Endoscopic Assessment and Management of Colorectal Serrated Lesions: Current Comparative Practice, Challenges, and Future Directions

Sep 23, 2026

Uploaded by Mabel

Serrated-carcinoma pathway explains about 15%–30% of sporadic colorectal cancers and drives a disproportionate share of right-sided interval cancers. Key precursors include sessile serrated lesions (SSL) and SSL with dysplasia (SSLD), plus traditional serrated adenoma and superficially serrated adenoma. Evidence for optimal resection indications, technique choice, and post-resection surveillance intervals remains limited and varies across Western and Japanese guidelines. This narrative review proposes practical, standardized approaches grounded in clinicopathologic insights.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages10

Reading Time25 min

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Introduction

Clinicopathological Features of Serrated Lesion

Sessile Serrated Lesion

Digestive Endoscopy REVIEW OPEN ACCESS Endoscopic Assessment and Management of Colorectal Serrated Lesions: Current Comparative Practice, Challenges, and Future Directions Toshio Uraoka1 | Yasushi Yamasaki2 | Kenichiro Imai3 | Hirohito Tanaka1 | Keigo Sato1 | Yuki Itoi1 | Hiroko Hosaka1 | Shiko Kuribayashi1 | Hemchand Ramberan4 | Yoji Takeuchi1 1Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, Gunma, Japan | 2Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan | 3Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan | 4Sentara Health Gastroenterology Specialists, Newport News, Virginia, USA Correspondence: Toshio Uraoka ([uraoka@gunma-u.ac.jp](uraoka@gunma-u.ac.jp); [toshi_urao@yahoo.co.jp](toshi_urao@yahoo.co.jp)) Received: 25 December 2025 | Revised: 4 May 2026 | Accepted: 28 May 2026 Keywords: Colorectal cancer | endoscopic resection | serrated lesion | sessile serrated lesion | sessile serrated lesion with dysplasia ABSTRACT Serrated-carcinoma pathway accounts for approximately 15%–30% of sporadic colorectal cancers (CRC) and contributes disproportionately to right-sided interval cancers. Key precursors include sessile serrated lesion (SSL) and SSL with dysplasia (SSLD); traditional serrated adenoma, and also the recently described superficially serrated adenoma which warrants attention. However, high-quality evidence guiding best practice for resection indications, technique selection, and post-resection surveillance intervals remains limited and varied, with differences between Western and Japanese guidelines. This narrative review integrates clinicopathologic and practical perspectives to provoke further discussion for a standardized universal guideline approach. For nondysplastic SSLs, cold polypectomy techniques may be considered in selected lesions with defined margins and detailed documentation, whereas those with suspected dysplasia, non-lifting or scarring, requiring en bloc resection, favor endoscopic mucosal resection or endoscopic submucosal dissection for accurate histopathology. Surveillance should be prioritized by histopathology and completeness of resection, with an index shorter interval assessment of the resection site at 6–12 months after piecemeal resection or when margins are involved or indeterminate, followed by risk-tiered intervals. Because the detection of serrated lesions determines resection type, quality and surveillance interval, endoscopists should standardize bowel preparation, lesion assessment after mucus cap clearance, use image-enhanced endoscopy when appropriate, and apply targeted dye spray when borders are indistinct. Finally, we outline priority research; prospective, serrated lesion-focused cohorts and trials—to ascertain durable outcomes of cold snare resection strategies, refine surveillance intervals, and reconcile regional practice differences, with the overarching goal of reducing post-colonoscopy interval CRC and overall CRC incidence with high-quality colonoscopy. 1 | Introduction Although colorectal cancer (CRC) has long been known to arise through the adenoma–carcinoma sequence and de novo pathways, the serrated polyp-carcinoma sequence (serrated pathway) has more recently been recognized as a different path to carcinogenesis with distinctive features, including enrichment of BRAF or KRAS mutations, CpG island methylation phenotype, and microsatellite instability [1–4] . The serrated pathway is estimated to account for approximately 15%–30% of sporadic CRCs, representing a substantial proportion [1, 3, 4] . Large serrated lesions are particularly common in women and older adults and are considered to carry a higher risk of malignant transformation. In addition, lifestyle factors such as obesity, smoking, This is an open access article under the terms of the Creative Commons Attribution License

FAQs

What is the serrated-carcinoma pathway and why is it clinically important?

It accounts for about 15%–30% of sporadic colorectal cancers and contributes disproportionately to right-sided interval cancers. It involves distinct molecular and clinicopathologic features and key precursor lesions such as SSL and SSLD.

Which endoscopic resection and technique choices does the review recommend for SSL and SSLD?

For nondysplastic SSL, cold polypectomy may be considered for selected lesions with defined margins and detailed documentation. For suspected dysplasia, non-lifting or scarring, en bloc resection is favored using endoscopic mucosal resection or endoscopic submucosal dissection to enable accurate histopathology.

How should surveillance intervals be determined after resection of serrated lesions?

Surveillance should prioritize histopathology and completeness of resection. An earlier shorter-interval assessment (e.g., 6–12 months) is recommended after piecemeal resection, or when margins are involved or indeterminate, followed by risk-tiered intervals.

Sep 23, 2026

Uploaded by Mabel