Come and get me if you can!

This sizeable polyp was discovered at the ileo-caecal valve and was referred for resection. Samples have not been taken to avoid tethering down making the endoscopic resection uneccessarily difficult. 
HOW WOULD YOU APPROACH THE LESION?

■ Back off and take some samples

Yes, and perhaps request a CT!

■ Attempt an EMR

You first need to decide what this is!

■ Consider removal by ESD

Can't be adenomatous, it's growing out of the TI!

■ Underwater EMR

Would also be ill advised

■ Refer for surgery

If this is what you think it is, then Yes!

explanation

In most cases, I would say 'if it lifts it will shift'.  However, in this case I wouldn't bother with a test-lift.  The reason is that the thing is growing out of the terminal ileum. You don't get adenomatous polyps growing out of the TI!  This must be something else! In fact the true lesion may be larger than the red nipple-like polyp. 

Even though there are no large 'tell-tale' vessels running up it's side, the only thing of this size, growing out of the TI, is a NET!   A lymphoma was my second guess. 

TI NET's are often bad news and should be considered for surgical resection. There is another odd thing about NET's growing in the terminal ileum.  The WHO grading system doesn't seem to relate to the aggressiveness of the lesions behaviour ! 

This was only WHO grade I (proliferation index was only 1.8%) but on a full analysis after the right hemi-colectomy, the NET was found to be a invading into the muscle propria layer and with metastatic deposits in 2 out of 12 resected lymph nodes (T2,N1) as well as ulcerated deposits of NET in the nearby pericolic fat on the serosal surface.   The moral of the story?  In the terminal ileum, 'well differentiated NET' doesn't mean that it's well behaved!