Abstract
Prompt diagnosis and correct management of the so called “serrated lesions” (SLs) of the colon-rectum are generally considered of crucial importance in the past years, mainly due to their histological heterogeneity and peculiar clinical and molecular patterns; sometimes, they are missed at conventional endoscopy and are possibly implicated in the genesis of interval cancers. The aim of this review is to focus on the diagnostic challenges of serrated lesions, underlying the role of both conventional endoscopy and novel technologies. We will show how an accurate and precise diagnosis should immediately prompt the most appropriate therapy other than defining a proper follow-up program. It will be emphasized how novel endoscopic techniques may provide better visualization of mucosal microsurface structures other than enhancing the microvascular architecture, in order to better define and characterize specific patterns of mucosal lesions of the gastrointestinal tract. Standard therapy of SLs of the colon-rectum is still very debated, also due to the relatively lack of studies focusing on treatment issues. The high risk of incomplete resection, together with the high rate of postcolonoscopy interval cancers, suggests the need of an extra care when facing this kind of lesions. Given this background, we will outline useful technical tips and tricks in the resection of SLs, taking aspects such as the size and location of the lesions, as well as novel available techniques and technologies, other than future perspectives, including confocal laser endomicroscopy into consideration. Follow-up of SLs is another hot topic, also considering that their clinical impact has been misunderstood for a long time. The incidence of the so called interval colorectal cancer underlines how some weaknesses exist in current screening and follow-up programs. Considering the lack of wide consensus for the management of some SLs, we will try to summarize and clarify the best strategies for their optimal management.
Highlights
Colorectal carcinoma (CRC) is the most common gastrointestinal malignancy as well as the second cause of cancer-related death in USA [1], accounting for almost 50000 deaths and 130000 newly diagnosed cases
Similar results come from other smaller series [72,73,74,75], whereas the risk to find a colorectal cancer at the first endoscopy or at follow-up in patients with Serrated polyposis syndrome (SPS) ranged from 25% to 70%
We have recently demonstrated in a randomized back-to-back trial at our institution [77] that this disposable device, made of a double row of flexible finger-like projection and applied at the tip of the colonoscope, is able to increase the detection of small adenomas (
Summary
Colorectal carcinoma (CRC) is the most common gastrointestinal malignancy as well as the second cause of cancer-related death in USA [1], accounting for almost 50000 deaths and 130000 newly diagnosed cases. Studies in the field of “cancer biology” and prevention led to the concept that colorectal cancer is a heterogeneous disease, developing from different types of “precursors” and, at least, through three different molecular patterns, as further discussed below Both clinical and preclinical researches focused for decades on the role of “adenomatous polyps” as cancer precursors; the adenoma-carcinoma sequence, involving the accumulation of different progressive genetic mutations (APC, K-RAS, DCC, and p53), is widely recognized, and around 50-70% of CRC arises from conventional adenomas and is “microsatellite stable” [2]. Sessile serrated adenoma/polyps with cytologic dysplasia (SSA/P-Ds) meet these criteria, impairing the role of screening colonoscopies in CRC prevention [10] They usually have a right-side colonic location, show molecular hypermethylation, and may appear relatively soon after a complete colonoscopy [11, 12]. Frontiers have been discussed, the role of confocal laser endomicroscopy
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