Types of colorectal adenoma

While most colorectal polyps can be classified as either adenomas (AD) or hyperplastic polyps (HP), approximately 5 % have some of the features of these lesions but are distinguishable from both. These lesions include sessile serrated adenoma or polyp (SSP), mixed polyp (MP), and traditional serrated adenoma (SA). These relatively recently described entities account for only about 3%, 1% and 1% of colorectal polyps respectively. Nevertheless, they may serve as the precursor lesions of the subset of colorectal cancer (15-20%) with extensive DNA methylation, mutation of BRAF, and DNA microsatellite instability. This overview summarises the key morphological features of traditional and newer types of colorectal polyps. It also discusses the differing molecular signatures of polyps, focusing on mutation of BRAF and KRAS and alterations of TP53 and the DNA repair genes O-6-Methylguanine DNA Methyltransferase (MGMT) and MLH1. A more detailed description of the features of MPs and SA is then developed and it is shown that these polyps are highly heterogeneous lesions in terms of both morphology and molecular pathology. Finally, a simple working nomenclature for the diagnostic reporting of colorectal polyps is suggested. In this system, MPs and SAs are combined as 'serrated polyps with dysplasia'. It is likely that the recognition and diagnosis of serrated polyps of the colorectum will assume increasing importance in the coming years and that their complex morphology and molecular heterogeneity will present interesting challenges for pathologists, scientists and clinicians.