The clinical impact of serrated colorectal polyps

Figures & data

Figure 1 Serrated polyps of the colorectum.

Abbreviations: GCHP, goblet cell hyperplastic polyp; HP, hyperplastic polyp; MPHP, mucin-poor hyperplastic polyp; MVHP, microvesicular hyperplastic polyp; SSP, sessile serrated polyp; TSA, traditional serrated adenoma.

Figure 2 Endoscopic and histologic appearance of serrated polyps including (A, B) a microvesicular hyperplastic polyp, (C, D) sessile serrated polyp, and (E, F) traditional serrated adenoma.

Figure 3 Serrated carcinogenesis.

Notes: *While GCHPs are theorized to be the precursor of TSAs, this link has not been definitively proven. Dashed arrows represent possible, but unproven steps.
Abbreviations: CIMP, CpG island methylation phenotype; GCHP, goblet cell hyperplastic polyp; MSI, microsatellite instable; MSS, microsatellite stable; MVHP, microvesicular hyperplastic polyp; SSP, sessile serrated polyp; TSA, traditional serrated adenoma.

Table 1 Summary of literature on the risk factors for SSPs, including data from individual studies and meta-analysis where available

Risk factors	Studies, (n SSPs)	Results (OR/RR/IDRa [95% CI])
Age	Anderson et al,^Citation63 (n=90)	Per year increase: 1.05 (1.02–1.08)
	Buda et al,^Citation52 (n=23)	<50 years: 1.00 (ref)
		50–69 years: 5.8 (1.3–26.8)
		≥70 years: 9.3 (1.9–45.4)
	Burnett-Hartman et al,^Citation59 (n=149)	<50 years: 1.00 (ref)
		50–59 years: 1.63 (0.72–3.67)
		60–69 years: 2.09 (0.87–5.00)
		≥70 years: 2.19 (0.83–5.76)
	Hetzel et al,^Citation17 (n=46)	Per year increase: 1.00 (0.96–1.03)
Sex	Burnett-Hartman et al,^Citation59 (n=149)	Male: 1.00 (ref)
		Female: 1.37 (0.82–2.28)
	Hetzel et al,^Citation17 (n=46)	Female: 1.00 (ref)
		Male: 1.55 (0.93–2.61)
	Lash et al,^Citation15 (n=2416)	Male: 1.00 (ref)
		Female: 1.21 (1.11–1.32)
Race	Burnett-Hartman et al,^Citation59 (n=149)	White: 1.00 (ref)
		African-American: 0.21 (0.02–2.14)
		Asian/Pacific Islander: 1.33 (0.54–2.44)
Socioeconomic status	Burnett-Hartman et al,^Citation59 (n=149)	High school or less: 1.0 (ref)
		Some college: 2.60 (1.08–6.24)
		College graduate: 3.35 (1.41–7.99)
		Graduate degree: 3.63 (1.55–8.54)
FH of CRC	Burnett-Hartman et al,^Citation59 (n=149)	No FH: 1.00 (ref)
		FH: 1.54 (0.97–2.43)
Smoking	Bailie et al,^Citation61 meta-analysis	Never smoker: 1.00 (ref)
		Current/ever smoker: 3.40 (1.90–6.07)
Alcohol	Bailie et al,^Citation61 meta-analysis	Low alcohol intake: 1.00 (ref)
		Higher/highest alcohol intake: 1.85 (1.03–3.32)
Obesity	Bailie et al,^Citation61 meta-analysis	Low BMI: 1.00 (ref)
		BMI ≥ 30: 1.31 (0.89–1.92)
Physical activity	Bailie et al,^Citation61 meta-analysis	Low physical activity: 1.00 (ref)
		High physical activity: 0.80 (0.43–1.48)
Diabetes	Anderson et al,^Citation63 (n=90)	Nondiabetic: 1.00 (ref)
		Diabetic: 4.57 (2.36–8.82)
Fiber intake	Davenport et al,^Citation64 (n=214)	Low fiber (<13 g/day): 1.00 (ref)
		High fiber (>25 g/day): 0.46 (0.19–0.68)
Dietary folate	Davenport et al,^Citation64 (n=214)	Low folate (<395 mg/day): 1.00 (ref)
		High folate (>812 mg/day): 0.51 (0.26–0.98)
Calcium intake	Davenport et al,^Citation64 (n=214)	Low calcium (<596 mg/day): 1.00 (ref)
		High calcium (>1217 mg/day): 0.54 (0.28–1.06)
Fat intake	Davenport et al,^Citation64 (n=214)	Low fat (<48 g/day): 1.00 (ref)
		High fat (>98 g/day): 3.09 (1.24–7.72)
Red meat intake	Davenport et al,^Citation64 (n=214)	Low red meat (<16 g/day): 1.00 (ref)
		High red meat (>73 g/day): 3.38 (1.90–6.00)
NSAIDs	Bailie et al,^Citation61 meta-analysis	Low/no use: 1.00 (ref)
		Regular/current use: 0.62 (0.42–0.92)
HRT	Bailie et al,^Citation61 meta-analysis	Nonuser: 1.00 (ref)
		User: 1.41 (0.82–2.41)

Notes: Bolded results indicate statistical significance,

a multivariate OR reported when provided.

Abbreviations: BMI, body mass index; CI, confidence interval; Ref, reference; CRC, colorectal cancer; FH, family history; IDR, incidence density ratio; OR, odds ratio; RR, relative risk; SSPs, sessile serrated polyps; NSAIDs, nonsteroidal anti-inflammatory drugs; HRT, hormone replacement therapy.

Figure 4 Novel colonoscopic technologies.

Notes: (A) Cap-assisted colonoscopy, (B) panoramic colonoscopy being attached to standard colonoscope and demonstrating added visual fields, (C) wide-angled colonoscopy demonstrating improved visual field with added lenses, (D) retroscope colonoscopy through port of standard colonoscope, (E) endocuff colonoscopy.

Table 2 Current recommendations for surveillance intervals after colonoscopy with serrated polyps

Histology	Size	Number	Location	Guideline-recommended surveillance interval (years)
				Consensus^Citation20	US MSTF^Citation127	European^Citation128
HP	<10 mm	Any	Recto sigmoid	10	10	10
HP	≤5 mm	≤3	Proximal to sigmoid	10	No rec	No rec
HP	Any	≥4	Proximal to sigmoid	5	No rec	No rec
HP	>5 mm	≥1	Proximal to sigmoid	5	No rec	No rec
SSP	<10 mm	<3	Any	5	5	No rec
SSP	<10 mm	≥3	Any	3	5a	No rec
SSP	≥10 mm	1	Any	3	3	No rec
SSP	≥10 mm	≥2	Any	1–3	3	No rec
SSPD	Any	Any	Any	1–3	3	No recb
TSA	<10 mm	<3	Any	5	3	10
TSA	≥10 mm	1	Any	3	3	3
TSA	<10 mm	≥3	Any	3	3	1–3
Combined conventional and serrated polyps	Any	Any	Any	No rec	No rec	No rec
Serrated polyposis syndrome	See text	See text	See text	1	1	No rec

Notes:

a No specific recommendation regarding shortened interval for ≥3 SSPs.

b European guidelines recommend that “mixed polyps” be managed like conventional adenomas, which could include surveillance from 1 to 10 years based on the number and size of SSPDs.

Abbreviations: HP, hyperplastic polyp; US MSTF, US Multisociety Task Force; rec, recommendation; SSP, sessile serrated polyp; SSPD, sessile serrated polyp with dysplasia; TSA, traditional serrated adenoma.

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