Expert Panel Seeks to Guide Referral for Large Polyps

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WASHINGTON—A panel of 24 international experts has developed standards for referral for large nonpedunculated colorectal polyps, offering a list of 19 statements to guide clinicians about factors that could indicate submucosal invasion or contribute to complications during resection.

“The consensus statements can aid in improving the triage and planning of endoscopic resection techniques for large colorectal polyps and ultimately contribute to reducing colorectal cancer incidence and mortality,” said investigator Sam Seleq, MBChB, presenting the research on the statements at DDW 2024 (abstract 207).

Patients with large nonpedunculated colorectal polyps often are referred to expert centers for endoscopic resection. Relevant information needs to be conveyed to the therapeutic endoscopist to allow for triage and planning of resection technique, said Dr. Seleq, a senior medical officer at Te Whatu Ora, Waitemata, in Auckland, New Zealand, who conducted this research while a GI fellow at St. Michael’s Hospital, in Toronto.

The experts were recruited by a steering committee, largely based on their significant publications in this field and/or experience with relevant societies. The panel applied Delphi methodology to establish consensus on minimum expected standards. They conducted three rounds of surveys to achieve consensus, with quantitative and qualitative data analyzed in each round. The first round resulted in 44 statements, which were narrowed down to 19 and ranked in order of priority using the 5-point Likert scale. Consensus was indicated by 80% agreement.

“There was an emphasis on balance,” weighing how detailed the information could be versus being user-friendly and easy for referral decisions, Dr. Seleq said.

The panel identified five factors related to patient medical findings, five related to previous endoscopy findings, four related to the relevant lesion, one associated with patient demographics, and four reflecting the conclusion and outcomes.

Consensus on Clinicopathologic Features

Consensus was reached for factors predictive of submucosally invasive cancer and complications during resection:

• polyp location, morphology, histopathology and size;
• patient age and referral indication; and
• procedurally relevant medications, such as antiplatelet and anticoagulant drugs.

While most of the 19 statements were considered by most experts to be of “very high priority,” Dr. Seleq said, they were ranked in order of importance, with the top-rated statements as follows:

• The location of the polyp must be clearly documented in the referral report, including the segment of the colon and the distance from the anal verge.
• A detailed summary of the histopathologic results obtained from the pathology report; any relevant findings—such as tumor grade, stage and margins—must be included.
• The size of the polyp must be documented in the referral report as it is an important factor in determining the risk for malignancy and the appropriate management strategy.
• The patient’s age must be documented.
• The reason for the referral must be included.

Other factors of high importance included the presence of nearby tattooing, conclusions from the examination, history of attempted endoscopic mucosal resection or endoscopic submucosal dissection, documentation of adverse events from previous procedures, and recommendations to the patient.

“High-quality photography was universally agreed upon,” Dr. Seleq said. Photodocumentation allows for accurate lesion characterization for resection planning (such as the need to go directly to surgery) and prevents repeat diagnostic colonoscopy, but “may be limited by poor-quality photographs or transmission issues, such as faxing.” Consequently, the group recommended photodocumentation with white light and high-definition imaging, with and without near focus.

In addition, the panel considered information related to biopsies to be important, but assessment of microsurface and microvascular features was an area that failed to garner consensus. “This is likely to change with time, with improved education online, lesion assessment and characterization, and universally available high-definition scopes,” Dr. Seleq predicted.

Commenting on the research, Carol Burke, MD, a staff member in the Department of Gastroenterology, Hepatology and Nutrition and the Director of the Center for Polyposis at Cleveland Clinic in Cleveland, expressed concern that a list of 19 recommendations would be daunting for referring colonoscopists. “In America, the more you ask for, the less you get. You’ll have no people referring you large polyps.”

Instead, Dr. Burke asked Dr. Seleq to list the three most important features that would help stratify patients and inform endoscopists. He responded that location, size and histopathology of the polyp would be most important. He added that accurate photodocumentation and sizing are critical. “Take as many pictures, close up, as you can.

“We hope these standards,” he said, “will facilitate consistent and comprehensive reporting, reduce unnecessary endoscopy and improve patient outcomes.”

—Caroline Helwick

Dr. Burke reported a financial relationship with Sebela. Dr. Seleq reported no relevant financial disclosures.