Comparison of the morphology and histopathology of large nonpedunculated colorectal polyps in the rectum and colon: implications for endoscopic treatment

Cronin, Oliver; Sidhu, Mayenaaz; Shahidi, Neal; O’Sullivan, Tim; Whitfield, Anthony; Wang, Hunter; Kumar, Puja; Hourigan, Luke F.; Burgess, Nicholas G.; Bourke, Michael J.

doi:10.1016/j.gie.2022.02.022

Cited by 13 publications

(15 citation statements)

References 50 publications

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“…As expected, LocRRs were obtained in lengthier procedures, with larger lesions, with a much larger proportion of non-granular LSTs, with lesions that were already submitted to previous treatments and with the non-lifting sign, and with procedures that needed complementary techniques. Most of these are known risk factors for difficult and non-curative colorectal ESDs [ 6 , 27 , 28 , 29 ], so this baseline difference was expected in this retrospective analysis.…”

Section: Discussionmentioning

confidence: 90%

Risk of Residual Neoplasia after a Local-Risk Resection of Colorectal Lesions by Endoscopic Submucosal Dissection: A Multinational Study

Santos-Antunes,

Pioche,

Ramos-Zabala

et al. 2023

JCM

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Endoscopic submucosal dissection (ESD) in colorectal lesions is demanding, and a significant rate of non-curative procedures is expected. We aimed to assess the rate of residual lesion after a piecemeal ESD resection, or after an en bloc resection but with positive horizontal margins (local-risk resection—LocRR), for colorectal benign neoplasia. A retrospective multicenter analysis of consecutive colorectal ESDs was performed. Patients with LocRR ESDs for the treatment of benign colorectal lesions with at least one follow-up endoscopy were included. A cohort of en bloc resected lesions, with negative margins, was used as the control. A total of 2255 colorectal ESDs were reviewed; 352 of the ESDs were “non-curative”. Among them, 209 were LocRR: 133 high-grade dysplasia and 76 low-grade dysplasia. Ten cases were excluded due to missing data. A total of 146 consecutive curative resections were retrieved for comparison. Compared to the “curative group”, LocRRs were observed in lengthier procedures, with larger lesions, and in non-granular LSTs. Recurrence was higher in the LocRR group (16/199, 8% vs. 1/146, 0.7%; p = 0.002). However, statistical significance was lost when considering only en bloc resections with positive horizontal margins (p = 0.068). In conclusion, a higher rate of residual lesion was found after a piecemeal ESD resection, but not after an en bloc resection with positive horizontal margins.

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Section: Discussionmentioning

confidence: 90%

Risk of Residual Neoplasia after a Local-Risk Resection of Colorectal Lesions by Endoscopic Submucosal Dissection: A Multinational Study

Santos-Antunes,

Pioche,

Ramos-Zabala

et al. 2023

JCM

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“…[4] Whereas LNPCPs located in the proximal colon have a low risk of SMIC, lesions in the distal colon, particularly rectosigmoid, are at far greater risk. [4, 21 ] Whilst these individual risk factors are widely reported, their collective influence on SMIC risk is now also well recognised. [4, 22 , 23 ] The interaction of these characteristics however is complex and difficult to apply in a real-world setting.…”

Section: Discussionmentioning

confidence: 99%

A simplified algorithm to evaluate the risk of submucosal invasive cancer in large (≥20 mm) nonpedunculated colonic polyps

O'Sullivan,

Craciun,

Byth

et al. 2024

Endoscopy

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Background and aims: Recognition of submucosal invasive cancer (SMIC) in large (20mm) non-pedunculated colonic polyps (LNPCPs) informs selection of the optimal resection strategy. LNPCP location, morphology and size influence the risk of SMIC, however currently no meaningful application of this information has simplified the process to make it accessible and broadly applicable. We developed a decision-making algorithm to simplify the identification of LNPCP subtypes with increased risk of potential SMIC. Methods: Patients referred for LNPCP resection from September 2008-November 2022 were enrolled. LNPCPs with SMIC were identified from endoscopic resection specimens, lesion biopsies, or surgical outcomes. Decision tree analysis of lesion characteristics identified in multivariable analysis was used to create a hierarchical classification of SMIC prevalence. Results: 2451 LNPCPs were analysed. 1289 (52.6%) were flat, 1043 (42.6%) nodular and 118 (4.8%) depressed. SMIC was confirmed in 273 (11.1%) of LNPCPs and associated with depressed and nodular versus flat morphology (OR 35.7 CI 22.6-56.5 and 3.5 CI 2.6-4.9, p<0.001 respectively); left versus right colon location (OR 3.2, CI 2.5-4.1, p<0.001); non-granular (NG) versus granular (G) (OR 2.4 CI 1.9-3.1, p<0.001) and size (OR 1.12 per 10mm increase CI 1.05-1.19, p<0.001). Decision tree analysis targeting SMIC identified 8 terminal nodes: SMIC prevalence was 62% in depressed LNPCPs, 19% in nodular left colon LNPCPs and 20% in nodular right colon NG LNPCPs. Conclusions: This decision-making algorithm simplifies identification of LNPCPs with an increased risk of potential SMIC. When combined with surface optical evaluation, it facilitates accurate lesion characterisation and resection choices.

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“…The EMR approach is safe, efficient, and cost-effective compared with surgical alternatives [28,29]. The indications for EMR and ESD for colorectal lesions were addressed in the recent ESD guideline [30] and apply also to this guideline.…”

Section: Definitions Of Polypectomy and Mucosectomymentioning

confidence: 99%

“…In a recent international multicenter parallel-design randomized trial of 660 patients, involving 17 endoscopists of varying experience, all of whom completed a CSP training module [9,29], the use of a thin-wire (0.30 mm) or conventional thick-wire (0.47 mm) snare for CSP of small colorectal polyps (≤ 10 mm) resulted in a very low overall IRR of 1.5 % (as proven by quadrantic resection margin biopsies) [55]. There was no difference in the IRRs in the thin-and thick-wire arms (RR HSP was historically preferred for polyps of 10-19 mm.…”

Section: Resection Of Small Polyps (6-9 Mm)mentioning

confidence: 99%

Colorectal polypectomy and endoscopic mucosal resection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2024

Ferlitsch,

Hassan,

Bisschops

et al. 2024

Endoscopy

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Main Recommendations 1 ESGE recommends cold snare polypectomy (CSP), to include a clear margin of normal tissue (1–2 mm) surrounding the polyp, for the removal of diminutive polyps (≤ 5 mm).Strong recommendation, high quality of evidence. 2 ESGE recommends against the use of cold biopsy forceps excision because of its high rate of incomplete resection.Strong recommendation, moderate quality of evidence. 3 ESGE recommends CSP, to include a clear margin of normal tissue (1–2 mm) surrounding the polyp, for the removal of small polyps (6–9 mm).Strong recommendation, high quality of evidence. 4 ESGE recommends hot snare polypectomy for the removal of nonpedunculated adenomatous polyps of 10–19 mm in size.Strong recommendation, high quality of evidence. 5 ESGE recommends conventional (diathermy-based) endoscopic mucosal resection (EMR) for large (≥ 20 mm) nonpedunculated adenomatous polyps (LNPCPs).Strong recommendation, high quality of evidence. 6 ESGE suggests that underwater EMR can be considered an alternative to conventional hot EMR for the treatment of adenomatous LNPCPs.Weak recommendation, moderate quality of evidence. 7 Endoscopic submucosal dissection (ESD) may also be suggested as an alternative for removal of LNPCPs of ≥ 20 mm in selected cases and in high-volume centers.Weak recommendation, low quality evidence. 8 ESGE recommends that, after piecemeal EMR of LNPCPs by hot snare, the resection margins should be treated by thermal ablation using snare-tip soft coagulation to prevent adenoma recurrence.Strong recommendation, high quality of evidence. 9 ESGE recommends (piecemeal) cold snare polypectomy or cold EMR for SSLs of all sizes without suspected dysplasia.Strong recommendation, moderate quality of evidence. 10 ESGE recommends prophylactic endoscopic clip closure of the mucosal defect after EMR of LNPCPs in the right colon to reduce to reduce the risk of delayed bleeding.Strong recommendation, high quality of evidence. 11 ESGE recommends that en bloc resection techniques, such as en bloc EMR, ESD, endoscopic intermuscular dissection, endoscopic full-thickness resection, or surgery should be the techniques of choice in cases with suspected superficial invasive carcinoma, which otherwise cannot be removed en bloc by standard polypectomy or EMR.Strong recommendation, moderate quality of evidence.

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Comparison of the morphology and histopathology of large nonpedunculated colorectal polyps in the rectum and colon: implications for endoscopic treatment

Cited by 13 publications

References 50 publications

Risk of Residual Neoplasia after a Local-Risk Resection of Colorectal Lesions by Endoscopic Submucosal Dissection: A Multinational Study

Risk of Residual Neoplasia after a Local-Risk Resection of Colorectal Lesions by Endoscopic Submucosal Dissection: A Multinational Study

A simplified algorithm to evaluate the risk of submucosal invasive cancer in large (≥20 mm) nonpedunculated colonic polyps

Colorectal polypectomy and endoscopic mucosal resection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2024

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