Dysplasia in pseudopolyps: selection bias, reactive atypia, and the ulcer paradox

Dear Editor, We have reviewed with great interest the prospective study by De Cristofaro et al. on dysplasia in pseudopolyps that were resected endoscopically in patients with inflammatory bowel disease (IBD).1 However, this research method has limitations. The 12% dysplasia rate reported by the authors presents a critical methodological problem due to the exclusion of widespread pseudopolyposis, which significantly impairs mucosal imaging. The 124 resected polyps do not represent the entire spectrum of pseudopolyps encountered in the IBD follow-up population, but only those lesions suspected or technically suitable for resection as determined by the endoscopist. This endoscopist-focused selection, while providing subjectivity, creates a significant bias and may be overly assertive in drawing inferences about the malignant potential of pseudopolyps. Existing studies emphasize that in colons with a high pseudopolyp burden—particularly giant or carpet-type pseudopolyposis—neoplastic lesions may remain concealed within pseudopolyps, and these patients require careful surveillance or targeted resection.2 Notably, this subgroup, which arguably carries the highest risk of masking dysplasia or carcinoma, was excluded from the study.