The April 2008 issue of GI & Hepatology News (GIHN) featured an article by Roy M. Soetikno, MD, MS, FASGE and his colleagues from the Palo Alto VA Medical Center in California. They drew our attention to nonpolypoid (flat) colonic lesions in an article from JAMA (2008;299:1027-35).
Coincidentally, the week before this article appeared, I was sitting with Roy in Kyoto, Japan, at a conference of international experts focused on flat colonic lesions. The Japanese definitions of flat and depressed lesions were markedly different from those used by Western physicians. We now know that most flat lesions seen by U.S.-based endoscopists are sessile serrated adenomas (SSAs). SSAs at that time also were a new and controversial classification. SSAs were first described by Torlakovic and Snover in 1996 (Gastroenterology 1996;110:748-55).
Dale Snover, MD, was my golfing partner and read pathology slides for our practice in Minneapolis, so we were the first gastroenterologists in the country to grapple with the clinical implications of SSAs. Roy’s article was accompanied by an excellent commentary by Jerome D. Waye, MD, FASGE, who emphasized the importance of a slow withdrawal time and meticulous visual technique during colonoscopy.
Key points in the JAMA article were a) prevalence of flat lesions was about 9% in a screening population, b) small flat polyps can harbor advanced histologic changes including cancers, and c) many physicians who perform colonoscopy missed these lesions putting patients at risk for interval colon cancers.
Dr. John I. Allen
The GIHN piece, referencing Soetikno’s article, helped inform us about an important (and confusing) problem in our colon cancer prevention efforts. As numerous authors subsequently highlighted (see Gastroenterology 2016;151:870-8) most cancers, missed at initial colonoscopy, are proximal and frequently develop from SSAs. We continue to work to reduce missed cancers and thanks to this seminal article, we have better insights about how to achieve this goal.
John I. Allen, MD, MBA, AGAF, is professor of medicine in the division of gastroenterology and hepatology at the University of Michigan, Ann Arbor, and the Editor in Chief of GI & Hepatology News.
