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Multiple Serrated Polyps and Serrated Polyposis Syndrome: Equally Hazardous?

1 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 Dear Editors: Serrated polyposis syndrome (SPS) is perhaps the least understood andmost prevalent polyposis syndrome currently known and is associated with an increased prevalence of colorectal cancer (CRC). In screening populations, prevalence rates of up to 1:127 are reported. Little is known about the pathophysiology, but likely a combination of genetic and environmental factors (most notably smoking) lies at the heart of this disease. The limited understanding of the syndrome’s etiology has led to the use of clinical diagnostic criteria, which were arbitrarily defined by the World Health Organization (WHO). Therefore, it is of great importance to investigate whether these criteria indeed identify those patients that need strict surveillance. With great interest we read the article by Egoavil et al, who assessed the risk of CRC in patients with SPS, as compared with those who harbor multiple serrated polyps (MSP) but do not fulfill the WHO criteria. The authors conclude that patients with MSP(ie,>10 polyps of which 50% are serrated polyps) harbor the same risk of developing CRC as patients with SPS and should require the same follow-up as proposed for SPS patients, that is, annual or biannual colonoscopy. Although interesting results, we believe that the patient selection and retrospective study design significantly impair the external validity of this study. Also, the final statement regarding the expansion of the definition of the WHO criteria seems debatable. The authors selected their patients from a previously collected cohort that underwent colonoscopy because of either symptoms, screening, or familial screening.Although the indication for colonoscopy is of great influence on the pretest likelihood of detecting CRC, differences in indications between the SPS and MSP group were not reported, hindering comparison. For example, the greater number of adenomas in the MSP group could suggest that a greater proportion of this group was derived from a fecal immunochemical test-based screening program, a triage method to identify patients with advanced adenomas and CRC. If so, this could be an important reason for the substantial CRC prevalence in the MSP group. Second, the study represents only a selective subgroup of SPS patients with possibly a lower risk for CRC. Patients were included in the initial cohort if 10 polyps were found (not including distal hyperplastic polyps). From this cohort, the authors selected 2 groups of patients: those fulfilling theWHO criteria for SPS, and thosewith 50%serratedpolyps. Patients fulfillingWHO criterion 1, but not harboring 10 polyps, were not included. According to Table 1, smokers and probably also patients fulfilling WHO criterion 3, are overrepresented in the SPS group. This type of SPS patients have been shown to have a markedly lower risk of CRC in a previous study.