Management of Colorectal Sessile Serrated Lesions in Elderly Patients

ABSTRACT

Sessile serrated lesions (SSLs) are established precursor lesions of colorectal cancer arising through the serrated neoplasia pathway and are estimated to account for a substantial proportion of sporadic colorectal cancers. Accumulating evidence has clarified their distinctive endoscopic, histopathological, and molecular characteristics, including frequent BRAF mutations, CpG island methylator phenotype (CIMP), and progression toward microsatellite instability–high carcinoma. Although the natural history of nondysplastic SSLs is generally slow, lesions that acquire dysplasia may demonstrate more rapid neoplastic progression. With increasing global longevity, the management of SSLs in elderly patients has become a clinically important issue. In this population, clinical decision‐making is complicated by higher risks of colonoscopy‐related adverse events, antithrombotic use, comorbidities, frailty, and reduced tolerance to bowel preparation or sedation. At the same time, the oncologic benefit of endoscopic treatment or continued surveillance may be limited by remaining life expectancy. Current surveillance recommendations for SSLs are gradually becoming more explicit across regions; however, these recommendations are largely extrapolated from studies of conventional adenomas and mixed‐age populations, and elderly‐specific evidence remains limited. Consequently, the management of elderly patients with colorectal SSLs requires individualized decision‐making integrating lesion‐related risk, procedural burden, frailty, life expectancy, and the quality of prior colonoscopic examinations. This review summarizes current evidence regarding colorectal SSLs and discusses practical considerations for individualized management in elderly patients, with particular emphasis on balancing oncologic benefit against procedural risk and long‐term surveillance burden in an aging society.

1. Introduction

Sessile serrated lesions (SSLs) are established precursor lesions in the serrated neoplasia pathway, estimated to account for up to 15%–30% of sporadic colorectal cancers [1]. Over the past decade, extensive research has clarified their distinctive endoscopic, histopathological, and molecular hallmarks, including BRAF V600E mutations, the CpG island methylator phenotype (CIMP), and progression toward microsatellite instability–high (MSI‐H) carcinoma [2, 3, 4, 5, 6]. Although the natural history of non‐dysplastic SSLs is generally indolent, often spanning 10–15 years [7], the development of dysplasia can trigger relatively rapid neoplastic progression, representing a critical window for clinical intervention [8, 9].

With increasing global longevity, the clinical management of SSLs in elderly patients has emerged as a complex and increasingly important issue. In an aging society, clinicians frequently face a fundamental dilemma: the long‐term oncologic benefit of preventing a slow‐growing cancer must be balanced against limited life expectancy and an increased risk of procedure‐related complications. Elderly patients often present with unique clinical profiles—including frailty, multiple comorbidities, and polypharmacy, particularly the use of antithrombotic agents—all of which significantly influence both the safety and the necessity of endoscopic intervention.

Despite the growing clinical importance of this population, high‐quality evidence specifically focused on elderly patients with SSLs remains limited. Most currently available data are derived from studies involving mixed‐age or average‐risk populations, and direct evidence addressing elderly‐specific biological behavior, optimal surveillance strategies, or procedural outcomes remains scarce. Consequently, clinical decision‐making in elderly patients often requires extrapolation from general SSL data in combination with broader geriatric principles and individualized risk assessment.

Therefore, rather than attempting to establish definitive elderly‐specific biological conclusions, this review aims to provide a practical and clinically oriented framework for the management of colorectal SSLs in elderly patients. By integrating currently available evidence with general principles of geriatric endoscopy and real‐world clinical considerations, we discuss key areas of uncertainty and emphasize individualized decision‐making that balances oncologic benefit against procedural burden and life expectancy in an aging population.

2. Prevalence of SSLs

The histopathological definition of serrated lesions has evolved [10, 11, 12, 13, 14], with the terminology shifting from sessile serrated adenoma/polyp (SSA/P) to SSL in the 2019 WHO classification [15]. This update simplified diagnostic criteria by emphasizing the presence of architecturally distorted crypts, potentially leading to increased recognition of SSLs compared with earlier classifications. Key differences between the WHO and JSCCR criteria are summarized in Table 1.

TABLE 1.

Classification and terminology of serrated colorectal lesions according to the WHO and JSCCR guidelines.

	The 4th edition of the WHO classification (2010)	The Japanese Society for Cancer of the Colon and Rectum (JSCCR) criteria	The 5th edition of the WHO classification (2019)
Terminology	SSA/P	SSA/P	SSL
Crypt findings	1. Crypt dilation	1. Dilated crypts	1. Horizontal extension along the muscularis mucosae
	2. L‐shaped or inverted T‐shaped bases	2. Irregular branching of crypts	2. Basal crypt dilatation
	3. Serration extending into the deep portion of the crypt	3. Horizontally arranged crypts in the deep layer (inverted T‐shaped or L‐shaped crypts)	3. Serration extending to the crypt base
	4. Mitotic figures involving the upper third of the crypts		4. Asymmetric proliferation
Diagnostic criteria	At least two to three adjacent crypts demonstrating The above characteristics are present.	Two or more of the above three criteria must be identified In at least 10% of the lesion area.	At least one clearly distorted crypt exhibiting Any of the above four features is identified.

Abbreviations: ESGE, European Society of Gastrointestinal Endoscopy; JGES, Japan Gastroenterological Endoscopy Society; JSCCR, Japanese Society for Cancer of the Colon and Rectum; SSL, sessile serrated lesion; USMSTF, U.S. Multi‐Society Task Force on Colorectal Cancer; WHO, World Health Organization.

The reported prevalence of SSLs varies widely across studies, ranging approximately from 1.4% to 8% [16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26].

This variability is likely attributable to multiple factors, including: (1) differences in endoscopists' recognition skills and detection techniques, (2) variations in the performance of endoscopic imaging devices, (3) interobserver variability among pathologists [27], and (4) historical changes in diagnostic criteria as the terminology evolved from SSA/P to SSL. A meta‐analysis reported a more consistent prevalence of around 4.6%, which is generally regarded as a representative estimate at present [22].

In recent years, reported detection rates of SSLs have gradually increased. However, this trend should be interpreted with caution, as it likely reflects, at least in part, improved endoscopic recognition, increased awareness among endoscopists, and changes in diagnostic criteria, rather than a definitive increase in true disease prevalence [17]. Indeed, one study demonstrated an increase in SSL prevalence from 30.7% in 2019 to 38.3% in 2021 following implementation of the updated criteria [28]. Under the 2019 WHO system, the identification of even a single “distorted crypt” is sufficient for an SSL diagnosis, meaning that some lesions previously categorized as microvesicular hyperplastic polyp (MVHP) are now included within the SSL spectrum.

Ethnic variation has also been reported; for example, the prevalence of SSLs in Asian populations is estimated to be approximately 4.0% [29]. However, such comparisons should be interpreted cautiously, as differences in study design, diagnostic criteria, and detection practices may significantly influence reported prevalence rates.

Importantly, data specifically addressing the prevalence of SSLs in elderly populations remains limited, and current estimates are largely extrapolated from studies including broader age groups. Given these limitations, careful interpretation of epidemiological data is warranted, particularly when applying these findings to elderly patients.

3. Frequency of SSLD: Analysis Incorporating Lesion Size

The reported frequency of SSLs with dysplasia (SSLD) ranges from approximately 5% to 14%, while SSL‐derived carcinoma is observed in 0.9%–1.3% of cases [7, 30, 31]. Although SSLs < 10 mm without dysplasia are associated with a low risk of colorectal cancer [32], once dysplasia develops, neoplastic progression can be relatively rapid [33, 34].

Overall, the risk of SSLD increases with lesion size, a pattern consistent with conventional adenomatous lesions: reported rates of SSLD are 0.9%–1.2% for lesions ≤ 5 mm, increasing significantly to 15.3%–17.3% for those ≥ 21 mm [35, 36, 37, 38, 39]. Notably, larger SSLs are associated with a substantially higher risk of dysplasia, with SSLD reported in up to 37.2% of lesions ≥ 20 mm [33, 40, 41, 42, 43]. While this relationship has important clinical implications, direct evidence regarding age‐related differences in lesion characteristics remains limited.

While environmental factors such as smoking and metabolic syndrome have been linked to SSL development [44, 45, 46, 47, 48], their specific impact on elderly populations remains inconsistent. Taken together, while lesion size is a well‐established risk factor for SSLD, the extent to which this relationship is modified by aging itself remains to be fully elucidated. Nevertheless, the clinical convergence of larger lesion size and advanced age underscores the need for heightened vigilance during colonoscopy in older patients to detect and appropriately manage these high‐risk, size‐dependent dysplastic changes.

4. Molecular Characteristics and Age‐Related Considerations of SSLs

The serrated neoplasia pathway is characterized by distinct molecular features, including BRAF V600E mutations and a high prevalence of the CIMP [1, 2, 3, 4, 5, 6]. These alterations are considered early events in serrated tumorigenesis and distinguish this pathway from the conventional adenoma–carcinoma sequence. In advanced lesions, MLH1 promoter methylation frequently leads to MSI‐H colorectal cancer, representing a key mechanism of malignant transformation. Genome‐wide methylation analyses have further highlighted the importance of epigenetic dysregulation in this pathway, supporting the role of widespread DNA methylation changes in the development and progression of serrated lesions. Emerging evidence also suggests that microRNAs may be involved in serrated tumorigenesis. For example, miR‐31 has been reported to be associated with BRAF‐mutated colorectal cancer, while miR‐135b has been implicated in promoting proliferative activity through regulation of the Wnt signaling pathway [49, 50]. Consistent with these findings, studies analyzing molecular alterations in serrated lesions have also highlighted the complexity of epigenetic regulation in this pathway [51]. These findings underscore the central role of epigenetic alterations in serrated tumorigenesis. However, the extent to which these molecular mechanisms influence the biological behavior of SSLs in elderly patients remains unclear. At present, it also remains uncertain whether these molecular features differ significantly between elderly and younger populations.

In this context, the current evidence does not support molecular characteristics alone as a sufficient basis for risk stratification in elderly patients. Therefore, management decisions should be individualized, taking into account life expectancy, comorbidities, and the specific endoscopic characteristics of each lesion.

5. Endoscopic Features of SSLs and SSLDs

SSLs are typically flat and often covered with adherent mucus, making them easily overlooked under white‐light imaging (WLI) alone. Understanding the characteristic findings of each observation modality is essential for improving diagnostic accuracy (Figure 1).

FIGURE 1.

Representative endoscopic features characteristic of sessile serrated lesions (SSLs). (a) Mucous cap covering the lesion surface. (b) Cloud‐like surface appearance. (c) Dilated and branching vessels (DBVs) indicated by white arrows. (d) Small dark spots within the crypts (white arrows). (e) Expanded crypt openings (ECOs). (f) Varicose microvascular vessels (VMVs) indicated by white arrows. (g) Magnifying chromoendoscopy with crystal violet staining demonstrating a type II open pit pattern. (h) Magnifying chromoendoscopy with crystal violet staining demonstrating a type IIIH pit pattern. These findings have been commonly reported as endoscopic hallmarks of SSLs in previous studies.

5.1. WLI

Characteristic features of SSLs include a pale or faded color tone, the presence of a mucus cap [38], and a cloud‐like surface [52]. Under WLI, lesion borders may appear indistinct, contributing to the risk of missed detection.

5.2. Narrow‐Band Imaging (NBI)/Blue‐Light Imaging (BLI)

In non‐dye‐based imaging, SSLs often exhibit dark spots, which correspond to small brownish openings within an otherwise bland surface architecture resembling the surrounding mucosa [52].

With magnification, SSLs typically show minimal vascularity and are commonly classified as JNET type 1 [53].

More detailed endoscopic features have also been described, including dilated and branching vessels (DVBs), representing dilated, branching superficial vessels [54], various microvascular vessels (VMVs), reflecting subtle deep mucosal microvascular structures [55].

5.3. Chromoendoscopy With Magnification

Unlike the typical type II pit pattern of hyperplastic polyps, SSLs frequently demonstrate an open type II pit pattern, characterized by enlarged, irregularly shaped crypt openings. This pattern has been reported to have high sensitivity and specificity for SSLs [56, 57].

5.4. Endoscopic Features Suggestive of SSLD (Dysplasia)

When dysplasia develops within an SSL, characteristic focal abnormal findings may emerge. Representative endoscopic appearances of SSLD, including lesions with intramucosal and submucosal invasive cancer, are shown in Figure 2.

FIGURE 2.

Representative endoscopic features of sessile serrated lesions with dysplasia (SSLD) at different stages of neoplastic progression. (a–c) SSLD without carcinoma. (a) A flat lesion covered with mucus, showing a focal nodular elevation (white box). (b) Magnifying NBI image of the boxed area demonstrating a neoplastic pattern consistent with JNET type 2A. (c) Magnifying chromoendoscopy with crystal violet staining of the same area showing a type IV pit pattern. (d–f) SSLD with intramucosal carcinoma. (d) A flat lesion with a coarse nodular component at the lesion margin (white box). (e) Magnifying NBI of the nodular component demonstrating JNET type 2A. (f) Magnifying chromoendoscopy with crystal violet staining of the nodular component showing a type IIIL pit pattern. (g–i) SSLD with submucosal invasive carcinoma (SM massive). (g) A reddish depressed area contiguous with the surrounding flat lesion (white arrows). (h) Magnifying NBI of the depressed area demonstrating irregular vascular structures at the lesion margin, consistent with JNET type 2B. (i) Magnifying chromoendoscopy with crystal violet staining showing a severely irregular type VI pit pattern. The lesion shown in panels (g–i) exhibited rapid progression over several months. Endoscopic submucosal dissection was performed, and histopathology revealed submucosal invasive adenocarcinoma arising in an SSL, resulting in non‐curative resection and subsequent surgical management.

These findings include:

• Double elevation or nodular components (Figure 2a,d)

• Central depression or localized erythema [57] (Figure 2g)

• Subpedunculated morphological changes.

• Disrupted surface pattern or irregular microvasculature on NBI/BLI [58] (Figure 2b,e,h)

• JNET type 2 or type 3 appearance [56] (Figure 2e,h)

• Type III, IV, or V pit patterns on magnifying chromoendoscopy [56, 57] (Figure 2c,f,i).

These findings serve as important red flags, signaling progression from a non‐dysplastic SSL to SSLD and warranting careful assessment and timely intervention.

While the fundamental endoscopic features of SSLs and SSLDs do not differ significantly between age groups, several factors specific to elderly patients may hinder accurate diagnosis. In older individuals, inadequate bowel preparation—often due to decreased intestinal motility or poor tolerance to large‐volume polyethylene glycol—can easily obscure the subtle features of SSLs, such as the mucus cap or pale color tone. Furthermore, the presence of redundant colonic folds and diverticular disease, which are more prevalent in the elderly, necessitates even more meticulous observation to avoid missing these often flat and inconspicuous lesions.

These age‐related factors may complicate careful mucosal inspection and potentially contribute to diagnostic difficulty, particularly in the proximal colon, although direct evidence regarding higher SSL miss rates in elderly patients remains limited. This consideration is clinically relevant given the known predominance of serrated lesions in the proximal colon.

6. Procedural Risks and Safety of Colonoscopy in Elderly Patients

The benefits of endoscopic resection for SSLs must be weighed against the increased risk of procedure‐related adverse events in elderly patients. Accumulating data indicate that advanced age is an independent risk factor for complications during and after colonoscopy.

6.1. Overall Adverse Events and Perforation

Large‐scale cohort studies and meta‐analyses have demonstrated that the risk of colonoscopy‐related adverse events increases with advancing age, particularly in patients aged 80 years or older. The incidence of serious complications, including perforation, is consistently higher in this population, with relative risks reported to be approximately 1.5‐ to 2.6‐fold greater than in younger cohorts [59, 60, 61]. These findings are thought to reflect age‐related structural changes, such as reduced colonic wall integrity, increased prevalence of diverticular disease, and greater technical difficulty due to colonic tortuosity.

6.2. Post‐Polypectomy Bleeding (PPB) and Antithrombotic Therapy

Elderly patients are more likely to receive antithrombotic therapy for cardiovascular and cerebrovascular comorbidities, which contributes to an increased risk of PPB. Both advanced age [62] and antithrombotic use [63, 64, 65] have been identified as independent risk factors for delayed PPB. The peri‐procedural management of these agents remains challenging, as interruption may increase thromboembolic risk, whereas continuation increases bleeding risk. Therefore, individualized risk–benefit assessment is essential when planning endoscopic resection in elderly patients.

6.3. Bowel Preparation and Sedation‐Related Risks

The safety and quality of colonoscopy in elderly patients are also influenced by bowel preparation and sedation. Inadequate bowel preparation is more common in older individuals and is associated with reduced mucosal visibility and increased adenoma miss rates, potentially compromising the reliability of surveillance strategies [66, 67]. In addition, elderly patients are more susceptible to preparation‐related adverse events, including dehydration, electrolyte imbalance, and functional decline [59, 68].

Sedation‐related cardiopulmonary complications, such as hypoxia, hypotension, and arrhythmias, are also more frequently observed in elderly patients, particularly in those with underlying comorbidities, and represent the most common category of colonoscopy‐related adverse events [59].

6.4. Frailty, Sarcopenia, and Advanced Endoscopic Procedures

Importantly, procedural risk in elderly patients is not determined by chronological age alone. Frailty and sarcopenia have emerged as key determinants of vulnerability to endoscopic interventions [69, 70]. These conditions are associated with reduced physiological reserve, increased susceptibility to sedation‐related complications, and delayed post‐procedural recovery.

In the context of therapeutic procedures, particularly endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), which often require longer procedure times and deeper levels of sedation, frailty and sarcopenia may further increase the risk of adverse events and hospitalization [69]. Although data specifically addressing SSLs are limited, these patient‐related factors are highly relevant when considering resection strategies in elderly individuals.

6.5. Clinical Implications

Taken together, these findings highlight that the procedural risk of colonoscopy in elderly patients is multifactorial and increases substantially with advancing age. Therefore, the indication for endoscopic resection and surveillance should not be based solely on lesion characteristics but must also incorporate patient‐specific factors, including comorbidities, frailty, and overall life expectancy. This consideration is particularly important in the management of SSLs, given their generally indolent natural history.

7. Strategies for Endoscopic Resection of SSLs in Elderly Patients

The primary goal of SSL resection in elderly patients is the prevention of colorectal cancer while minimizing procedure‐related adverse events. In elderly patients, several studies and clinical guidelines have highlighted that strategies for SSL resection differ from those applied to younger populations, primarily due to differences in life expectancy and procedure‐related risk.

Cold snare polypectomy (CSP) is increasingly used as a practical strategy for non‐dysplastic SSLs, even when piecemeal resection is required for larger lesions [71, 72, 73, 74]. Although piecemeal CSP is increasingly accepted for large non‐dysplastic SSLs, local residual or recurrent lesions may occur after piecemeal resection. Previous studies in the general population have reported recurrence rates ranging from approximately 4% to 5% following piecemeal cold snare resection of large SSLs [71, 74]. However, the clinical implications of such recurrence may differ significantly in elderly patients. Given the generally slow neoplastic progression of nondysplastic SSLs and the competing risks associated with aging, frailty, comorbidities, and repeated colonoscopic procedures, the potential benefit of strict surveillance should be carefully weighed against the cumulative procedural burden and life expectancy. Therefore, decisions regarding post‐resection surveillance should be individualized based on a holistic patient assessment rather than driven solely by the risk of local recurrence. The absence of electrocautery significantly reduces the risk of post‐polypectomy bleeding and delayed perforation, which is particularly beneficial in elderly patients with multiple comorbidities or those receiving antithrombotic therapy. Alternative minimally invasive resection strategies, such as underwater EMR (UEMR), have also been reported for intermediate‐sized SSLs, with favorable complete resection rates in selected cases. Although evidence specific to elderly patients remains limited, these approaches may represent additional therapeutic options when appropriate expertise is available [75].

However, the endoscopic identification of dysplasia within an SSL remains imperfect. Although characteristic features of SSLD can often be recognized with careful inspection using advanced imaging techniques, accurate detection is not always possible. This limitation is particularly relevant in elderly patients, in whom suboptimal bowel preparation [66, 67] and anatomical factors may hinder careful inspection, although direct evidence remains limited. Therefore, careful lesion assessment using high‐definition endoscopy, NBI, and magnifying chromoendoscopy is essential before selecting CSP. Recent advances in computer‐aided characterization systems may further improve the endoscopic recognition and characterization of serrated lesions, including SSLs, although their specific utility in elderly patients remains to be established [76]. When dysplasia is suspected based on features such as nodular elevation or irregular vascular or pit patterns, conventional hot snare polypectomy or ESD should be considered to ensure complete oncologic resection and accurate histopathological evaluation. In contrast, for lesions confidently diagnosed as non‐dysplastic SSLs, CSP remains a rational and safe option in elderly patients to mitigate risks associated with thermal injury.

Therefore, in elderly patients, the selection of resection technique should not rely solely on lesion characteristics but must incorporate an individualized assessment of procedural risk, including comorbidities, antithrombotic therapy, and overall functional status.

8. Surveillance Strategies in Elderly Patients

Current post‐resection surveillance intervals for SSLs are primarily extrapolated from longitudinal studies focusing on adenomatous polyps (Table 2). Major international guidelines, including the US Multi‐Society Task Force (US‐MSTF) [77, 78], the European Society of Gastrointestinal Endoscopy (ESGE) [79], and the Japan Gastroenterological Endoscopy Society (JGES) [80, 81], have proposed specific intervals for SSLs based on their size, number, and the presence of dysplasia (Table 3). While these structured surveillance programs aim to reduce the risk of post‐colonoscopy colorectal cancer [82, 83, 84, 85], their clinical utility in elderly populations remains uncertain, as competing risks of mortality may outweigh the long‐term benefits of cancer prevention.

TABLE 2.

Surveillance recommendations after resection of conventional colorectal adenomas according to major international guidelines.

USMSTF		ESGE		JGES
Normal	10 years
1–2 adenomas < 10 mm	7–10 years	1–4 adenomas < 10 mm	Return to screening (10 years)	≤ 2 Non‐advanced adenomas	3–5 years
3–4 adenomas < 10 mm	3–5 years			3–9 non‐advanced adenomas	3 years
5–10 adenomas	3 years	≥ 5 adenomas < 10 mm	3 years	*Advanced adenoma	1–3 years
*Advanced adenoma	3 years	At least 1 adenoma ≥ 10 mm	3 years	≥ 10 Non‐advanced adenomas	1 year
≥ 11 adenoma	1 year	> 10 adenomas	Referred for genetic counseling	≥ 20 mm adenoma	1 year
Piecemeal resection of adenoma ≥ 20 mm	6 month	Piecemeal resection of adenoma ≥ 20 mm	3–6 months	Tis, T1 cancer	1 year

Abbreviations: ESGE, European Society of Gastrointestinal Endoscopy; JGES, Japan Gastroenterological Endoscopy Society; USMSTF, U.S. Multi‐Society Task Force on Colorectal Cancer.

*Advanced adenoma includes adenomas ≥ 10 mm, adenomas with villous or tubulovillous histology, and those with high‐grade dysplasia. ESGE recommendations apply irrespective of villous or tubulovillous components.

TABLE 3.

Post‐resection surveillance recommendations for SSLs according to major international guidelines.

USMSTF		ESGE		JGES
≤ 20 HP < 10 mm	10 years	< 10 mm without dysplasia	Return to screening (10 years)	SSL (regardless of the lesion size or number)	3–5 years
1–2 SSLs < 10 mm	5–10 years
3–4 SSLs < 10 mm	3–5 years
HP ≥ 10 mm	3–5 years
5–10 SSLs	3 years
SSL ≥ 10 mm	3 years	At least 1 SSL ≥ 10 mm	3 years
SSLD	3 years	SSLD	3 years	SSLD	3 years
		Serrated polyposis syndrome	1 year	Serrated polyposis syndrome	1 year
Piecemeal resection of SSL ≥ 20 mm	6 month	Piecemeal resection of SSL ≥ 20 mm	3–6 months

Abbreviations: ESGE, European Society of Gastrointestinal Endoscopy; JGES, Japan Gastroenterological Endoscopy Society; SSL, sessile serrated lesion; SSLD, sessile serrated lesion with dysplasia; USMSTF, U.S. Multi‐Society Task Force on Colorectal Cancer.

In elderly patients, the decision to continue or discontinue surveillance should be guided by a comprehensive assessment of the benefit–harm balance, considering lesion and patient‐related factors.

8.1. Lesion‐Related Risk

High‐risk lesions: SSL ≥ 20 mm or SSL with dysplasia (SSLD).

Intermediate‐risk lesions: SSLs 10–19 mm or multiple SSLs.

Low‐risk lesions: SSLs < 10 mm without dysplasia.

Lesions removed by piecemeal resection, particularly large SSLs, have been reported to carry a higher risk of local recurrence and therefore warrant careful surveillance.

8.2. Patient‐Related Risk

Reported considerations include estimated life expectancy, use of antithrombotic agents, American Society of Anesthesiologists (ASA) physical status, frailty, cardiopulmonary function and sedation risk, and cognitive status. Several studies have indicated that patients with a life expectancy < 5 years, multiple antithrombotic therapies, ASA physical status ≥ 4, severe frailty, or significant cardiopulmonary impairment derive limited benefit from continued surveillance [59, 60, 61].

8.3. Quality of the Previous Colonoscopy

Quality indicators of the most recent colonoscopic examination reported to influence surveillance decisions include achievement of adequate bowel preparation (clean colon), successful cecal intubation, and absence of poorly visualized segments.

High‐risk lesions, such as SSLs ≥ 20 mm or SSLD, have generally been considered appropriate for active treatment when clinically feasible, irrespective of age. Although SSLs have malignant potential, progression from nondysplastic SSL to dysplasia and subsequent carcinoma has been estimated to require 10–15 years, which is generally considered longer than the conventional adenoma–carcinoma sequence [7]. On the other hand, the risk of serious colonoscopy‐related complications in patients aged 80 years or older is substantially higher than in younger cohorts [59, 60, 61]. These considerations are particularly relevant in SSL management, in which repeated surveillance colonoscopy is frequently recommended because of the risk of metachronous serrated lesions and the importance of careful proximal colon evaluation. Consequently, in elderly patients, the cumulative procedural burden associated with long‐term surveillance strategies should be carefully balanced against the expected oncologic benefit. Therefore, the potential oncologic benefit of surveillance diminishes when a patient's life expectancy is limited, particularly when it is estimated to be less than approximately 10 years [86, 87]. In clinical practice, a life expectancy of approximately 10 years is often considered a practical reference point when weighing the potential benefits of continued surveillance against its risks, although this should not be interpreted as a strict cutoff, and individualized assessment remains essential [86, 87]. In individuals with limited life expectancy or significant frailty, discontinuation of surveillance may be an appropriate option.

Figure 3 illustrates a proposed clinical decision‐making framework integrating lesion‐related risk, patient context, and colonoscopy quality to support individualized management in elderly patients.

FIGURE 3.

Proposed clinical decision‐making framework for the management of sessile serrated lesions in elderly patients. This schematic illustrates a pragmatic approach to the management of SSLs in elderly patients by integrating three key domains: Lesion‐related risk, patient‐related factors, and the quality of the most recent colonoscopic examination. Given the limited availability of elderly‐specific evidence, management decisions often rely on individualized clinical judgment. Based on the balance between oncologic risk and procedural burden, potential management strategies include active endoscopic resection, standard endoscopic treatment, modification of surveillance intervals, or discontinuation of surveillance. This framework is intended to support clinical decision‐making in the context of uncertainty.

9. Conclusion

Clinical management of SSLs in elderly patients requires a nuanced balance between the long‐term benefits of cancer prevention and the immediate risks of procedure‐related complications. While evidence specifically addressing the geriatric population remains limited, SSLs are generally characterized by a slow natural history, although a subset of lesions may progress to dysplasia or carcinoma. This biological heterogeneity underscores the importance of individualized decision‐making in this population.

Meticulous endoscopic assessment is essential to identify high‐risk features such as dysplasia, for which conventional resection methods should be considered. Conversely, for lesions confidently diagnosed as non‐dysplastic SSLs, low‐risk techniques such as CSP may be particularly advantageous in elderly patients, especially those receiving antithrombotic therapy.

Given the increasing procedural risk and competing mortality in elderly populations, clinical decision‐making should be guided by an integrated assessment of oncologic risk and patient‐specific factors rather than lesion characteristics alone. In this context, the decision to pursue resection or surveillance should be individualized, considering overall health status, comorbidities, and life expectancy.

Further prospective studies are warranted to establish robust, age‐specific strategies that optimize clinical outcomes while minimizing unnecessary interventions in an aging society.

Author Contributions

D.O. and N.K.: conception and design. D.O. and N.K. wrote the article, and all authors participated in drafting and critical revision of the article for important intellectual content. All authors gave final approval of the article and agreed to all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding

The authors have nothing to report.

Ethics Statement

The authors have nothing to report.

Conflicts of Interest

N.K. is a deputy editor‐in‐chief of Digestive Endoscopy. Y.T. has received honoraria for lectures from Olympus Co. M.F. has received honoraria for lectures from Olympus Co and Fujifilm Co. The other authors declare no conflicts of interest related to this study.