Gastroenterology

Gastroenterology

Volume 159, Issue 5, November 2020, Pages 1916-1934.e2
Gastroenterology

AGA Section
Endoscopic Recognition and Management Strategies for Malignant Colorectal Polyps: Recommendations of the US Multi-Society Task Force on Colorectal Cancer

https://doi.org/10.1053/j.gastro.2020.08.050Get rights and content

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Literature Review

The English language medical literature was searched using MEDLINE, EMBASE, and Cochrane Database of Systematic reviews from January 1980 to December 31, 2018. A combination of key words and Medical Subject Headings were used and are summarized in Appendix 1. Review articles, meta-analyses, and editorials were reviewed for additional references.

Grading of Evidence

The US Multi-Society Task Force on Colorectal Cancer (USMSTF) consists of gastroenterologists with expertise in colorectal neoplasia (ie, CRC and

Definition of Malignant Polyp

The term malignant polyp refers to a colorectal polyp including flat lesions with neoplastic invasion of the submucosa without extension into the muscularis propria.2,9 Another term for such lesions is submucosally invasive polyps. The Vienna classification system is a consensus between Western and Japanese pathologists for classifying gastrointestinal epithelial neoplasia into 5 categories (Table 2).10 According to this classification, malignant polyps would fall under category 5.2 (submucosal

Endoscopic and Histologic Classification Systems Used in This Document

The optimal management of malignant polyps in modern colonoscopy is based on the endoscopic diagnosis. Before endoscopic resection, every colorectal lesion detected at colonoscopy should undergo complete assessment of the lesion morphology, surface, and vessel pattern. A skilled assessment, often accompanied by dye-based chromoendoscopy or electronic-based image enhancement, will identify lesions with endoscopic features that are specific for deep submucosal invasion of cancer (see below). Deep

Endoscopic Surface Pattern Classifications

Endoscopic assessment of colorectal polyps and lesions to predict the histologic class (ie, adenoma vs serrated class) and determine the presence of features associated with deep submucosal invasion are important skills for the modern colonoscopist. Endoscopic assessment can be assisted by illumination with wavelengths that enhance blood vessels and delineate surface features (eg, narrow band imaging [NBI]; Olympus, Center Valley, PA and Fujinon Blue Light Imaging; Fujinon, Valhalla, NY) or by

Paris Classification

Proposed in 2002 at the Paris collaborative meeting,30 the Paris classification is an endoscopic classification of superficial colorectal lesion morphology, whereby a lesion is superficial when its endoscopic appearance suggests that the depth of penetration in the digestive wall is not more than into the submucosa, that is, there is no infiltration of the muscularis propria. The Paris classification describes 3 major superficial morphologies with subtypes. Lesions are classified as polyps

Kikuchi and Kitajima Classification Systems for Depth of Submucosal Invasion

Accurate measurement of the depth of invasion in malignant polyps generally requires specific handling of the pathology specimen, that is, pinning the cut surface of the specimen to a stiff material before immersion into formalin. Pinning the specimen enables the cut sections to be properly oriented for evaluation by the pathologist (ie, at right angles to the plane of the resection). For sessile malignant polyps, the Kikuchi classification describes the depth of invasion by dividing the

Key Questions, Recommendations, and Discussion

Question 1a: Which endoscopic features in a colorectal polyp predict deep submucosal cancer?

Question 1b: When deep submucosal cancer is suspected, how should nonpedunculated and pedunculated polyps be managed?

Recommendation 1a: We recommend that both pedunculated and nonpedunculated polyps with the following features be considered to have deep submucosal invasion: NICE classification type 3 or Kudo classification of type V (VN and VI).

Strong recommendation; high-quality evidence

Recommendation

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      Several reasons have been proposed as contributors to this survival difference, including differences in clinical presentation, embryologic origin, genetic profile, and immune microenvironment.10–14 While this observation was initially reported for stage IV tumors, it has since been similarly described for nonmetastatic cancers; however, there is a scarcity of data on the role of laterality in the prognosis of malignant polyps treated with endoscopic resection only.2,3,5,15 Therefore, we hypothesized that the more aggressive biologic behavior observed in advanced right-sided colon cancers would be similarly represented in malignant polyps, and this location would be associated with lower overall survival (OS) rates.

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    This article is being published jointly in Gastroenterology, The American Journal of Gastroenterology, and Gastrointestinal Endoscopy.

    Conflicts of interest The authors disclose no conflicts of interest relative to the current work since 2016. Industry relationships for authors (consulting, research, reimbursement) without conflict of interest relevant to the current work since 2016: D. K. Rex (Olympus, Boston Scientific, Covidien, Lumendi, Salix, Aries, Cook Medical, ERBE, Bausch Health Inc, Novo Nordisk, Endochoice, Braintree Laboratories, Norgine, Endokey, EndoAid, Medivators, Satisfai Health); Sapna Syngal (Chirhoclin, Cook, Myriad Genetics, Inc, DC Health, Inc); D. Lieberman (Covidien, Freenome Holdings, Inc, Ironwood, Check-Cap, CEGX); D. Robertson (Covidien, Freenome Holdings, Inc, Amadix); T. Kaltenbach (Aries Pharmaceuticals, Micro-Tech Endoscopy, Olympus, Boston Scientific, Medtronic); A. Shaukat (Iterative Scopes, Freenome Holdings Inc); S. Gupta (Freenome Holdings, Inc, Guardant Health, Inc, Mallinckrodt Pharmaceuticals); C. Burke (Salix Pharmaceuticals, Ferring Pharmaceuticals, Aries Pharmaceuticals, Pfizer, Cancer Prevention Pharmaceuticals, Janssen Pharmaceuticals; SLA Pharma AG; Freenome Holdings, Inc). The remaining authors disclose no conflicts.

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