Incidence of microscopic residual adenoma after complete wide-field endoscopic resection of large colorectal lesions: evidence for a mechanism of recurrence

Emmanuel, Andrew; Williams, Sophie; Gulati, Shraddha; Ortenzi, Monica; Gunasingam, Nishmi; Burt, Margaret; Ratcliff, Simbisai; Hayee, Bu’Hussain; Haji, Amyn

doi:10.1016/j.gie.2021.02.010

Cited by 15 publications

(18 citation statements)

References 26 publications

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“…A recent study from Emmanuel et al reinforces this concept, where they detected microscopic residual adenoma in 19% of macroscopically clear defect margins. However, this study also found a significant proportion of microscopic residual adenoma in the resection bed of EMR defects [22]. These findings support our results, as although hot avulsion has been proven to be a safe and effective tool for removing non-lifting visible polyp within the resection bed that cannot be removed by snare, residual microscopic polyp tissue may remain [6].…”

Section: Accepted Manuscriptsupporting

confidence: 90%

Need for adjunctive removal techniques for endoscopic mucosal resection of large non-pedunculated colonic polyps is predictive of recurrence

Mosko

May

et al. 2022

Endosc Int Open

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Background and Study Aims: Endoscopic mucosal resection (EMR) allows for safe and effective removal of large non-pedunculated colon polyps, but recurrence remains a significant concern. Risk factors for recurrence have previously been reported, however, the significance of these factors have varied and has uncertain applicability with recent advances in EMR techniques. We aimed to evaluate rates and risk factors for recurrence in recent years from a major Canadian referral center Patients and Methods: Consecutive patients between April 1, 2017, to March 1, 2019, who underwent piecemeal EMR were retrospectively identified. Patients with non-pedunculated colorectal polyps ≥ 2 cm removed by piecemeal EMR with available follow-up data were included. Results: 517 patients were reviewed, with 265 patients satisfying inclusion criteria. The median age was 67 years (IQR 14); 48% were female. 15% had a recurrence on follow-up endoscopy. Adjunctive removal techniques were utilized in 31% of patients, 95% of which was hot avulsion. The use of adjunctive removal techniques (OR 2.87, p=0.004) and male gender (OR 3.31, p=0.003) was significantly predictive of recurrence on multivariate analysis. Receiver operating curve characteristics demonstrated good performance of these factors in predicting recurrence (AUC=0.70). Conclusions: The use of adjunctive removal techniques, particularly hot avulsion and male gender are predictive of recurrence after piecemeal EMR of large non-pedunculated colorectal polyps. Male patients and those who require hot avulsion may be considered high risk for recurrence and warrant closer follow-up.

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Section: Accepted Manuscriptsupporting

confidence: 90%

Need for adjunctive removal techniques for endoscopic mucosal resection of large non-pedunculated colonic polyps is predictive of recurrence

Mosko

May

et al. 2022

Endosc Int Open

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“…However, a large cohort study, comparing extended EMR with standard EMR did not show a reduction of recurrence after extended EMR 35 . Furthermore, a recent retrospective observational study by Emmanuel et al showed that microscopic residual adenoma was detected at the apparently normal defect margins in 19 % of cases after wide-field EMR 36 . These studies suggest that wide-field EMR is not the appropriate technique to secure that all microscopic adenomatous tissue is being resected and prevent recurrence.…”

Section: Discussionmentioning

confidence: 99%

“…However, larger prospective or randomized studies might be desired to validate these outcomes. In the future, expanding the scope to not only treating defect margins, but also the base of resection, might be important to further reduce recurrence 36 38 .…”

Section: Discussionmentioning

confidence: 99%

Thermal ablation of mucosal defect margins to prevent local recurrence of large colorectal polyps: a systematic review and meta-analysis

et al. 2022

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Background: Endoscopic mucosal resection of large non-pedunculated colorectal polyps is characterized by a high risk of recurrence. Thermal ablation of the mucosal defect margins may reduce recurrence in these lesions, but a systematic overview of the current evidence is lacking. Materials and methods: We searched Pubmed, Embase and Cochrance until July 2021, for studies on thermal ablation of mucosal defect margins of large non-pedunculated colorectal polyps. Main goal of this meta-analysis was to identify pooled risk difference of recurrence between thermal ablation vs. no adjuvant treatment. Secondary goal was to identify pooled recurrence rate after STSC and APC. Results: Ten studies on thermal ablation of mucosal defect margins were included, with 3 studies on argon plasma coagulation, 6 studies on snare tip soft coagulation and 1 study comparing both treatment modalities, representing a total of 316 APC cases and 1598 STSC cases. Overall pooled risk difference of recurrence was -0.17 (95% CI -0.22 – -0.12) as compared to no adjuvant treatment. Pooled risk difference was -0.16 (95% CI -0.19 – -0.14) for STSC and -0.26 (95% CI -0.80 – 0.28) for APC. Pooled recurrence rate was 4% (95%-CI 2-8%) for STSC and 9% (95%-CI 4-19%) for APC. Conclusions: Thermal ablation of mucosal defect margins significantly reduces recurrence rate in large non-pedunculated colorectal lesions compared to no adjuvant treatment. While no evidence for superiority exists, snare tip soft coagulation may be preferred over argon plasma coagulation, because this method is the most evidence-based, and cost-effective modality.

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“…Emmanuel et al 5 present evidence that residual microscopic neoplasia remains in a significant proportion of patients who have undergone EMR, supporting the hypothesis that continuous resection or ablation to avoid tissue bridges results in a reduction of recurrence. The use of the EndoRotor appears to be a safe method for resecting residual neoplasia while still providing viable tissue for histopathologic examination.…”

mentioning

confidence: 82%

“…In this issue of Gastrointestinal Endoscopy, Emmanuel et al 5 explore the hypothesis that residual tissue after EMR is the likely cause of recurrence, rather than de novo neoplasm, by determining the incidence of microscopic residual neoplasia in apparently macroscopically normal areas after resection. This retrospective observational study included a selected group of patients undergoing EMR (n Z 38) or knife-assisted snare resection (n Z 3) of colorectal lesions 20 mm during a 20-month period in a single tertiary referral center for early colorectal cancer and advanced endoscopic resection.…”

mentioning

confidence: 99%

Recurrence after endoscopic mucosal resection: there’s more to it than meets the eye

Dhillon

Ravindran

Thomas‐Gibson

2021

Gastrointestinal Endoscopy

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Incidence of microscopic residual adenoma after complete wide-field endoscopic resection of large colorectal lesions: evidence for a mechanism of recurrence

Cited by 15 publications

References 26 publications

Need for adjunctive removal techniques for endoscopic mucosal resection of large non-pedunculated colonic polyps is predictive of recurrence

Need for adjunctive removal techniques for endoscopic mucosal resection of large non-pedunculated colonic polyps is predictive of recurrence

Thermal ablation of mucosal defect margins to prevent local recurrence of large colorectal polyps: a systematic review and meta-analysis

Recurrence after endoscopic mucosal resection: there’s more to it than meets the eye

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