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World J Gastroenterol. Aug 7, 2018; 24(29): 3250-3259
Published online Aug 7, 2018. doi: 10.3748/wjg.v24.i29.3250
Endoscopic diagnosis of sessile serrated adenoma/polyp with and without dysplasia/carcinoma
Takashi Murakami, Naoto Sakamoto, Akihito Nagahara
Takashi Murakami, Naoto Sakamoto, Akihito Nagahara, Department of Gastroenterology, Juntendo University School of Medicine, Tokyo 113-8421, Japan
Author contributions: Murakami T mainly contributed to this work, generated the figures and wrote the manuscript; Sakamoto N and Nagahara A contributed equally to the writing of the manuscript.
Conflict-of-interest statement: The authors declare no conflicts of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Takashi Murakami, MD, PhD, Assistant Professor, Department of Gastroenterology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan. t-murakm@juntendo.ac.jp
Telephone: +81-3-38133111 Fax: +81-3-38138862
Received: April 2, 2018
Peer-review started: April 3, 2018
First decision: May 30, 2018
Revised: June 27, 2018
Accepted: June 28, 2018
Article in press: June 28, 2018
Published online: August 7, 2018
Processing time: 122 Days and 21.2 Hours
Abstract

Sessile serrated adenoma/polyps (SSA/Ps) are early precursor lesions in the serrated neoplasia pathway, which results in colorectal carcinomas with BRAF mutations, methylation for DNA repair genes, a CpG island methylator phenotype, and high levels of microsatellite instability. Some of these lesions can rapidly become dysplastic or invasive carcinomas that exhibit high lymphatic invasion and lymph node metastasis potentials. Detecting serrated lesions, including SSA/Ps with and without dysplasia/carcinoma, is critical, but SSA/Ps can be difficult to detect, are inconsistently identified by endoscopists and pathologists, and are often incompletely resected. Therefore, SSA/Ps are considered to be major contributors to “interval cancers”. If colonoscopists can identify the specific endoscopic characteristics of SSA/Ps, their detection and the effectiveness of colonoscopy may improve. Here, the endoscopic features of SSA/Ps with and without dysplasia/carcinoma, including the characteristics determined using magnifying endoscopy, are reviewed in the context of previous reports. Endoscopically, these subtle polyps are like hyperplastic polyps, because they are slightly elevated and pale. Unlike hyperplastic polyps, SSA/Ps are usually larger than 5 mm, frequently covered by a thin layer called the ‘‘mucus cap’’, and are more commonly located in the proximal colon. Magnifying narrow-band imaging findings, which include dark spots inside the crypts and varicose microvascular vessels, in addition to the type II-open pit patterns detected using magnifying chromoendoscopy, effectively differentiate SSA/Ps from hyperplastic polyps. The lesions’ endoscopic characteristics, which include their (semi)pedunculated morphologies, double elevations, central depressions, and reddishness, and the use of magnifying endoscopy, might help to detect dysplasia/carcinoma within SSA/Ps. Greater awareness may promote further research into improving the detection, identification, and complete resection rates of SSA/Ps with and without dysplasia/carcinoma and reduce the interval cancer rates.

Keywords: Sessile serrated adenoma/polyp; Invasive carcinoma arising from sessile serrated adenoma/polyp; Serrated neoplasia pathway; Endoscopic diagnosis; Sessile serrated adenoma/polyp with cytological dysplasia

Core tip: The endoscopic features of sessile serrated adenoma/polyps (SSA/Ps) with and without dysplasia/carcinoma are reviewed. Conventional endoscopic characteristics, including a proximal location, a slightly elevated morphology, a pale color, and a mucus cap, are useful for diagnosing SSA/Ps. Magnifying narrow-band imaging, which detects dark spots inside the crypts and varicose microvascular vessels, and magnifying chromoendoscopy, which identifies the type II-open pit pattern, are also effective for differentiating between SSA/Ps and hyperplastic polyps. Furthermore, the lesions’ endoscopic characteristics, which include their (semi)pedunculated morphologies, double elevations, central depressions, and reddishness, and the use of magnifying endoscopy, might help to detect dysplasia/carcinoma within SSA/Ps.