Endoscopic and pathological features of neoplastic transformation of gastric hyperplastic polyps:Retrospective study of 4010 cases

BACKGROUND Hyperplastic polyps,which represent 30%-93%of all gastric epithelial polyps,are the second most common type of gastric polyps after fundic gland polyps.They were previously considered to have no risk of neoplastic transformation.Recently,an increasing number of cases of gastric hyperplastic polyps(GHPs)combined with neoplastic changes have been reported;however,the specific mechanism underlying their transformation has not been thoroughly explored.AIM To investigate the clinical,endoscopic,and pathological characteristics of the neoplastic transformation of GHPs and explore the risk factors.METHODS A retrospective analysis was performed on 4010 cases of GHPs diagnosed by gastroscopy and pathological examination at the hospital from 2005 to 2021.In total,3874,119,and 17 cases were in the group without intraepithelial neoplasia(IN),with low-grade IN,and with high-grade IN,respectively.The data analysis examined the association of endoscopic and pathological features with risk factors for neoplastic transformation.Factors with significant differences were entered into univariate logistic regression,followed by multivariate logistic regression analysis.RESULTS Univariate analysis revealed diameter,multiple polyp presence,redness,rough surface,lobulation,erosion,Yamada classification,location,and gastric mucosa were risk factors for neoplastic transformation.Multivariate analysis showed that age>65 years[odds ratio(OR)=1.789;95%confidence interval(CI):1.227-2.609;P=0.003],male sex(OR=1.680;95%CI:1.158-2.438;P=0.006),multiple polyps(OR=1.851;95%CI:1.230-2.784;P=0.003),pedunculated or semi-pedunculated shape(OR=2.722;95%CI:1.689-4.388;P<0.001),and polyp diameter were significantly associated with GHPs that demonstrated neoplastic transformation.Compared with chronic superficial gastritis,autoimmune gastritis,atrophic gastritis,and gastritis with IN were independent risk factors for neoplastic transformation[(OR=2.672;95%CI:1.559-4.579;P<0.001),(OR=1.876;95%CI:1.134-3.103;P=0.014),and(OR=5.299;95%CI:3.173–8.849;P<0.001),respectively].CONCLUSION Male sex,age>65 years,multiple polyps,pedunculated or semi-pedunculated shape,polyp size>1 cm,and specific background gastric mucosa are key indicators for predicting neoplastic transformation of GHPs.

Hyperplastic polyposis associated with two asynchronous colon cancers

We report a patient with hyperplastic polyposis who had two asynchronous colon cancers, a combined adenoma-hyperplastic polyp, a serrated adenoma, and tubular adenomas. Hyperplastic polyposis is thought to be a precancerous lesion; and adenocarcinoma arises from hyperplastic polyposis through the hyperplastic polyp-adenoma-carcinoma sequence. Most polyps in patients with hyperplastic polyposis present as bland- looking hyperplastic polyps, which are regarded as non- neoplastic lesions; however, the risk of malignancy should not be underestimated. In patients with multiple hyperplastic polyps, hyperplastic polyposis should be identified and followed up carefully in order to detect malignant transformation in the early stage.

Pathophysiological and clinical aspects of gastric hyperplastic polyps

Gastric polyps become a major clinical problem because of high prevalence and tendency to malignant transformation of some of them. The development of gastric hyperplastic polyps results from excessive proliferation of foveolar cells accompanied by their increased exfoliation, and they are macroscopically indistinguishable from other polyps with lower or higher malignant potential. Panendoscopy allows detection and differentiation of gastric polyps, usually after obtaining histopathological biopsy specimens. Unremoved gastric hyperplastic polyps may enlarge and sometimes spontaneously undergo a sequential progression to cancer. For this reason, gastric hyperplastic polyps larger than 5 mm in size should be removed in one piece. After excision of polyps with atypical focal lesion, endoscopic surveillance is suggested depending on histopathological diagnosis and possibility of confirming the completeness of endoscopic resection. Because of the risk of cancer development also in gastric mucosa outside the polyp, neighboring fragments of gastric mucosa should undergo microscopic investigations. This procedure allows for identification of patients who can benefit most from oncological endoscopic surveillance. If Helicobacter pylori(H. pylori) infection of the gastric mucosa is confirmed, treatment strategies should include eradication of bacteria, which may prevent progression of intestinal metaplasia. The efficacy of H. pylori eradication should be checked 3-6 mo later.

Sex-influenced association of non-alcoholic fatty liver disease with colorectal adenomatous and hyperplastic polyps

AIM To investigate the relationship between non-alcoholic fatty liver disease(NAFLD) and colorectal adenomatous and hyperplastic polyps.METHODS A retrospective cross-sectional study was conducted on 3686 individuals undergoing health checkups(2430 males and 1256 females). All subjects underwent laboratory testing,abdominal ultrasonography,colonoscopy,and an interview to ascertain the baseline characteristics and general state of health. Multinomial logistic regression analysis was performed to examine the association between NAFLD and the prevalence of colorectal adenomatous and hyperplastic polyps.Furthermore,the relationship was analyzed in different sex groups. Subgroup analysis was performed based on number,size,and location of colorectal polyps.RESULTS The prevalence of colorectal polyps was 38.8% in males(16.2% for adenomatous polyps and 9.8% for hyperplastic polyps) and 19.3% in females(8.4% for adenomatous polyps and 3.9% for hyperplastic polyps). When adjusting for confounding variables,NAFLD was significantly associated with the prevalence of adenomatous polyps(OR = 1.28,95%CI: 1.05-1.51,P < 0.05) and hyperplastic polyps(OR = 1.35,95%CI: 1.01-1.82,P < 0.05). However,upon analyzing adenomatous and hyperplastic polyps in different sex groups,the significant association remained in males(OR = 1.53,95%CI: 1.18-2.00,P < 0.05; OR = 1.42,95%CI: 1.04-1.95,P < 0.05) but not in females(OR = 0.44,95%CI: 0.18-1.04,P > 0.05; OR = 1.18,95%CI: 0.50-2.78,P > 0.05). CONCLUSION NAFLD is specifically associated with an increased risk of colorectal adenomatous and hyperplastic polyps in men. However,NAFLD may not be a significant factor in the prevalence of colorectal polyps in women.

Endoscopic mucosal resection of large hyperplastic polyps in 3 patients with Barrett’s esophagus

AIM： To report the endoscopic treatment of large hyperplastic polyps of the esophagus and esophagogastric junction （EGJ） associated with Barrett＇s esophagus （BE） with low-grade dysplasia （LGD）, by endoscopic rnucosal resection （EMR）. METHODS： Cap fitted EMR （EMR-C） was performed in 3 patients with hyperplastic-inflammatory polyps （HIPs） and BE. RESULTS： The polyps were successfully removed in the 3 patients. In two patients, with short segment BE （SSBE） （≤ 3 cm）, the metaplastic tissue was completely excised. A 2 cm circumferential EMR was performed in one patient with a polyp involving the whole EGJ. A simultaneous EMR-C of a BE-associated polypoid dysplastic lesion measuring 1 cm × 10 cm, was also carried out. In the two patients, histologic assessment detected LGD in BE. No complications occurred. Complete neosquamous reepithelialization occurred in the two patients with SSBE. An esophageal recurrence occurred in the remaining one and was successfully retreated by EMR. CONCLUSION： EMR-C appears to be a safe and effective method for treating benign esophageal mucosal lesions, allowing also the complete removal of SSBE.

Novel classification of gastric polyps:The good,the bad and the ugly

Gastric polyps(GPs)are increasingly common.On upper endoscopy,they should be examined with white light and occasionally chromoendoscopy,and their morphology classified according to the Paris classification.Most GPs have a typical endoscopic appearance and can be associated with diseases like Helicobacter pylori infection.Histological examination is necessary for an accurate diagnosis.While most polyps are non-neoplastic and do not require treatment,some carry a risk of malignancy or are already malignant.Therefore,understanding the diagnosis,classification,and management of GPs is crucial for patient prognostication.Our new classification categorizes GPs into"good","bad",and"ugly"based on their likelihood of becoming malignant.We aim to provide descriptions of the endoscopic appearance,pathology,treatment,and follow-up for different GPs,as well as clinical management flowcharts.

Distinct gut microbiomes in Thai patients with colorectal polyps

BACKGROUND Colorectal polyps that develop via the conventional adenoma-carcinoma sequence[e.g.,tubular adenoma(TA)]often progress to malignancy and are closely associated with changes in the composition of the gut microbiome.There is limited research concerning the microbial functions and gut microbiomes associated with colorectal polyps that arise through the serrated polyp pathway,such as hyperplastic polyps(HP).Exploration of microbiome alterations asso-ciated with HP and TA would improve the understanding of mechanisms by which specific microbes and their metabolic pathways contribute to colorectal carcinogenesis.AIM To investigate gut microbiome signatures,microbial associations,and microbial functions in HP and TA patients.METHODS Full-length 16S rRNA sequencing was used to characterize the gut microbiome in stool samples from control participants without polyps[control group(CT),n=40],patients with HP(n=52),and patients with TA(n=60).Significant differences in gut microbiome composition and functional mechanisms were identified between the CT group and patients with HP or TA.Analytical techniques in this study included differential abundance analysis,co-occurrence network analysis,and differential pathway analysis.RESULTS Colorectal cancer(CRC)-associated bacteria,including Streptococcus gallolyticus(S.gallolyticus),Bacteroides fragilis,and Clostridium symbiosum,were identified as characteristic microbial species in TA patients.Mediterraneibacter gnavus,associated with dysbiosis and gastrointestinal diseases,was significantly differentially abundant in the HP and TA groups.Functional pathway analysis revealed that HP patients exhibited enrichment in the sulfur oxidation pathway exclusively,whereas TA patients showed dominance in pathways related to secondary metabolite biosynthesis(e.g.,mevalonate);S.gallolyticus was a major contributor.Co-occurrence network and dynamic network analyses revealed co-occurrence of dysbiosis-associated bacteria in HP patients,whereas TA patients exhibited co-occurrence of CRC-associated bacteria.Furthermore,the co-occurrence of SCFA-producing bacteria was lower in TA patients than HP patients.CONCLUSION This study revealed distinct gut microbiome signatures associated with pathways of colorectal polyp development,providing insights concerning the roles of microbial species,functional pathways,and microbial interactions in colorectal carcinogenesis.

How to"pick up"colorectal serrated lesions and polyps in daily histopathology practice:From terminologies to diagnostic pitfalls

Over the last decade,our knowledge of colorectal serrated polyps and lesions has significantly improved due to numerous studies on this group of precursor lesions.Serrated lesions were misleading as benign before 2010,but they are currently reclassified as precancerous lesions that contribute to 30%of colorectal cancer through the serrated neoplasia pathway.The World Health Organization updated the classification for serrated lesions and polyps of the colon and rectum in 2019,which is more concise and applicable in daily practice.The responsible authors prescribe that“colorectal serrated lesions and polyps are characterized by a serrated(sawtooth or stellate)architecture of the epithelium.”From a clinical standpoint,sessile serrated lesion(SSL)and SSL with dysplasia(SSLD)are the two most significant entities.Despite these advancements,the precise diagnosis of SSL and SSLD based mainly on histopathology remains challenging due to various difficulties.This review describes the nomenclature and the terminology of colorectal serrated polyps and lesions and highlights the diagnostic criteria and obstacles encountered in the histopathological diagnosis of SSL and SSLD.

Gastric hyperplastic polyp with focal cancer

This paper reports a rare case of early adenocarcinoma within the gastric hyperplastic polyp,that was completely resected during an endoscopic procedure,and discusses current recommendations in such cases.Endoscopic resection of polyps with focal dysplasia or cancer is commonly indicated,as long as the procedure can be performed safely.After complete excision of a polyp with atypical focal lesion,endoscopic surveillance is suggested.The frequency of surveillance endoscopy should depend on the precise histopathological diagnosis and possibility of confirming the completeness of the endoscopic resection.If the completeness of the procedure is confirmed both macro-and microscopically,gastric resection does not have to be performed.A follow-up esophago-gastroduodenoscopy should be performed at 1 year and then at 3 years.

DISTINGUISHING BETWEEN HYPERPLASTIC AND ADENOMATOUS POLYPS AND NORMAL COLONIC MUCOSA BY USING MULTIPHOTON LASER SCANNING MICROSCOPY

Precisely distinguishing between hyperplastic and adenomatous polyps and normal human colonic mucosa at the cellular level is of great medical significance.In this work,multiphoton laserscarming microscopy(MPLSM)was used to obtain the high.-contrast images and the morpho-logical characteristics from normal colonic mucosa,hyperplastic polyps and tubular adenoma.Byintegrating the length and area measurement tools and computing tool,we quantified thedifference of crypt morphology and the alteration of nuclei in normal and diseased human colonicmucosa.Our results demonstrated that the morphology of crypts had an obvious tendency tocystic dilatation or elongated in hyperplastic polyps and tubular adenoma.The cont ent andnumber of mucin droplets of the scattered goblet cells had a piecemeal reduction in hyperplastic polyps and a large decrease in tubular adenoma The nuclei of epithelial cells might be elongated and pseudostratified,but overt dysplasia was absent in hyperplastic polyps.Nevertheless,thenuclei showed enlarged,crowded,stratified and a rod-like structure,with loss of polarity intubular adenoma.These results suggest that MPLSM has the capacity to distinguish betweenhyperplastic and adenomat ous polyps and normal human colonic mucosa at the celular level.

Effect of drug treatment on hyperplastic gastric polyps infected with Helicobacter pylorh A randomized, controlled trial

AIM： To study the effects of drug treatment on hyperplastic gastric polyps infected with Helicobacter pylori （H pylori. METHODS： Forty-eight patients with hyperplasticgastric polyps （3-10 mm in diameter） infected with Hpylori were randomly assigned to a treatment group （n = 24） which received proton-pump inhibitor （omeprazole or lansoprazole）, clarithromycin, bismuth citrate and tinidazole, and a control group （n = 24） which received protective agent of gastric mucosa （tepretone） . Patients underwent endoscopy and H pylori examination regularly before enrollmentand 1-12 mo after treatment. RESULTS： Twenty-two patients in the treatment group and 21 in the control group completed the entire test protocol. In the treatment group, polyps disappeared 1-12 mo （average, 6.5 ± 1.1 too） after the treatment in 15 of 22 patients （68.2%） and H pylori infection was eradicated in 19 of the 22 patients （86.4%）. However, 12 months after the study, no change in polyps or H pylori status was seen in any controls （^bp 〈 0.01）. CONCLUSION： Most hyperplastic gastric polyps disappear after eradication of H pylori.

Serrated polyps of the colon and rectum:Remove or not?

In recent years,the serrated neoplasia pathway where serrated polyps arise as a colorectal cancer has gained considerable attention as a new carcinogenic pathway.Colorectal serrated polyps are histopathologically classified into hyperplastic polyps(HPs),sessile serrated lesions,and traditional serrated adenomas;in the serrated neoplasia pathway,the latter two are considered to be premalignant.In western countries,all colorectal polyps,including serrated polyps,apart from diminutive rectosigmoid HPs are removed.However,in Asian countries,the treatment strategy for colorectal serrated polyps has remained unestablished.Therefore,in this review,we described the clinicopathological features of colorectal serrated polyps and proposed to remove HPs and sessile serrated lesions≥6 mm in size,and traditional serrated adenomas of any size.

Serrated polyposis syndrome:Molecular,pathological and clinical aspects

Hyperplastic polyps have traditionally been considered not to have malignant potential.New pathological classification of serrated polyps and recent discoveries about the serrated pathway of carcinogenesis have revolutionized the concepts and revitalized the research in this area.Until recently,it has been thought that most colorectal cancers arise from conventional adenomas via the traditional tumor suppressor pathway initiated by a mutation of the APC gene,but it has been found thatthis pathway accounts for only approximately 70%-80% of colorectal cancer(CRC)cases.The majority of the remaining colorectal cancer cases follow an alternative pathway leading to CpG island methylator phenotype carcinoma with BRAF mutation and with or without microsatellite instability.The mechanism of carcinomas arising from this alternative pathway seems to begin with an activating mutation of the BRAF oncogene.Serrated polyposis syndrome is a relatively rare condition characterized by multiple and/or large serrated polyps of the colon.Clinical characteristics,etiology and relationship of serrated polyposis syndrome to CRC have not been clarified yet.Patients with this syndrome show a high risk of CRC and both sporadic and hereditary cases have been described.Clinical criteria have been used for diagnosis and frequent colonoscopy surveillance should be performed in order to prevent colorectal cancer.In this review,we try to gather new insights into the molecular pathogenesis of serrated polyps in order to understand their possible clinical implications and to make an approach to the management of this syndrome.

Successful endoscopic submucosal dissection of a giant polyp in a 21-month-old female

Endoscopic submucosal dissection(ESD)is now recognized as the preferred treatment modality for gastrointestinal epithelial lesions.A 21-month-old female was admitted with a giant hyperplastic polyp causing a gastric outlet obstruction.Successful ESD was performed with caution.The post-procedural course was uneventful without a bleeding episode.Although further study of the feasibility of ESD in early children is necessary,ESD could be applied to avoid laparotomy even in young children.

Evaluation of magnifying colonoscopy in the diagnosis of serrated polyps

AIM:To elucidate the colonoscopic features of serrated lesions of the colorectum using magnifying colonoscopy.METHODS:Broad division of serrated lesions of the colorectum into hyperplastic polyps(HPs),traditional serrated adenomas(TSAs),and sessile serrated adenomas/polyps(SSA/Ps) has been proposed on the basis of recent molecular biological studies.However,few reports have examined the colonoscopic features of these divisions,including magnified colonoscopic findings.This study examined 118 lesions excised in our hospital as suspected serrated lesions after magnified observation between January 2008 and September 2011.Patient characteristics(sex,age),conventional colonoscopic findings(location,size,morphology,color,mucin) and magnified colonoscopic findings(pit pattern diagnosis) were interpreted by five colonoscopists with experience in over 1000 colonoscopies,and were compared with histopathological diagnoses.The pit patterns were categorized according to Kudo's classification,but a more detailed investigation was also performed using the subclassification [type Ⅱ-Open(type Ⅱ-O),type Ⅱ-Long(type Ⅱ-L),or type Ⅳ-Serrated(type Ⅳ-S)] proposed by Kimura T and Yamano H.RESULTS:Lesions comprised 23 HPs(23/118:19.5%),39 TSAs(39/118:33.1%:with cancer in one case),50 SSA/Ps(50/118:42.4%:complicated with cancer in three cases),and six others(6/118:5.1%).We excluded six others,including three regular adenomas,one hamartoma,one inflammatory polyp,and one juvenile polyp for further analysis.Conventional colonoscopy showed that SSA/Ps were characterized as larger in diameter than TSAs and HPs(SSA/P vs HP,13.62 ± 8.62 mm vs 7.74 ± 3.24 mm,P < 0.001;SSA/Ps vs TSA,13.62 ± 8.62 mm vs 9.89 ± 5.73 mm,P < 0.01);common in the right side of the colon [HPs,30.4%(7/23):TSAs,20.5%(8/39):SSA/P,84.0%(42/50),P < 0.001];flat-elevated lesion [HPs,30.4%(7/23):TSAs,5.1%(2/39):SSA/Ps,90.0%(45/50),P < 0.001];normal-colored or pale imucosa [HPs,34.8%(8/23):TSAs,10.3%(4/39):SSA/Ps,80%(40/50),P < 0.001];and with large amounts of mucin [HPs,21.7%(5/23):TSAs,17.9%(7/39):SSA/Ps,72.0%(36/50),P < 0.001].In magnified colonoscopic findings,17 lesions showed either type Ⅱ pit pattern alone or partial type Ⅱ pit pattern as the basic architecture,with 14 HPs(14/17,70.0%) and 3 SSA/Ps.Magnified colonoscopy showed the type Ⅱ-O pit pattern as characteristic of SSA/Ps [sensitivity 83.7%(41/49),specificity 85.7%(54/63)].Cancer was also present in three lesions,in all of which a type Ⅵ pit pattern was also present within the same lesion.There were four HPs and four TSAs each.The type Ⅳ-S pit pattern was characteristic of TSAs [sensitivity 96.7%(30/31),specificity 89.9%(72/81)].Cancer was present in one lesion,in which a type Ⅵ pit pattern was also present within the same lesion.In our study,serrated lesions of the colorectum also possessed the features described in previous reports of conventional colonoscopic findings.The pit pattern diagnosis using magnifying colonoscopy,particularly magnified colonoscopic findings using subclassifications of surface architecture,reflected the pathological characteristics of SSA/Ps and TSAs,and will be useful for colonoscopic diagnosis.CONCLUSION:We suggest that this system could be a good diagnostic tool for SSA/Ps using magnifying colonoscopy.

BRAF, K-ras and BAT26 mutations in colorectal polyps and stool

AIM： To assess the feasibility of using BRAF, K-ras and BAT26 genes as stool-based molecular markers for detection of colorectal adenomas and hyperplastic polyps （HPs）. METHODS： We applied PCR-SSCP and direct sequencing to detect BRAF mutations of polyps and paired stool samples. Primer-mediated restriction fragment length polymorphism （RFLP） analysis and mutant-enriched PCR were used in detection of K-ras mutations of polyp tissues and paired stool samples respectively. BAT26, a microsatellite instability marker was examined by detection of small unstable alleles in a poly （A） repeat. RESULTS： No genetic alterations were detected in the 36 colonoscopically normal patients in either tissues or stools. BRAF, K-ras and BAT26 mutations were found in 4 （16%）, 10 （40%） and 3 （12%） of 25 adenoma tissues and among them, 75%, 80% and 100% of patients were observed to contain the same mutations in their corresponding stool samples. In HPs, mutations of BRAF and K-ras were detected in the tumor DNA of 2 （11.1%） and 8 （33.3%） of 18 patients respectively, all of whom had identical alterations in their stools. Taken together, the three genetic markers detected 15 （60%） of 25 adenomas and 8 （44.4%） of 18 HPs. The sensitivity of stool detection was 80% for adenomas and 100% for HPs with an overall specificity of 92% for adenomas and 100% for HPs. CONCLUSION： BRAF, K-ras and BAT26 genes have the potential to be molecular markers for colorectal adenomas and HPs, and can be used as non-invasive screening markers for colorectal polyps.

Gastric Polyps in a Digestive Endoscopy Center in Dakar

Introduction: The gastric polyp is a tumor protruding into the gastric lumen. It is asymptomatic most often with a risk of malignant degeneration closely related to its histological nature. These data are very rare in Africa. Objectives: Reporting the frequency and endoscopic and histological characteristics of gastric polyps in the digestive endoscopy center of Aristide Le Dantec hospital in Dakar. Patients and methods: This was a retrospective study carried out in the digestive endoscopy center of Aristide Le Dantec Hospital in Dakar from January 2012 to December 2016. We have included all patients with one or more gastric polyps coupled with histological findings available. Results: There were 60 patients with gastric polyps, hence a prevalence of 0.8%. We included 37 patients. Their mean age was 46 years [21 years - 75 years]. The sex-ratio was 0.48. Epigastralgia was the most frequent endoscopic indication (51.3%). The polyp was unique in 26 patients (70.3%) with an average size of 6.87 mm [2 - 15 mm]. Polyps were sessile in 31 cases (83.8%) and pediculate in 6 cases (16.2%). They were most often in the antrum (51.4%). Antral erosions (13.5%) and fundic atrophy (13.5%) were the main associated endoscopic lesions. These were hyperplastic polyps in 27% of cases and adenoma in 16.2% of cases. Chronic atrophic gastritis (10.8%) and intestinal metaplasia (10.8%) were the main histological lesions associated with polyps. Helicobacter pylori (Hp) were present in 17 patients (45.9%). Conclusion: The prevalence of gastric polyps is 0.8% in the endoscopy center of Aristide Le Dantec hospital. They are usually hyperplastic or adenomatous.

Endoscopic diagnosis for colorectal sessile serrated lesions

BACKGROUND Hyperplastic polyps are considered non-neoplastic, whereas sessile serrated lesions(SSLs) are precursors of cancer via the ‘‘serrated neoplastic pathway’’. The clinical features of SSLs are tumor size(> 5 mm), location in the proximal colon, coverage with abundant mucus called the ‘‘mucus cap’’, indistinct borders, and a cloud-like surface. The features in magnifying narrow-band imaging are varicose microvascular vessels and expanded crypt openings. However, accurate diagnosis is often difficult.AIM To develop a diagnostic score system for SSLs.METHODS We retrospectively reviewed consecutive patients who underwent endoscopic resection during colonoscopy at the Toyoshima endoscopy clinic. We collected data on serrated polyps diagnosed by endoscopic or pathological examination. The significant factors for the diagnosis of SSLs were assessed using logistic regression analysis. Each item that was significant in multivariate analysis was assigned 1 point, with the sum of these points defined as the endoscopic SSL diagnosis score. The optimal cut-off value of the endoscopic SSL diagnosis score was determined by receiver-operating characteristic curve analysis.RESULTS Among 1288 polyps that were endoscopically removed, we analyzed 232 diagnosed as serrated polyps by endoscopic or pathological examination. In the univariate analysis, the location(proximal colon), size(> 5 mm), mucus cap, indistinct borders, cloud-like surface, and varicose microvascular vessels were significantly associated with the diagnosis of SSLs. In the multivariate analysis, size(> 5 mm;P = 0.033), mucus cap(P = 0.005), and indistinct borders(P = 0.033) were independently associated with the diagnosis of SSLs. Size > 5 mm, mucus cap, and indistinct borders were assigned 1 point each and the sum of these points was defined as the endoscopic SSL diagnosis score. The receiver-operating characteristic curve analysis showed an optimal cut-off score of 3, which predicted pathological SSLs with 75% sensitivity, 80% specificity, and 78.4% accuracy. The pathological SSL rate for an endoscopic SSL diagnosis score of 3 was significantly higher than that for an endoscopic SSL diagnosis score of 0, 1, or 2(P < 0.001).CONCLUSION Size > 5 mm, mucus cap, and indistinct borders were significant endoscopic features for the diagnosis of SSLs. Serrated polyps with these three features should be removed during colonoscopy.

Serrated neoplasia of the colorectum

Serrated polyps of the colorectum form a group of related lesions which include aberrant crypt foci (ACF), conventional hyperplastic polyps, mixed (admixed) polyps, serrated adenomas and sessile serrated adenomas. In recent years the molecular differences between these morphologically similar lesions have been highlighted, and their differing biological potential has been realised. In particular, the sessile serrated adenoma has become recognised as the precursor lesion to a group of sporadic colorectal carcinomas characterised by morphological and molecular features distinct from conventional adenomas. These recent findings have challenged the long held paradigm that all colorectal carcinomas arise via the traditional adenoma-carcinoma sequence. In addition, they present a major challenge for the early detection and management of colorectal cancer, which is no longer regarded as a homogeneous entity.

Serrated lesions:A challenging enemy

The serrated pathway accounts for 30%-35%of colorectal cancer(CRC).Unlike hyperplastic polyps,both sessile serrated lesions(SSLs)and traditional serrated adenomas are premalignant lesions,yet SSLs are considered to be the principal serrated precursor of CRCs.Serrated lesions represent a challenge in detection,classification,and removal–contributing to post-colonoscopy cancer.Therefore,it is of the utmost importance to characterize these lesions properly to ensure complete removal.A retrospective cohort study developed a diagnostic scoring system for SSLs to facilitate their detection endoscopically and subsequent removal.From the study,it can be ascertained that both indistinct border and mucus cap are essential in both recognizing and diagnosing serrated lesions.The proximal colon poses technical challenges for some endoscopists,which is why high-quality colonoscopy plays such an important role.The indistinct border of some SSLs poses another challenge due to difficult complete resection.Overall,it is imperative that gastroenterologists use the key features of mucus cap,indistinct borders,and size of at least five millimeters along with a high-quality colonoscopy and a good bowel preparation to improve the SSL detection rate.