Differential pre-malignant programs and microenvironment chart distinct paths to malignancy in human colorectal polyps

Colorectal cancers (CRCs) arise from precursor polyps whose cellular origins, molecular heterogeneity, and immunogenic potential may reveal diagnostic and therapeutic insights when analyzed at high resolution. We present a single-cell transcriptomic and imaging atlas of the two most common human colorectal polyps, conventional adenomas and serrated polyps, and their resulting CRC counterparts. Integrative analysis of 128 datasets from 62 participants reveals adenomas arise from WNT-driven expansion of stem cells, while serrated polyps derive from differentiated cells through gastric metaplasia. Metaplasia-associated damage is coupled to a cytotoxic immune microenvironment preceding hypermutation, driven partly by antigen-presentation differences associated with tumor cell-differentiation status. Microsatellite unstable CRCs contain distinct non-metaplastic regions where tumor cells acquire stem cell properties and cytotoxic immune cells are depleted. Our multi-omic atlas provides insights into malignant progression of colorectal polyps and their microenvironment, serving as a framework for precision surveillance and prevention of CRC. [Display omitted] •A single-cell resolution atlas of human adenomas and serrated polyps•Serrated polyps arise from metaplasia as opposed to stem cell expansion•Cytotoxic immunity in serrated polyps occurs independently of hypermutation•Distinct immune microenvironments track tumor cell-differentiation states A single-cell resolution atlas of human colorectal polyps maps out distinct paths for pre-cancer to cancer transformation, accompanied by differential immune microenvironment features.