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15 What Are theOptions forManagement ofLarge Colonic Polyps?
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Quality of
evidence
High
N/A
N/A
N/ANSp=0.015
12.5% vs. 18.8%
0% vs. 0%
43.8% vs. 25%
0% vs. 6.3%
9.5±0.7 vs.
7.3±0.6
Moderate
SignicantNSSignicant
28.6% vs. 4.8%
52.4% vs. 69.1%
Low
p=0.038NSNS
17.7±9.3 vs.
12±7.4
5.7% vs. 15.9%
p<0.001
p<0.001
0% vs. 2.9%
0% vs. 2.9%
42.9% vs. 65.2%
32.9% vs. 59.4%
p<0.001
25.7% vs. 3.1%
185
Complication (other)
En bloc resection
Incomplete resection
Procedure time, min
En bloc resection
Procedure time, min
Complication (any)
Bleeding
Perforation
En bloc resection
(69)
Intervention
group Control group Outcome measures Results Signicance
Study Design
RCT EMR (12) CP (11) Complete resection 75% vs. 18% p=0.006 High
RCT EMR (16) U-EMR (16) Immediate bleeding
a
Study
Horiuchi 2015
[21]
Table 15.3 Summary of studies comparing EMR with other techniques
Yen etal. [22]
EMR (42) U-EMR (42) Bleeding
Retrospective
Cohort
b
Chien etal. [23]
EMR (140) Hybrid ESD
Cohort
Lee 2011 [14] Retrospective
R0 resection
Recurrence
EMR (310) Surgery (81) Complication (any) 0.6% vs. 22.2% p=0.00001 Low
Cohort
Patel 2019 [24] Retrospective
Controlled Trial, U-EMR Underwater EMR
En bloc resection: resection of a polyp in one-piece. R0 resection: resection of a polyp in one-piece with histologically proven negative margins. Complete
resection: resection of a polyp with histologically proven negative margins (not necessarily in one-piece). Incomplete resection: histologically proven margin
CP Conventional Polypectomy, EMT Endoscopic Mucosal Resection, ESD Endoscopic Submucosal Dissection, NS Non-signicant, RCT Randomized
positivity
Difference (%95 CI) levels for bleeding and procedure time are -23.8 ([-38.9]-[-8.7]) and -5.2 ([-8.9]-[-1.6]), respectively
Model failed to converge to assess the signicance level for immediate bleeding, complications, and en bloc resection
a
b
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ESD vs. CP+EMR.Studies comparing ESD with EMR reported conicting results
on perforation rates [10–16]. Some studies reported signicantly higher perforation
rates with ESD (when compared with EMR) [12, 13, 16], whereas some [10, 11, 14,
15] reported no signicant difference. When Hybrid ESD was compared to EMR [12]
and ESD [17–19], there was no signicant difference in perforation rates, with the
exception of 1 study, in which ESD was associated with higher perforation rates [12].
S. Yilmaz and E. Gorgun
Tumor Recurrence
7 studies reported tumor recurrence rates [9, 11–16]. Compared with CP+EMR [9]
and EMR [11–15], ESD was associated with signicantly lower local recurrence
rates. No signicant difference was observed when ESD and U-EMR were compared with each other [16]. Compared to EMR, Hybrid ESD was associated with
lower recurrence rates [12].
Secondary Outcomes
[10] [11, 13, 15–20, 22, 23], studies evaluated the procedure time. ESD, when com-
pared with EMR and Hybrid ESD, was associated with signicantly higher procedure time [11, 13, 15–19]. Gamaleldin etal. [20] compared procedure times between
ESD and surgery (laparoscopic resection) and found no signicant difference.
U-EMR achieved signicantly shorter procedure times than EMR [22, 23].
[3] [14, 15, 20], studies assessed the length of hospital stay. Among 2 studies
comparing EMR and ESD [14, 15], Soliman etal. [14] reported signicantly higher
length of hospital stay associated with ESD, whereas Ham etal. [15] reported no
signicant difference. Compared to surgery, ESD was associated with shorter length
of hospital stay in one study [20], but the result was not statistically signicant.
Ham etal. [15] compared the cost of initial resection between ESD and EMR
(piecemeal), and reported that ESD was associated with signicantly higher cost.
However, patients undergoing EMR needed signicantly higher number of follow up colonoscopies, which in turn evened up the cumulative costs associated with two
procedures. Gamaleldin et al. [20] compared the technical costs associated with
ESD vs. surgery and reported that the cost of ESD was 60% of the cost of surgery.
This result was statistically signicant.
Recommendation
Management of large colonic polyps (≥2cm) require more invasive techniques than
CP (Evidence: moderate; Recommendation: strong). ESD is associated with higher
en-bloc and R0 resection, and lower recurrence rates than EMR. Therefore, for the
management of colonic polyps ≥2cm, ESD should be considered (Evidence: lowmoderate; Recommendation: strong).
15 What Are theOptions forManagement ofLarge Colonic Polyps?
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Compared to surgery, EMR and ESD are associated with lower complication
rates and cost. Furthermore, some patients might be poor surgical candidates (e.g.,
patients with severe comorbidities). Therefore, when possible, EMR and ESD
should be preferred rather than surgery (Evidence: low, Recommendation: strong).
Hybrid ESD is an alternative option for the management of large colonic polyps,
providing shorter procedure times than ESD with equal or lower complication rates.
However, it can be associated with lower en-bloc and R0 resection rates. Therefore,
it can be an option in the treatment of large colonic polyps in certain situations
(Evidence: low, Recommendation: weak).
187
Personal View
Early detection and removal of colorectal neoplasms with colonoscopic polypectomy is a well-established means of decreasing colorectal cancer incidence and mortality [25, 26]. In general, majority of colorectal neoplasms are ≤1cm and can safely
and effectively be removed with standard polypectomy [4]. However, 2–15% of polyps are not amenable for conventional colonoscopic removal due to a variety of reasons such as large size, difcult location, previous resection attempts etc [27, 28]
Traditionally, treatment of endoscopically unresectable tumors has required surgical resection / colectomy due to limited availability of management options and
concerns for malignancy. However, we have previously reported that only 8.4% of
these specimens harbor malignancy [28]. Moreover, colectomy for endoscopically
unresectable tumors is associated with 17–25.3% morbidity and 0.8–1.5% mortality
risk [29, 30].
Advanced endoscopic resection techniques such as EMR, ESD and Hybrid ESD
have been introduced for removal of these complex lesions while allowing patients
to avoid the morbidity and mortality of surgical resection [31, 32]. EMR is highly
effective in the treatment of colorectal lesions <2cm, achieving 86–97.5% en-bloc
and 76.6–95.5% R0 resection rates [33, 34]. When EMR is used to resect large
lesions, en-bloc and R0 resection rates range 26.3–54% [10–14, 35] and 26.3–37%
[10, 12, 14], respectively. Luigiano et al. [35] reported their outcomes with 174
EMRs performed for lesions larger than 2cm, and mentioned that en-bloc resection
was possible only for lesions <3 cm. Iizuka et al. [10] reported that tumor size
≥2 cm is an independent risk factor for piecemeal resection following
EMR.Piecemeal resection reduces the reliability of the histopathological assessment, and is associated with higher local recurrence rates [15, 36]. Given that
increased polyp size is a predictor for malignancy [6, 37], en-bloc resection is preferred to allow accurate histopathological assessment and curative resection [5].
U-EMR uses oating effect of water submersion instead of submucosal injection.
Water submersion helps mucosa and submucosa to be separated from the muscularis layer, hence enables snaring of the polyp [38]. A meta-analysis published in
2020 [39] showed that U-EMR is associated with higher en-bloc resection and
lower recurrence rates, and shorter procedure time without any difference in complication rates when compared with conventional EMR.
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S. Yilmaz and E. Gorgun
Colorectal ESD is an endoscopic resection technique which allows for en-bloc
resection of a neoplasm regardless of its size [8]. For treatment of polyps larger than
2cm, several case series and comparative studies reported 83.5–100% [9, 11–19,
40, 41] en-bloc and 73–94.9% [12, 14–19, 40, 41] R0 resection rates with
ESD. Consequently, tumor recurrence rates following ESD range from 0.5% to
7.6% [9, 11, 13–15], which is signicantly lower compared to EMR [11, 12, 14, 16]
and CP [9]. Despite these advantages, colorectal ESD has not been widely accepted
in clinical practice because it is a technically challenging procedure given the troublesome anatomy of the colon with its folds, exures, thinner wall and narrower
lumen. In fact, perforation rates following ESD can be as high as 10.7% [42].
Colorectal ESD requires a high level of skill. In 2011, Nakajima etal. [43] evaluated the learning curve for ESD in trainees who are experienced in gastric ESD. They
reported that after experience with ≥30 cases, trainees were able to perform colorectal ESD without signicant complications. In their systematic review, Rajendran
etal. [44] assessed learning curves for colorectal polyp resection techniques. They
concluded that to achieve en-bloc resection rate of 80% and R0 resection rate of
70%, a trainee must perform 20–40 cases. Competency in safety was achieved at
20–200 cases. Compared to other techniques, ESD requires a longer procedure time
[11, 13, 16–19]. Rajendran etal. [44] also reported that procedural speed increases
after 30 cases. Nevertheless, for lesions >4cm, ESDmust be performed by experienced endoscopists, due to the longer procedure time [9]. In our experience and
based on our unpublished data, prociency in performing ESD was achieved after
completing around 100 cases.
Hybrid ESD involves circumferential mucosal incision followed by submucosal
dissection to a certain degree and snare resection of the polyp. Since it is a technique
that can use the advantages of both ESD and snaring, it is an attractive method to
achieve safe, rapid, en-bloc resection of colorectal neoplasms [18]. While studies
agree on Hybrid ESD being performed faster [17–19] than ESD, it might be inferior
in terms of achieving en-bloc & R0 resection of large polyps [12, 17].
In conclusion, large polyps are not amenable to be resected with CP. EMR is an
attractive option for the management of polyps that are unsuitable for CP, however,
its efcacy is limited for lesions larger than 2cm [5]. ESD achieves higher en-bloc
and R0 resection and lower tumor recurrence rates. However, it is a technically challenging procedure and might be associated with higher perforation rates.
Nevertheless, it remains to be safer and more cost-effective than surgery [20].
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S. Yilmaz and E. Gorgun
Management oftheMalignant Colon
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Polyp: Resection or Surveillance?
AhmedA.Eltahir andRadhikaK.Smith
Introduction
Malignant polyps are dened as polyps containing cancer cells that invade into but
not through the submucosa of the colon [1]. Malignant polyps make up to 11% of
colorectal polyps [2–4]. Over the last 20 years, participation in age appropriate
colonoscopy screening has more than doubled leading to a 60% increase in the
detection of malignant polyps [5]. With the adoption of advanced endoscopic techniques such as endoscopic mucosal resection (EMR) and, more recently, endoscopic
submucosal dissection (ESD), complete polypectomy at the time of endoscopy is
becoming more commonplace. When these polyps are completely removed at the
time of endoscopy it questions the need for an oncologic resection at these very
early stages of malignancy. Complete endoscopic removal could potentially avoid
the morbidity and mortality associated with subsegmental colectomies and
lymphadenectomy.
When weighing the risks and benets of surgical resection versus ongoing surveillance after polypectomy, the main clinical dilemma to consider is the potential
for regoinal spread to the lymph nodes. It is assumed that malignant polyps are all
very early cancers but our current locoregional staging relies on lymphadenectomy.
The submucosal plane houses the lymphatics and vasculature, and invasive cells in
this layer allow for the potential for regional lymph node metastasis [6]. There are
also certain histological characteristics such as positive margins, poor differentiation, lymphovascular invasion, tumor budding, and deep submucosal invasion which
are associated with lymph node spread and worse outcomes [7, 8]. The
16
A. A. Eltahir (*) · R. K. Smith (*)
Washington University St. Louis, St. Louis, MO, USA
e-mail: a.a.eltahir@wustl.edu; radhikasmith@wustl.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
K. Umanskiy, N. Hyman (eds.), Difcult Decisions in Colorectal Surgery,
Difcult Decisions in Surgery: An Evidence-Based Approach,
https://doi.org/10.1007/978-3-031-42303-1_16
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consideration of these factors, in addition to patients’ underlying health and preferences, should drive the conversation for management of malignant polyps.
A. A. Eltahir and R. K. Smith
Search Strategy
A comprehensive search of PUBMED, Cochrane Library, and the Embase database
was completed to identify cohort studies, reviews, meta-analysis, and other articles
pertaining to malignant colon polyps. The search was limited to articles published
in English between 2002 and 2022. The following keywords were used: malignant,
colon, polyp, carcinoma, pT1, endoscopic resection, and surveillance.
Studies were included if they examined histological characteristics and their
association with mortality, lymph node spread, residual disease, recurrence, or
adverse outcomes. Studies which had incomplete histological evaluations of specimen were excluded. Studies which included benign polyps or advanced carcinomas
in their analysis were also excluded. If articles were published using the same data,
only the most recent article was included.
Results
Malignant polyps account for up to 11% of colorectal polyps [2–4]. Their lymph
node metastatic potential ranges from 6.6 to 16% [9–12]. A variety of retrospective
and prospective studies were conducted to better prognosticate the risks of these
early malignancies to spread to the regional lymph nodes. These data could better
inform clinicians on how to best manage these polyps and potentially avoid overtreatment with surgical resection. Studies published over the last several decades
have reported on the metastatic risk to the lymph node of malignant polyps, differentiating them into low and high risk features [13].
Depth ofInvasion
Polyp morphology has been linked to risk for nodal invasion with sessile polyps
having a higher likelihood of lymph node spread when compared to pedunculated
polyps. Different classications are used to grade the level of invasion of pedunculated and sessile polyps. The Haggitt classication is used for pedunculated polyps
as seen in Fig.16.1. Overall incidence of lymph node spread in pedunculated polyps
is approximately 6%. Many studies have shown that risk of lymph node spread is
<1% of polyps with Haggitt level 1,2, and 3 invasion when the polyp is completely
removed. Level four invasion, however, is associated with a lymph node metastasis
risk of up to 27% [14, 15]. Depth of submucosal invasion in sessile polyps on the
other hand are divided into thirds according to the Kikuchi classication as seen in
Fig.16.2, which can also be seen in the histology slides in Figs.16.3, 16.4 and 16.5.
SM1 polyps carry a risk of lymph node spread of 1–3%, SM2 have an 8% risk, and
Muscularis
mucosa
Adenocarcinoma
4
Submucosa
Adenocarcinoma
SM1
SM2
SM3
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193
Adenomatous
epithelium
Mucosa
Submucosa
Muscularis propria
Level 0
Level 1
Level 2
Level 3
Level
Fig. 16.1 Haggitt classication of pedunculated polyp. (This gure was illustrated by
Shawna Duan)
Adenomatous
epithelium
Mucosa
Muscularis
mucosa
Muscularis
propria
Fig. 16.2 Kikuchi classication of sessile polyp. (This gure was illustrated by Shawna Duan)
SM3 have a risk of 23–27% [16, 17]. It is hard to measure relative invasion of endoscopically resected polyps as the whole submucosa is usually not resected.
Therefore, studies have looked at the degree of invasion with invasion of more than
1mm associated with a higher risk of lymph node spread [7].
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Fig. 16.3 Kikuchi SM 1.
(This gure produced
thanks to Dr. Kathleen
Byrnes and Washington
University in St. Louis
Pathology Department)
Fig. 16.4 Kikuchi SM 2.
(This gure produced
thanks to Dr. Kathleen
Byrnes and Washington
University in St. Louis
Pathology Department)
A. A. Eltahir and R. K. Smith
Margin Positivity
Histologically incomplete resection of malignant polyps is associated with both
lymph node metastasis and residual disease. Boenicke etal. retrospectively studied
105 patients with malignant polyps. They found that histologically incomplete
removal was signicantly associated with lymph node spread with an odds ratio of
10.2 [18]. A meta-analysis encompassing 815 patients found that tumors with lymph
node spread had a 2.36 odds of having positive margins [19]. Butte etal. found that
16% of patients with less than 1mm margins had residual disease while no patients
with a margin 1mm or greater had residual disease [20]. Kim etal. also found that
positive margins were twice as likely to have residual disease [21].
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