To the Editor.—In our recent descriptive timeline of the nomenclature changes for sessile serrated lesion of the colorectum,1  we referenced our international survey assessing pathologist attitudes regarding the World Health Organization (WHO) adoption of this term in 2019.2  Herein, we elaborate on the survey findings.

Our survey focused on the use of, and preferences for, the term sessile serrated lesion. It included 5 multiple-choice questions and an open-ended question providing respondents an opportunity for open commentary. The survey was distributed to practicing pathologists interested in gastrointestinal pathology via email and Twitter (San Francisco, California). Anonymous responses were collected during a 10-day period and analyzed.

We received 358 responses. The multiple-choice questions and their responses are enumerated in the Table. Most respondents (n = 275; 77%) practiced in North America. Prior to the 2019 publication of the 5th edition of the WHO classification of tumors of the digestive system,2  96% (n = 344) of respondents used sessile serrated adenoma (n = 143; 40%), sessile serrated polyp (n = 74; 21%), or combinations thereof (n = 126; 35%). Nearly all pathologists (315 of 317; >99%) in North America, South America, Asia, and Australia/New Zealand used this terminology, whereas a substantial minority of European pathologists (11 of 40; 28%) already used sessile serrated lesion (Figure 1).

Survey Questions and Responses Regarding Sessile Serrated Lesion

Survey Questions and Responses Regarding Sessile Serrated Lesion
Survey Questions and Responses Regarding Sessile Serrated Lesion
Figure 1

Regional differences in terminology preference prior to new recommendations. Most respondents used sessile serrated adenoma (SSA), sessile serrated polyp (SSP), or similar terminology. Significantly more European pathologists (28%) already used the term sessile serrated lesion compared with other regions (P < .001).

Figure 2. Regional differences in acceptance of the term sessile serrated lesion. Relatively few North American pathologists (29%) responded that they planned on adopting the new terminology, whereas respondents from Europe (78%) and Asia (70%) appeared generally in favor of using sessile serrated lesion going forward (P < .001). Note: One North American respondent did not provide a response.

Figure 1

Regional differences in terminology preference prior to new recommendations. Most respondents used sessile serrated adenoma (SSA), sessile serrated polyp (SSP), or similar terminology. Significantly more European pathologists (28%) already used the term sessile serrated lesion compared with other regions (P < .001).

Figure 2. Regional differences in acceptance of the term sessile serrated lesion. Relatively few North American pathologists (29%) responded that they planned on adopting the new terminology, whereas respondents from Europe (78%) and Asia (70%) appeared generally in favor of using sessile serrated lesion going forward (P < .001). Note: One North American respondent did not provide a response.

Most respondents (219 of 358; 61%) reported that they did not intend to adopt the new terminology, with preferences highly correlated with geographic location of practice (Figure 2). Most North American pathologists (195 of 274; 71%) expressed disinterest in following the new WHO recommendation, whereas pathologists in Europe and Asia (31 of 40 [78%] and 21 of 30 [70%], respectively) planned to use sessile serrated lesion (P < .001). Proponents of the new terminology generally cited the view that sessile serrated lesion seemed more accurate than sessile serrated adenoma/polyp based on their understanding of the entity (71 of 138; 51%) and/or new evidence (31 of 138; 22%). Twenty-two percent (31 of 138) who supported the new nomenclature hoped to standardize terminology or abide by international recommendations. Only 11% (15 of 138) felt influenced by the preferences of their colleagues.

Of those who declined to adopt sessile serrated lesion, most (186 of 219; 85%) did so to avoid confusion and/or frustration among gastroenterologists. A substantial number also felt the proposed terminology was neither more accurate than current language (119 of 219; 54%) nor sufficiently superior to established terms (70 of 219; 32%) to justify its use. Furthermore, 10% (21 of 219) reasoned that they simply disliked the new terminology and preferred not to change their practice styles.

Eighty-seven (24%) of the 358 respondents offered opinions in the free-text open commentary space. Among the 79% (69 of 87) directly reflecting attitudes toward the new recommendations, we considered 22% (15 of 69) as positive; these often stated sessile serrated adenoma was a misleading term for these nondysplastic polyps. We considered another 22% (15 of 69) as neutral comments reflecting ambivalence toward the proposed changes. We considered the remaining 56% (39 of 69) as negative opinions, some of which expressed frustration with the WHO for changing nomenclature. The majority of comments from North America were negative (35 of 58; 60%), with 21% positive (12 of 58) and 19% neutral (11 of 58). Comments from Europe and Asia were distributed equally among the 3 categories (2 of 6 [33%] each and 1 of 3 [33%] each, respectively).

We conclude that opinions regarding sessile serrated lesion are highly variable depending on practice location, hindering uniform adoption of the term going forward.

1.
Booth
AL,
Taggart
MW,
Ono
Y,
Gonzalez
RS.
From mixed hyperplastic/adenomatous polyp to sessile serrated lesion
:
a long and winding road for long and winding crypts [published online December 22
,
2020]
.
Arch Pathol Lab Med. doi:10.5858/arpa.2020-0591-RA
2.
Pai
RK,
Mäkinen
MJ,
Rosty
C.
Colorectal serrated lesions and polyps
.
In:
WHO Classification of Tumours Editorial Board, ed. WHO Classification of Tumours: Digestive System Tumours. 5th ed
.
Lyon, France
:
International Agency for Research on Cancer;
2019
.

The authors have no relevant financial interest in the products or companies described in this article.

Presented at the United States and Canadian Academy of Pathology annual meeting; March 3, 2020; Los Angeles, California.