What is the appropriate management for a polypoid mass?

Management of Polypoid Masses

The appropriate management of a polypoid mass depends critically on its location, size, morphology, and histologic features, with endoscopic resection being the primary approach for most benign and early malignant lesions, while surgical intervention is reserved for lesions with high-grade features, incomplete resection, or evidence of invasive malignancy. 1

Initial Assessment and Characterization

The first step is to determine the exact location and characteristics of the polypoid mass:

• Document size, morphology (pedunculated vs sessile), border clarity, presence of ulceration, and whether the lesion appears completely resectable endoscopically 1
• Classify polypoid lesions as either polypoid (≥2.5 mm tall), non-polypoid (<2.5 mm), or invisible (detected on non-targeted biopsy) 1
• Assess for features suggesting malignancy including size >15 mm, sessile shape, irregular borders, ulceration, or heterogeneous enhancement patterns 1

Location-Specific Management

Colorectal Polypoid Masses

For colorectal polyps, complete endoscopic resection is the standard approach for most lesions, with the goal of en bloc (one-piece) removal to allow proper histologic assessment: 1, 2

• Perform snare polypectomy for pedunculated polyps, ensuring the entire stalk is removed with adequate margin 1
• For sessile or flat lesions, inject saline into the submucosa to lift the polyp before resection (endoscopic mucosal resection) 3
• Submit the entire specimen for pathologic examination with the resection margin inked to assess completeness of excision 1

Critical pathologic features that determine need for surgical resection include: 1, 2

• Margin status: Cancer within 1 mm of resection margin or positive margins requires surgical resection 1
• Depth of invasion: Invasive carcinoma penetrating beyond the muscularis mucosae (not just carcinoma-in-situ) constitutes true malignancy 4
• Presence of lymphovascular invasion, poor differentiation, or high-grade histology 1
• Piecemeal resection of malignant polyps (incomplete assessment of margins) 1, 3

If favorable histologic features are present (well-differentiated, no lymphovascular invasion, clear margins >2 mm, complete excision), endoscopic polypectomy alone is adequate with close surveillance 1, 4

Gastric Polypoid Masses

Management varies by polyp type: 2

• Fundic gland polyps do not require excision unless >1 cm, located in the antrum, show ulceration, or have atypical features 2
• For hyperplastic polyps, test for and eradicate H. pylori first, as up to 70% regress after eradication; perform repeat endoscopy 3-6 months later to assess regression 2
• Resect hyperplastic polyps >1 cm, pedunculated polyps, or symptomatic polyps; always resect polyps >3 cm regardless of H. pylori status due to high cancer risk 2, 5
• All gastric adenomas must be resected due to significant cancer progression risk—up to 30% have synchronous gastric adenocarcinoma and 50% of adenomas >2 cm contain foci of adenocarcinoma 2

Gallbladder Polypoid Masses

For gallbladder polyps >10 mm, advanced imaging is critical to differentiate benign from malignant lesions: 1

• Use contrast-enhanced ultrasound (CEUS) or MRI to assess vascularity and enhancement patterns—malignant lesions show early peripheral enhancement with intralesional branching vessels 1
• Short-interval follow-up ultrasound within 1-2 months with optimized technique can help differentiate tumefactive sludge from true masses 1
• Cholecystectomy is indicated for polyps with suspicious features including heterogeneous enhancement, ulceration, or rapid growth 1

Inflammatory Bowel Disease-Associated Dysplasia

Special considerations apply to polypoid dysplasia in IBD patients: 1

• Polypoid dysplasia can be adequately treated by polypectomy if the lesion is completely excised and there is no evidence of non-polypoid or invisible dysplasia elsewhere in the colon 1
• Non-polypoid dysplasia is ominous—the 5-year cumulative incidence of high-grade dysplasia or colorectal cancer is 65.2% for non-polypoid dysplasia versus only 6.0% for polypoid dysplasia 1
• Every patient with endoscopically unresectable non-polypoid dysplasia should undergo immediate colectomy, regardless of dysplasia grade 1
• Polyps with dysplasia arising proximal to segments with macroscopic or histologic colitis involvement are considered sporadic adenomas and treated accordingly 1

Critical Pitfalls to Avoid

• Attempting piecemeal resection of malignant polyps prevents adequate histologic assessment of margins and depth of invasion, potentially leading to inadequate treatment 1, 3
• Failing to ink the resection margin before pathologic sectioning makes margin assessment impossible 1
• Not submitting the entire polyp for histologic examination can miss focal areas of invasive carcinoma 1
• For gastric hyperplastic polyps, failing to assess for H. pylori before resection misses the opportunity for medical regression 2
• Removing small distal hyperplastic colorectal polyps and inappropriately intensifying surveillance leads to unnecessary procedures 2

Follow-up Strategy

After complete endoscopic resection of benign or favorable malignant polyps: 2, 4

• Perform surveillance colonoscopy at 6 months for duodenal adenomas to assess for recurrence 2
• For colorectal malignant polyps with favorable features treated endoscopically alone, close clinical and endoscopic follow-up is essential 4
• Repeat endoscopy 3-6 months after H. pylori eradication for gastric hyperplastic polyps to assess regression 2