Malignant colorectal polyps present a common dilemma in clinical practice. Complete endoscopic removal may be adequate treatment, but the risk of lymph node metastases may prompt consideration of major colorectal resection, with significant potential risks associated. Although the incidence of endoscopically resected malignant polyps is increasing, our ability to predict lymph node metastases remains poor with the vast majority of patients undergoing surgical resection being found to have no residual cancer in the resection specimen. This presentation will review the best available evidence to assist clinical decision-making and discuss the path forward for this significant clinical problem.