Colorectal Polyp/Early Cancer · Endoscopic Resection vs Surgery

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Size/morphology/deep-invasion signs
   Size / morphology (LST) / signs of deep invasion? (Signs of deep invasion: surface depression, Kudo Vi pit pattern, JNET 2B/3, NICE 3.)
   • Diminutive/small (<10 mm) → <10 mm → cold snare
   • Large (≥10–20 mm), LST, no deep-invasion signs → LST → EMR
   • ≥20 mm LST / suspected superficial invasion / needs en-bloc pathology → Large/suspected superficial invasion → ESD
   • Deep submucosal invasion (≥1000 µm/SM2)/poorly differentiated/lymphovascular+/Haggitt 4 → Deep invasion → surgical colectomy
2. [End] <10 mm → cold snare
   <10 mm → cold snare polypectomy; send the whole specimen for pathology.
3. [End] LST → EMR
   ≥10–20 mm flat/LST, no deep invasion → endoscopic mucosal resection (EMR; piecemeal if >20 mm); assess completeness, with re-resection/early surveillance if needed.
4. [End] Large/suspected superficial invasion → ESD
   ≥20 mm LST / suspected superficial invasion / needs en-bloc pathology → endoscopic submucosal dissection (ESD) for en-bloc resection, allowing accurate staging and curative assessment.
5. [End] Deep invasion → surgical colectomy
   Deep submucosal invasion (≥1000 µm/SM2)/poorly differentiated/lymphovascular+/pedicle Haggitt 4 → surgical colectomy + lymphadenectomy (laparoscopic preferred). Note: for a malignant polyp with margin ≥1 mm, no lymphovascular invasion, SM <1000 µm and good differentiation, endoscopic resection alone suffices.

Source guidelines & references

• Colorectal polypectomy (ESGE polypectomy guideline; USMSTF; deep invasion 1000 µm threshold)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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