College of American Pathologists



Serrated Polyps, Part 1: Their Confusing History

Posted January 13, 2014

Ryan C. Romano, DO

Historically, colorectal polyps have been classified into two major categories, nonneoplastic and neoplastic, each group having its own signature lesion. Traditionally, hyperplastic polyps nearly exclusively comprosed the nonneoplastic group.1 The majority of remaining polyps was classified as adenomas and were generally thought to be the exclusive precursors to colorectal cancer due to an increased risk of malignant progression when exhibiting villous histology or high-grade dysplasia, or when greater than 1 cm in diameter.2,3 This dichotomous classification system existed for decades, though not without controversy.

Hyperplastic polyps (HPs) were traditionally considered a single entity despite variations in morphologic appearance. They typically demonstrate a prominent serrated or saw-toothed appearance of the basal half of the crypts with rare to absent nuclear atypia or stratification, and normal surface maturation.1,4,5 The serrated histologic architecture is a product of decreased apoptosis of epithelial cells, leading to increased numbers of retained cells and the characteristic serrated appearance.5,6 HPs characteristically are less than 5 mm in size, located in the rectosigmoid and left colon, and carry minimal risk of progression to malignancy. There is a suggested slight increased risk of malignant potential when located in the proximal colon or when larger than 10 mm.6-8 Endoscopically, they are often flat to slightly elevated and pale, and they generally flatten upon insufflation of air.5,6 In general, HPs are considered microsatellite stable and have no consistent immunohistochemical staining pattern. Though some distinct architectural patterns have been suggested, routine subclassifcation of HPs has not been universally adopted in clinical or pathologic practice.6

Traditional serrated adenoma (TSA) is another type of serrated polyp. Originally classified in 1990, TSAs are predominantly left-sided lesions that show prominent serration and traditional adenomatous dysplasia consisting of nuclear enlargement, hyperchromasia, and stratification. TSAs carry a higher risk of progression to carcinoma than traditional adenomas.6,9

The controversy over this dichotomous (hyperplastic polyp and adenoma) classification was born out of reports beginning in the 1970s linking adenocarcinoma with seemingly innocuous hyperplastic polyps.10-12 In 1996 Torlakovic and Snover published the landmark paper that served as the catalyst for further investigation; it described cases of adenocarcinoma that arose out of polyps in patients with hyperplastic polyposis syndrome.13 The polyps of these patients had a unique morphology akin to that of TSAs; however, as compared to the TSAs, the polyps described in this manuscript exhibited less traditional cytologic adenomatous atypia and were more likely to be sessile.13 Detailed analysis of these “hybrid” lesions has given rise to a distinct polyp known as the sessile serrated adenoma (SSA).2,9,13 SSAs characteristically exhibit dilated, branching crypts that are often flattened near the base along the muscularis mucosae, sometimes described as a “boot,” or T- and L-shaped.4,6 Hyperserration of the crypt epithelium is also prominent in the lower third of the crypts. Immunohistochemical profiles have been examined, but they are much too inconsistent to be used routinely in diagnosis.

Collectively, the family of serrated polyps includes hyperplastic polyps, traditional serrated adenomas, sessile serrated adenomas, which are synonymous with sessile serrated polyps (SSP), and mixed polyps that have features of conventional adenomas and serrated polyps.2,5,14 One can see how terminology might hamper appropriate classification of these lesions and effective communication between pathologists and clinicians. In fact, one author describes these lesions in this manner: “A serrated (saw-toothed) architecture is the common morphologic denominator of a group of polypoid bowel lesions that have gained a lot of attention lately and which have generated a still evolving terminology which at this moment seems hopelessly confusing.”15 The distinction of these lesions from one another is based primarily on histologic features identified microscopically, by endoscopic appearance, genetic mutations, and clinical behavior.6,15 Unfortunately, there is significant overlap of morphologic features and considerable interobserver variability in classification of these lesions, making it difficult to accurately assign epidemiological and molecular data, as well as make appropriate recommendations for clinical management.4,16-18

In our follow-on article, we will examine the family of serrated polyps in more detail, including the unique molecular pathway that helps define these lesions.

See Table 1


  1. Snover DC, Jass JR, Fenoglio-Preiser C, Batts KP. Serrated polyps of the large intestine: a morphologic and molecular review of an evolving concept. Am J Clin Pathol. 2005;124(3):380–391.
  2. Sugumar A, Sinicrope FA. Serrated polyps of the colon. F1000 Medicine Reports. 2010;2:89. doi:10.3410/M2-89.
  3. O’Brien MJ, Winawer SJ, Zauber AG, et al. The National Polyp Study. Patient and polyp characteristics associated with high-grade dysplasia in colorectal adenomas. Gastroenterology. 1990;98(2):371–379.
  4. Leggett B, Whitehall V. Role of the serrated pathway in colorectal cancer pathogenesis. Gastroenterology. 2010;138(6):2088–2100. doi:10.1053/j.gastro.2009.12.066.
  5. Odze RD, Goldblum JR. Surgical Pathology of the GI Tract, Liver, Biliary Tract, and Pancreas. 2nd ed. Philadelphia, PA: Saunders Elsevier; 2009:.498-507.
  6. 6
  7. Aust DE, Baretton GB. Members of the Working Group GI-Pathology of the German Society of Pathology. Serrated polyps of the colon and rectum (hyperplastic polyps, sessile serrated adenomas, traditional serrated adenomas, and mixed polyps)—proposal for diagnostic criteria. Virchows Arch. 2010;457(3):291–297.
  8. Weston AP, Campbell DR. Diminutive colonic polyps: histopathology, spatial distribution, concomitant significant lesions, and treatment complications. Am J Gastroenterol. 1995;90(1):24-–28.
  9. Provenzale D, Garrett JW, Condon SE, Sandler RS. Risk for colon adenomas in patients with rectosigmoid hyperplastic polyps. Ann Intern Med. 1990;113(10):760–763.
  10. Longacre TA, Fenoglio-Preiser CM. Mixed hyperplastic adenomatous polyps/serrated adenomas. A distinct form of colorectal neoplasia. Am J Surg Pathol. 1990;14(6):524–537.
  11. Whittle TS Jr, Varner W, Brown FM. Giant hyperplastic polyp of the colon simulating adenocarcinoma. Am J Gastroenterol. 1978;69(1):105-107.
  12. Cooper HS, Patchefsky AS, Marks G. Adenomatous and carcinomatous changes within hyperplastic colonic epithelium. Dis Colon Rectum. 1979;22(3):152–156.
  13. Bengoechea O, Martinez-Peñuela JM, Larrínaga B, Valerdi J, Borda F. Hyperplastic polyposis of the colorectum and adenocarcinoma in a 24-year-old man. Am J Surg Pathol. 1987;11(4):323–327.
  14. Torlakovic E, Snover DC. Serrated adenomatous polyposis in humans. Gastroenterology. 1996;110(3):748–755.
  15. Rex DK, Ahnen DJ, Baron JA, et al. Serrated lesions of the colorectum: review and recommendations from an expert panel. Am J Gastroenterol. 2012;107(9):1315–1329.
  16. Rosai, J, et al. Rosai and Ackerman’s Surgical Pathology. 10th ed. Philadelphia, PA: Mosby Elsevier: 2009:. 752-757.
  17. Glatz K, Pritt B, Glatz D, Hartmann A, O’Brien MJ, Blaszyk H.. A multinational, internet-based assessment of observer variability in the diagnosis of serrated colorectal polyps. Am J Clin Pathol. 2007;127(6):938–945.
  18. Farris AB, Misdraji J, Srivastava A, et al. Sessile serrated adenoma: challenging discrimination from other serrated colonic polyps. Am J Surg Pathol. 2008;32(1):30–35.
  19. Sandmeier D, Seelentag W, Bouzourene H. Serrated polyps of the colorectum: is sessile serrated adenoma distinguishable from hyperplastic polyp in a daily practice? Virchows Arch. 2007;450(6):613–618.

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