Abstract
Recent advances, both in technology and technique, now allow endoscopists to successfully manage many patients with colorectal neoplasia who were previously referred for colectomy. Malignant polyps with superficial submucosal invasion can be cured with endoscopic resection, whereas surgery is reserved for those with high risk for lymph node metastasis. In this chapter, we briefly discuss colorectal cancer (CRC) carcinogenesis pathways, how to assess potentially malignant polyps for resectability, and then present a management algorithm.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
International Agency for Research on Cancer. Globocan 2018: cancer fact sheets – colorectal cancer. IARC. http://gco.iarc.fr/today/data.factsheets/cancers/10_8_9-Colorectum-fact-sheet.pdf.
Fleming M, Ravula S, Tatischchev SF, Wang HL, et al. Colorectal carcinoma: pathologic aspects. J Gastrointest Oncol. 2013;3:153–73.
Conteduca V, Sansonno D, Russi S, et al. Precancerous colorectal lesions. Int J Oncol. 2013;43:973–84.
Williams JG, Pullan RD, Hill J, et al. Management of the malignant colorectal polyp: ACPGBI position statement. Colorectal Dis. 2013;15(Suppl 2):1–38.
National Comprehensive Cancer Network. Clinical practice guidelines in oncology; colon cancer (v3.2018). Available at https://www.nccn.org/professionals/physician_gls/pdf/colon.pdf.
Rex DK, Hassan C, Bourke MJ. The colonoscopist’s guide to the vocabulary of colorectal neoplasia: histology, morphology, and management. Gastrointest Endosc. 2017;86:253–63.
Winawer SJ, Zauber AG, Ho MN, et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med. 1993;329:1977–81.
Atkin W, Morson B, Cuzick J. Long-term risk of colorectal cancer after excision of rectosigmoid adenomas. N Engl J Med. 1992;326:658–62.
Zauber AG, Winawer SJ, O’Brien MJ, et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med. 2012;366:687–96.
Keum N, Giovannucci E. Global burden of colorectal cancer: emerging trends, risk factors and prevention strategies. Nat Rev Gastroenterol Hepatol. 2019;16:713–32.
World Health Organization. Classification of tumours of the digestive tract. Lyon: IARC Press; 2019.
Dixon MF. Gastrointestinal epithelial neoplasia: Vienna revisited. Gut. 2002;51:130–1.
Salmo E, Haboubi N. Adenoma and malignant colorectal polyp: pathological considerations and clinical applications. EMJ Gastroenterol. 2018;7:92–102.
Fleming M, Ravula S, Tatishchev SF, et al. Colorectal carcinoma: pathologic aspects. J Gastrointest Oncol. 2012;3:153–73.
Heitman SJ, Ronskley PE, Hilsden RJ, et al. Prevalence of adenomas and colorectal cancer in average risk individuals: a systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2009;7:1272–8.
Crockett SD, Nagtegaal ID. Terminology, molecular features, epidemiology, and management of serrated colorectal neoplasia. Gastroenterology. 2019;157:949–66.
Saito S, Tajiri H, Ikegami M. Serrated polyps of the colon and rectum: endoscopic features including image enhanced endoscopy. World J Gastrointest Endosc. 2015;7:860–71.
Fearon ER, Vogelstein B. A genetic model for colorectal tumorigenesis. Cell. 1990;61:759–67.
Dow LE, O’Rourke KP, Simon J, et al. Apc restoration promotes cellular differentiation and reestablishes crypt homeostasis in colorectal cancer. Cell. 2015;161:1539–52.
Nakayama M, Oshima M. Mutant p53 in colon cancer. J Mol Cell Biol. 2019;11:267–76.
O’Brien MJ, Yang S, Clebanoff JL, et al. Hyperplastic (serrated) polyps of the colorectum: relationship of CpG island methylator phenotype and K-ras mutation to location and histologic subtype. Am J Surg Pathol. 2004;28:423–34.
Bond CE, Liu C, Kawamata F, et al. Oncogenic BRAF mutation induces DNA methylation changes in a murine model for human serrated colorectal neoplasia. Epigenetics. 2018;13:40–8.
Weisenberger DJ, Siegmund KD, Campman N, et al. CpG island methylator phenotype underlies sporadic microsatellite instability and is tightly associated with BRAF mutation in colorectal cancer. Nat Genet. 2006;38:787–93.
Rex DK, Shaukat A, Wallace MB. Optimal management of malignant polyps, from endoscopic assessment and resection to decisions about surgery. Clin Gastroenterol Hepatol. 2019;17:1428–37.
Compton CC. Key issues in reporting common cancer specimens: problems in pathologic staging of colon cancer. Arch Pathol Lab Med. 2006;130:318–24.
Moss A, Bourke MJ, Williams SJ, et al. Endoscopic mucosal resection outcomes and prediction of submucosal cancer from advanced colonic mucosal neoplasia. Gastroenterology. 2011;140:1909–18.
Lopez A, Bouvier AM, Jooste V, et al. Outcomes following polypectomy for malignant colorectala polyps are similar to those following surgery in the general population. Gut. 2019;68:111–7.
The Paris endoscopic classification for superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointest Endosc. 2003;58(6 suppl):S3–S43.
Endoscopic Classification Review Group. Update on the Paris classification of superficial neoplastic lesions in the digestive tract. Endoscopy. 2005;37:570–8.
Okamoto T, Tanaka S, Haruma K, et al. Clinicopathologic evaluation on colorectal laterally spreading tumor (LST). Nihon Shokakibyo Gakkai Zasshi. 1996;93:83–9.
Soetikno RM, Kaltenbach T, Rouse RV, et al. Prevalence of nonpolypoid (flat and depressed) colorectal neoplasms in asymptomatic and symptomatic adults. JAMA. 2008;299:1027–35.
Rembacken BJ, Fujii T, Cairns A, et al. Flat and depressed colonic neoplasms: a prospective study of 1000 colonoscopies in the UK. Lancet. 2000;355:1211–4.
Kudo S, Lambert R, Allen JL, et al. Nonpolypoid neoplastic lesions of the colorectal mucosa. Gastrointest Endosc. 2008;68(4 Suppl):S3–S47.
Burgess NG, Hourigan LF, Zanati SA, et al. Risk stratification for covert invasive cancer among patients referred for colonic endoscopic mucosal resection: a large multicenter cohort. Gastroenterology. 2017;153:732–42.
Kudo S, Hirota S, Nakajima T, et al. Colorectal tumours and pit pattern. J Clin Pathol. 1994;47:880–5.
Togashi K, Konishi F, Ishizuka T, et al. Efficacy of magnifying endoscopy in the differential diagnosis of neoplastic and non-neoplastic polyps of the large bowel. Dis Colon Rectum. 1999;42:1602–8.
Tung SY, Wu CS, Su MY. Magnifying colonoscopy in differentiating neoplastic from nonneoplastic colorectal lesions. Am J Gastroenterol. 2001;96:2628–32.
Konishi K, Kaneko K, Kurahashi T, et al. A comparison of magnifying and nonmagnifying colonoscopy for diagnosis of colorectal polyps: a prospective study. Gastrointest Endosc. 2003;57:48–53.
Draganov PV, Gotoda T, Yang D. Advanced techniques for endoscopic resection in the GI tract. 1st ed. Thorofare: Slack Incorporated; 2019. p. 26.
Sano Y, Horimatsu T, Fu KI, et al. Magnifying observation of microvascular architecture of colorectal lesions using a narrow band imaging system. Dig Endosc. 2006;18:S44–51.
Sano Y, Ikematsu H, Fu KI, et al. Meshed capillary vessels by use of narrow-band imaging for differential diagnosis of small colorectal polyps. Gastrointest Endosc. 2009;69:278–83.
Katagiri A, Fu KI, Sano Y, et al. Narrow band imaging with magnifying colonoscopy as a diagnostic tool for predicting the histology of early colorectal neoplasia. Aliment Pharmacol Ther. 2008;27:1269–74.
Ikematsu H, Matsuda T, Emura F, et al. Efficacy of capillary pattern type IIIA/IIIB by magnifying narrow band imaging for estimating depth of invasion of early colorectal neoplasms. BMC Gastroenterol. 2010;10:33.
Sano Y, Tanaka S, Kudo S, et al. Narrow-band imaging (NBI) magnifying endoscopic classification of colorectal tumors proposed by the Japan NBI Expert Team. Dig Endosc. 2016;28:526–33.
Hewett DG, Kaltenbach T, Sano Y, et al. Validation of a simple classification system for endoscopic diagnosis of small colorectal polyps using narrow-band imaging. Gastroenterology. 2012;143:599–607.
Puig I, Lopez-Ceron M, Arnau A, et al. Accuracy of the narrow-band imaging international colorectal endoscopic classification system in identification of deep invasion in colorectal polyps. Gastroenterology. 2019;156:75–87.
Haggitt RC, Glotzbach RE, Soffer EE, et al. Prognostic factors in colorectal carcinomas arising in adenomas: implications for lesions removed by endoscopic polypectomy. Gastroenterology. 1985;89:328–36.
Kudo S. Endoscopic mucosal resection of flat and depressed types of early colorectal cancer. Endoscopy. 1993;25:455–61.
Kikuchi R, Takano M, Takagi K, et al. Management of early invasive colorectal cancer. Risk of recurrence and clinical guidelines. Dis Colon Rectum. 1995;38:1286–95.
Nascimbeni R, Burgart LJ, Nivatvongs S, et al. Risk of lymph node metastasis in T1 carcinoma of the colon and rectum. Dis Colon Rectum. 2002;45:200–6.
Kitajima K, Fujimori T, Fujii S, et al. Correlations between lymph node metastasis and depth of submucosal invasion in submucosal invasive colorectal carcinoma: a Japanese collaborative study. J Gastroenterol. 2004;39:534–43.
Ueno H, Mochizuki H, Hashiguchi Y, et al. Risk factors for an adverse outcome in early invasive colorectal carcinoma. Gastroenterology. 2004;127:385–94.
Beaton C, Twine CP, Williams GL, et al. Systematic review and meta-analysis of histopathological factors influencing the risk of lymph node metastasis in early colorectal cancer. Colorectal Dis. 2013;15:788–97.
Jayanna M, Burgess NG, Sing R, et al. Cost-analysis of endoscopic mucosal resection vs surgery for large laterally spreading colorectal lesions. Clin Gastroenterol Hepatol. 2016;14:271–8.
Ahlenstiel G, Hourigan LF, Brown G, et al. Actual endoscopic versus predicted surgical mortality for treatment of advanced mucosal neoplasia of the colon. Gastrointest Endosc. 2014;80:668–76.
Uno Y, Munakata A. The non-lifting sign of invasive colon cancer. Gastrointest Endosc. 1994;40(4):485–9.
Repici A, Wallace M, Sharma P, et al. A novel submucosal injection solution for endoscopic resection of large colorectal lesions: a randomized, double-blind trial. Gastrointest Endosc. 2018;88:527–35.
Moss SJ, Williams LF, Hourigan LF, et al. Long-term adenoma recurrence following wide-field endoscopic mucosal resection (WF-EMR) for advanced colonic mucosal neoplasia is infrequent: results and risk factors in 1000 cases from the Australian Colonic EMR (ACE) study. Gut. 2015;64:57–65.
Pohl H, Grimm IS, Moyet MT, et al. Clip closure prevents bleeding after endoscopic resection of large colon polyps in a randomized trial. Gastroenterology. 2019;157:977–84.
Khashab M, Eid E, Rusche M, et al. Incidence and predictors of “late” recurrences after endoscopic piecemeal resection of large sessile adenomas. Gastrointest Endosc. 2009;70:344–9.
Klein A, Tate DJ, Jayasekeran V, et al. Thermal ablation of mucosal defect margins reduces adenoma recurrence after colonic endoscopic mucosal resection. Gastroenterology. 2019;156:604–13.
Benson AB 3rd, Venook AP, Cederquist L, et al. Colon cancer, version 1.2017, NCCN clinical practice guideline in oncology. J Natl Compr Canc Netw. 2017;15:370–98.
Ono H, Kondo H, Gotoda T, et al. Endoscopic mucosal resection for treatment of early gastric cancer. Gut. 2001;48:225–9.
Fujishiro M, Yahagi N, Nakamura M, et al. Successful outcomes of a novel endoscopic treatment for GI tumors: endoscopic submucosal dissection with a mixture of high-molecular-weight hyaluronic acid, glycerin, and sugar. Gastrointest Endosc. 2006;63:243–9.
Mehta N, Strong AT, Franco M, et al. Optimal injection solution for endoscopic submucosal dissection: a randomized controlled trial of Western solutions in a porcine model. Dig Endosc. 2018;30:347–53.
Miura Y, Hayashi Y, Lefor AK, et al. The pocket-creation method of ESD for gastric neoplasms. Gastrointest Endosc. 2016;83:457–8.
Yang D, Draganov PV. Gaining traction: pulley-ing your weight during endoscopic submucosal dissection. Gastrointest Endosc. 2019;89:185–7.
Yang D, Jawaid S, Perbtani YB, et al. Endoscopic submucosal dissection of a large rectal lesion by use of a novel tissue retractor system. VideoGIE. 2019;4:37–9.
Takezawa T, Hayashi Y, Shinozaki S, et al. The pocket-creation method facilitates colonic endoscopic submucosal dissection (with video). Gastrointest Endosc. 2019;89:1045–53.
Taku K, Sano Y, Fu KI, et al. Iatrogenic perforation associated with therapeutic colonoscopy: a multicenter study in Japan. J Gastroenterol Hepatol. 2007;22:1409–14.
Lee EJ, Lee JB, Lee SH, et al. Endoscopic submucosal dissection for colorectal tumors – 1,000 colorectal ESD cases: one specialized institute’s experiences. Surg Endosc. 2013;27:31–9.
Saito Y, Uraoka Y, Yamaguchi Y, et al. A prospective, multicenter study of 1111 colorectal endoscopic submucosal dissections (with video). Gastrointest Endosc. 2010;72:1217–25.
Kotzev AI, Yang D, Draganov PV. How to master endoscopic submucosal dissection in the USA. Dig Endosc. 2019;31:94–100.
Fuccio L, Hassan C, Ponchon T, et al. Clinical outcomes after endoscopic submucosal dissection for colorectal neoplasia: a systematic review and met-analysis. Gastrointest Endosc. 2017;86:74–86.
Yang D, Aihara H, Perbtani YB, et al. Safety and efficacy of endoscopic submucosal dissection for rectal neoplasia: a multicenter North American experience. Endosc Int Open. 2019;07:E1–9.
Moore JS, Cataldo PA, Osler T, et al. Transanal endoscopic microsurgery is more effective than traditional transanal excision for resection of rectal masses. Dis Colon Rectum. 2008;51:1026–31.
de Graaf EJR, Doornebosch PG, Tetteroo GWM, et al. Transanal endoscopic microsurgery is feasible for adenomas throughout the entire rectum: a prospective study. Dis Colon Rectum. 2009;52:1107–13.
Tsai BM, Finne CO, Nordenstam JF, et al. Transanal endoscopic microsurgery resection of rectal tumors: outcomes and recommendations. Dis Colon Rectum. 2010;53:16–23.
Barendse RM, Musters GD, de Graaf EJ, et al. Randomised controlled trial of transanal endoscopic microsurgery versus endoscopic mucosal resection for large rectal adenomas (TREND Study) Gut. 2018;67:837–46.
Lee L, Burke JP, deBeche-Adams T, et al. Transanal minimally invasive surgery for local excision of benign and malignant rectal neoplasia. Outcomes from 200 consecutive cases with midterm follow up. Ann Surg. 2018;267:910–6.
ASGE Technology Committee, Kethu SR, Banerjee S, Desilets D, et al. Endoscopic tattoing. Gastrointest Endosc. 2010;72:681–5.
Matsuda T, Fukuzawa M, Uraoka T, et al. Risk of lymph node metastasis in patients with pedunculated type early invasive colorectal cancer: a retrospective multicenter study. Cancer Sci. 2011;102:1693–7.
Yang D, Othman M, Draganov PV. Endoscopic mucosal resection vs endoscopic submucosal dissection for Barrett’s esophagus and colorectal neoplasia. Clin Gastroenterol Hepatol. 2019;17:1019–28.
Tanaka S, Kashida H, Saito Y, et al. JGES guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection. Dig Endosc. 2015;27:417–34.
Bach SP, Hill J, Monson JRT, Transanal Endoscopic Microsurgery (TEM) Collaboration, et al. A predictive model for local recurrence after transanal endoscopic microsurgery for rectal cancer. Br J Surg. 2009;96:280–90.
Allaix ME, Arezzo A, Caldart M, et al. Endoscopic microsurgery for rectal neoplasms: experience of 300 consecutive cases. Dis Colon Rectum. 2009;52:1831–6.
Chang HC, Huang SC, Chen JS, et al. Risk factors for lymph node metastasis in pT1 and pT2 rectal cancer: a single-institute experience in 943 patients and literature review. Ann Surg Oncol. 2012;19:2477–84.
Gimon TI, Dykstra MA, Chezar K, et al. Malignant colorectal polyp pathology: are we getting sufficient information to make decisions? Dis Colon Rectum. 2020;63:135–42.
Sharma V, Junejo MA, Mitchel PJ. Current management of malignant colorectal polyps across a regional United Kingdom cancer network. Dis Colon Rectum. 2020;63:39–45.
Cao Y, Liao C, Tan A, et al. Meta-analysis of endoscopic submucosal dissection versus endoscopic mucosal resection for tumors of the gastrointestinal tract. Endoscopy. 2009;41:751–7.
Niimi K, Fujishiro M, Kodashima S, et al. Long-term outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms. Endoscopy. 2010;42:723–9.
Yoda Y, Ikematsu H, Matsuda T, et al. A large-scale multicenter study of long-term outcomes after endoscopic resection for submucosal invasive colorectal cancer. Endoscopy. 2013;45:718–24.
Lieberman DA, Rex DK, Winawer SJ, et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on colorectal cancer. Gastroenterology. 2012;143:844–57.
Hassan C, Quintero E, Dumonceau JM, et al. Post-polypectomy colonoscopy surveillance: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy. 2013;45:842–51.
Holt BA, Bourke MJ. Wide field endoscopic resection for advanced colonic mucosal neoplasia: current status and future directions. Perspect Clin Gastroenterol Hepatol. 2012;10(9):969–79.
Tanaka S, et al. High-magnification colonoscopy (with videos). Gastrointest Endosc. 2006;64(4):604–13.
Nivatvongs S. Surgical management of malignant colorectal polyps. Surg Clin North Am. 2002;82:959–66.
Mohamed M, Schofield JB. The pathology of colorectal polyps and cancers (including biopsy). Surgery. 2014;32:165–71.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2022 Springer Nature Switzerland AG
About this chapter
Cite this chapter
Yang, D., Whiteford, M.H. (2022). Management of Malignant Polyps. In: Steele, S.R., Hull, T.L., Hyman, N., Maykel, J.A., Read, T.E., Whitlow, C.B. (eds) The ASCRS Textbook of Colon and Rectal Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-66049-9_23
Download citation
DOI: https://doi.org/10.1007/978-3-030-66049-9_23
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-030-66048-2
Online ISBN: 978-3-030-66049-9
eBook Packages: MedicineMedicine (R0)