Polyp like a firework!

This polyp is pretty when viewed by the endoscopy but stunning below the microscope! 
WHAT IS THE HISTOLOGY?

a) Tubular adenoma (TA)

This polyp is prettier than that!

b) Tubulovillous adenoma (TVA)

Endoscopically it could be but histology says otherwise!

c) Villous adenoma (VA)

Absolutely!

d) Traditional Serrated Adenoma (TSA)

Endoscopically Yes, but histologically No!

e) Sessile Serrated Lesion (SSL)

Would be unusal for an SSL to be 'subpedunculated'

explanation

Endoscopically it can be difficult to recognise a villous adenoma. Unless you submerge the lesion to see the villi rise up like the arms of a sea anemone.  Apparently, they are quite difficult to 'process' by the pathology lab as well. They are fragile and those beautiful villi, easily become damaged. 

Of course, villous adenomas are regarded as 'high risk lesions'.  The other high risk findings often used as surrogate markers for cancer in guidelines are: having 3 or more adenomas, polyps 10mm or larger, and polyps harbouring high-grade dysplasia.  

However, if you have to make a choice of the two strongest predictors of future cancer risk, a study in Gastroenterology found that it would be;  finding a polyp 2cm or larger and resecting a polyp found to harbour HGD [Gastroenterology 2019;158(4);875-83].