Skip to main content
SpringerLink
Log in

Sessile Serrated Polyps: Detection, Eradication, and Prevention of the Evil Twin

  • Colon (C Burke, Section Editor)
  • Published:
Current Treatment Options in Gastroenterology Aims and scope Submit manuscript

Opinion Statement

The sessile serrated polyp (SSP), also known as sessile serrated adenoma, is the evil twin among the colorectal cancer precursors. As will be described, these lesions have multiple aliases (serrated adenoma, serrated polyp, or serrated lesion among others), they hang out in a bad neighborhood (the poorly prepped right colon), they hide behind a mask of mucus, they are difficult for witnesses (pathologists) to identify, they are difficult for police (endoscopists) to find, they are difficult to permanently remove from the society (high incomplete resection rate), they can be impulsive (progress rapidly to colorectal cancer (CRC)), and enforcers (gastroenterologists) do not know how best to control them (uncertain surveillance recommendations). There is no wonder that there is a need to understand these lesions well, learn how best to prevent the colonic mucosa from going down this errant path or, if that fails, detect these deviants and eradicate them from the colonic society. These lesions should be on endoscopists’ most wanted list.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References and Recommended Reading

  1. Longacre TA, Fenoglio-Preiser CM. Mixed hyperplastic adenomatous polyps/serrated adenomas. A distinct form of colorectal neoplasia. Am J Surg Pathol. 1990;14(6):524–37.

    Article  CAS  PubMed  Google Scholar 

  2. Torlakovic E et al. Morphologic reappraisal of serrated colorectal polyps. Am J Surg Pathol. 2003;27(1):65–81.

    Article  PubMed  Google Scholar 

  3. Rex DK et al. Serrated lesions of the colorectum: review and recommendations from an expert panel. Am J Gastroenterol. 2012;107(9):1315–29. quiz 1314, 1330.

    Article  PubMed Central  PubMed  Google Scholar 

  4. Montgomery E. Serrated colorectal polyps: emerging evidence suggests the need for a reappraisal. Adv Anat Pathol. 2004;11(3):143–9.

    Article  PubMed  Google Scholar 

  5. Bosman FT, World Health Organization., and International Agency for Research on Cancer. WHO classification of tumours of the digestive system. 4th ed. World Health Organization classification of tumours. Lyon: IARC Press; 2010. 417 p.

    Google Scholar 

  6. Bettington M et al. Critical appraisal of the diagnosis of the sessile serrated adenoma. Am J Surg Pathol. 2014;38(2):158–66.

    Article  PubMed  Google Scholar 

  7. Kim SW et al. A significant number of sessile serrated adenomas might not be accurately diagnosed in daily practice. Gut Liver. 2010;4(4):498–502.

    Article  PubMed Central  PubMed  Google Scholar 

  8. Tinmouth J, et al. Sessile serrated polyps at screening colonoscopy: have they been under diagnosed? Am J Gastroenterol. 2014.

  9. Singh H et al. Pathological reassessment of hyperplastic colon polyps in a city-wide pathology practice: implications for polyp surveillance recommendations. Gastrointest Endosc. 2012;76(5):1003–8.

    Article  PubMed  Google Scholar 

  10. Lieberman DA et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2012;143(3):844–57.

    Article  PubMed  Google Scholar 

  11. Vogelstein B et al. Genetic alterations during colorectal-tumor development. N Engl J Med. 1988;319(9):525–32.

    Article  CAS  PubMed  Google Scholar 

  12. Bettington M et al. The serrated pathway to colorectal carcinoma: current concepts and challenges. Histopathology. 2013;62(3):367–86.

    Article  PubMed  Google Scholar 

  13. Yang S 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(11):1452–9.

    Article  PubMed  Google Scholar 

  14. Crockett SD, et al. Sessile serrated adenomas: an evidence-based guide to management. Clin Gastroenterol Hepatol. 2013.

  15. Singh H et al. The reduction in colorectal cancer mortality after colonoscopy varies by site of the cancer. Gastroenterology. 2010;139(4):1128–37.

    Article  PubMed  Google Scholar 

  16. Brenner H et al. Protection from colorectal cancer after colonoscopy: a population-based, case-control study. Ann Intern Med. 2011;154(1):22–30.

    Article  PubMed  Google Scholar 

  17. Farrar WD et al. Colorectal cancers found after a complete colonoscopy. Clin Gastroenterol Hepatol. 2006;4(10):1259–64.

    Article  PubMed  Google Scholar 

  18. Arain MA et al. CIMP status of interval colon cancers: another piece to the puzzle. Am J Gastroenterol. 2010;105(5):1189–95.

    Article  PubMed  Google Scholar 

  19. Pohl H et al. Incomplete polyp resection during colonoscopy-results of the complete adenoma resection (CARE) study. Gastroenterology. 2013;144(1):74–80.e1.

    Article  PubMed  Google Scholar 

  20. Leung K et al. Ongoing colorectal cancer risk despite surveillance colonoscopy: the Polyp Prevention Trial Continued Follow-up Study. Gastrointest Endosc. 2010;71(1):111–7.

    Article  PubMed Central  PubMed  Google Scholar 

  21. Robertson DJ et al. Colorectal cancers soon after colonoscopy: a pooled multicohort analysis. Gut. 2014;63(6):949–56.

    Article  PubMed  Google Scholar 

  22. Sanaka MR et al. Adenoma and sessile serrated polyp detection rates: variation by patient sex and colonic segment but not specialty of the endoscopist. Dis Colon Rectum. 2014;57(9):1113–9.

    Article  PubMed  Google Scholar 

  23. Hetzel JT et al. Variation in the detection of serrated polyps in an average risk colorectal cancer screening cohort. Am J Gastroenterol. 2010;105(12):2656–64.

    Article  PubMed  Google Scholar 

  24. Kim HY et al. Age-specific prevalence of serrated lesions and their subtypes by screening colonoscopy: a retrospective study. BMC Gastroenterol. 2014;14:82.

    Article  PubMed Central  PubMed  Google Scholar 

  25. Hazewinkel Y et al. Prevalence of serrated polyps and association with synchronous advanced neoplasia in screening colonoscopy. Endoscopy. 2014;46(3):219–24.

    PubMed  Google Scholar 

  26. Lash RH, Genta RM, Schuler CM. Sessile serrated adenomas: prevalence of dysplasia and carcinoma in 2139 patients. J Clin Pathol. 2010;63(8):681–6.

    Article  PubMed  Google Scholar 

  27. Kahi CJ et al. Prevalence and variable detection of proximal colon serrated polyps during screening colonoscopy. Clin Gastroenterol Hepatol. 2011;9(1):42–6.

    Article  PubMed  Google Scholar 

  28. de Wijkerslooth TR et al. Differences in proximal serrated polyp detection among endoscopists are associated with variability in withdrawal time. Gastrointest Endosc. 2013;77(4):617–23.

    Article  PubMed  Google Scholar 

  29. Payne SR 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.

    Article  PubMed  Google Scholar 

  30. Abdeljawad K, et al. Sessile serrated polyp prevalence determined by a colonoscopist with a high lesion detection rate and an experienced pathologist. Gastrointest Endosc. 2014.

  31. Butterly L 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.

    Article  PubMed Central  PubMed  Google Scholar 

  32. Anderson JC et al. Impact 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.

    Article  PubMed  Google Scholar 

  33. Tadepalli US et al. A morphologic analysis of sessile serrated polyps observed during routine colonoscopy (with video). Gastrointest Endosc. 2011;74(6):1360–8.

    Article  PubMed  Google Scholar 

  34. Sato R et al. The diagnostic accuracy of high-resolution endoscopy, autofluorescence imaging and narrow-band imaging for differentially diagnosing colon adenoma. Endoscopy. 2011;43(10):862–8.

    Article  CAS  PubMed  Google Scholar 

  35. Pasha SF et al. Comparison of the yield and miss rate of narrow band imaging and white light endoscopy in patients undergoing screening or surveillance colonoscopy: a meta-analysis. Am J Gastroenterol. 2012;107(3):363–70. quiz 371.

    Article  PubMed  Google Scholar 

  36. Omata F et al. Image-enhanced, chromo, and cap-assisted colonoscopy for improving adenoma/neoplasia detection rate: a systematic review and meta-analysis. Scand J Gastroenterol. 2014;49(2):222–37.

    Article  PubMed  Google Scholar 

  37. Kashida H et al. Endoscopic characteristics of colorectal serrated lesions. Hepatogastroenterology. 2011;58(109):1163–7.

    Article  PubMed  Google Scholar 

  38. Hazewinkel Y et al. Endoscopic features of sessile serrated adenomas: validation by international experts using high-resolution white-light endoscopy and narrow-band imaging. Gastrointest Endosc. 2013;77(6):916–24.

    Article  PubMed  Google Scholar 

  39. Boparai KS et al. Increased polyp detection using narrow band imaging compared with high resolution endoscopy in patients with hyperplastic polyposis syndrome. Endoscopy. 2011;43(8):676–82.

    Article  CAS  PubMed  Google Scholar 

  40. Kamiński MF et al. Advanced imaging for detection and differentiation of colorectal neoplasia: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2014;46(5):435–49.

    Article  PubMed  Google Scholar 

  41. Harrison M, Singh N, Rex DK. Impact of proximal colon retroflexion on adenoma miss rates. Am J Gastroenterol. 2004;99(3):519–22.

    Article  PubMed  Google Scholar 

  42. Hewett DG, Rex DK. Miss rate of right-sided colon examination during colonoscopy defined by retroflexion: an observational study. Gastrointest Endosc. 2011;74(2):246–52.

    Article  PubMed  Google Scholar 

  43. Pishvaian AC, Al-Kawas FH. Retroflexion in the colon: a useful and safe technique in the evaluation and resection of sessile polyps during colonoscopy. Am J Gastroenterol. 2006;101(7):1479–83.

    Article  PubMed  Google Scholar 

  44. Yen AW, Leung JW, Leung FW. A new method for screening and surveillance colonoscopy: combined water-exchange and cap-assisted colonoscopy. J Interv Gastroenterol. 2012;2(3):114–9.

    Article  PubMed Central  PubMed  Google Scholar 

  45. Singh R et al. Real-time histology with the endocytoscope. World J Gastroenterol. 2010;16(40):5016–9.

    Article  PubMed Central  PubMed  Google Scholar 

  46. Kudo S et al. Diagnosis of colorectal tumorous lesions by magnifying endoscopy. Gastrointest Endosc. 1996;44(1):8–14.

    Article  CAS  PubMed  Google Scholar 

  47. Kimura T et al. A novel pit pattern identifies the precursor of colorectal cancer derived from sessile serrated adenoma. Am J Gastroenterol. 2012;107(3):460–9.

    Article  CAS  PubMed  Google Scholar 

  48. Kutsukawa M et al. Efficiency of endocytoscopy in differentiating types of serrated polyps. Gastrointest Endosc. 2014;79(4):648–56.

    Article  PubMed  Google Scholar 

  49. Patel SG, Ahnen DJ. Prevention of interval colorectal cancers: what every clinician needs to know. Clin Gastroenterol Hepatol. 2014;12(1):7–15.

    Article  PubMed  Google Scholar 

  50. Pohl H, Robertson DJ. Colorectal cancers detected after colonoscopy frequently result from missed lesions. Clin Gastroenterol Hepatol. 2010;8(10):858–64.

    Article  PubMed  Google Scholar 

  51. Gurudu SR et al. Sessile serrated adenomas: demographic, endoscopic and pathological characteristics. World J Gastroenterol. 2010;16(27):3402–5.

    Article  PubMed Central  PubMed  Google Scholar 

  52. Fahrtash-Bahin F et al. Snare tip soft coagulation achieves effective and safe endoscopic hemostasis during wide-field endoscopic resection of large colonic lesions (with videos). Gastrointest Endosc. 2013;78(1):158–163.e1.

    Article  PubMed  Google Scholar 

  53. Jung M. The ‘difficult’ polyp: pitfalls for endoscopic removal. Dig Dis. 2012;30 Suppl 2:74–80.

    Article  PubMed  Google Scholar 

  54. Binmoeller KF et al. “Underwater” EMR without submucosal injection for large sessile colorectal polyps (with video). Gastrointest Endosc. 2012;75(5):1086–91.

    Article  PubMed  Google Scholar 

  55. Wang AY et al. Underwater endoscopic mucosal resection of colorectal neoplasia is easily learned, efficacious, and safe. Surg Endosc. 2014;28(4):1348–54.

    Article  PubMed  Google Scholar 

  56. Omata F et al. Modifiable risk factors for colorectal neoplasms and hyperplastic polyps. Intern Med. 2009;48(3):123–8.

    Article  PubMed  Google Scholar 

  57. Terry MB et al. Risk factors for advanced colorectal adenomas: a pooled analysis. Cancer Epidemiol Biomarkers Prev. 2002;11(7):622–9.

    PubMed  Google Scholar 

  58. Aune D et al. Dietary fibre, whole grains, and risk of colorectal cancer: systematic review and dose-response meta-analysis of prospective studies. BMJ. 2011;343:d6617.

    Article  PubMed Central  PubMed  Google Scholar 

  59. Clark JC et al. Prevalence of polyps in an autopsy series from areas with varying incidence of large-bowel cancer. Int J Cancer. 1985;36(2):179–86.

    Article  CAS  PubMed  Google Scholar 

  60. Kearney J et al. Diet, alcohol, and smoking and the occurrence of hyperplastic polyps of the colon and rectum (United States). Cancer Causes Control. 1995;6(1):45–56.

    Article  CAS  PubMed  Google Scholar 

  61. Martínez ME et al. A case-control study of dietary intake and other lifestyle risk factors for hyperplastic polyps. Gastroenterology. 1997;113(2):423–9.

    Article  PubMed  Google Scholar 

  62. Shrubsole MJ et al. Alcohol drinking, cigarette smoking, and risk of colorectal adenomatous and hyperplastic polyps. Am J Epidemiol. 2008;167(9):1050–8.

    Article  PubMed  Google Scholar 

  63. Schreiner MA, Weiss DG, Lieberman DA. Proximal and large hyperplastic and nondysplastic serrated polyps detected by colonoscopy are associated with neoplasia. Gastroenterology. 2010;139(5):1497–502.

    Article  PubMed  Google Scholar 

  64. Wallace K et al. The association of lifestyle and dietary factors with the risk for serrated polyps of the colorectum. Cancer Epidemiol Biomarkers Prev. 2009;18(8):2310–7.

    Article  PubMed Central  PubMed  Google Scholar 

  65. Burnett-Hartman AN et al. Differences in epidemiologic risk factors for colorectal adenomas and serrated polyps by lesion severity and anatomical site. Am J Epidemiol. 2013;177(7):625–37.

    Article  PubMed Central  PubMed  Google Scholar 

  66. Chia VM et al. Risk of microsatellite-unstable colorectal cancer is associated jointly with smoking and nonsteroidal anti-inflammatory drug use. Cancer Res. 2006;66(13):6877–83.

    Article  CAS  PubMed  Google Scholar 

  67. Algra AM, Rothwell PM. Effects of regular aspirin on long-term cancer incidence and metastasis: a systematic comparison of evidence from observational studies versus randomised trials. Lancet Oncol. 2012;13(5):518–27.

    Article  CAS  PubMed  Google Scholar 

  68. Burn J et al. Long-term effect of aspirin on cancer risk in carriers of hereditary colorectal cancer: an analysis from the CAPP2 randomised controlled trial. Lancet. 2011;378(9809):2081–7.

    Article  PubMed Central  PubMed  Google Scholar 

  69. Kawasaki T et al. Cyclooxygenase-2 overexpression is common in serrated and non-serrated colorectal adenoma, but uncommon in hyperplastic polyp and sessile serrated polyp/adenoma. BMC Cancer. 2008;8:33.

    Article  PubMed Central  PubMed  Google Scholar 

  70. Nishihara R et al. Aspirin use and risk of colorectal cancer according to BRAF mutation status. JAMA. 2013;309(24):2563–71.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  71. Liao X et al. Aspirin use, tumor PIK3CA mutation, and colorectal-cancer survival. N Engl J Med. 2012;367(17):1596–606.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  72. Rosty C et al. Phenotype and polyp landscape in serrated polyposis syndrome: a series of 100 patients from genetics clinics. Am J Surg Pathol. 2012;36(6):876–82.

    Article  PubMed Central  PubMed  Google Scholar 

  73. Cathomas G. PIK3CA in colorectal cancer. Front Oncol. 2014;4:35.

    Article  PubMed Central  PubMed  Google Scholar 

  74. Bouwens MW et al. Simple clinical risk score identifies patients with serrated polyps in routine practice. Cancer Prev Res (Phila). 2013;6(8):855–63.

    Article  Google Scholar 

  75. https://www.nccn.org/store/login/login.aspx?ReturnURL=http://www.nccn.org/professionals/physician_gls/pdf/colorectal_screening.pdf

  76. Vu HT et al. Individuals with sessile serrated polyps express an aggressive colorectal phenotype. Dis Colon Rectum. 2011;54(10):1216–23.

    Article  PubMed  Google Scholar 

  77. Snover D, Ahnen DJ, Burt RW, Odze RD. Serrated polyps of the colon and rectum and serrated polyposis. In: Bosman FT, Carneiro F, Hruban RH, Theise ND, editors. WHO classification of tumours of the digestive system. Lyon: IARC; 2010. p. 160–5.

    Google Scholar 

  78. Biswas S et al. High prevalence of hyperplastic polyposis syndrome (serrated polyposis) in the NHS bowel cancer screening programme. Gut. 2013;62(3):475.

    Article  PubMed  Google Scholar 

  79. Boparai KS et al. Increased colorectal cancer risk during follow-up in patients with hyperplastic polyposis syndrome: a multicentre cohort study. Gut. 2010;59(8):1094–100.

    Article  PubMed  Google Scholar 

  80. Kalady MF et al. Defining phenotypes and cancer risk in hyperplastic polyposis syndrome. Dis Colon Rectum. 2011;54(2):164–70.

    Article  PubMed  Google Scholar 

  81. Hyman NH, Anderson P, Blasyk H. Hyperplastic polyposis and the risk of colorectal cancer. Dis Colon Rectum. 2004;47(12):2101–4.

    Article  PubMed  Google Scholar 

  82. Boparai KS et al. Increased colorectal cancer risk in first-degree relatives of patients with hyperplastic polyposis syndrome. Gut. 2010;59(9):1222–5.

    Article  CAS  PubMed  Google Scholar 

Download references

Compliance with Ethics Guidelines

Conflict of Interest

Joshua C. Obuch and Courtney M. Pigott declare that they have no conflict of interest.

Dennis J. Ahnen has received board membership payments and paid travel accommodations from EXACT Sciences, Inc., and board membership payments from Cancer Prevention Pharmaceuticals.

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.

Author information

Authors and Affiliations

  1. Department of Medicine, Division of Gastroenterology, University of Colorado School of Medicine, Denver, CO, USA

    Joshua C. Obuch MD, Courtney M. Pigott MD & Dennis J. Ahnen MD

  2. Gastroenterology of the Rockies, Denver, CO, USA

    Dennis J. Ahnen MD

Authors
  1. Joshua C. Obuch MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Courtney M. Pigott MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Dennis J. Ahnen MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Dennis J. Ahnen MD.

Additional information

This article is part of the Topical Collection on Colon

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Obuch, J.C., Pigott, C.M. & Ahnen, D.J. Sessile Serrated Polyps: Detection, Eradication, and Prevention of the Evil Twin. Curr Treat Options Gastro 13, 156–170 (2015). https://doi.org/10.1007/s11938-015-0046-y

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11938-015-0046-y

Keywords

Search

Navigation