Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

suitable for endoscopic resection

1st line – endoscopic resection

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ACUTE
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suitable for endoscopic resection
1st line – 

endoscopic resection

Endoscopic resection of nonmalignant polyps is preferred to surgical resection, where possible, because it is associated with lower morbidity and mortality.[63] Large broad-based polyps, or those situated in anatomically inaccessible areas, are usually unsuitable for endoscopic resection. Polyps that are unsuitable for endoscopic resection require open or laparoscopic bowel resection.[64]

Removal of polyps significantly reduces the risk of death from colorectal cancer.[60][61][62]

Polyps are removed for histologic examination to exclude malignancy and/or to manage polyp-associated symptoms or complications.

Endoscopic polypectomy is usually performed by simple snare excision or by "hot biopsy" (in which monopolar diathermy is used to excise the polyp and simultaneously coagulate its base).

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) utilize saline injections to lift the area of mucosa to be resected, followed by resection of mucosa and upper submucosa using either suction and a snare or a submucosal resection device. [Figure caption and citation for the preceding image starts]: Colonic adenoma pre-excisionFrom the personal collection of Dr G. Malietzis; used with permission [Citation ends].com.bmj.content.model.Caption@7eeee4a8[Figure caption and citation for the preceding image starts]: PostpolypectomyFrom the personal collection of Dr G. Malietzis; used with permission [Citation ends].com.bmj.content.model.Caption@40c868d2 These are particularly useful if the polyp is sessile (flat) rather than pedunculated (with a stalk). The effectiveness of EMR and ESD for treating large colorectal polyps has been confirmed by systematic reviews.[65][66]

Polyps that do not rise easily with submucosal saline or hyaluronidase infiltration are highly suspicious for invasive malignancy. Successful endoscopic mucosal resection is unlikely if three or more quadrants do not rise easily with fluid infiltration; surgical management is more suitable in these cases.

Plus – surveillance

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ACUTE
|
suitable for endoscopic resection
Plus – 

surveillance

Treatment recommended for ALL patients in selected patient group

Surveillance after polypectomy is individualized to the patient's risk of colorectal cancer. Colorectal cancer risk is determined by the presence, number, and size of polyps found at index colonoscopy, as well as by factors such as age and family history.

The US Multi-Society Task Force on Colorectal Cancer recommends that patients with 1 to 2 small (<1 cm) low-grade tubular adenomas should undergo repeat colonoscopy in 5 to 10 years.[71] Finding 3 to 10 adenomas, or any adenoma ≥1 cm, displaying high-grade dysplasia, or with villous features, should prompt repeat colonoscopy at 3 years; >10 adenomas at a single examination should prompt follow-up in <3 years and a familial syndrome should be considered.[71] Sessile adenomas removed piecemeal should be reviewed within 1 year to ensure complete removal.[71] The US National Comprehensive Cancer Network guidelines recommend colonoscopy 6 months after piecemeal resection; the European Society for Gastroenterology recommends colonoscopy at 3-6 months for any piecemeal endoscopic resection of polyps ≥2 cm.​[47][72]​

People with high-risk adenomas have a three- to fourfold higher risk of incident colorectal cancer during follow-up, compared with people with no adenomas or low-risk adenomas.[49]

If a patient has had invasive adenocarcinoma in a polyp that was completely excised, colonoscopy is recommended 1 year after index colonoscopy.[68] If an advanced adenoma (villous polyp, polyp >10 mm, or high-grade dysplasia) is present, colonoscopy should be repeated after 1 year. If there is no advanced adenoma, colonoscopy is recommended at 3 years, and then every 5 years.[68]

Consider – colectomy with en bloc resection of lymph nodes

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ACUTE
|
suitable for endoscopic resection
Consider – 

colectomy with en bloc resection of lymph nodes

Treatment recommended for SOME patients in selected patient group

Colectomy with en bloc resection of lymph nodes may be considered for some patients with polyps that contain invasive cancer.[68] Polyps are considered malignant if cancer invades through the muscularis mucosa into the submucosa. Carcinoma in situ is not considered malignant because it is unable to metastasize to regional lymph nodes.[68]

Management of polyps containing invasive cancer depends on the type of polyp and the presence or absence of favorable histologic features.[68] Favorable histologic features are: well-differentiated or moderately differentiated (grade 1 or 2) adenocarcinoma; no angiolymphatic invasion; negative margin of resection.[68][69]

Surgery is not required for patients with completely resected pedunculated polyps with favorable histologic features.[68]

Patients with completely resected sessile polyps with favorable histologic features may be considered for observation or for colectomy with en bloc removal of regional lymph nodes.[68] Patients with sessile polyps may have increased risk of disease recurrence, mortality, and metastases compared with patients with pedunculated polyps.[70]

See Colorectal cancer for further details on surgery for invasive colorectal cancer.

If a specimen is fragmented, resection margins cannot be assessed, or there are unfavorable histologic features, the patient should undergo further investigations to assess the extent of disease prior to colectomy with en bloc removal of regional lymph nodes.[68]

See Colorectal cancer for further details on the investigation and management of such patients.

unsuitable for endoscopic resection

1st line – surgery

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ACUTE
|
unsuitable for endoscopic resection
1st line – 

surgery

Endoscopic resection of nonmalignant polyps is preferred to surgical resection, where possible, because it is associated with lower morbidity and mortality.[63] Large broad-based polyps, or those situated in anatomically inaccessible areas, are usually unsuitable for endoscopic resection and require open or laparoscopic bowel resection.[64]

Surgical polypectomy may be required if a polyp is very low in the rectum and its distal margin cannot be safely endoscopically resected. Small polyps (up to 8 mm) may be removed using a cold snare technique where electrocautery is not required. This technique has confirmed efficacy.[67]

Plus – surveillance

Back
ACUTE
|
unsuitable for endoscopic resection
Plus – 

surveillance

Treatment recommended for ALL patients in selected patient group

Surveillance after polypectomy is individualized to the patient's risk of colorectal cancer. Colorectal cancer risk is determined by the presence, number, and size of polyps found at index colonoscopy, as well as by factors such as age and family history.

The US Multi-Society Task Force on Colorectal Cancer recommends that patients with 1 to 2 small (<1 cm) low-grade tubular adenomas should undergo repeat colonoscopy in 5 to 10 years.[71] Finding 3 to 10 adenomas, or any adenoma ≥1 cm, displaying high-grade dysplasia, or with villous features, should prompt repeat colonoscopy at 3 years; >10 adenomas at a single examination should prompt follow-up in <3 years and a familial syndrome should be considered.[71] Sessile adenomas removed piecemeal should be reviewed within 1 year to ensure complete removal.[71] The US National Comprehensive Cancer Network guidelines recommend colonoscopy 6 months after piecemeal resection; the European Society for Gastroenterology recommend colonoscopy at 3-6 months for any piecemeal endoscopic resection of polyps ≥2 cm.​[47][72]​

People with high-risk adenomas have a three- to fourfold higher risk of incident colorectal cancer during follow-up, compared with people with no adenomas or low-risk adenomas.[49]

If a patient has had invasive adenocarcinoma in a polyp that was completely excised, colonoscopy is recommended 1 year after index colonoscopy.[68] If an advanced adenoma (villous polyp, polyp >10 mm, or high-grade dysplasia) is present, colonoscopy should be repeated after 1 year. If there is no advanced adenoma, colonoscopy is recommended at 3 years, and then every 5 years.[68]

Consider – colectomy with en bloc resection of lymph nodes

Back
ACUTE
|
unsuitable for endoscopic resection
Consider – 

colectomy with en bloc resection of lymph nodes

Treatment recommended for SOME patients in selected patient group

Colectomy with en bloc resection of lymph nodes may be considered for some patients with polyps that contain invasive cancer.[68] Polyps are considered malignant if cancer invades through the muscularis mucosa into the submucosa. Carcinoma in situ is not considered malignant because it is unable to metastasize to regional lymph nodes.[68]

Management of polyps containing invasive cancer depends on the type of polyp and the presence or absence of favorable histologic features.[68] Favorable histologic features are: well-differentiated or moderately differentiated (grade 1 or 2) adenocarcinoma; no angiolymphatic invasion; negative margin of resection.[68][69]

Surgery is not required for patients with completely resected pedunculated polyps with favorable histologic features.[68]

Patients with completely resected sessile polyps with favorable histologic features may be considered for observation or for colectomy with en bloc removal of regional lymph nodes.[68] Patients with sessile polyps may have increased risk of disease recurrence, mortality, and metastases compared with patients with pedunculated polyps.[70]

See Colorectal cancer for further details on surgery for invasive colorectal cancer.

If a specimen is fragmented, resection margins cannot be assessed, or there are unfavorable histologic features, the patient should undergo further investigations to assess the extent of disease prior to colectomy with en bloc removal of regional lymph nodes.[68]

See Colorectal cancer for further details on the investigation and management of such patients.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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