Colorectal polyps found on physical examination, cut or not?

It is only for medical professionals to read and refer to those who meet these 3 characteristics, please cut! In 2015, the Japanese Society of Gastroenterology (JSGE) published the "Evidence-Based Clinical Practice Guidelines for Colorectal Polyp Management" (hereinafter referred to as the "Guide") for the first time, and the guidelines were revised once in 2020.

The guideline makers searched PubMed, ICHUSHI and other literatures from 1983 to 2018 in English and Japanese to answer a series of questions about the diagnosis and treatment of colorectal polyps, and post-treatment monitoring.

The following is the content of the guide, let's take a look! 1 What shape and size of adenoma meet the indications for endoscopic resection? (1) Endoscopic resection should be performed for lesions ≥6mm; [strong recommendation (agreement rate 100%), level of evidence B] (2) Principle of microadenomatous polyps ≤5mm should also be performed endoscopic resection, but it may not be resected.
Colonoscopy follow-up observation; [weak recommendation (agreement rate 82%), level of evidence D] (3) flat and sunken tumorous lesions even if ≤5mm should be endoscopic resection.

[Strong recommendation (agreement rate 100%), level of evidence D] 2 How should hyperplastic polyps (HP) be managed? (1) Follow-up is recommended for HP ≤5mm in rectum and sigmoid colon.

[Weak recommendation (agreement rate 100%), level of evidence B]3 What are the indications for cold snare polypectomy (CSP)? (1) CSP is suitable for sessile benign adenomas <10mm; [weak recommendation (agreement rate of 100%), level of evidence B] (2) Among them, for small lesions ≤5mm, CSP is recommended, and for lesions of 6-9mm , CSP can be used [strong recommendation (agreement rate 100%), level of evidence B] (3) However, even if the polyp is ≤5mm, if the lesion is "flat and sunken" or is suspected of being cancer under colonoscopy, it should be Avoid the use of CSP.

[Weak recommendation (agreement rate 100%), level of evidence B] 👇👇Slide view CSP was developed by Tappero et al.
in 1992 as a technique for endoscopic resection of small colorectal lesions ≤5mm in size.

Because the principle is mechanical resection instead of electrocautery, the incidence of post-polypectomy bleeding, post-polypectomy syndrome (peritonitis caused by thermal injury) and delayed perforation is lower, and the operation time and resection time are shorter.

Because of these advantages, CSP is now widely used in Japan.

According to ESGE guidelines, CSP is strongly recommended as a resection method for small lesions ≤5mm, but if the lesion is between 6-9mm, the recommended level of CSP will be lowered.

However, a randomized trial, a meta-analysis and a histological evaluation study in Japan concluded that CSP can be used as a standard method for endoscopic resection of 6-9mm lesions.

Cold forceps polypectomy using biopsy forceps is suitable for lesions less than 3mm in size.

For lesions ≥ 6mm, compared with conventional polypectomy or EMR, CSP has a series of disadvantages, such as a higher risk of bleeding, and about 10% of the lesions cannot be resected, the rate of complete muscular mucosal resection is low, and the resectable mucosa The depth of the lower layer is limited.

In addition, because it is difficult to receive detailed histological evaluation of smooth muscle layer (SM) samples resected by CSP, CSP is not suitable for lesions that may have involved SM, such as suspected cancer or "flat and depressed" lesions, even if these lesions are ≤5mm .

4How to diagnose and treat colorectal serrated lesions? Serrated lesions of the colorectal include sessile serrated adenoma/polyp (SSA/P), traditional serrated adenoma (TSA) and HP.

When diagnosing through endoscopy, the location, shape, and surface features of the lesion (including manifestations under magnifying endoscopy) are of great significance.

SSA/P and TSA may develop into cancer, so it is recommended to treat them.

[Weak recommendation (agreement rate 100%), level of evidence C] 👇👇Slide to view 1.
Diagnosis (1) SSA/PSSA/P usually occurs in the right colon, usually flat or broad-based lesions with a diameter greater than 10mm, pale in color, The surface of the lesion is accompanied by a large amount of mucin.

Narrowband imaging technology (NBI) and magnifying endoscopy are shown as the Japanese Narrowband Imaging Technology Expert Group (JNET) Type 1.

According to Uraoka's report, the vasodilation and the presence of branches (varices of microvessels) should be suspected of SSA/P.

The characteristic lesion under magnifying endoscopy is type II pit.

If the lesion has a central depression, redness, or two-layer bulge, it should be suspected of dysplasia and/or cancer.

In addition, most SSA/P with dysplasia and/or cancer exhibited type II and other types of pit patterns (including mixed patterns of type III, IV, and V).

Some studies also believe that if the NBI magnifying endoscopy sees irregular blood vessels, it can be diagnosed as comorbid cancer.

(2) TSATSA is a prominent red lesion commonly found in the left colorectal.

The surface structure has a typical "pine cone" or "coral-like branch" appearance.

TSA has unique endoscopy results, making diagnosis possible.

On NBI, extensive expansion of the capillary network to the interstitium can be observed.

The endoscopic magnification of TSA shows IIIH pit, IVH pit, and saw-shaped IV.

Therefore, based on the results of endoscopy, TSA can be distinguished from SSA/P and HP.

(3) HPHP lesions have been reported in all segments, mainly in the distal colorectum.

They are usually <5mm, pale and flat.

JNET type 1 can be seen on NBI, and type II pit can be seen under magnifying endoscopy.

2.
Treatment: SSA/P and TSA have the possibility of malignant transformation and should be removed (1) SSA/P 1.
5%-20% of SSA/P can progress to cancer, and SSA/P should be resected under endoscopic surgery. (2) TSA TSA may develop into cancer.

As with typical adenomas, it is recommended to remove TSA with a diameter> 5 mm.

Most studies recommend resection of SSA/P lesions with a diameter> 10 mm.

However, when it is suspected that the serrated lesion is associated with dysplasia and/or cancer, it should be removed regardless of the size of the lesion.

(3) HP HP may be a precursor lesion of SSA/P and/or TSA, however, HP does not need to be removed for HP <5mm in diameter.

5Which method of treatment should be used for lateral growth tumors? (1) For larger LST, you should choose endoscopic submucosal dissection (ESD) or split endoscopic mucosal resection (EMR) according to the subtype of LST (through the appropriate use of magnifying endoscopy and ultrasound endoscopy) [Strong recommendation (agreement rate 100%), level of evidence C] 👇👇Slide to view According to morphological classification, LST can be divided into granular type (LST-G) and non-granular type (LST-NG).

LST-G can be further subdivided into homogeneous type and nodular mixed type, and LST-NG can be subdivided into "flat raised type" and "pseudo depressed type".

Most LST-G are considered adenomatous lesions.

6Which colorectal tumors can be sliced ​​EMR? (1) Adenoma or Tis carcinoma with a clear preoperative diagnosis can be resected by partial EMR, but the local recurrence rate of partial resection is high, so it must be used with caution.

[Weak recommendation (agreement rate 100%), level of evidence C] 7 How should colonoscopy monitoring be performed after endoscopic resection of colorectal adenoma? (1) Colonoscopy should be followed up within 3 years after polypectomy.

[Weak recommendation (agreement rate 100%), level of evidence B] 👇👇Slide to view relevant European and American guidelines suggest that the optimal interval for colonoscopy should be based on the number of adenomas, the size of the largest polyp, and the histopathological findings of the polyp (Including villi components or high-grade dysplasia) make individualized decisions.

However, in general, it is recommended that patients with 3 or more adenoma polyps less than 10mm (low-grade dysplasia [LGD]) or polyps with high-grade dysplasia or villous components should undergo colonoscopy monitoring 3 years after surgery.

8How to monitor after endoscopic resection of T1(SM) colorectal cancer? (1) Local recurrence, lymph node metastasis and distant metastasis must be closely monitored, and careful follow-up should be performed for at least 3 years after endoscopic resection.

[Weak recommendation (agreement rate 100%), level of evidence C] 9 What is the diagnosis and management of colorectal neuroendocrine tumors? (1) Rectal submucosal tumors (SMT), especially those located in the lower rectum, are most likely to be neuroendocrine tumors (NET).
It is strongly recommended to use spray staining to confirm that the tumor surface is covered by normal mucosa, and according to tumor size and surface characteristics, Determine whether endoscopic or surgical resection is required.

[Strong recommendation (agreement rate 100%), level of evidence B] 10 How should non-neoplastic polyps be managed? (1) It is recommended to divide non-neoplastic colorectal polyps into hamartoma, inflammatory, or proliferative; [ Strong recommendation (100% consent rate), level of evidence D] (2) Although most non-neoplastic colorectal polyps do not require endoscopic resection, if the polyps show symptoms such as bleeding, induced intussusception, or the polyp is suspected of being cancer , It is recommended to remove.

[Strong recommendation (100% consent rate), level of evidence D]11 Is there a difference between the management of familial adenomatous polyposis (FAP) and attenuated familial adenomatous polyposis (AFAP)? (1) It is recommended for patients with FAP and AFAP to undergo colonoscopy monitoring from adolescence; [Strong recommendation (agreement rate of 100%), level of evidence C] (2) Because AFAP complicates colorectal cancer, it is recommended that patients be preventive Colonectomy.

[Strong recommendation (agreement rate 100%), level of evidence C] 👇👇 Swipe to view AFAP refers to the presence of as many as 100 colorectal adenomas in patients 25 years and older.

FAP includes mutations in the APC and MUTYH genes, and each subtype has a high risk of colorectal cancer.

12Which ulcerative colitis (UC) patients should be monitored for colorectal cancer, and how should they be monitored? ▌ People suitable for screening: (1) If the patient has been sick for 8-10 years and has extensive left colitis, he should start colonoscopy monitoring; [Strong recommendation (agreement rate 100%), evidence Level B] (2) For patients whose remission is not observed under endoscopy, colonoscopy monitoring is recommended as soon as possible; [weak recommendation (agreement rate 100%), level of evidence B]▌ Monitoring method: (3) Colonoscopy is recommended Check the entire colon, and use pigment endoscopy and/or NBI for targeted biopsy, pay attention to raised lesions and any changes in the structure or color of the mucosa that are different from the surrounding area; [Strong recommendation (agreement rate 100%), evidence Level B] (4) It is recommended to perform a stepwise biopsy for each segment of the colon.

[Weak recommendation (agreement rate 100%), level of evidence B] 👇👇Slide to view Endoscopic cancer surveillance for UC patients has been shown to be effective in reducing colorectal cancer-related mortality.

Since it is difficult to detect atypical hyperplasia of the mucosa during the active stage of the disease, the guidelines recommend that colonoscopy be started 8-10 years after the onset of UC.

13 If atypical hyperplasia or cancer is found in UC, should all the lesions be surgically removed? Is mild atypical hyperplasia an indication for surgery? (1) If mild atypical hyperplasia is detected in the flat mucosa, it is recommended to consult several people An experienced pathologist will make a decision afterwards; [weak recommendation (agreement rate of 100%), level of evidence C] (2) If mild atypical hyperplasia is detected in an elevated lesion and sporadic adenoma is highly suspected, then It is recommended to undergo endoscopic resection and detailed pathological examination; [Strong recommendation (agreement rate of 100%), level of evidence C] (3) If cancer or high-grade atypical hyperplasia is found, and it is determined to be related to colitis, it is recommended Total colorectal resection.

[Strong recommendation (agreement rate 100%), level of evidence C] 👇👇Slide to view At present, there is no standard treatment plan for LGD on flat mucosa.

It is very important to distinguish between atypical hyperplasia and sporadic adenoma associated with colitis.

If sporadic adenoma is highly suspected, endoscopic resection should be performed.

However, for uplifted atypical hyperplasia, even if the degree of atypical hyperplasia on the surface is low, there can be a high degree of atypical hyperplasia in the deep part, and even accompanied by invasive cancer.
Therefore, when such a lesion is found, it will be 3 months later.
Endoscopic monitoring should be strengthened.

References: [1] Tanaka S, Saitoh Y, Matsuda T, et al.
Evidence-based clinical practice guidelines for management of colorectal polyps[J].
J Gastroenterol.
2021 Apr;56(4):323-335.
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