Endoscopic management of colorectal polyps: From benign to malignant polyps

Abstract

Colorectal cancer (CRC) is the third most common cancer worldwide and the second leading cause of cancer related death in the world. The early detection and removal of CRC precursor lesions has been shown to reduce the incidence of CRC and cancer-related mortality. Endoscopic resection has become the first-line treatment for the removal of most precursor benign colorectal lesions and selected malignant polyps. Detailed lesion assessment is the first critical step in the evaluation and management of colorectal polyps. Polyp size, location and both macro- and micro- features provide important information regarding histological grade and endoscopic resectability. Benign polyps and even malignant polyps with superficial submucosal invasion and favorable histological features can be adequately removed endoscopically. When compared to surgery, endoscopic resection is associated with lower morbidity, mortality, and higher patient quality of life. Conversely, malignant polyps with deep submucosal invasion and/or high risk for lymph node metastasis will require surgery. From a practical standpoint, the most appropriate strategy for each patient will need to be individualized, based not only on polyp- and patient-related characteristics, but also on local resources and expertise availability. In this review, we provide a broad overview and present a potential decision tree algorithm for the evaluation and management of colorectal polyps that can be widely adopted into clinical practice.

Keywords: Colorectal cancer, Colon polyps, Malignant polyps, Endoscopic resection, Endoscopic mucosal resection, Endoscopic submucosal dissection

Core Tip: Endoscopic resection is a proven strategy for the management of benign and selected malignant colorectal polyps. When compared to surgery, endoscopic resection is less costly and associated with improved clinical outcomes and patient satisfaction. Detailed lesion assessment, including endoscopic imaging and histopathology, play a critical role in directing subsequent treatment strategies. Ultimately, the most appropriate intervention will depend on various factors, including patient and lesion characteristics, as well as local resources and expertise availability. Establishing the multidisciplinary collaboration between referring physicians, endoscopists, surgeons and pathologists is the basis for ensuring best practices for the management of colorectal polyps.