Indications for Endoscopic Submucosal Dissection (ESD) in Sessile Polyps

Primary Indications for ESD

The American Gastroenterological Association recommends ESD as a Grade I indication 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 indication for flat lesions 5-20 mm and mucosal/submucosal adenomas >20 mm 1, 2
The American Gastroenterological Association recommends ESD as a Grade II alternative for sessile lesions >10 mm suspected to be villous adenomas or sessile serrated adenomas/polyps, with EMR as the Grade I recommendation 1, 2
The American Gastroenterological Association recommends piecemeal EMR (PEMR) as Grade I and ESD as Grade II for mucosal or submucosal adenomas >20 mm 1, 2
The American Gastroenterological Association recommends EMR as Grade I and ESD as Grade II for flat lesions 5-20 mm 1, 2

The US Multi-Society Task Force identifies large-sized lesions (>20 mm) where en bloc resection using inject-and-cut EMR is difficult as a scenario where ESD should be considered over conventional EMR 3
The US Multi-Society Task Force identifies lesions suspected to have submucosal invasion as a scenario where ESD should be considered over conventional EMR 3
The US Multi-Society Task Force identifies mucosal lesions with fibrosis as a scenario where ESD should be considered over conventional EMR 3
The US Multi-Society Task Force identifies local residual early carcinoma after endoscopic resection as a scenario where ESD should be considered over conventional EMR 3
The US Multi-Society Task Force identifies non-polypoid colorectal dysplasia in patients with inflammatory bowel disease as a scenario where ESD should be considered over conventional EMR 3

For lesions 5-20 mm, consider EMR first, but ESD if fibrosis or suspected invasion, as recommended by the American Gastroenterological Association 1, 2
For lesions >20 mm, piecemeal EMR (PEMR) is Grade I, but ESD is preferred for en bloc resection, as recommended by the American Gastroenterological Association 1, 2
For villous adenomas ≥25 mm, ESD is the Grade I recommendation, as recommended by the American Gastroenterological Association 1, 2

The American Gastroenterological Association recommends that all non-pedunculated polyps suspected of malignancy require definitive pathology confirmation before deciding on endoscopic resection 1, 2
T1-stage cancer carries approximately 15% risk of regional lymph node metastasis, which cannot be determined by endoscopic resection alone, as reported by the American Gastroenterological Association 1, 2
After endoscopic treatment for T1 colon cancer with submucosal invasion <1 mm, comprehensive staging is mandatory, including local colonoscopy examination, CEA testing, abdominal ultrasound, and chest and abdominal CT scans, as recommended by the American Gastroenterological Association 1, 2
Histological criteria for curative endoscopic resection of T1 colon cancer include submucosal invasion <1 mm, absence of lymphovascular invasion, well-differentiated tumors, no tumor budding, and distance of tumor to margin ≥1 mm, as recommended by the American Gastroenterological Association 1, 2
The European Society of Gastrointestinal Endoscopy recommends a stepwise approach to reduce perforation risk and improve procedure control 4, 5

The American Gastroenterological Association recommends ESD as the first-line endoscopic approach for lateral spreading tumors ≥20 mm, villous adenomas ≥25 mm, sessile polyps with fibrosis, and T1 colon cancer with submucosal invasion <1 mm, due to the high risk of submucosal invasion and the need for en bloc resection 6
The US Multi-Society Task Force identifies large-sized lesions (>20 mm) where inject-and-cut EMR cannot achieve en bloc resection, lesions with suspected submucosal invasion, and local residual early carcinoma after prior endoscopic resection as scenarios where ESD should replace conventional EMR 7

The Paris Classification and Surface Morphology can be used to identify high-risk sessile polyps requiring ESD, with features such as LST-NG (non-granular laterally spreading tumors) with sessile shape or depression, LST-G (granular) with a dominant nodule, and depressed (0-IIc) morphology predicting higher risk of submucosal invasion 7
The NICE 3 classification features (disrupted surface pattern, absent vessels, or dark brown color) have 94% accuracy for predicting deep submucosal invasion, and the Kudo pit pattern type V or VN has 90.4% sensitivity and 88.4% specificity for invasive cancer 7

The American College of Gastroenterology recommends that all non-pedunculated polyps suspected of malignancy require definitive pathology confirmation before deciding on endoscopic resection, and that biopsy the area of surface disruption and tattoo the lesion (not in or near cecum) 6
The presence of NICE 3 or Kudo VN features indicates deep submucosal invasion with high lymph node metastasis risk, and the patient should be directed to surgery rather than attempting ESD 7

ESD is considered curative ONLY when ALL of the following are met: submucosal invasion <1 mm, absence of lymphovascular invasion, well or moderately differentiated tumor, no tumor budding (low-grade budding acceptable), and distance of tumor to margin ≥1 mm (negative resection margins) 6