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PubMed This is a summary of 15 peer-reviewed journal articles Updated
Gastroenterology

Decoding Your Pathology: Understanding SSLs, TSAs, and HPs

At a Glance

In Serrated Polyposis Syndrome (SPS), understanding your pathology report is key to managing your colon cancer risk. High-risk polyps like Sessile Serrated Lesions (SSLs) and Traditional Serrated Adenomas (TSAs), especially those with dysplasia or larger than 10mm, require frequent screening.

Reading a pathology report can feel like trying to decode a foreign language. However, for patients with Serrated Polyposis Syndrome (SPS), these reports contain vital clues about your unique risk profile. Your doctor uses these details—specifically the type, size, and location of your polyps—to determine how often you need to be screened [1][2].

The Three Main Types of Serrated Polyps

Not all serrated polyps are the same. Your report will likely mention one of these three terms. Understanding them helps clarify your risk:

Polyp Type Description and Risk Level
Hyperplastic Polyp (HP) The most common type. Historically considered harmless. Low immediate risk, but having a very high number of them (especially >20) contributes to an SPS diagnosis [3][4].
Sessile Serrated Lesion (SSL) The “hallmark” of SPS. They are flat, harder to spot, and have a clear potential to develop into cancer via the serrated pathway [5][6].
Traditional Serrated Adenoma (TSA) The rarest type, but carry a very high risk. They look structurally different under the microscope and are considered “advanced” precursors to cancer [7][8].

What is Dysplasia?

If your report mentions dysplasia, it means that some of the cells in a polyp have started to look abnormal under the microscope.

  • Significance: Dysplasia is a “warning light” [9]. It indicates that the polyp has taken a significant step toward becoming cancerous.
  • Management: Finding dysplasia—especially in an SSL—often means your doctor will recommend more frequent check-ups to ensure no other high-risk growths are developing [2][10].

Why Size and Location Matter

In the world of SPS, the right side of your colon (the “proximal” colon) is a high-priority area. Polyps found here, especially SSLs, are more likely to harbor the genetic changes that lead to cancer [6][11].

  • Size (10 mm or larger): Large polyps are more likely to contain dysplasia or early cancer cells [12]. This is why the WHO diagnostic criteria specifically track polyps that are 10 mm or bigger [4].
  • Proximal Location: Polyps in the upper/right side of the colon are sometimes “stealthy”—they are flatter and match the color of the colon lining, making them harder to find without advanced techniques like chromoendoscopy [13][14].

Your Report Completeness Checklist

A high-quality report is your best defense. Ensure your documentation includes the following details for every polyp found. If any of these are missing, ask your doctor for an addendum:

  • [ ] Histology: Identifies if the polyp is an HP, SSL, or TSA [15].
  • [ ] Size: Confirms if polyps are under 5mm, 5-9mm, or ≥10 mm [12].
  • [ ] Location: Doctors must know if polyps are in the “proximal” (right) colon or distal (left) colon [6].
  • [ ] Dysplasia Status: Tells you if the cells have begun pre-cancerous changes [9].
  • [ ] Completeness of Removal: Confirms the doctor “got it all” during the procedure [2].

Common questions in this guide

What is the difference between an HP, SSL, and TSA polyp?
Hyperplastic polyps (HP) are the most common and generally lower risk, though having many of them contributes to an SPS diagnosis. Sessile serrated lesions (SSL) and traditional serrated adenomas (TSA) are higher-risk polyps that have a clear potential to develop into colon cancer.
What does dysplasia mean on my colon pathology report?
Dysplasia means that some cells within the polyp have started to look abnormal under a microscope. It acts as a warning sign indicating the polyp has taken a significant step toward becoming cancerous, which often means you will need more frequent colonoscopies.
Why does the location of my colon polyps matter?
Polyps found on the right side, or proximal colon, are often flatter and harder to spot. In Serrated Polyposis Syndrome, right-sided polyps are more likely to undergo genetic changes that lead to cancer, making them a high priority for removal.
What information must be included in a complete colonoscopy pathology report?
A comprehensive pathology report should list the specific type of each polyp (histology), its exact size, its location in the colon, whether any dysplasia is present, and confirmation that the polyp was completely removed.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.How many of my polyps were SSLs versus HPs, and how many were found in the proximal (right side) colon?
  2. 2.Did any of my polyps show signs of dysplasia? If so, does that change my surveillance schedule?
  3. 3.Were all of my polyps larger than 5 mm successfully removed during this procedure?
  4. 4.Can you provide me with a summary that clearly lists the size, location, and type of every polyp found?

Questions For You

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References

References (15)
  1. 1

    Serrated polyposis syndrome; epidemiology and management.

    Carballal S, Balaguer F, IJspeert JEG

    Best practice & research. Clinical gastroenterology 2022; (58-59()):101791 doi:10.1016/j.bpg.2022.101791.

    PMID: 35988960
  2. 2

    Optimal Endoscopic Treatment and Surveillance of Serrated Polyps.

    Gupta V, East JE

    Gut and liver 2020; (14(4)):423-429 doi:10.5009/gnl19202.

    PMID: 31581390
  3. 3

    The histologic features, molecular features, detection and management of serrated polyps: a review.

    Wang JD, Xu GS, Hu XL, et al.

    Frontiers in oncology 2024; (14()):1356250 doi:10.3389/fonc.2024.1356250.

    PMID: 38515581
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    Impact of changing diagnostic criteria on the diagnosis of serrated polyposis syndrome.

    McWhinney CD, Lahr RE, Lee CJ, et al.

    Endoscopy international open 2023; (11(1)):E39-E42 doi:10.1055/a-1958-2529.

    PMID: 36618871
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    Serrated polyps of the colon and rectum: Remove or not?

    Sano W, Hirata D, Teramoto A, et al.

    World journal of gastroenterology 2020; (26(19)):2276-2285 doi:10.3748/wjg.v26.i19.2276.

    PMID: 32476792
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    Serrated polyps and polyposis of the colon: a brief review for surgeon endoscopists.

    Hyun E, Helewa RM, Singh H, et al.

    Canadian journal of surgery. Journal canadien de chirurgie 2021; (64(6)):E561-E566 doi:10.1503/cjs.018820.

    PMID: 34728521
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    Molecular and histologic considerations in the assessment of serrated polyps.

    Yang HM, Mitchell JM, Sepulveda JL, Sepulveda AR

    Archives of pathology & laboratory medicine 2015; (139(6)):730-41 doi:10.5858/arpa.2014-0424-RA.

    PMID: 26030242
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    Analysis of Immunohistochemical Expression of BRAF (V600E) Mutation in Serrated Colorectal Polyps: A Study from Tertiary Hospital in Oman.

    Al Ghafri A, Sayed SG, Al Badi S, et al.

    Asian Pacific journal of cancer prevention : APJCP 2024; (25(7)):2567-2571 doi:10.31557/APJCP.2024.25.7.2567.

    PMID: 39068592
  9. 9

    Clinical risk factors of colorectal cancer in patients with serrated polyposis syndrome: a multicentre cohort analysis.

    IJspeert JE, Rana SA, Atkinson NS, et al.

    Gut 2017; (66(2)):278-284 doi:10.1136/gutjnl-2015-310630.

    PMID: 26603485
  10. 10

    Germline variant testing in serrated polyposis syndrome.

    Murphy A, Solomons J, Risby P, et al.

    Journal of gastroenterology and hepatology 2022; (37(5)):861-869 doi:10.1111/jgh.15791.

    PMID: 35128723
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    The molecular characteristics of colonic neoplasms in serrated polyposis: a systematic review and meta-analysis.

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    The journal of pathology. Clinical research 2016; (2(3)):127-37 doi:10.1002/cjp2.44.

    PMID: 27499922
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    Colorectal cancer risk factors in patients with serrated polyposis syndrome: a large multicentre study.

    Carballal S, Rodríguez-Alcalde D, Moreira L, et al.

    Gut 2016; (65(11)):1829-1837 doi:10.1136/gutjnl-2015-309647.

    PMID: 26264224
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    Panchromoendoscopy Increases Detection of Polyps in Patients With Serrated Polyposis Syndrome.

    López-Vicente J, Rodríguez-Alcalde D, Hernández L, et al.

    Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association 2019; (17(10)):2016-2023.e6 doi:10.1016/j.cgh.2018.10.029.

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    Reassessment colonoscopy to diagnose serrated polyposis syndrome in a colorectal cancer screening population.

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    Serrated Polyposis Syndrome in a Young Adolescent Patient.

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    PMID: 35984457

This page is intended to help you understand common terms on your pathology report for educational purposes only. Always consult your gastroenterologist or pathologist for interpreting your specific results and determining your screening schedule.

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