Serrated adenoma of the colorectum: colonoscopic and histologic features

doi:10.1016/S0016-5107(99)70292-0

Gastrointestinal Endoscopy

Volume 49, Issue 6, June 1999, Pages 736-742

https://doi.org/10.1016/S0016-5107(99)70292-0 Get rights and content

Abstract

Background: Serrated adenoma is a recently recognized epithelial neoplasm of the colorectum. The aim of this study is to clarify the colonoscopic features of serrated adenomas. Methods: The endoscopic findings for 52 serrated adenomas of the colorectum were investigated; these were then divided into three groups according to surface features. The histologic type (tubular, tubulovillous or villous) and the incidence of high-grade dysplasia were compared among the three groups. Results: The surface under chromoscopy showed a hyperplastic pattern in 17 lesions, a cerebriform pattern in 18 lesions and a combined pattern in 17 lesions. The tubular type of serrated adenoma was predominant in the hyperplastic pattern group (94%), whereas the tubulovillous or villous histologic types were frequent in the cerebriform pattern (89%) and combined pattern (82%) groups. High-grade dysplasia was found in 18% of the combined pattern adenomas; the incidence was lower in hyperplastic (6%) or cerebriform pattern (0%) adenomas. Conclusions: Surface features of serrated adenomas have a close correlation with their histologic type. A combined hyperplastic-cerebriform surface pattern under chromoscopy was seen only in serrated adenomas. (Gastrointest Endosc 1999;49:736-42.)

Section snippets

Patients and Methods

We reviewed colonoscopy records at our institution from the period between April 1995 and March 1998 and made a list of patients with serrated adenoma. The histologic diagnosis of serrated adenoma was based on the criteria described by Longacre and Fenoglio-Preiser. ⁹ In brief, histologic confirmation of (1) a serrated glandular pattern simulating hyperplasia, (2) the presence of goblet cell immaturity, (3) upper crypt zone mitosis, and (4) the prominence of nuclei were the criteria for

Clinical and endoscopic features

There were 29 men and 15 women; their ages at the time of colonoscopy ranged from 41 to 73 years, with a mean age of 62 years. The indication for colonoscopy included positive fecal occult blood in 22 patients, hematochezia in 8 patients and other abdominal symptoms (diarrhea, abdominal pain or constipation) in the remaining 14 patients. Synchronous traditional adenoma was found in 25 patients. None of the patients had synchronous invasive colorectal cancer or any family history suggestive of

Discussion

The term “serrated adenoma” was introduced by Fenoglio-Preiser et al.¹² in 1988. Although they proposed that this type of adenoma should be regarded as a distinctive pathologic entity, they also reported that serrated adenoma represented less than 0.0005% of colorectal adenomas.9, 12 In contrast, we found a greater prevalence of neoplasms compatible with the histologic criteria of serrated adenoma from our own colonoscopic survey. It would therefore seem likely that serrated adenoma is a much

References (23)

HH Teoh et al.
Dysplastic and malignant areas in hyperplastic polyps of the large intestine
Pathology
(1989)
RA Wolber et al.
Flat adenomas of the colon
Hum Pathol
(1991)
T Matsumoto et al.
Minute non-polypoid adenoma of the colon detected by colonoscopy: correlation between endoscopic and histologic findings
Gastrointest Endosc
(1992)
E Torlakovic et al.
Serrated adenomatous polyposis in humans
Gastroenterology
(1996)
BG McCann
A case of metaplastic polyposis of the colon associated with focal adenomatous change and metachronous adenocarcinomas
Histopathology
(1988)
O Bengoechea et al.
Hyperplastic polyposis of the colorectum and adenocarcinoma in a 24-year-old man
Am J Surg Pathol
(1987)
H Jørgensen et al.
Hyperplastic polyposis of the large bowel
Scand J Gastroenterol
(1996)
G Franzin et al.
Hyperplastic (metaplastic) polyps of the colon
Am J Surg Pathol
(1984)
G Franzin et al.
Adenocarcinoma occurring in a hyperplastic (metaplastic) polyp of the colon
Endoscopy
(1982)
SJ Urbanski et al.
Mixed hyperplastic adenomatous polyps: an underdiagnosed entity
Am J Surg Pathol
(1984)

JO Gabbers et al.

Mixed hyperplastic and neoplastic polyp of the colon: an immunohistochemical study

Virchows Arch [A]

(1986)

Cited by (61)

Optical biopsy of sessile serrated adenomas: Do these lesions resemble hyperplastic polyps under narrow-band imaging?
2013, Gastrointestinal Endoscopy
Citation Excerpt :
Few studies have described the endoscopic appearance of SSAs when advanced imaging technologies were used. In a study that used chromoendoscopy, the surface patterns of 52 serrated adenomas were characterized as hyperplastic (small crypt openings) in 7 (41%), cerebriform (tortuous and cerebriform structures) in 4 (24%), and a combination of the two in 6 (35%).19 Those authors noted that inspection at colonoscopy might be insufficient to differentiate HPs from serrated adenomas, given that it was difficult to differentiate the hyperplastic pattern of serrated adenomas from the HPs themselves.19
Serrated colorectal lesions include hyperplastic polyps (HPs) and sessile serrated adenomas (SSAs). Optical biopsy could misclassify SSAs as unimportant if they resemble HPs.
To explore the narrow-band imaging (NBI) features of SSAs. We hypothesized that SSAs resemble HPs under NBI.
Retrospective analysis of data from our prospective study of NBI in routine practice.
Single specialty group.
Patients undergoing colonoscopy.
Colonoscopy.
Polyp histology prediction by community gastroenterologists. Features of SSAs versus HPs and adenomas by using the Narrow-Band Imaging International Colorectal Endoscopic (NICE) Classification.
Among 2388 lesions, 141 were diagnosed on pathology as SSAs, 465 as HPs, and 1546 as adenomas. Each individual NICE feature of HPs was found in 38% to 42% of SSAs, 66% to 67% of HPs, and 15% to 20% of adenomas (P < .001 for each). Each individual NICE feature of adenomas was found in 57% to 62% of SSAs, 33% to 34% of HPs, and 80% to 84% of adenomas (P < .001 for each). Compared with HPs, SSAs were less likely (odds ratio [OR] 0.74; 95% confidence interval [CI], 0.69-0.79) and adenomas were even less likely (OR 0.62; 95% CI, 0.59-0.64) to have all 3 NICE features of HPs. SSAs >5 mm were more likely than smaller SSAs to have all 3 NICE features of adenomas. SSA location did not predict NBI features. Analyses restricted to high-confidence lesions showed similar results.
The endoscopists were not NBI experts.
Community gastroenterologists observed a profile of NICE features among SSAs that was intermediate to the profiles observed for HPs and adenomas. These results require confirmation by NBI experts.
Serrated lesions and hyperplastic (serrated) polyposis relationship with colorectal cancer: Classification and surveillance recommendations
2013, Gastrointestinal Endoscopy
Citation Excerpt :
This lesion, first defined as a serrated adenoma,46,47 is mostly located in the rectosigmoid area but has a predisposition for larger lesions (>10 mm) involving the right side of the colon. They account for only 0.6% to 1.3% of all colorectal polyps and 1.7% of all adenomas.47,48 A relatively high proportion of CRCs (5.8%) include residual TSAs.49
The cutting edge of serrated polyps: A practical guide to approaching and managing serrated colon polyps
2013, Gastrointestinal Endoscopy
Serrated adenoma: A distinct form of non-polypoid colorectal neoplasia?
2010, Gastrointestinal Endoscopy Clinics of North America
Citation Excerpt :
Other studies have shown that traditional serrated adenoma is identified in up to 7% of colonoscopies, with most polyps (54%) occurring on the left side of the colon.3,13 Traditional serrated adenomas often have a pedunculated or broad-based polypoid pattern of growth, with a cerebriform or flower petal-like endoscopic appearance.12,17–19 Small polyps, however, are endoscopically indistinguishable from hyperplastic polyps.13
Pragmatic classification of superficial neoplastic colorectal lesions
2009, Gastrointestinal Endoscopy
Citation Excerpt :
The surface pit pattern varies from type II in small serrated adenomas to types IIIL and IV in large adenomas and type Vi or VN in carcinomas. An endoscopic survey conducted with 52 serrated adenomas41 classified their surface microarchitecture as hyperplastic in 17, cerebriform in 18, and mixed in 17. A histopathologic study of 178 traditional serrated adenomas42 showed that high-risk intramucosal neoplasia was more frequent in nonpolypoid (25.2%) than in polypoid (9.2%) lesions.
Hyperplastic polyposis syndrome: a pilot study for the differentiation of polyps by using high-resolution endoscopy, autofluorescence imaging, and narrow-band imaging
2009, Gastrointestinal Endoscopy
Endoscopic differentiation and removal of potentially premalignant sessile serrated adenomas (SSAs) may be important steps in preventing the development of colorectal cancer in hyperplastic polyposis syndrome (HPS).
To assess the value of high-resolution endoscopy, autofluorescence imaging (AFI), and narrow-band imaging (NBI) for differentiating polyps in HPS.
A prospective polyp series.
Single tertiary referral center.
Seven patients with HPS underwent colonoscopy with endoscopic trimodal imaging, which incorporates high-resolution endoscopy, AFI, and NBI in 1 system. All detected polyps were analyzed with AFI for color and with NBI for Kudo pit pattern and vascular pattern intensity.
The accuracy, sensitivity, and specificity of AFI and NBI in differentiating detected polyps were determined by using histology as the criterion standard.
A total of 19 hyperplastic polyps (HPs), 32 SSAs, and 15 adenomas were detected. For differentiating SSAs from HPs, AFI color, Kudo pit pattern, and vascular pattern intensity resulted in a diagnostic accuracy of 55%, 55%, and 52%, respectively. For differentiating adenomas from HPs, the accuracy was 65%, 94%, and 90%, respectively. Macroscopically, the combination of a size of 3 mm or larger and a proximal location resulted in the highest accuracy (76%) for differentiating SSAs from HPs.
Small sample size.
Endoscopic differentiation between HPs and SSAs by using endoscopic trimodal imaging proved unsatisfactory. Differentiation of adenomas from HPs was possible with NBI but not with AFI.

View all citing articles on Scopus

^☆: Reprint requests: Takayuki Matsumoto, MD, Division of Gastroenterology, Department of Medicine, Kawasaki Medical School, 577 Matsushima, Kurashiki-City, Okayama 701-0192, Japan.

^☆☆: 37/1/95736

View full text

Serrated adenoma of the colorectum: colonoscopic and histologic features☆,☆☆

Abstract

Section snippets

Patients and Methods

Clinical and endoscopic features

Discussion

Pathology

Hum Pathol

Gastrointest Endosc

Gastroenterology

A case of metaplastic polyposis of the colon associated with focal adenomatous change and metachronous adenocarcinomas

Histopathology

Hyperplastic polyposis of the colorectum and adenocarcinoma in a 24-year-old man

Am J Surg Pathol

Hyperplastic polyposis of the large bowel

Scand J Gastroenterol

Hyperplastic (metaplastic) polyps of the colon

Am J Surg Pathol

Adenocarcinoma occurring in a hyperplastic (metaplastic) polyp of the colon

Endoscopy

Mixed hyperplastic adenomatous polyps: an underdiagnosed entity

Am J Surg Pathol

Mixed hyperplastic and neoplastic polyp of the colon: an immunohistochemical study

Virchows Arch [A]