- 1 Definition
- 2 Background
- 3 Evidence
- 3.1 Systematic review evidence
- 3.1.1 Risk of metachronous colorectal cancer
- 3.1.2 Risk of metachronous advanced conventional adenoma
- 3.1.3 Risk of metachronous ‘advanced neoplasia’
- 3.1.4 Risk of metachronous serrated polyps
- 3.1.5 Risk of metachronous advanced serrated polyps
- 3.2 Overview of additional evidence (non-systematic literature review)
- 3.1 Systematic review evidence
- 4 Evidence summary and recommendations
- 4.1 Notes on recommendations
- 4.2 Health system implications
- 4.3 Summary of findings from studies reported in systematic review
- 4.4 International guidelines for surveillance after removal of serrated polyps at baseline colonoscopy
- 5 References
- 6 Appendices
Serrated polyps (SPs) include the premalignant lesions sessile serrated adenomas (SSAs) and traditional serrated adenomas (TSAs) and the usually benign hyperplastic polyps. SSAs, TSAs and large (≥10mm) hyperplastic polyps are clinically significant serrated polyps.
This section considers first surveillance intervals following removal of clinically significant SPs only and with synchronous conventional adenomas.
For surveillance intervals following removal of conventional adenomas only see First surveillance intervals following removal of low-risk conventional adenomas only (SAD1) and First surveillance intervals following removal of high-risk conventional adenomas only (SAD2).
For information and guidance on serrated polyposis syndrome, see Serrated polyposis syndrome.
At the time of the previous edition of these guidelines (Australian clinical practice guidelines for surveillance colonoscopy), there was insufficient evidence to differentiate follow-up protocols for SPs from those for standard adenoma follow-up. Since then, the 2010 World Health Organization classification has become well established, with reduced variability among histopathologists in applying these diagnostic criteria. In addition, there has been improved endoscopist recognition of proximal serrated polyps although there is still great variability. Although the evidence base remains limited, there is now sufficient information to allow specific recommendations.
Sessile serrated adenomas
Sessile serrated adenomas (SSAs) are expected to be diagnosed in over 5% of colonoscopies and undoubtedly have malignant potential.
Predominantly found in the proximal colon, SSAs are subtle, sessile lesions and this may make it difficult to define the edges of the lesion to ensure complete resection.The natural history of SSAs is still imperfectly understood but recent evidence suggests SSAs without dysplasia are indolent lesions with a mean dwell time of over 15 years. If cytological dysplasia does develop, the dwell time is thought to be short and carcinoma may develop in less than one year.
Traditional serrated adenomas
Traditional serrated adenomas (TSAs) are rare, accounting for only approximately 1% of all polyps. They are typically polypoid lesions in the distal colon and their molecular features suggest they should be treated like advanced conventional adenomas, with a significant risk of progression to malignancy if not resected.
Due to their rarity, there are no meaningful data regarding the risk of metachronous neoplasia (MN) after their removal and international guidelines are based solely on expert opinion.
Hyperplastic polyps (HP) are common. Small, distal HPs have no significant malignant potential.Proximal HPs are early stage lesions unlikely to progress unless they develop features of an SSA. However, a true proximal HP is unlikely to be over 1cm in size; such lesions should be reviewed by an expert histopathologist to confirm the histopathological diagnosis.
Advanced serrated polyps
Advanced serrated polyps (ASP) refer to a sessile serrated adenoma ≥10mm in size and/or with associated conventional dysplasia, or traditional serrated adenomas of any size.
Serrated polyposis syndrome
Serrated polyposis syndrome is described in detail in Clinical practice guidelines for the prevention, early detection and management of colorectal cancer (see Serrated polyposis syndrome). No genetic cause has been established and it is possible there is a continuum between patients with multiple sporadic SSAs and those meeting the definition of serrated polyposis. This is particularly the case for patients meeting the World Health Organization definition of at least 5 serrated polyps proximal to the sigmoid colon with ≥2 of these being >10mm and the count being cumulative.
When serrated polyposis syndrome is first diagnosed, several colonoscopies may be required within 1–2 years to clear the colon of significant polyps. If this can be achieved, there is expert consensus that the risk of cancer justifies ongoing surveillance colonoscopy every 1 to 3 years with the aim of removing all polyps ≥5mm and that, if this is impossible, colectomyThe surgical removal of all or part of the colon. and ileorectal anastomosis should be considered. This is supported by direct evidence.Back to top
What is the appropriate first surveillance interval following complete removal of serrated polyps? [SAD4]
Systematic review evidence
The systematic review identified one level II study from Argentina with a high risk of bias and two level III-2 studies from the USA with a low risk of bias. Overall, the evidence is not necessarily generalisable to the Australian healthcare environment, but can probably be sensibly applied. Importantly, the colonoscopies in these studies were performed between 2004 and 2011 and histopathology was meticulously assessed. Although colonoscopy quality parameters were included, the SSA detection rates were still lower than the 5% anticipated with high quality colonoscopy (suggesting a level of missed lesions). The outcomes assessed were various combinations of the incidence of metachronous colorectal cancer (CRC), advanced conventional adenomas, SSAs and ASPs.
The quality of the three studies was low. Limited power precluded definitive conclusions.
The systematic review findings are summarised in Table 10 below.
Risk of metachronous colorectal cancer
Three of four cohort studies reported no incidences of colorectal cancer within 3–5 years for those classified at index as having clinically significant serrated polyps, SSAs or serrated adenomas with or without non-advanced or advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia.. For those with SSAs coexisting with high risk adenoma at index, a 1.00% incidence of colorectal cancer (one case) at a mean and standard deviation of 3.54 (±1.43) years was reported.
Risk of metachronous advanced conventional adenoma
The US study by Macaron et al found that having an SSA as well as either low-risk or high-risk conventional adenoma did not significantly change the risk of metachronous advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia. (MAA) during surveillance compared with not having an SSA. In their study, the risk was 27% at 3 years in the group with both high-risk adenoma with SSA, and 0% in the group with both low-risk adenoma and SSA.
In the Argentinian study by Pereyra et al, there was no increased risk of MAA for synchronous low-risk adenoma and SSA, compared to low-risk adenoma alone.
In contrast, there was an increased risk of MAA in individuals with both high-risk adenoma and SSA, compared to high-risk adenoma alone (35.7% risk of MAA at 3 years for high-risk adenoma with synchronous SSA at baseline colonoscopy and 17.9% risk of MAA at 3 years for high-risk adenoma alone).
The US study of Melson et al had a composite end-point including both MAA and metachronous advanced serrated polyps, so the incidence of MAA alone could not be determined with respect to the initial baseline findings. The findings suggest that the presence of an initial SSA increased the rate of metachronous advanced neoplasia, compared with conventional adenomas alone.
In subgroups of individuals with SSAs only at baseline colonoscopy, the 5-year risk of MAA was 12.8%in one study and 8.3% in another, but could not be determined in the third study. This is similar to the risk with low-risk adenoma at baseline.
Risk of metachronous ‘advanced neoplasia’
The study of Melson et al used the end point of metachronous ‘advanced neoplasia’ during surveillance and defined this as MAA and/or SSA >1cm or SSA with high-grade dysplasia (HGD). Over a mean follow-up of 3.86 years, individuals with SSAs alone had an incidence of 6.31% of metachronous ‘advanced neoplasia’. Over a mean follow-up of 3.63 years, patients with 1 or 2 adenomas (including SSAs, if present) with each polyp <1cm had an incidence of 6.67% of advanced neoplasia. Over a mean follow-up of 1.98 years individuals with ≥3 adenomas (including SSAs if present) or an adenoma ≥1cm or with HGD or villous histology had an incidence of metachronous ‘advanced neoplasia’ of 18.75%. In all groups combined, the presence of an initial SSA increased the rate of metachronous ‘advanced neoplasia’ from 11.1% to 26.3%.
Risk of metachronous serrated polyps
In the two US studies, subjects without SSA at baseline had a very low incidence of any SSA during surveillance (<6%). Data addressing this could not be extracted from the Argentinian paper. In the study of Melson et al the incidence of metachronous SSA was 33.3% over 3.94 years for individuals with SSAs with or without low-risk adenoma at baseline and was 32.98% over 3.54 years for individuals with high risk SSAs alone (≥1cm or dysplastic or ≥3) or SSA combined with high-risk adenoma. The incidence of metachronous SSA in individuals with SSA at baseline was 42.67% at 4 years in the Argentinian study. It should be noted that the prevalence of SSA at baseline colonoscopy in these studies was <5% and some of these ‘metachronous’ SSAs were probably missed lesions. It will be interesting to determine the incidence of metachronous SSA when studies are published with a high prevalence of SSA at baseline colonoscopy.
Risk of metachronous advanced serrated polyps
It is of major interest to determine if ASPs at baseline predict a higher risk of metachronous ASPs. These were not reported by the Argentinian study. Melson et al defined ASP as: SSA ≥1cm or with HGD, but included these with MAA as a composite end point of metachronous ‘advanced neoplasia’, making it difficult to calculate the separate risks. Macaron et al defined ASP as: SSA or HP >1cm, SSA with conventional dysplasia or TSA of any size (Table 8). When comparing patients with SSA <10mm in size to those with ASPs at baseline colonoscopy, the incidences of metachronous ASP at 3 years were 0% and 6.5%, respectively, and at 5 years were 4.3% and 11.5%. These findings demonstrate a nonsignificant trend (p=0.11) towards an increased incidence of metachronous ASP over time in those with ASP at baseline. The study may have been underpowered to detect a difference in metachronous ASP rates, as only 12 of the 157 patients had ASPs.
The Argentinian study found no statistically significant increase in risk of metachronous SSA according to characteristics at baseline of: size >10mm (relative risk [RR] 1.82, confidence intervalA measure that quantifies the uncertainty in measurement. When reported as 95% CI, it is the range of values within which we can be 95% sure that the true value for the whole population lies. [CI] 0.40–9.34, p=0.59), cytologic dysplasia (RR 1.00, CI 0.15–4.32, p=1.00), right sided location (RR 2.12, CI 0.47–11.53, p=0.48) and more than three SPs (RR 1.69, CI 0.06–20.00. p=0.65). Again, power was limited by small numbers.
Cumulative incidence of metachronous advanced serrated polyp
|Table 8. Cumulative incidence of metachronous advanced serrated polyp (Macaron et al )|
|Baseline findings||SSA or TSA only||SSA or TSA and LRA||SSA or TSA and HRA|
|HRA: high-risk adenoma; LRA: low-risk adenoma; SSA: sessile serrated adenoma; TSA: traditional serrated adenoma|
Overview of additional evidence (non-systematic literature review)
Other longitudinal data
US Data from the New Hampshire Colonoscopy Registry published after the completion of the systematic review period provides further evidence that the combination of SSA and/or TSA with high-risk adenoma at baseline colonoscopy predicts a higher risk of metachronous high-risk adenoma . Over a median follow-up of 4.9 years, individuals with high-risk adenoma combined with either SSA or TSA at baseline had a 16.04-fold increased risk of metachronous high-risk adenoma compared with individuals with no polyps at baseline. Those with high-risk adenoma but no SSA or TSA had a 3.86-fold increased risk. The risk for the combination of low-risk adenoma and SSA or TSA at baseline was 2.88 (1.67–7.13) compared with those with no polyps, similar to that of those with low-risk adenoma alone, 1.93 (1.41–2.62).
This study also provided further evidence that having an SSA or TSA at baseline was associated with a significant risk of metachronous serrated polyps ≥1cm (9.6% over 4.9 years). The risk was present in those with serrated polyps alone or combined with either low-risk adenoma or high-risk adenoma . Of note, the SSA detection rate at baseline was <4% and some of the metachronous serrated polyps may have been missed lesions. The risk of metachronous serrated polyps ≥1cm was highest in those who had high-risk adenoma and serrated polyps ≥1cm at baseline, compared with individuals with no polyps (RR 17.45). In contrast, individuals without an SSA or TSA at baseline had a very low risk of metachronous serrated polyps ≥1cm.
There is evidence that serrated polyps ≥10mm are more frequently associated with synchronous advanced neoplasia. This evidence supports recommendations for earlier repeat surveillance in these patients in several clinical practice guidelines.
There is strong evidence that SSAs with dysplasia have a high chance of becoming malignant and there have been numerous reports of SSAs ‘caught in the act’ of transitioning to conventional dysplasia and then to invasive carcinoma. The relative rarity of these lesions compared with the proportion of cancers bearing the molecular hallmarks of the serrated pathway and the similarity of the mean ages of patients with SSA with dysplasia and with serrated pathway cancers suggests that SSAs with dysplasia have a short dwell time before malignant conversion. Based on this evidence, several guidelines recommend earlier repeat surveillance in these patients.Back to top
Clinical practice guidelines from other countries
Guideline recommendations are summarised in Table 11 below.
In 2012, the update of the guidelines for surveillance after polypectomy by the US Multi-Society Task Force (USMTF) on Colorectal Cancer was published. The recommendations on serrated polyps were based on low quality evidence available up to 2011. These guidelines recommended surveillance colonoscopy in 5 years for SSAs <10mm without dysplasia and in 3 years for SSAs ≥10mm or with dysplasia. In the same year an expert panel published a consensus opinion with similar recommendations, but with additional advice that if there were 3 or more SSAs <10mm without dysplasia the interval should be 3 years, and with dysplasia the interval should be 1 to 3 years.
The European Society of Gastrointestinal Endoscopy (ESGE) guidelines published in 2013 again noted the low quality of evidence and recommended patients with SSAs ≥10mm or with dysplasia should be considered similar to those with high-risk conventional adenomas, and should be offered surveillance colonoscopy at 3 years. The ESGE guidelines regarded other SSAs as similar to in risk to low-risk conventional adenomas, recommended surveillance colonoscopy at 10 years in these patients.
Most recently, the British Society of Gastroenterology (BSG) published a position statement on serrated polyps, in which they recommended that patients with SSAs ≥10mm or with conventional dysplasia should be offered surveillance colonoscopy at 3 years, but that other patients with SSAs should not be offered surveillance unless they meet criteria for serrated polyposis.
None of the above guidelines makes recommendations for combined serrated polyps and conventional adenomas, with the BSG stating the groups should be considered separately. The BSG  and USMTF guidelines recommended surveillance at 3 years for all TSAs. All other guidelines recommended surveillance at 3 years for TSA ≥10mm, with other intervals varying from 'return to routine population screening' or colonoscopy at 5 or 10 years.
The question of the potential of large HPs is acknowledged by the BSG, US Consensus Panel and ESGE in that they are included in the guidelines, with a 3-year surveillance interval recommended in two of the three guidelines and 5-year intervals in one for HPs ≥10mm. The US Consensus Panel goes further, recommending that patients with proximal small HPs (defined as proximal to the sigmoid and <10mm) should undergo surveillance depending on size and number.
Evidence summary and recommendations
| Three of four cohort studies reported no incidences of colorectal cancer within 3–5 years for those classified at index as having clinically significant serrated adenomas, sessile serrated adenomas or serrated adenomas with or without non-advanced or advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia..
For those with sessile serrated adenomas coexisting with high-risk adenoma at index, a 1.00% incidence of colorectal cancer (one case) at a mean and standard deviation of 3.54 (±1.43) years was reported.
|II, III-2||, , , |
|For those with sessile serrated adenomas at index, incidence of conventional adenoma was 34.67% after surveillance at 4.0±1.17 years.||II|||
| In subgroup analysis according to adenoma risk at index colonoscopy, incidences of conventional adenoma were:
| Index features significantly associated with an increase in risk for metachronous conventional adenoma at an overall follow-up of 4.0±1.17 years were:
| The cumulative incidence of advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia. at 1–5 years increased at a similar rate for patients with index serrated adenoma only (0.0–10.0%) and those with both serrated adenoma and non-advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia. (0.0–7.0%).
For those with serrated adenoma with advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia., cumulative incidence increased from 8.3–27.0% at 1–2 years and remained steady at 27.0% at 2–5 years.
|There were no statistically significant differences in cumulative incidence of advanced serrated adenoma over 1–5 years between patients with index features of sessile serrated adenomas <10mm, and those with hyperplastic polyp or sessile serrated adenoma ≥10mm, traditional serrated adenoma or sessile serrated adenoma with low grade dysplasia (p=0.59).||III-2|||
| One study reported that, after 6 years follow-up, patients with an index sessile serrated adenoma only had a cumulative advanced neoplasm-free rate of 91.7% over the same period (6 years).
For those with an index sessile adenoma and synchronous low-risk adenomas, the cumulative advanced neoplasm-free rate was 100%.
For those with index sessile serrated adenomas and synchronous high-risk adenomas, the cumulative advanced neoplasm-free rate was 0%.
|For those with sessile serrated adenomas at index, the incidence of sessile serrated adenoma was 42.67% after follow-up 4.0±1.17 years.||II|||
| In subgroup analysis according to adenoma risk status at index colonoscopy, incidences of sessile serrated adenoma were:
| In the one study that reported metachronous sessile serrated adenoma as an outcome, there was no significant evidence to suggest an increase in risk at an overall mean follow-up time of 4 (±1.17) years based on the following index features:
|The incidence of advanced serrated polyps for those with index serrated adenoma only was 5.41% at a mean follow-up time of 3.86 (±1.39) years.||III-2|||
| Among patients with serrated adenomas at index and advanced serrated polyps at follow-up:
| The cumulative incidence of advanced serrated polyps at 1–5 years increased at a similar rate for patients with index serrated adenoma only (0.0–7.00%) and those with both serrated adenoma and non-advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia. (0.0–11.00%).
For those with serrated adenoma with advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia., cumulative incidence of advanced serrated polyps remained steady at 9.00% from 2–5 years.
|There were no evidence to suggest statistically significant differences in the cumulative incidence of advanced serrated polyps over 1–5 years between patients with index features of sessile serrated adenomas <10mm, and those with hyperplastic polyp or sessile serrated adenoma ≥10mm, traditional serrated adenoma or sessile serrated adenoma with low-grade dysplasia (p=0.11).||II|||
Sessile and traditional serrated adenomas (with or without conventional adenomas)
First surveillance intervals should be no greater than 5 years and should be based on features of synchronous conventional adenomas (if present) following complete removal of sessile and traditional serrated adenomas.
Sessile and traditional serrated adenomas (with or without conventional adenomas)
First surveillance intervals should be based on the number, size and presence of dysplasia in the serrated polyps and synchronous conventional adenomas (if present) following complete removal of sessile and traditional serrated adenomas.
3 years for:
1 year for:
3 years for:
1 year for:
1 year for:
Surveillance is recommended for ‘clinically significant’ serrated polyps:
High-quality endoscopy is imperative to identify accurately and to completely remove sessile and traditional serrated adenomas and synchronous conventional adenomas.
Polyp/adenoma size as per the endoscopist documentation should be used for determining surveillance intervals. All endoscopists should ensure size measurements are accurate using a reference standard (eg an open biopsy forceps or snare).
Polyps removed should be submitted separately for histologic assessment to inform surveillance recommendations.
High-quality pathology interpretation is critical to correctly diagnose sessile and traditional serrated lesions and advanced serrated polyps.
High-quality reporting from endoscopists and pathologists is required to allow accurate risk stratification for surveillance interval recommendations.
Surveillance intervals should be determined after the colon has been cleared of all significant neoplasia, once histology is known and in the context of individualised assessment of benefit to the patient.
Small, particularly distal, true hyperplastic polyps do not require surveillance.
Clinicians should be aware of the cumulative serrated polyp count and diagnostic criteria for serrated polyposis syndrome and recommend surveillance. See Clinical practice guidelines for the prevention, early detection and management of colorectal cancer, Serrated polyposis syndrome for diagnostic criteria and recommended surveillance.
Notes on recommendations
The systematic review, although limited, demonstrated differences in the risk of metachronous neoplasia dependent on features of the SSAs and TSAs and the presence of synchronous conventional (tubular, tubulovillous and villous) adenomas, suggesting surveillance should occur within 5 years.
These recommendations are conservative, but prudence is warranted at present. The consensus-based recommendations to guide clinical practice are also informed by potentially prognostic features of serrated adenomas recognised in the general literature review:
- The risk of MAA is increased when an individual has both SSA and high-risk conventional adenoma at baseline colonoscopy, compared with high-risk conventional adenomas alone.
- The risk of metachronous SSA is much higher in those who have had an SSA alone, or SSAs synchronous with low or high risk conventional adenomas, than in those with conventional adenomas without SSAs at baseline colonoscopy.
- The risk of metachronous ASPs seems to increase over time for those with SSA or TSA at baseline colonoscopy. Studies are underpowered to determine if the characteristics of serrated polyps at baseline can predict a clinically significant risk of metachronous advanced serrated polyps.
- The risk of metachronous ‘advanced neoplasia’ including both advanced adenomas and ASPs seems to be higher in those with combined SSA and conventional adenomas at baseline.
- There is variability in international guidelines with acknowledgement of the limited evidence base. Expert opinion regarding the importance of serrated polyps of large size, associated with dysplasia and multiplicity has led to these factors being incorporated into existing international guidelines.
- Expert opinion recognises the unclear potential of large (≥10mm) hyperplastic polyps.
- Expert opinion and some direct evidence supports increased surveillance when the number of serrated polyps meets the definition of serrated polyposis.
Summary of recommendations for first surveillance intervals following removal of clinically significant serrated polyps (with or without conventional adenomas)
Table 9. Summary of recommendations for first surveillance intervals following removal of clinically significant serrated polyps (± conventional adenomas)
Health system implications
These guidelines are the first ever to separate conventional and serrated adenomas. There will be a learning curve for health care providers. The aim of the tables and colour-coding in this section is to facilitate transition from the old to new guidelines. An educational program and simple decision aids, such as wall charts and online decision tools, would help healthcare provider become familiar with the recommendations for surveillance intervals. These could be developed, promoted and distributed in conjunction with the relevant professional bodies and healthcare providers in the public and private domains.
The importance of high-quality endoscopy and pathology reporting cannot be overstated. Training and accreditation programmes should reflect these needs.
The resourcing implications of these guidelines are unclear but important to establish. There is likely to be an increased cost for pathologic assessment if a substantial proportion of health care providers currently do not submit all polyps removed for pathologic assessment or do not separate specimens.
Barriers to implementation
The main barrier for implementation of these recommendations will be dissemination across Australia and familiarisation for health care providers. This will be facilitated by a coordinated implementation and evaluation program.
Summary of findings from studies reported in systematic review
|Table 10. Findings of the studies reported in the systematic review|
|Study||Design||Outcome||Baseline colonoscopy findings|
non-advanced conventional adenoma
advanced conventional adenoma
|Isolated serrated polyps||Combined serrated polyp and low-risk conventional adenoma||Combined serrated polyp and high-risk conventional adenoma|
|Single centre retrospective
|Advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia.||NAA (n=69) 6/69=8.7%
|AA (n=29) 6/29=20.7%
|SP* only (n=111)
3.86 (±1.39) Y
|SP with NAA (n=30)
3.63 (±1.47) Y
|SP with AA (n=16)
1.98 (±1.41) Y
|Advanced serrated polyps†||1/69=1.4%||0/29=0%||6/111=5.4%||3/30=10%||2/16=12.5%|
|Single centre prospective 4/2007–12/2009
|Advanced neoplasia||NAA (n=140) 11/140=7.9%
|AA (n=87) 20/87=23%
|SSA only (n=47)
4 (±1.17) Y 45.36m
|SSA with LRA (n=14)
4 (±1.17) Y 49.85m
|SSA with HRA (n=14)
4 (±1.17) Y 46.42m
RR 4.88 (1.05–26.9, p=0.02)
|Single centre retrospective 1/2005 -12/2011
^TSA 6/166=3.6% (excluded in MAN analysis)
|LRA (n=370) 29/370=7.8%
CRC 2 (6.9%)
|HRA (n=252) 40/252=15.9% 40.1±20.9m||SSA^ only (n=106)
Low risk SP only 10/56=17.9% (p=0.024)
High risk SP only‡ 16/50=32%
|LRA including SSAs: (n=66)
FU 3.94 (±1.39) 47.3±16.7m
LRA with SSA
|HRA including SSAs (n=94)
FU 3.54 (±1.43) 42.5±17.2m
CRC 1 (1/94=3.3%)
HRA with SSA
|SSA||LRA 16/370=4.3%||HRA 15/252=6.0%||22/66=33.3% (p=0.001)||31/94=33.0% (p=0.001)|
|*SP at baseline: SSA±dysplasia, TSA, HP≥10mm AA: ≥10mm/villous/HGD NAA: <10mm without HGD or villosityThe state of being villous, a histopathological feature of some tubular adenomas. Villous adenoma is a type of polyp found in the colon or rectum that appear as a cauliflower-like mass.; †ASP: SSA or HP ≥10mm, SSA with dysplasia or TSA of any size; ‡High-risk SP: TSA and SSA with dysplasia LRA with SSAs – included either a low-risk SSA and a low-risk adenoma or only a low-risk SSA; LRA only included 1–2 TA <10mm without dysplasia.
AA: advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia.; ASP: advanced serrated polyp; CRC: colorectal cancer; HRA: high-risk adenoma; LRA: low-risk adenoma; m: months; MAN: metachronous advanced neoplasia; NAA: non-advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia.; SP: serrated polyp; SSA: sessile serrated adenoma; TSA: traditional serrated adenoma; Y: years.
International guidelines for surveillance after removal of serrated polyps at baseline colonoscopy
|Table 11. International guidelines for surveillance after removal of serrated polyps at baseline colonoscopy|
|Guideline||Serrated Polyp Category|
|Location||Sized <5mm||5–9mm||≥10mm||Dysplasia||Sized <10mm||Sized ≥10mm||Sized <10mm||Sized ≥10mm|
|Cancer Council Australia (2011)||Any||No surveillance||N/A||N/A||1 Y||N/A|
|BSG (2017)||Any||No surveillance||3 Y||3 Y||No surveillance||3 Y||3 Y||1 Y||Consider each
|ESGE (2013)||Any||Screening or 10 Y||3 Y||3 Y||Screening or 10 Y||3 Y||Screening
or 10 Y
|US consensus panel (2012)||Proximal to sigmoid||10 Y if ≤3
5 Y if ≥4
|5 Y||5 Y||1–3 Y||5 Y if 1–2
3 Y if ≥3
1-3 Y if ≥2
|5 Y if 1-2||3 Y||1 Y||N/A|
|Distal||10 Y||10 Y|
|USMTF/AGA (2012)||Proximal to sigmoid||3 Y||5 Y if 1
3 Y if ≥2
|3Y||3 Y||3 Y||1 Y||N/A|
|European (2010)||10 Y if distal to rectosigmoid||10 Y
1–3 Y if ≥3
|HP: Hyperplastic polyp; N/A: non-applicable; NR: not recorded; SPs: serrated polyp;Y: years. SSAs: sessile serrated adenoma; TSA: traditional serrated adenoma.|
- Cancer Council Australia Colonoscopy Surveillance Working Party. Clinical Practice Guidelines for Surveillance Colonoscopy – in adenoma follow-up; following curative resection of colorectal cancer; and for cancer surveillance in inflammatory bowel disease. Sydney: Cancer Council Australia; 2011 Dec.
- Bosman FT, Carneiro F, Hruban R H, Theise N. WHO classification of tumours of the digestive system, fourth edition. France: IARC; 2010 [cited 2018 Jul 10] Available from: http://www.ncbi.nlm.nih.gov/nlmcatalog/101553728.
- East JE, Atkin WS, Bateman AC, Clark SK, Dolwani S, Ket SN, et al. British Society of Gastroenterology position statement on serrated polyps in the colon and rectum. Gut 2017 Jul;66(7):1181-1196 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/28450390.
- Bettington M, Walker N, Rosty C, Brown I, Clouston A, McKeone D, et al. Clinicopathological and molecular features of sessile serrated adenomas with dysplasia or carcinoma. Gut 2017 Jan;66(1):97-106 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26475632.
- Sheridan TB, Fenton H, Lewin MR, Burkart AL, Iacobuzio-Donahue CA, Frankel WL, et al. Sessile serrated adenomas with low- and high-grade dysplasia and early carcinomas: an immunohistochemical study of serrated lesions "caught in the act". Am J Clin Pathol 2006 Oct;126(4):564-71 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16938659.
- Oono Y, Fu K, Nakamura H, Iriguchi Y, Yamamura A, Tomino Y, et al. Progression of a sessile serrated adenoma to an early invasive cancer within 8 months. Dig Dis Sci 2009 Apr;54(4):906-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/18688718.
- 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 Jan;125(1):132-45 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16483002.
- Cancer Council Australia Colorectal Cancer Guidelines Working Party. Clinical practice guidelines for the prevention, early detection and management of colorectal cancer. Sydney: Cancer Council Australia; 2017 Available from: https://wiki.cancer.org.au/australia/Guidelines:Colorectal_cancer.
- Carballal S, Rodríguez-Alcalde D, Moreira L, Hernández L, Rodríguez L, Rodríguez-Moranta F, et al. Colorectal cancer risk factors in patients with serrated polyposis syndrome: a large multicentre study. Gut 2015 Aug 11 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26264224.
- IJspeert JE, Rana SA, Atkinson NS, van Herwaarden YJ, Bastiaansen BA, van Leerdam ME, et al. Clinical risk factors of colorectal cancer in patients with serrated polyposis syndrome: a multicentre cohort analysis. Gut 2017 Feb;66(2):278-284 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26603485.
- Hazewinkel Y, Tytgat KM, van Eeden S, Bastiaansen B, Tanis PJ, Boparai KS, et al. Incidence of colonic neoplasia in patients with serrated polyposis syndrome who undergo annual endoscopic surveillance. Gastroenterology 2014 Jul;147(1):88-95 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24657624.
- Pereyra L, Zamora R, Gómez EJ, Fischer C, Panigadi GN, González R, et al. Risk of Metachronous Advanced Neoplastic Lesions in Patients with Sporadic Sessile Serrated Adenomas Undergoing Colonoscopic Surveillance. Am J Gastroenterol 2016 Jun;111(6):871-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/27068719.
- Melson J, Ma K, Arshad S, Greenspan M, Kaminsky T, Melvani V, et al. Presence of small sessile serrated polyps increases rate of advanced neoplasia upon surveillance compared with isolated low-risk tubular adenomas. Gastrointest Endosc 2016 Aug;84(2):307-14 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26855297.
- Macaron C, Vu HT, Lopez R, Pai RK, Burke CA. Risk of Metachronous Polyps in Individuals With Serrated Polyps. Dis Colon Rectum 2015 Aug;58(8):762-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26163955.
- Anderson JC, Butterly LF, Robinson CM, Weiss JE, Amos C, Srivastava A. Risk of Metachronous High-Risk Adenomas and Large Serrated Polyps in Individuals With Serrated Polyps on Index Colonoscopy: Data From the New Hampshire Colonoscopy Registry. Gastroenterology 2018 Jan;154(1):117-127.e2 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/28927878.
- Schreiner MA, Weiss DG, Lieberman DA. Proximal and large hyperplastic and nondysplastic serrated polyps detected by colonoscopy are associated with neoplasia. Gastroenterology 2010 Nov;139(5):1497-502 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20633561.
- Hiraoka S, Kato J, Fujiki S, Kaji E, Morikawa T, Murakami T, et al. The presence of large serrated polyps increases risk for colorectal cancer. Gastroenterology 2010 Nov;139(5):1503-10, 1510.e1-3 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20643134.
- Hassan C, Quintero E, Dumonceau JM, Regula J, Brandão C, Chaussade S, et al. Post-polypectomy colonoscopy surveillance: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2013 Oct;45(10):842-51 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24030244.
- Lieberman DA, Rex DK, Winawer SJ, Giardiello FM, Johnson DA, Levin TR. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2012 Sep;143(3):844-857 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22763141.
- Rex DK, Ahnen DJ, Baron JA, Batts KP, Burke CA, Burt RW, et al. Serrated lesions of the colorectum: review and recommendations from an expert panel. Am J Gastroenterol 2012 Sep;107(9):1315-29; quiz 1314, 1330 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22710576.
- Anderson JC, Baron JA, Ahnen DJ, Barry EL, Bostick RM, Burke CA,Bresalier RS, Church TR, Cole BF, Cruz-Correa M, Kim AS, Mott LA, Sandler RS, Robertson DJ. Factors Associated With Shorter Colonoscopy Surveillance Intervals for Patients With Low-risk Colorectal Adenomas and Effects on Outcome. Gastroenterology 2017.
- Holt BA, Bourke MJ. Wide field endoscopic resection for advanced colonic mucosal neoplasia: current status and future directions. Clin Gastroenterol Hepatol 2012 Sep;10(9):969-79 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22642950.
- Atkin WS, Valori R, Kuipers EJ, Hoff G, Senore C, Segnan N, et al. European guidelines for quality assurance in colorectal cancer screening and diagnosis. First Edition--Colonoscopic surveillance following adenoma removal. Endoscopy 2012 Sep;44 Suppl 3:SE151-63 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23012119.
|PICO question SAD 4||Evidence statement form SAD4||Systematic review report SAD4|