What are the indications for Endoscopic Submucosal Dissection (ESD) in cases of sessile polyps?

Indications for Endoscopic Submucosal Dissection (ESD) in Sessile Polyps

For sessile colorectal polyps, ESD is indicated as a Grade I recommendation for T1 colon cancer with submucosal invasion <1 mm, lateral spreading tumors ≥20 mm, and polyps with fibrosis, while it serves as a Grade II recommendation for flat lesions 5-20 mm and mucosal/submucosal adenomas >20 mm. 1

Primary Indications for ESD

Size-Based Indications

• Sessile lesions >10 mm suspected to be villous adenomas or sessile serrated adenomas/polyps: EMR is Grade I recommendation, with ESD as Grade II alternative 1
• Mucosal or submucosal adenomas >20 mm: Piecemeal EMR (PEMR) is Grade I, ESD is Grade II recommendation 1
• Flat lesions 5-20 mm: EMR is Grade I, ESD is Grade II recommendation 1

High-Priority ESD Indications (Grade I)

The following represent the strongest indications where ESD is the preferred first-line approach:

• T1 stage colon cancer with submucosal invasion <1 mm 1
• Lateral spreading tumors ≥20 mm 1
• Colon polyps with fibrosis 1
• Villous adenomas ≥25 mm 1

Lesion Characteristics Favoring ESD

The US Multi-Society Task Force identifies specific scenarios where ESD should be considered over conventional EMR:

• Large-sized lesions (>20 mm) where en bloc resection using inject-and-cut EMR is difficult 1
• Lesions suspected to have submucosal invasion (large depressed lesions or pseudodepressed LST-NG lesions) 1
• Mucosal lesions with fibrosis 1
• Local residual early carcinoma after endoscopic resection 1
• Non-polypoid colorectal dysplasia in patients with inflammatory bowel disease 1

Morphologic Considerations

Lateral Spreading Tumors (LST)

Different LST subtypes have varying indications for ESD:

• LST-NG (non-granular) with pseudodepression: High risk of submucosal invasion (27.8% for 10-19 mm, 41.4% for 20-29 mm), making ESD preferable for accurate pathologic assessment 1
• LST-NG flat elevated: Moderate risk of submucosal invasion (6.4% for 10-19 mm, 10.4% for 20-29 mm) 1
• LST-G (granular) with mixed-sized nodules: Higher risk of submucosal invasion (7.1% for <20 mm, 38% for >20 mm), with largest nodule requiring en bloc resection 1

Sessile Polyps with Specific Features

• Suspected high-grade intraepithelial neoplasia ≤20 mm expected to be completely resected: EMR is Grade I, ESD is Grade II 1
• Sessile lesions with nonlifting sign due to fibrosis: ESD may be necessary when standard EMR is technically challenging 1

Clinical Decision-Making Algorithm

Step 1: Size Assessment

• 5-20 mm: Consider EMR first; ESD if fibrosis or suspected invasion 1
• >20 mm: PEMR is Grade I, but ESD preferred for en bloc resection 1
• ≥25 mm villous adenomas: ESD is Grade I recommendation 1

Step 2: Morphology Evaluation

• Flat or depressed features: Higher suspicion for invasion, favor ESD 1
• LST-NG morphology: Strong consideration for ESD due to invasion risk 1
• Presence of fibrosis: ESD indicated over standard EMR 1

Step 3: Histologic Suspicion

• Suspected T1 cancer with <1 mm invasion: ESD is Grade I recommendation 1
• Need for accurate pathologic staging: ESD provides superior en bloc resection for complete histologic assessment 1, 2

Important Caveats and Pitfalls

Pre-Procedure Considerations

• All non-pedunculated polyps suspected of malignancy require definitive pathology confirmation before deciding on endoscopic resection 1
• T1-stage cancer carries approximately 15% risk of regional lymph node metastasis, which cannot be determined by endoscopic resection alone 1

Post-ESD Requirements for T1 Cancer

After endoscopic treatment for T1 colon cancer with submucosal invasion <1 mm, comprehensive staging is mandatory:

• Local colonoscopy examination 1
• CEA testing 1
• Abdominal ultrasound 1
• Chest and abdominal CT scans 1

Curative Resection Criteria

Histological criteria for curative endoscopic resection of T1 colon cancer include:

• Submucosal invasion <1 mm 1
• Absence of lymphovascular invasion 1
• Well-differentiated tumors 1
• No tumor budding 1
• Distance of tumor to margin ≥1 mm 1

Technical Limitations

• ESD has relatively few indications even at experienced centers because most colorectal neoplasms are benign and can be resected using piecemeal EMR with minimal recurrence risk 1
• Procedure time is significantly longer for ESD: mean 127.5 minutes overall, with lesions 50-140 mm requiring 217 minutes versus 92.7 minutes for 20-49 mm lesions 3
• R0 resection rates decrease with size: 70.8% for 20-49 mm lesions versus 40.5% for 50-140 mm lesions 3

Complication Considerations

• Perforation risk is higher with ESD than EMR (9.3% microperforation rate), though most are microperforations managed endoscopically without emergency surgery 3
• Delayed bleeding occurs in 2.7% of cases 3
• The European Society of Gastrointestinal Endoscopy recommends a stepwise approach to reduce perforation risk and improve procedure control 4, 5