Serrated Lesions in Ulcerative Colitis: Beyond Endoscopic Resection

Colectomy remains the standard curative treatment for ulcerative colitis-associated neoplasia (UCAN). This is clearly stated in international guidelines and reflects two key features of ulcerative colitis (UC): chronic inflammation and a high risk of multifocal neoplasia [1-3]. Even with recent advances in endoscopic imaging and resection techniques, local treatment alone cannot remove the long-term cancer risk in the diseased colon. When discussing endoscopic management in UC, it is therefore essential to recognize that colectomy, rather than endoscopic resection, remains the definitive oncologic therapy. Within this framework, improved endoscopic diagnosis has expanded the role of endoscopic resection for carefully selected, well-demarcated visible lesions in UC [1, 4]. In selected patients, this approach may allow deferral of immediate colectomy. However, it should be regarded as a conditional, organ-preserving strategy and not as a curative alternative. Endoscopic resection in UC is appropriate only when it is part of a long-term management plan that recognizes that cancer risk remains and requires strict surveillance [2-5]. In this context, Nishio et al. evaluated the short- and long-term outcomes of endoscopic resection for serrated lesions in patients with UC [6]. Their retrospective exploratory study showed that endoscopic resection of serrated lesions is technically feasible and can be performed with acceptable short-term safety. Notably, their cohort included one case of invasive cancer arising from a traditional serrated adenoma, and metachronous UC-associated neoplasia developed in 50% of patients with ulcerative colitis-associated serrated adenomas during follow-up. This finding indicates that, while endoscopic resection is technically valid, its oncologic limitations should not be overlooked. An important message from the Nishio study is that serrated lesions in UC should not be automatically considered sporadic. Although these lesions may appear similar to sporadic serrated lesions on endoscopy, the development of metachronous UCAN after resection suggests that at least some arise within an inflammation-related, neoplasia-prone mucosal field [6]. This observation suggests that management strategies for sporadic colorectal neoplasia should not be directly applied to patients with UC without careful consideration of the disease background. One possible explanation for these findings is that the molecular and pathological backgrounds of TSA or ulcerative colitis-associated serrated adenomas may differ from those of sporadic sessile serrated lesions. Chronic inflammation and long-standing mucosal injury in UC may promote an inflammation-related serrated pathway, resulting in a neoplasia-prone field effect rather than isolated sporadic tumorigenesis. These findings emphasize that UC-associated lesions should be managed within a multidisciplinary framework. Appropriate decision-making requires close collaboration among experienced endoscopists, gastrointestinal pathologists familiar with UC-associated neoplasia, and IBD specialists [2-5]. Endoscopic resection should not be viewed as the end of treatment. Instead, it represents one step in long-term disease management and must be followed by continuous and careful surveillance. From a clinical standpoint, the results of Nishio et al. support endoscopic resection as a reasonable option for selected serrated lesions when performed by experienced endoscopists [2, 4, 7-9]. Nevertheless, patient selection must be strict. Equally important is patient communication. Patients should be clearly informed that endoscopic resection does not eliminate cancer risk and does not remove the possibility that colectomy may be required in the future. Several limitations should be considered when interpreting this study. These include its retrospective design, single-center setting, and the limited number of serrated lesions analyzed. In addition, standardized diagnostic criteria for serrated lesions in UC have not yet been fully established [2]. The study also did not address serrated epithelial change (SEC). SEC is considered a non-neoplastic serrated alteration observed in the background mucosa of UC. Although it has been associated with an increased risk of synchronous or metachronous neoplasia, it is not currently recognized as a definitive precancerous lesion [10]. Further research is needed to clarify its clinical significance. In conclusion, Nishio et al. provide important insights into the management of serrated lesions in ulcerative colitis. Their study demonstrates that endoscopic resection is feasible in the short term, but long-term UC-associated neoplasia risk remains, underscoring that colectomy remains the standard curative treatment. In clinical practice, careful patient selection is essential when considering endoscopic resection for serrated lesions in UC. This approach should be limited to well-demarcated visible lesions in patients with controlled inflammation, in whom complete resection is feasible and strict post-treatment surveillance can be ensured. The author has nothing to report. The author declares no conflicts of interest. This article is linked to Nishio et al. papers. To view this article, visit http://doi.org/10.1111/den.70089.