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• W2766887152 abstract "Serrated polyposis syndrome (SPS) is perhaps the least understood and most prevalent polyposis syndrome currently known and is associated with an increased prevalence of colorectal cancer (CRC).1IJspeert J.E.G. et al.Gut. 2017; 66: 278-284Crossref PubMed Scopus (73) Google Scholar, 2Carballal S. et al.Gut. 2015; : 1-9Google Scholar In screening populations, prevalence rates of up to 1:127 are reported.3IJspeert J.E.G. et al.Gut. 2016; 0 (gutjnl-2015–3107842)Google Scholar 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.1IJspeert J.E.G. et al.Gut. 2017; 66: 278-284Crossref PubMed Scopus (73) Google Scholar, 2Carballal S. et al.Gut. 2015; : 1-9Google Scholar 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).4Snover D.C. et al.Lyon. 2010; : 160-165Google Scholar 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,5Egoavil C. et al.Gastroenterology. 2017; 153: 106-112Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar 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 the WHO criteria for SPS, and those with ≥50% serrated polyps. Patients fulfilling WHO 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.1IJspeert J.E.G. et al.Gut. 2017; 66: 278-284Crossref PubMed Scopus (73) Google Scholar Third, the primary endpoint in this study was the risk of CRC during surveillance. The authors concluded that CRC risk during follow-up was equal in both groups. Although the number of surveillance colonoscopies was identical between groups, the time interval between colonoscopies was not reported. It is very plausible that SPS patients received more strict surveillance, decreasing CRC incidence. In addition, the quality of the colonoscopy procedure is of great importance for detecting serrated polyps. As the authors state, it is possible that MSP cases have not been diagnosed as SPS during baseline colonoscopy owing to suboptimal polyp detection rates. Details about the cases of interval CRCs are crucial to understand why they occurred and how they could have been prevented. In this respect, patient-specific details about surveillance intervals, findings at initial colonoscopy, and colonoscopy quality would be informative, but were not presented in the current study. Considering the limited amount of supporting evidence, studies questioning the durability of the WHO criteria will improve future guidelines. Because of the lack of prospective studies, for now we will have to rely on retrospective studies such as the study of Egoavil et al.5Egoavil C. et al.Gastroenterology. 2017; 153: 106-112Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar Although biased, this study perfectly showed that the WHO criteria draw a firm line within a disease that seems to be more of a continuum. However, the authors’ recommendation to expand SPS surveillance guidelines to all MSP patients and their first-degree relatives seems reversed reasoning and would unnecessarily expose thousands of individuals to frequent colonoscopy. We believe that the current WHO guidelines already identify a group of patients with a highly variable CRC risk. Future prospective studies should aim to identify those patients with a truly increased risk of CRC, enabling to redefine the current WHO criteria for SPS and provide risk-based surveillance intervals. ReplyGastroenterologyVol. 153Issue 6PreviewWe sincerely appreciate the comments of Bleijenbert et al regarding our study. However, we would like to specify some of these comments. Bleijenbert et al point out potential differences in indications between serrated polyposis syndrome (SPS) and multiple serrated polyps (MSP) patients as a putative cause for the high rate of colorectal cancer (CRC) between these last cases. Although not reported in the manuscript, no differences in the indication for colonoscopy were found between SPS and MSP patients. Full-Text PDF" @default.
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• W2766887152 date "2017-12-01" @default.
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• W2766887152 title "Multiple Serrated Polyps and Serrated Polyposis Syndrome: Equally Hazardous?" @default.
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• W2766887152 doi "https://doi.org/10.1053/j.gastro.2017.05.069" @default.
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