Management of Colorectal Sessile Serrated Lesions in Elderly Patients

Sessile serrated lesions (SSLs) are established precursor lesions of colorectal cancer arising through the serrated neoplasia pathway and are estimated to account for a substantial proportion of sporadic colorectal cancers. Accumulating evidence has clarified their distinctive endoscopic, histopathological, and molecular characteristics, including frequent BRAF mutations, CpG island methylator phenotype (CIMP), and progression toward microsatellite instability-high carcinoma. Although the natural history of nondysplastic SSLs is generally slow, lesions that acquire dysplasia may demonstrate more rapid neoplastic progression. With increasing global longevity, the management of SSLs in elderly patients has become a clinically important issue. In this population, clinical decision-making is complicated by higher risks of colonoscopy-related adverse events, antithrombotic use, comorbidities, frailty, and reduced tolerance to bowel preparation or sedation. At the same time, the oncologic benefit of endoscopic treatment or continued surveillance may be limited by remaining life expectancy. Current surveillance recommendations for SSLs are gradually becoming more explicit across regions; however, these recommendations are largely extrapolated from studies of conventional adenomas and mixed-age populations, and elderly-specific evidence remains limited. Consequently, the management of elderly patients with colorectal SSLs requires individualized decision-making integrating lesion-related risk, procedural burden, frailty, life expectancy, and the quality of prior colonoscopic examinations. This review summarizes current evidence regarding colorectal SSLs and discusses practical considerations for individualized management in elderly patients, with particular emphasis on balancing oncologic benefit against procedural risk and long-term surveillance burden in an aging society.