The serrated pathway and colorectal cancer: what the gastroenterologist should know

Serrated polyps can progress to colorectal cancer (CRC), through a pathway that is distinct from the conventional adenoma-carcinoma sequence. This pathway includes hyperplastic polyps (HPs), sessile serrated polyps (SSPs), and traditional serrated adenomas (TSAs).

Our review includes the histology and pathological challenges, carcinogenesis, risk factors, detection, emerging technologies, resection, and surveillance.

Serrated polyp management presents many detection, diagnosis, resection, and surveillance challenges. Missed serrated polyps contribute to preventable CRCs. A new SSP detection rate benchmark will guide endoscopists with a goal when improving detection. Furthermore, new SSP-specific surveillance strategies may also aid in reducing CRC burden. Histologic differentiation remains a challenge, underscoring the need for standardized pathology practices and exploring novel ways to stratify risk independent of histology, given interobserver variation. Moreover, the clinical significance of proximal HPs requires further clarification. Which HPs < 1 cm require closer surveillance intervals? Molecular profiling may help identify markers that separate proximal low risk from high-risk HP. The best approach for resection of serrated polyps also needs to be clarified. There is also a lack of robust longitudinal outcome data to guide surveillance recommendations since current guidelines are based on low quality of evidence.