Sessile Serrated Polyp Management

Introduction to SSPs

Sessile serrated polyps (SSPs) account for 15-30% of colorectal cancers through the serrated pathway, and complete endoscopic resection is the recommended treatment to prevent colorectal cancer 1, 2
SSPs represent the major precancerous serrated lesion, found in 8-9% of screening colonoscopies and predominantly located in the proximal colon, with established cancer risk 1, 3, 4
These lesions account for up to 30% of all colorectal cancers through the CpG island methylator phenotype (CIMP) pathway with BRAF mutations 1, 2
SSPs with cytologic dysplasia are considered more advanced lesions in the polyp-cancer sequence and carry higher malignant potential 1, 3

Complete endoscopic resection is mandatory using endoscopic mucosal resection (EMR) techniques for SSPs ≥10 mm or with dysplasia 2, 5
Resection should be performed by operators with expertise in managing large non-polypoid colorectal polyps, particularly for proximal lesions ≥10 mm 5
Standard polypectomy techniques should be applied for SSPs <10 mm without dysplasia, though the flat morphology can make them difficult to grip 5
Cold snaring is preferred for proximal colon lesions <10 mm 5

For piecemeal EMR of lesions ≥20 mm, a site check at 2-6 months is recommended to assess for residual tissue 2, 5, 6
For lesions 10-20 mm resected piecemeal, endoscopist discretion is advised regarding 2-6 month site check versus standard surveillance 5
SSPs ≥10 mm or with dysplasia require one-off surveillance colonoscopy at 3 years 2, 6, 7
SSPs <10 mm without dysplasia have no clear indication for surveillance unless meeting criteria for serrated polyposis syndrome 2, 6, 7

Incomplete resection is the major concern, and up to 50% of large SSPs may be removed incompletely with standard techniques, contributing to interval cancer risk 1, 3, 8
SSPs are more difficult to detect than conventional adenomas due to flat morphology and absence of surface blood vessels 1, 3, 8
Pathologist variability exists in differentiating hyperplastic polyps from SSPs, leading to inconsistent reporting 1, 3
Surgical resection should be considered when lesions are not amenable to complete endoscopic resection due to size, site, or technical factors 2, 6
Segmental colectomy is strongly recommended for incompletely resectable SSPs given their malignant potential 6
For patients meeting WHO criteria for serrated polyposis syndrome, annual to biennial colonoscopic surveillance is required due to elevated CRC risk and rapid polyp development 2, 6
Referral to clinical genetics services or polyposis registry is recommended for patients with serrated polyposis syndrome 6, 7