A WHO update on Serrated Polyps
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![[Epub ahead of print] Sessile serrated adenomas and classical adenomas: An epigenetic perspective on premalignant neoplastic lesions of the](/docs-images/82/85288633/images/1-5.jpg "gastrointestinal tract.")
1 A WHO update on Serrated Polyps Arzu Ensari, MD, PhD Department of Pathology Ankara University Medical School Am J Gastroenterol Nov 2. [Epub ahead of The Clinical Significance of Serrated Polyps. Huang CS, Farraye FA, Yang S, O'Brien MJ. Int J Cancer Dec 10. [Epub ahead of print] Sessile serrated adenomas and classical adenomas: An epigenetic perspective on premalignant neoplastic lesions of the gastrointestinal tract. Dhir M, Yachida S, Van Neste L, Glöckner SC, Jeschke J, Pappou EP, Montgomery EA, Herman JG, Baylin SB, Iacobuzio-Donahue C, Ahuja N. 1
2 Sessile serrated adenoma Pedunculated serrated adenoma Matsumoto, 1999 Matsumoto, 1999 Serrated adenoma Hirono, 2004 Hyperplastic polyp Hirono, 2004 Variant Hyperplastic polyp Jass, 2004 LG dysplastic serrated adenoma Goldstein,
3 overlaps in serrated polyps No concensus on terminology and diagnostic criteria Unreliable molecular data We need to set diagnostic criteria! 3
4 Serrated Polyps Hyperplastic polyp (>75%) Sessile serrated adenoma/polyp (15-25%) (Traditional) serrated adenoma (<10%) (Ad)Mixed polyp Sessile serrated adenoma/polyp with dysplasia Hyperplastic polyposis Serrated polyposis WHO
5 Serrated lesions WHO
6 HP Simple crypt architecture Narrow crypt base Dilated crypts in upper half Serration in upper half Extended proliferation zone Thickened basement membrane 6
7 Not used in routine No clinical significance Mikrovesicular (MVHP) Commonest HP Entire colon Serration prominent Microvacuolation Precursor of SSA/P? Goblet cell (GCHP) Second common Left colon Hyperplastic goblet cells Serration subtle Mucin-poor (MPHP) Very rare Serration prominent Nuclear atypia present WHO
8 SSA/P > 0.5cm, flat lesion Right colon & appendix Architectural Dilatation and branching of basal crypts Inverted, T- or L-shaped crypts Serration both on surface and at base Cytological Asymmetrical distribution of goblet cells Mitosis in upper crypts No dysplasia as a rule SSA/P 8
9 9
10 Straight and narrow crypts <%50 Dilated, T-L- shaped in >2-3 adjacent crypts 10
11 SSA/P cell types crypt base cells (undifferentiated) goblet cells foveolar-type cells HP 11 (64.7) SSA 6 (35.3) TSA 0 Mixed 0 Unclass 0 11
12 12
13 Dysplasia in serrated polyps Premalignant lesion LG and HG dysplasia can occur SSA/P with dysplasia-replaces mixed polyp Traditional -adenomatous- dysplasia Serrated dysplasia (Goldstein, 2008) enlarged round nuclei irregular nuclear membrane prominent nucleoli coarse chromatin 13
14 1424-1C-1&2 HP 0 SSA 4 (23.5) TSA 2 (11.8) Mixed 8 (47.1) Unclass 3 (17.6) 14
15 WHO
16 TSA Entire colon (mostly left) > 1cm, protuberant/pedunculated Villiform surface, complex architecture Irregular, branching and crowding crypts Ectopic crypts Eosinophilic cytoplasm Mild pseudostratification (midphasic nuclei) No surface maturation 16
17 Filliform SA/TSA Large pedunculated polyp Frequent in rectosigmoid 17
18 Ectopic crypts WHO
19 (A) Crypts showing basal dilation and serration in a crescendo fashion in sessile serrated adenomas/polyps (H&E, 200). Ensari A et al. J Clin Pathol 2010;63: by BMJ Publishing Group Ltd and Association of Clinical Pathologists 19
20 MVHP Dysplastic SSA/P Adenocarcinoma SSA/P BRAF mutation Methylation in MLH1 (inhibition of apoptosis) dysplasia MSI H CA TSA? CIMP-H MSS CA KRAS? MGMT metilasyonu? MSI-L CA MSS CA Serrated polyposis At least 5 serrated polyps proximal to sigmoid colon, 2 > 10mm Any number of serrated polyps proximal to sigmoid colon in a person with 1st degree relative with SPS >20 serrated polyps of any size throughout colon WHO,
21 Type 1 SPS Multiple SSA/P Large polyps Proximal colon Ca risk BRAF mutations Type 2 SPS Numerous <5mm HP Entire colon Ca risk Ø KRAS mutations 21
22 Treatment & follow-up All polyps should be excised (except <5mm, distally located, multiple HPs) >1cm polyps should be completely excised Few small polyps - 5 year interval Large polyps - 3 year interval Dysplastic SSA/P control in 1 year, then 3 year interval WHO 2010 WHO 2010 Giant HP Variant HP Serrated adenoma Mixed polyp Hyperplastic polyposis Transitional forms??? Appendix???? IBH-associated serrated polyps????? 22
23 21 European pathologists 1st round - H&E slide set of serrated polyps 2nd round All 70 cases Criteria list A European Multicenter Study on Serrated Polyps Diagnostic categories Concensus discussions after each round Kappa analysis accompanied both sets Overall agreement for the first & second rounds Rounds 1st group (n=15) 2nd group (n=55) Total (n=70) 1st Round kappa value CI lower-ci upper p value nd Round kappa value CI lower-ci upper p value
24 Overall agreement for diagnostic categories 1st Round HP SSA TSA MP UCP 1st group (n=15) 2nd group (n=55) Total (n=70) 2nd Round 1st group (n=15) 2nd group (n=55) Total (n=70) NS p< NS p= p= NS NS NS HP SSA TSA MP UCP NS NS p= p= NS NS NS Thank you 24
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