Serrated Polyps Quiz

Below you find the correct answers to the 20 cases of the quiz and the percentage of answers given by the participants. The online quiz has been answered by 168 pathologists around the world in January/February 2006. One classic example each of (1) sessile serrated adenoma, (2) traditional serrated adenoma, and (3) hyperplastic polyp is provided as a virtual slide for self-teaching and review purposes. Try to find similarities and differences, as outlined in the following paper: 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; 124:380-391.

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Case 1

75 year-old female, polyp (2.5cm) of the descending colon. The architecture is pedunculated and villiform with serrated glands. There is a uniform population of eosinophilic columnar cells extending to the surface showing mild nuclear pseudostratification and hyperchromasia. Mitoses are uncommon. (Click on the small thumbnail images to see the full view! Close the image window after viewing the image!)

What is your diagnosis for case 1

1 Hyperplastic polyp — 5.4%

2 Traditional serrated adenoma — 45.8%

3 Sessile serrated adenoma — 9.5%

4 Tubular/villous/tubulovillous adenoma — 39.3%

Case 2

63 year-old male, polyp (0.7cm) of the rectum. The lower third of crypts is generally narrow and is lined by proliferative cells. Serration is noted only in the upper half to one-third of crypts. Crypt dilatation and architectural disarray are not present or are not prominent. At the surface, goblet cells are apparent, and pseudostratified and hyperchromatic nuclei are not readily seen. Mitoses are restricted to the lower third of the crypts.

What is your diagnosis for case 2

1 Hyperplastic polyp — 90.5%

2 Traditional serrated adenoma — 3.6%

3 Sessile serrated adenoma — 5.4%

4 Tubular/villous/tubulovillous adenoma — 0.6%

Case 3

49 year-old female, polyp (0.7cm) of the rectum. The architecture is pedunculated and villiform with serrated glands. There is a uniform population of eosinophilic columnar cells extending to the surface showing mild nuclear pseudostratification and hyperchromasia. Mitoses are uncommon.

What is your diagnosis for case 3

1 Hyperplastic polyp — 3.0%

2 Traditional serrated adenoma — 46.4%

3 Sessile serrated adenoma — 26.8%

4 Tubular/villous/tubulovillous adenoma — 23.8%

Case 4

52 year-old female, polyp (0.8cm) of the cecum. The architecture is mostly tubular with some villiform growth. However, serrated glands are not readily seen. There is a uniform population of dysplastic columnar cells with definitive nuclear pseudostratification and moderate to marked hyperchromasia. Mitoses are not difficult to find.

What is your diagnosis for case 4

1 Hyperplastic polyp — 0.0%

2 Traditional serrated adenoma — 1.8%

3 Sessile serrated adenoma — 1.8%

4 Tubular/villous/tubulovillous adenoma — 96.4%

Case 5

68 year-old male, polyp (0.5cm) of the cecum. The lower third of crypts is generally narrow and is lined by proliferative cells. Serration is noted only in the upper half to one-third of crypts. Crypt dilatation and architectural disarray are not present or are not prominent. At the surface, goblet cells are apparent, and pseudostratified and hyperchromatic nuclei are not readily seen. Mitoses are restricted to the lower third of the crypts.

What is your diagnosis for case 5

1 Hyperplastic polyp — 81.5%

2 Traditional serrated adenoma — 6.0%

3 Sessile serrated adenoma — 11.3%

4 Tubular/villous/tubulovillous adenoma — 1.2%

Case 6

75 year-old female, polyp (0.9cm) of the transverse colon. The lower third of crypts is generally narrow and is lined by proliferative cells. Serration is noted only in the upper half to one-third of crypts. Crypt dilatation and architectural disarray are not present or are not prominent. At the surface, goblet cells are apparent, and pseudostratified and hyperchromatic nuclei are not readily seen. Mitoses are restricted to the lower third of the crypts.

What is your diagnosis for case 6

1 Hyperplastic polyp — 75.0%

2 Traditional serrated adenoma — 7.7%

3 Sessile serrated adenoma — 16.7%

4 Tubular/villous/tubulovillous adenoma — 0.6%

Case 7

71 year-old female, polyp (0.5cm) of the rectum. The architecture is mostly tubular with some villiform growth. However, serrated glands are not readily seen. There is a uniform population of dysplastic columnar cells with definitive nuclear pseudostratification and moderate to marked hyperchromasia. Mitoses are not difficult to find.

What is your diagnosis for case 7

1 Hyperplastic polyp — 1.8%

2 Traditional serrated adenoma — 3.0%

3 Sessile serrated adenoma — 7.1%

4 Tubular/villous/tubulovillous adenoma — 88.1%

Case 8

41 year-old male, polyp (1.0cm) of the transverse colon. A "disorganized" serrated architecture is evident, and there is frequent crypt dilatation and crypt branching, especially at the base of crypts. Many crypts show serration that starts at or near the base of the crypt. The surface epithelium is mostly bland with some tufting.

What is your diagnosis for case 8

1 Hyperplastic polyp — 20.8%

2 Traditional serrated adenoma — 24.4%

3 Sessile serrated adenoma — 53.6%

4 Tubular/villous/tubulovillous adenoma — 1.2%

Case 9

42 year-old female, polyp (1.3cm) of the sigmoid colon. The lower third of crypts is generally narrow and is lined by proliferative cells. Serration is noted only in the upper half to one-third of crypts. Crypt dilatation and architectural disarray are not present or are not prominent. At the surface, goblet cells are apparent, and pseudostratified and hyperchromatic nuclei are not readily seen. Mitoses are restricted to the lower third of the crypts.

What is your diagnosis for case 9

1 Hyperplastic polyp — 61.3%

2 Traditional serrated adenoma — 15.5%

3 Sessile serrated adenoma — 22.0%

4 Tubular/villous/tubulovillous adenoma — 1.2%

Case 10

52 year-old male, polyp (1.8cm) of the transverse colon. The architecture is pedunculated and villiform with serrated glands. There is a uniform population of eosinophilic columnar cells extending to the surface showing mild nuclear pseudostratification and hyperchromasia. Mitoses are uncommon.

What is your diagnosis for case 10

1 Hyperplastic polyp — 0.6%

2 Traditional serrated adenoma — 49.4%

3 Sessile serrated adenoma — 19.0%

4 Tubular/villous/tubulovillous adenoma — 31.0%

Case 11

58 year-old female, polyp (1.2cm) of the ascending colon. A "disorganized" serrated architecture is evident in some, but not all areas. There is patchy crypt dilatation and crypt branching, and focal early herniation of epithelium into the submucosa. Some crypts show serration that starts at or near the base of the crypt. The surface epithelium is mostly bland with some tufting. This lesion shows significant morphologic overlap with hyperplastic polyp.

What is your diagnosis for case 11

1 Hyperplastic polyp — 44.6%

2 Traditional serrated adenoma — 17.9%

3 Sessile serrated adenoma — 37.5%

4 Tubular/villous/tubulovillous adenoma — 0.0%

Case 12

49 year-old male, polyp (0.5cm) of the rectum. The lower third of crypts is generally narrow and is lined by proliferative cells. Serration is noted only in the upper half to one-third of crypts. Crypt dilatation and architectural disarray are not present or are not prominent. At the surface, goblet cells are apparent, and pseudostratified and hyperchromatic nuclei are not readily seen. Mitoses are restricted to the lower third of the crypts.

What is your diagnosis for case 12 — %

1 Hyperplastic polyp — 80.4%

2 Traditional serrated adenoma — 8.9%

3 Sessile serrated adenoma — 7.1%

4 Tubular/villous/tubulovillous adenoma — 3.6%

Case 13

62 year-old male, polyp (3.0cm) of the sigmoid colon. The architecture is pedunculated and villiform with serrated glands. There is a population of eosinophilic columnar cells extending to the surface showing mild nuclear pseudostratification and hyperchromasia. Mitoses are uncommon. Portions of this lesion show features of tubular/tubulovillous adenoma, highlighting possible morphologic overlap.

What is your diagnosis for case 13

1 Hyperplastic polyp — 0.6%

2 Traditional serrated adenoma — 34.5%

3 Sessile serrated adenoma — 5.4%

4 Tubular/villous/tubulovillous adenoma — 59.5%

Case 14

54 year-old male, polyp (0.6cm) of the ascending colon. The lower third of crypts is generally narrow and is lined by proliferative cells. Serration is noted only in the upper half to one-third of crypts. Crypt dilatation and architectural disarray are not present or are not prominent. At the surface, goblet cells are apparent, and pseudostratified and hyperchromatic nuclei are not readily seen. Mitoses are restricted to the lower third of the crypts.

What is your diagnosis for case 14

1 Hyperplastic polyp — 85.1%

2 Traditional serrated adenoma — 6.5%

3 Sessile serrated adenoma — 7.1%

4 Tubular/villous/tubulovillous adenoma — 1.2%

Case 15

55 year-old male, polyp (1.5cm) of the cecum. A "disorganized" serrated architecture is evident, and there is frequent crypt dilatation and crypt branching, especially at the base of crypts. Many crypts show serration that starts at or near the base of the crypt. Focal herniation of epithelium into the submucosa is evident. The surface epithelium is mostly bland with some tufting.

What is your diagnosis for case 15

1 Hyperplastic polyp — 11.3%

2 Traditional serrated adenoma — 27.4%

3 Sessile serrated adenoma — 60.1%

4 Tubular/villous/tubulovillous adenoma — 1.2%

Case 16

47 year-old male, polyp (0.6cm) of the ascending colon. The architecture is mostly tubular with some villiform growth. However, serrated glands are not readily seen. There is a uniform population of dysplastic columnar cells with definitive nuclear pseudostratification and moderate to marked hyperchromasia. Mitoses are not difficult to find.

What is your diagnosis for case 16

1 Hyperplastic polyp — 2.4%

2 Traditional serrated adenoma — 7.1%

3 Sessile serrated adenoma — 13.7%

4 Tubular/villous/tubulovillous adenoma — 76.8%

Case 17

59 year-old female, polyp (0.8cm) of the sigmoid colon. The lower third of crypts is generally narrow and is lined by proliferative cells. Serration is noted only in the upper half to one-third of crypts. Crypt dilatation and architectural disarray are not present or are not prominent. At the surface, goblet cells are apparent, and pseudostratified and hyperchromatic nuclei are not readily seen. Mitoses are restricted to the lower third of the crypts.

What is your diagnosis for case 17

1 Hyperplastic polyp — 80.4%

2 Traditional serrated adenoma — 7.1%

3 Sessile serrated adenoma — 7.7%

4 Tubular/villous/tubulovillous adenoma — 4.8%

Case 18

60 year-old male, polyp (3.0cm) of the transverse colon. A "disorganized" serrated architecture is evident, and there is some crypt dilatation and crypt branching, especially at the base of crypts. Serration that starts at or near the base of the crypt is focally present, as is early herniation of epithelium into the submucosa. The surface epithelium is mostly bland with some tufting.

What is your diagnosis for case 18

1 Hyperplastic polyp — 17.3%

2 Traditional serrated adenoma — 13.1%

3 Sessile serrated adenoma — 64.9%

4 Tubular/villous/tubulovillous adenoma — 4.8%

Case 19

43 year-old female, polyp (0.8cm) of the transverse colon. The lower third of crypts is generally narrow and is lined by proliferative cells. Serration is noted only in the upper half to one-third of crypts. Crypt dilatation and architectural disarray are not present or are not prominent. At the surface, goblet cells are apparent, and pseudostratified and hyperchromatic nuclei are not readily seen. Mitoses are restricted to the lower third of the crypts.

What is your diagnosis for case 19

1 Hyperplastic polyp — 74.4%

2 Traditional serrated adenoma — 11.3%

3 Sessile serrated adenoma — 14.3%

4 Tubular/villous/tubulovillous adenoma — 0.0%

Case 20

82 year-old male, polyp (0.5cm) of the rectum. The architecture is mostly tubular with some villiform growth. However, serrated glands are not readily seen. There is a uniform population of dysplastic columnar cells with definitive nuclear pseudostratification and moderate to marked hyperchromasia. Mitoses are not difficult to find.

What is your diagnosis for case 20

1 Hyperplastic polyp — 0.6%

2 Traditional serrated adenoma — 1.2%

3 Sessile serrated adenoma — 0.0%

4 Tubular/villous/tubulovillous adenoma — 98.2%