Serrated Polyps of the Colon - PowerPoint Presentation

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Serrated Polyps of the Colon - PPT Presentation

Aaron Sinclair MD University of Kansas School of Medicine Wichita Department of Family and Community Medicine Wesley Family Medicine Residency 8714 Learning Objectives Distinguish the malignant potential of serrated polyps and adenomas ID: 399391

polyps serrated hyperplastic adenomas serrated polyps adenomas hyperplastic sessile adenoma colon polyp years traditional 2012 risk ssa diagnosis polyposis number cancer size

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Slide1

Serrated Polyps of the Colon

Aaron Sinclair, MD

University of Kansas School of Medicine – Wichita

Department of Family and Community Medicine

Wesley Family Medicine Residency

8/7/14Slide2

Learning Objectives:

Distinguish the malignant potential of serrated polyps and adenomas

Identify when serrated polyps are considered serrated polyposis syndrome

Describe the relationship between hyperplastic polyps and serrated polypsSlide3

Case Presentation

male presents for screening colonoscopy.

Diverticula noted

40 cm and 80 cm there were 3-4 mm polyps completely excised with cold forceps biopsy.

Operative Report Recommendation at 10 years.

Pathology: Sessile Serrated Polyp – 2 days later.

Treatment:?Slide4

Classification - Serrated Polyps

World Health Organization (WHO)

Hyperplastic Polyps (HP)

Sessile Serrated Adenomas/polyps (SSA/P)

Traditional Serrated Adenomas (TSA)

Historical Context

1990 – First described in the literature

2005 - Pathological

distinctions first

appeared

2008 – First pathological diagnostic criteria and nomenclature introduced.

2010 – WHO adopted criteriaSlide5

Importance of Serrated Polyps

Prevalence of Proximal Serrated Polyps of 5-8% of all average risk screening colonoscopies

15-35% of all cancers are secondary to serrated polyps

The progression of dysplasia to cancer for Sessile Serrated Adenomas and Polyps is 10-15 years.

Only about 10% of all tubular adenomas progress to cancer

Typically tubular adenomas are larger, progress in 8-12 years to cancer.Slide6

Importance of Serrated Polyps

How many Repeat Normal 10 year follow-up Colonoscopies are you doing that quite possibly were serrated polyps not hyperplastic polyps?Slide7

Figure 3. A, Sessile serrated adenoma (SSA). Arrows mark edges of an SSA. B, An SSA with early carcinoma. The

erythematous/ulcerated area

represents the early carcinoma; the arrows indicate the edges of the residual SSA. Bars: 20 mm.

The serrated pathway to colorectal carcinoma:

current concepts

and

challenges.

Bettington

et al. Histopathology

2013, 62, 367–386.Slide8

errated

Adenoma Pathway

Sessile

serrated adenomas frequently (78%) have BRAF mutations or K-

ras

mutations (11

yperplastic polyps which

show frequent K-

ras

mutations (70%) with less common BRAF mutations (20%)

MLH1

promoter methylation is frequent in serrated polyps, suggesting that they give rise to sporadic colorectal carcinoma with MSI

Smoking

and estrogen withdrawal may be associated with serrated pathway carcinomaSlide9

80%Slide10

Classification - Serrated Polyps

World Health Organization (WHO)

Hyperplastic Polyps (HP)

Sessile Serrated Adenomas/polyps (SSA/P)

Traditional Serrated Adenomas (TSA)Slide11

Hyperplastic Polyps

80 - 90% of all Serrated Polyps

Malignant potential - <1%

Size: < 5mm

Typical Location is Recto-Sigmoid

Increases in number up to 50 years of age then stable thereafter.Slide12

Hyperplastic Polyps

Mucosa is typically paler

Size <5 mmSlide13

Sessile Serrated Adenomas/Polyps

8-15% of all Serrated Polyps

Malignant Potential – uncertain but higher than adenomatous polyps which is at least 25% over 10 years if larger than 2 cm.

Size is variable

Equally distributed between right and left colon.

Increases in number throughout life.Slide14

Sessile Serrated Polyp

Typically covered with a “mucus cap”

Grow horizontally, flat, sessile

Size is variable

50% >5mm

12-20% > 10 mm

Red and Puckered appearanceSlide15

Sessile Serrated Adenoma

Typically covered with a “mucus cap”

Size is variable typically greater than 5 mm

Red and Puckered appearanceSlide16

Traditional Serrated Adenomas

2-5% of all Serrated Polyps

Malignant Potential – 3 fold increased risk compared to Adenomatous Polyps

Predominately Left Sided

Increases in number throughout lifeSlide17

Traditional Serrated Adenoma

Variable size up to 5 cm

Often adenomatous appearing

Red appearanceSlide18
Slide19

How accurate are pathologist in depicting

a Serrated Polyp from a Hyperplastic Polyp?

The Clinical Significance of Serrated Polyps - Christopher S Huang, Francis A

Farraye

, Shi Yang and Michael J O'Brien American Journal of Gastroenterology Slide20

How Reliable is the Diagnosis

Virchows

Archives, 2012

70 cases using World Health Organization Pathological Diagnostic Criteria/Worksheets

16 European Pathologists

28 Hyperplastic Polyps

25 Sessile Serrated Adenomas/Polyps

11 Traditional Serrated Adenomas

15 Mixed HP with SSP features

How do you think the 16 pathologists do?Slide21

How Reliable is the Diagnosis

Virchows

Archives, 2012

16 European Pathologists

28 Hyperplastic Polyps – 44% got all 28

25 Sessile Serrated Adenomas/Polyps – 40% got all 20

11 Traditional Serrated Adenomas – 10% got all 11

15 Mixed HP with SSP features – 6% got all 15

How do you think the 16 pathologists did?

After 2 rounds and a conference reviewing the WHO diagnostic criteria, they were able to come to near perfect alignment on diagnosis.

The authors of this study stated that at best reproducibility of the

histopathological

diagnosis on a Serrated Polyp remains imperfect.Slide22

Identification in the presence of the prep.

The Clinical Significance of Serrated Polyps -

Christopher S Huang, Francis A

Farraye

, Shi Yang and Michael J O'Brien

American Journal of Gastroenterology Slide23

Hyperplastic Polyps vs Serrated Adenomas – are we missing them.

Polyp Miss Rates High for Colonoscopies Done After Poor Bowel Preparation

ScienceDaily

(June 13, 2011)

the context of suboptimal bowel preparation, of all adenomas identified, 42 percent were discovered only during a repeat

colonoscopy.Slide24

Current Recommendation for Hyperplastic Polyps

Remove all polyps when technically possible except for the small (<5mm) distal hyperplastic – appearing polyps that can be sample to confirm they are true HP’sSlide25

Serrated Polyposis Syndrome

At least 5 hyperplastic polyps proximal to the sigmoid colon

At least two of them greater than 10 mm

More than 30 hyperplastic polyps evenly distributed throughout the colon

Any number of hyperplastic polyps proximal to the sigmoid colon with a family member with diagnosis of Serrated Polyposis SyndromeSlide26

Serrated Polyposis Syndrome

Treatment is Colonoscopy every 1-3 years with complete removal of ALL polyps.

Start at age of 45 for first degree relatives or 5 years younger than the age of initial diagnosis

40% risk of lifetime cancer

Not all that different from Colorectal Cancer recommendations.Slide27

Surveillance Recommendations

Every 5 years if the Sessile Serrated Polyp/Adenoma are less than two in number and/or greater than 1 cm in size.

Every 3 years if the

Sessile Serrated Polyp/Adenoma are

three or more in

number

and/or greater

than 1 cm in

size

If a

Sessile Serrated Polyp/Adenoma

is removed and any comments of cytological dysplasia are mentioned, perform a one year post removal to ensure complete removal.Slide28

Surveillance Recommendations

Traditional Serrated Adenomas – follow the guidelines for typical adenomas.Slide29

Approach to the patient with colonic polyps. www.utdol.comSlide30

Measuring Quality

Current quality markers suggest

Screening

Colonoscopy of Average Risk Patients

Men – 25% Adenoma Detection Rate

Women – 15% Adenoma Detection Rate

Study of 15 Gastroenterologists between 2000-2009

Showed a serrated adenoma detection risk of 4.5% (Expected Prevalence Rate of 5-8%)

Correlated with quality marker expectations of the Adenoma Detection Rate

High

colonoscopic

prevalence of proximal colon serrated polyps in average-risk men and women.

Kahi

et al. Gastrointestinal Endoscopy 2012. 75.3Slide31

References

High

colonoscopic

prevalence of proximal colon serrated polyps in average-risk men and women.

Kahi

et al. Gastrointestinal Endoscopy 2012.

75.3

The Clinical Significance of Serrated Polyps -

Christopher

S Huang, Francis A

Farraye

, Shi Yang and Michael J

O'Brien. American

Journal of Gastroenterology

Serrated

Polyps of the colon and rectum, and serrated polyposis.

Snover

DC, Ahnen DJ et al. (2010)In: Bosman Et al. WHO Classification of tumours of the digestive system, 4th edition. pp 160-165The serrated pathway to colorectal carcinoma: current concepts and

challenges.

Bettington

et al.

JAN

2013

Serrated

plyps

of the colon and rectum – proposal for diagnostic criteria. Daniela E.

Aust

and Gustavo B.

Baretto

Virchows