gastrointest Endosc 2011; 73: 419-422