Colon – Sessile serrated adenoma

This article will help you read and understand your pathology report for sessile serrated adenoma.

by David Driman, MBChB FRCPC, updated on May 17, 2018

Quick facts:

• A sessile serrated adenoma is a non-cancerous growth that develops from the cells that line the inside of the colon.
• Sessile serrated adenoma is a type of polyp.
• Another name for sessile serrated adenoma is sessile serrated polyp.
• All sessile serrated adenomas are associated with an increased risk of cancer.

The normal colon

The colon is a part of the gastrointestinal tract which also includes the mouth, esophagus, stomach, small bowel, and anus. The colon is a long hollow tube that starts at the small bowel and ends at the anal canal. The colon is divided into sections which include the cecum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum.

The functions of the colon are to absorb water from the food that we eat and to move waste out of the body.

The colon is made up of five layers of tissue:

1. Mucosa – The mucosa is the tissue that lines the inside surface of the colon. The mucosa includes epithelial cells that form structures called glands. The glands are surrounded and supported by a tissue called lamina propria.
2. Submucosa – The submucosa sits directly below the mucosa. It contains many thick blood vessels and lymphatic channels.
3. Muscularis propria – The muscularis propria is a thick bundle of muscle. The muscles in the muscularis propria help move digested food and waste along the colon.
4. Subserosal adipose tissue – This is a layer of fat that sits directly below the muscularis propria. The subserosal adipose tissue is near the outside surface of the colon.
5. Serosa – The serosa is a thin layer of tissue that covers the subserosal adipose tissue and the outside of the colon.

Polyps

The epithelial cells that line the inside of the colon can develop into polyps, which are small growths. There are several different types of polyp. One of these is known as a sessile serrated adenoma (also known as sessile serrated polyp). Although they sound similar, sessile serrated adenomas are different from tubular, tubulovillous, and villous adenomas that also develop in the colon and rectum.

What is a sessile serrated adenoma?

Sessile serrated adenomas are non-cancerous growth but they can become cancerous if not completely removed. Sessile serrated adenomas are most often found in the right side of the colon, including parts of the colon that are designated as cecum, ascending and transverse colon, but they may occur in any location including the rectum.

Sessile serrated adenomas are relatively new types of polyps, having only been recognized for the past two or so decades. Before this, most of these polyps were called hyperplastic polyps, although we know now that they are different entities. Hyperplastic polyps still occur and are common, but they tend to be found on the left side of the colon, as opposed to the right-sided location of most sessile serrated polyps.

Unfortunately, it is possible for gastroenterologists and surgeons to miss sessile serrated adenomas when doing a colonoscopy as they can be very difficult to see. They can be flat and indistinct and may blend in with the surrounding lining of the colon.

Why is this important? Colon cancer can start in a sessile serrated adenoma. When cancer develops in a sessile serrated adenoma, it usually starts in a pre-cancerous condition called dysplasia.

Dysplasia

Dysplasia is a word pathologists use to describe an abnormal pattern of growth. In the colon, dysplasia can be either low grade or high grade, depending on how abnormal it looks to a pathologist when viewed under the microscope. High grade dysplasia is more closely related to cancer than low grade dysplasia.

Why is this important? All sessile serrated adenomas require complete removal at colonoscopy but the presence of dysplasia may require a quicker repeat colonoscopy if the removal wasn’t complete on the first visit.

Cancer (malignancy) in the sessile serrated adenoma

​Your pathologist will carefully examine the sessile serrated adenoma for any evidence of cancer (malignancy). If a cancer is seen, further surgery may be required.

The need for further surgery will depend on a variety of factors, such as the size of the cancer and whether or not it has been completely removed.

Margins

A margin in an adenoma is the part of the colon or rectum that the gastroenterologist or surgeon cut to remove the abnormal tissue.  Pathologists do not usually state in their report whether the sessile serrated adenoma has been completely removed or not, as this is thought to be best judged by the physician doing the colonoscopy.

If there is cancer within the adenoma, the pathology report must indicate the distance of the cancer from the margin (point at which the adenoma was attached to the colon).

Sessile serrated adenomas are often removed and sent to pathology as multiple pieces (fragments) of tissue. In some of these cases, it will not be possible for your pathologist to determine which piece is the real margin and the changes seen at the margin will not be described in your report.