What is the treatment for polyps?

Treatment of Polyps

Complete endoscopic polypectomy should be performed whenever the morphological structure of the polyp permits, with subsequent management determined by histological features and patient factors. 1

Types of Polyps and Initial Management

Non-malignant Polyps

• Adenomatous polyps (tubular, tubulovillous, or villous) without invasive cancer:
  • Complete endoscopic removal is sufficient if margins are clear
  • Follow-up colonoscopy in 3 years if polyp is <3 cm and completely removed 1
  • Follow-up colonoscopy within 1 year for larger polyps or incomplete removal 1

Hyperplastic Polyps (Gastric)

• Confirm diagnosis and absence of dysplasia histologically
• Evaluate for H. pylori and eradicate if present
• Resect polyps that are:

  • 1 cm in size

  • Pedunculated
  • Symptomatic (bleeding, obstruction)

  • 3 cm (always resect regardless of H. pylori status) 1

Gastric Adenomatous Polyps

• Require resection due to significant risk of progression to cancer
• Endoscopic resection is preferred
• En bloc excision with ESD (Endoscopic Submucosal Dissection) for sessile polyps >15 mm
• Follow-up gastroscopy at 6-12 months after resection 1

Management of Malignant Polyps

Malignant polyps are defined as those with cancer invading the submucosa (pT1). The decision-making algorithm for management depends on several factors:

Favorable Histologic Features (All must be present)

• Grade 1 or 2 differentiation
• No angiolymphatic invasion
• Clear resection margins
• Complete en bloc resection 1

Management Algorithm for Malignant Polyps:

1. Pedunculated polyps with favorable histologic features:

   • Endoscopic polypectomy alone is sufficient 1
   • No surgical resection required

2. Pedunculated polyps with cancer in stalk:

   • If margins are clear and other histologic features are favorable, endoscopic polypectomy may be sufficient 1
   • If margins are involved or unclear, surgical resection is recommended

3. Sessile polyps with invasive cancer:

   • Should be interpreted as having level 4 invasion (deep submucosal invasion)
   • Standard surgical resection recommended for patients with average operative risk 1

4. Any polyp with unfavorable histologic features:

   • Surgical resection with en bloc removal of lymph nodes is recommended 1
   • Unfavorable features include:
     • Grade 3 or 4 differentiation
     • Angiolymphatic invasion
     • Positive or unclear margins
     • Fragmented specimen 1

Special Considerations

Patient Factors

• Age and comorbidities must be considered when deciding on surgical intervention
• In elderly patients with significant comorbidities, endoscopic management alone may be appropriate even with some unfavorable features 1
• In young, healthy patients with very low surgical risk, surgery might be considered even with favorable histology to eliminate any risk of recurrence 1

Follow-up After Polypectomy

• All patients who have had polyps removed should undergo total colonoscopy to rule out synchronous polyps 1
• Appropriate surveillance endoscopy should follow based on polyp characteristics and number

Common Pitfalls to Avoid

1. Failure to mark the polyp site during colonoscopy if cancer is suspected
2. Inadequate histological assessment of polyp specimens
3. Overtreatment of pedunculated polyps with favorable histology
4. Undertreatment of sessile polyps with invasive features
5. Neglecting to perform complete colonoscopy to identify synchronous lesions

The evidence strongly supports that endoscopic polypectomy alone is curative for malignant pedunculated polyps with favorable histology, while surgical resection is necessary for sessile malignant polyps and those with unfavorable histologic features to optimize patient outcomes and survival.