Recommendations on Endoscopic Removal of Colorectal Lesions (USMSTF, 2020)

US Multi-Society Task Force on Colorectal Cancer

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

May 11, 2020

The recommendations on endoscopic removal of colorectal lesions were published in March 2020 by the US Multi-Society Task Force on Colorectal Cancer (USMSTF).[1]

Lesion Assessment and Description

Documentation of endoscopic descriptors of the lesion (eg, location, size, and morphology) in the colonoscopy procedure report is suggested. Use of the Paris classification to describe surface morphology is suggested. For nonpedunculated adenomatous (Paris 0-II and 0-Is) lesions ≥10 mm, surface morphology should also be described as granular or nongranular lateral spreading lesions.

Photo documentation of all lesions ≥10 mm before removal is recommended, and photo documentation of the postresection defect is suggested.

Proficiency in using electronic-based or dye-based image-enhanced endoscopy techniques to apply optical diagnosis classifications for colorectal lesion histology is suggested.

Proficiency in endoscopic recognition of deep submucosal invasion is recommended.

Lesion Removal

Diminutive (≤ 5 mm) and small (6-9 mm) lesions

Cold snare polypectomy is recommended to remove these lesions. Cold forceps polypectomy should not be used to remove diminutive lesions. For lesions ≤ 2 mm, jumbo or large-capacity forceps polypectomy may be considered if cold snare polypectomy is difficult. Use of hot biopsy forceps for polypectomy of diminutive and small lesions is not recommended.

Nonpedunculated (10-19 mm) lesions

Cold or hot snare polypectomy (with or without submucosal injection) is suggested.

Nonpedunculated (≥20 mm) lesions

Endoscopic mucosal resection (EMR) is the preferred treatment method.

Resection should be performed by an endoscopist experienced in advanced polypectomy.

Snare resection of all grossly visible lesion tissue should be done in a single colonoscopy session and in the safest minimum number of pieces.

Use of a contrast agent in the submucosal injection solution is suggested. Tattoo, using sterile carbon particle suspension, should not be used as the submucosal injection solution. Use of a viscous injection solution is suggested.

Ablative techniques (eg, argon plasma coagulation [APC], snare-tip soft coagulation) should not be used on endoscopically visible residual tissue of a lesion.

Adjuvant thermal ablation of the post-EMR margin, where no endoscopically visible adenoma remains despite meticulous inspection, is suggested.

Detailed inspection of the postresection mucosal defect to identify features for perforation risk is recommended, with performance of endoscopic clip closure if necessary.

Prophylactic closure of resection defects ≥20 mm in the right colon is suggested when feasible.

Intraprocedural bleeding should be treated with endoscopic coagulation or mechanical therapy (eg, clip), with or without the use of dilute epinephrine injection.

Patients on antithrombotics who are candidates for endoscopic removal of a colorectal lesion ≥20 mm should receive individualized assessment to balance the risks of interrupting anticoagulation against the risks of significant bleeding.

Pedunculated lesions

Hot snare polypectomy is recommended for removal of pedunculated lesions ≥10 mm.

Prophylactic mechanical ligation of the stalk with a detachable loop or clips is recommended for pedunculated lesions with a head ≥20 mm or stalk thickness ≥5 mm.

Retrieval of large pedunculated polyp specimens en bloc is suggested to enable assessment of resection margins, instead of division of polyp heads to facilitate through-the-scope specimen retrieval.

Lesion Marking

Use of tattoo, using sterile carbon particle suspension, is recommended to demarcate any lesion that may require localization for future procedures. The tattoo should be placed at two or three separate sites located 3-5 cm anatomically distal to the lesion (anal side).

Endoscopists and surgeons should establish a standard location for tattoo injection relative to the colorectal lesion of interest at their institution.

Documentation of the details of the tattoo injection in the colonoscopy report is recommended, as well as photo documentation of the tattoo in relation to the lesion.


Intensive follow-up is recommended after piecemeal EMR (lesions ≥20 mm), with the first surveillance colonoscopy at 6 months and the next colonoscopies at 1 year and 3 years.

To assess for local recurrence, careful examination of the postmucosectomy scar site with enhanced imaging (dye-based or electronic-based) is suggested, along with targeted biopsies of the site.

When local recurrence is suspected, endoscopic resection is suggested, and ablation of the perimeter of the posttreatment site should be considered. Subsequent examinations are performed at 6- to 12-month intervals until there is no local recurrence. Once the resection site is clear, the next follow-ups are performed at 1-year and then 3-year intervals.

Detailed examination of the entire colon at the surveillance colonoscopy is recommended to assess for synchronous colorectal lesions.


Carbon dioxide insufflation is recommended instead of air during colonoscopy and EMR.

The use of microprocessor-controlled electrosurgical units is suggested.

Quality of Polypectomy

When an endoscopist is not confident of his or her ability to remove a suspected benign colorectal lesion completely, referral to an endoscopist experienced in advanced polypectomy is recommended in lieu of referral for surgery.

The resection method used should be documented in the procedure report.

Nonpedunculated lesions resected en bloc with endoscopic features suggestive of submucosal invasion should be retrieved and pinned to a flat surface before being submitted to the pathology laboratory.

For nonpedunculated colorectal lesions resected en bloc with submucosal invasion, pathologists should report depth of invasion, distance of the cancer from the vertical and lateral resection margin, and prognostic histologic features.

Pedunculated lesions should be resected en bloc, and when submucosal invasion is present, pathologists should report the distance of cancer from the cautery line, the degree of tumor differentiation, and the presence or absence of lymphovascular invasion.

Endoscopists should participate in a local quality-assurance program.

The percentage of patients undergoing colonoscopy who are referred to surgery for benign colorectal lesion management should be measured and reported.

The use of polypectomy competency assessment tools in endoscopic training programs and practice improvement programs is suggested.

For more information, please go to Colon Cancer, Rectal Cancer, and Colonoscopy.

For more Clinical Practice Guidelines, please go to Guidelines.


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