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Sessile serrated adenoma

From Libre Pathology

Sessile serrated adenoma, abbreviated SSA, is a premalignant

polyp of the large bowel. Sessile serrated adenoma
Diagnosis in short
It is also known as sessile serrated polyp (abbreviated SSP),
sessile serrated lesion and sessile serrated adenoma/polyp
(abbreviated SSA/P). In the United Kingdom, this entity and is
known as a sessile serrated lesion, a terminology that is likely to
be adopted in the 2019/5th edition WHO Blue Book.

This lesion should not be confused with the traditional serrated

adenoma, previously known as serrated adenoma.

Contents
1 General
2 Gross
3 Microscopic
3.1 Dysplasia
3.2 DDx
3.3 Images
4 IHC
5 Sign out
5.1 Dysplasia present
5.2 Block letters
5.2.1 Sign out comment
5.3 Micro
6 See also
SSA. H&E stain.
7 References

Synonyms sessile serrated lesion, sessile serrated

General polyp, sessile serrated adenoma/polyp

Colonic lesion. LM serrated epithelium, crypt base dilation,

May be seen in the context of serrated polyposis crypt branching, boot-shaped glands,
syndrome. horizontal glands
Approximately 5% of SSAs have dysplasia.[1]
LM DDx hyperplastic polyp, tubular adenoma
Epidemiology: when with dysplasia, mucosal prolapse
for left sided lesions or background of
Thought to lead to colorectal cancer through a different diverticulosis
pathway than most tumours in the left colon/rectum.
Microvesicular hyperplastic polyps are hypothesized to IHC Chromogranin A (completely) -ve
be the the precursor of SSAs.[2] Site colon - usually cecum or ascending
colon

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Gross Associated colorectal adenocarcinoma,

Dx hyperplastic polyp
Features:[3]
Syndromes serrated polyposis syndrome, MUTYH
Flat lesions, usually > 5 mm. polyposis syndrome
Typically have a "mucous cap" - present ~65% of the
time; useful for identification.
Prevalence common
Border not well-demarcated.
More common in the proximal colon. Endoscopy flat, usually > 5 mm, mucinous cap
Clin. DDx normal, hyperplastic polyp, other
Note:
intestinal polyps
Sessile lesions over 1 cm are usually SSAs.[3]

Image:

SSA - endoscopy (nature.com) (http://www.nature.com/ajg/journal/v105/n12/fig_tab/ajg2010330f1.html).[4]

Microscopic
Features:

Serrated epithelium at the surface and deep in the crypts.

Saw-tooth appearance, epithelium has jagged appearing edge.
Crypt dilation at base with serrations - key feature.
Very common -- anecdotally the most sensitive feature.
"Boot"-shape or "L"-shaped glands.
Shape may be similar to a hockey stick.
Horizontal crypts = crypt long axis parallel to the muscularis mucosae.
Crypt branching.
Submucosal lipoma or pseudolipoma is often seen in associated with SSA.[citation needed]
Perineuriomas are also seen in a small proportion of cases

Minimal extent criteria - number of abnormal crypts with the above features:

German Society of Pathology proposal: at least two abnormal crypts -- crypts do not have to be
adjacent.[5][6]
An expert panel lead by Rex states that one unequivocally altered crypt should prompt calling SSA.[3]
The 4th edition of the WHO blue book requires - depending on what you read:
Three adjacent crypts to be abnormal.[7]
Two or three adjacent crypts to be abnormal.[5]
The 5th edition is likely to make a single crypt sufficient for diagnosis.

Dysplasia

Sessile serrated adenomas typically lack "conventional" nuclear atypia, as seen in adenomata in the tubulovillous
spectrum. They are nonetheless neoplastic lesions on account of architectural "dysplasia". Additionally, dysplasia
may manifest in more than one way:

Intestinal or "cytological" dysplasia

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As seen in conventional adenomata, i.e. nuclear hyperchromasia and crowding. SSAs with nuclear atypia
may be referred to as advanced sessile serrated adenomas
Serrated dysplasia
Round nuclei, prominent nucleoli and eosinophilic cytoplasm
Minimal deviation dysplasia
As the name suggests, there is only minor architectural and cytological changes. These areas are associated
with loss of MLH1 immunostaining.[8]

DDx
Hyperplastic polyp.
Tubular adenoma - for SSA with dysplasia, TAs often less than 1 cm (uncommon for SSAs).
Mucosal prolapse - especially for left sided lesions and a background of diverticulosis.[9]

Images

SSA - low mag. SSA - intermed. mag. SSA - high mag. SSA - low mag.
(WC/Nephron) (WC/Nephron) (WC/Nephron) (WC/Nephron)

SSA - intermed. mag. SSA - very high mag.

(WC/Nephron) (WC/Nephron)

IHC
Chromogranin A -ve; complete loss of staining.[10]
Normal colorectal mucosa has scattered Chromogranin A-positive cells.
Hyperplastic polyp has increased scattered Chromogranin A-positive cells.

Sign out

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POLYP, CECUM, POLYPECTOMY:

- SESSILE SERRATED ADENOMA.
-- NEGATIVE FOR DYSPLASIA.

POLYP, ASCENDING COLON, POLYPECTOMY:

- SESSILE SERRATED ADENOMA.
-- NEGATIVE FOR DYSPLASIA.

POLYP, HEPATIC FLEXURE OF COLON, POLYPECTOMY:

- SESSILE SERRATED ADENOMA.
-- NEGATIVE FOR DYSPLASIA.

Dysplasia present

Polyp, Ascending Colon, Polypectomy or Biopsy:

- Sessile serrated adenoma with low-grade dysplasia, see comment.

Comment:
Sessile serrated adenomas with dysplasia are considered to be advanced lesions that
have an increased propensity to transform to adenocarcinoma. Complete endoscopic removal is recommended. If complete endoscopi

Block letters

POLYP, ASCENDING COLON, POLYPECTOMY:

- SESSILE SERRATED ADENOMA WITH DYSPLASIA.

The above mirrors the Canadian consensus.[11]

Sign out comment

The Canadian consensus[11] also advocates use of a comment, like the following statement:

Sessile serrated adenomas with dysplasia are considered to be advanced lesions that
have an increased propensity to transform to adenocarcinoma. Complete endoscopic removal
is recommended. If complete endoscopic removal cannot be achieved, short-term re-endoscopy
and biopsy, or surgical resection should be considered.

Micro

The section shows a small polypoid fragment of colonic mucosa with a serrated epithelium that focally extends to
the crypt base. Several dilated crypt bases are seen. One horizontal crypt and one boot-shaped crypt are present.
The epithelium matures to the surface. A small amount of submucosa is present and contains a benign lymphoid
aggregate.

See also
Colorectal polyps.

References
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12019/4/ Sessile serrated adenoma - Libre Pathology

Virchows Arch 457 (3): 291-7. doi:10.1007/s00428-

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