Clin Endosc.  2021 Jul;54(4):578-588. 10.5946/ce.2020.198.

Clinical Features and Predictors of Dysplasia in Proximal Sessile Serrated Lesions

• Tan YY
• Tay GSK
• Wong YJ
• Li JW
• Kwek ABE
• Ang TL
• Wang LM
• Tan MTK

• KMID: 2518862
• DOI: http://doi.org/10.5946/ce.2020.198

Abstract

Background/Aims
Proximal colorectal cancers (CRCs) account for up to half of CRCs. Sessile serrated lesions (SSLs) are precursors to CRC. Proximal location and presence of dysplasia in SSLs predict higher risks of progression to cancer. The prevalence of dysplasia in proximal SSLs (pSSLs) and clinical characteristics of dysplastic pSSLs are not well studied.
Methods
Endoscopically resected colonic polyps at our center between January 2016 and December 2017 were screened for pSSLs. Data of patients with at least one pSSL were retrieved and clinicopathological features of pSSLs were analysed. pSSLs with and without dysplasia were compared for associations.
Results
Ninety pSSLs were identified, 45 of which had dysplasia giving a prevalence of 50.0%. Older age (65.9 years vs. 60.1 years, p=0.034) was associated with the presence of dysplasia. Twelve pSSLs were 10 mm or larger. After adjusting for age, pSSLs ≥10 mm had an adjusted odds ratio of 5.98 (95% confidence interval, 1.21–29.6) of having dysplasia compared with smaller pSSLs.
Conclusions
In our cohort of pSSLs, the prevalence of dysplasia is high at 50.0% and is associated with lesion size ≥10 mm. Endoscopic resection for all proximal serrated lesions should be en-bloc to facilitate accurate histopathological examination for dysplasia as its presence warrants shorter surveillance intervals.

Keyword

Dysplasia; Large; Prevalence; Proximal; Sessile serrated lesion

Figure

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  Fig. 1. Proximal sessile serrated lesion without dysplasia. White light (A) and narrow band imaging (NBI) (B) views of a proximal sessile serrated lesion without dys Paris type 0-IIa lesion covered with a mucous cap. On NBI, the lesion has a similar colour to the back without brown vessels, findings consistent with type 1 neoplasm on narrow-band imaging international colorectal endoscopic classification.

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  Fig. 2. Proximal sessile serrated lesion with dysplasia. White light (A) and narrow band imaging (NBI) (B) views of a proximal sessile serrated lesion with dysplasia. Paris Type Is lesion with a nodular surface predictive of cytological dysplasia. On NBI, the lesion appears brown, with visible brown vessels and tubular branched white structures, findings consistent with type 2 neoplasm on narrow-band imaging international colorectal endoscopic (NICE) classification. Typically, NICE-2 lesions predict a histology of tubular adenoma with dysplasia.

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  Fig. 3. Proximal sessile serrated lesion without dysplasia. (A) Hematoxylin and eosin stained section of a 5-mm proximal sessile serrated lesion without dysplasia removed by snare polypectomy. (B, C) Low and mepower microscopic views highlighting the prominent serration with extension down to the basal crypt region and the unequivocal basal crypt dilation (×40, ×100 magnification).

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  Fig. 4. Proximal sessile serrated lesion with dysplasia. (A) Hematoxylin and eosin stained section of a 20-mm proximal sessile serrated lesion with dysplasia resected en bloc by endoscopic submucosal dissection. (B, C) Low and medium power microscopic views of the dysplasia resembling conventional adenoma type within the sessile serrated lesion that is defined by the charserration down to the basal crypt region with the dilation and horizontalization of the basal crypts along the muscularis mucosae (×40, ×100 magnification).

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  Fig. 5. Various endoscopic photos of small proximal sessile serrated lesions (≤5 mm) with dysplasia.

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  Fig. 6. Histopathology of a proximal sessile serrated lesion with dysplasia. (A) Hematoxylin and eosin stained section (×20) of a 5-mm proximal sessile serrated lesion with dysplasia. (B) Higher magnification of the dysplastic focus within the pSSL (×200) characterized by nuclear enlargement, hyperchromasia and pseudo stratification, changes in chromatin pattern and mitoses. pSSLs, proximal sessile serrated lesion.

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  Fig. 7. Histopathology of a proximal sessile serrated lesion with dysplasia. (A) Hematoxylin and eosin stained section of a proximal sessile serrated lesion with dysplasia removed in piecemeal. (B) Medium power view of the dysplascomponent identified in a superficial fragment (×100 magnification). (C-E) Fragments containing the characteristic histological features of sessile serrated lesion serration and basal crypt changes. Cautery artefact is present (×100 magnification).

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