Current strategies for malignant pedunculated colorectal polyps

Table 1 Histopathological factors predicting risk of lymph node metastases in malignant pedunculated colorectal polyps

Histopathological factors	Risk of LNM	Management
Depth of invasion in submucosa by the primary tumor of more than 1mm (Beaton et al[2])	High	Surgery with lymph node dissection
Poorly differentiated cancers (Beaton et al[2])
Tumor budding (Beaton et al[2], Sohn et al[18], Geramizadeh et al[7], Graham et al[22])
Lymphovascular invasion (Beaton et al[2])
Depth of invasion to the base of the stalk-Level 4 Haggitt (Nivatvongs et al[17], Kimura et al[19])
Submucosal invasion into the polyp stalk (Matsuda et al[16])
Micropapillary component (Sonoo et al[26], by Verdú et al[27], Mukai et al[28])
Head invasion (Kimura et al[19])		Surgical resection with lymph node dissection in case of additional pathological risk factors
Head invasion (Kitajima et al[15], Matsuda et al[16])	Low	Endoscopic polypectomy
Depth of submucosal invasion/stalk invasion < 3000 μm (Kitajima et al[15])
Tumor size (Nivatvongs et al[17])
Grading (Nivatvongs et al[17])
Pseudoinvasion (Backes et al[13])		Confirmation of t1 colorectal cancer by a second expert pathologist

LNM: Lymph node metastases.

Table 2 Endoscopic polypectomy in patients on antiplatelet therapy or anticoagulants (British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy Recommendations[71])

Thrombosis risk factors		High thrombotic risk	Low thrombotic risk	Post-polypectomy
Discontinuation of warfarin concerning the requirement for heparin bridging	Discontinuation of clopidogrel, prasugrel or ticagrelor	Continuing aspirin and liaising with a cardiologist about the risk/benefit of discontinuing P2Y12 receptor antagonists (high quality evidence, strong recommendation)	Continuing aspirin in patients on dual antiplatelet therapy (low quality evidence, weak recommendation)	Antiplatelet or anticoagulant therapy should be suspended up to 48 h after the procedure depending on the perceived bleeding and thrombotic risks (moderate quality evidence, strong recommendation)
Prosthetic metal heart valve in mitral position	Drug- eluting coronary artery stents within 12 mo of placement	Warfarin should be temporarily stopped and substituted with LMWH (low quality evidence, strong recommendation)	Discontinuing P2Y12 receptor antagonists 5 d before the procedure (moderate quality evidence, strong recommendation)
Prosthetic heart valve and atrial fibrillation	Bare metal coronary artery stents within 1 mo of placement.	The last dose of DOAC should be taken at least 48 h before the procedure (very low quality evidence, strong recommendation)	Discontinuing warfarin 5 d before the procedure (high quality evidence, strong recommendation)
Atrial fibrillation and mitral stenosis			Ensure the INR target < 1.5 prior to the procedure (low quality evidence, strong recommendation)
< 3 mo after venous thromboembolism

LMWH: Low molecular weight heparin; DOAC: Direct oral anticoagulants.