The US Multi-Society Task Force on Colorectal Cancer has issued a consensus statement on serrated polyposis syndrome, opening with the observation that it is the most common polyposis syndrome and that it frequently goes unrecognised.
The reasons it is missed are structural. Diagnosis rests on WHO clinical criteria built from the size, cumulative lifetime number and location of serrated polyps across the whole colon - which means it cannot be made from one procedure report. It requires somebody to add up findings across several colonoscopies, often performed by different endoscopists in different units, and nothing in a normal workflow prompts that. Management once recognised is meticulous inspection, complete clearing of the colon and frequent surveillance colonoscopy, with colorectal surgery reserved for those who develop cancer or whose polyp burden an expert endoscopist cannot control.
Two points settle recurring questions. There is no common germline pathogenic variant, so germline testing is indicated only where the patient independently meets criteria for a known hereditary syndrome - a negative panel does not exclude the diagnosis, which is clinical. And first-degree relatives are at raised colorectal cancer risk and should have colonoscopic screening, which is the step most often omitted because the syndrome was never named in the notes.
- Add serrated polyp counts across all previous colonoscopies before concluding the criteria are not met.
- Diagnosis is clinical; a negative germline panel does not exclude it.
- Order germline testing only where a known hereditary syndrome is suspected on other grounds.
- Arrange colonoscopic screening for first-degree relatives once the diagnosis is made.
- Write the diagnosis explicitly in the record, so the next endoscopist and the family both inherit it.
Why it matters
This is a diagnosis that has to be assembled across several procedures, which is precisely why the commonest polyposis syndrome is the one most often missed.
Don't overread it
A consensus statement synthesising existing evidence and expert opinion, not new outcome data.
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