Indications for Subsequent Surgery After Endoscopic Resection of Submucosally Invasive Colorectal Carcinomas

Choi, Dong Hyun; Sohn, Dae Kyung; Chang, Hee Jin; Lim, Sangwoo; Choi, Hyo Seong; Jeong, Seung‐Yong

doi:10.1007/dcr.0b013e318197e37f

Cited by 95 publications

(76 citation statements)

References 22 publications

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“…Although the implication of budding/sprouting in deeply invasive colorectal cancer was first reported in 1989, 25 many studies have also focused on budding/sprouting as a risk factor of lymph node metastasis in T1 colorectal cancer. [12][13][14][15][26][27][28][29][30][31][32] Some investigators refer to findings similar to budding/sprouting as 'unfavorable histology at the invasive front,' 33 'focal dedifferentiation,' 34 or 'tumor cell dissociation,' 35 although the definition is not always consistent. 13,25,32,36 In the evaluation of budding/sprouting, we adopted the definition of Ueno et al 13 because it is widely used and has good reproducibility.…”

Section: Discussionmentioning

confidence: 99%

A three-tier classification system based on the depth of submucosal invasion and budding/sprouting can improve the treatment strategy for T1 colorectal cancer: a retrospective multicenter study

et al. 2015

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More than 85% of patients with T1 colorectal cancer have no lymph node metastasis and can be cured by endoscopic resection. To avoid unnecessary surgery after complete endoscopic resection, accurate histologic methods for evaluating resected specimens are needed to discriminate those at high risk for lymph node metastasis. A retrospective multi-institutional, cross-sectional study of 806 T1 colorectal cancer patients was conducted. A budding/sprouting score was incorporated for predicting lymph node metastasis in addition to other parameters, including the depth of submucosal invasion, histologic grade, and lymphovascular invasion. Lymph node metastasis was detected in 97 patients. Independent predictors of lymph node metastasis by multivariate analysis were depth of submucosal invasion ≥ 1000 μm (odds ratio (95% confidence interval) = 5.56 (2.14-19.10)) and high-grade budding/sprouting (3.14 (1.91-5.21)). Among lesions with a depth of submucosal invasion ≥ 1000 μm, lymph node metastasis was detected in 59 (29%) of 207 patients with high-grade budding/ sprouting, and in 34 (9%) of 396 with low-grade budding/sprouting. Lymph node metastasis was detected in only 4 (2%) of 203 lesions with a depth of submucosal invasion o 1000 μm. Of these four tumors, three invaded lymphatic and/or venous vessels. Thus, the risk for lymph node metastasis can be classified into three groups: high risk with a depth of submucosal invasion ≥ 1000 μm and high-grade budding/sprouting, intermediate-risk with a depth of submucosal invasion ≥ 1000 μm and low-grade budding/sprouting, and low-risk with a depth of submucosal invasion o1000 μm. These findings revealed that a depth of submucosal invasion ≥ 1000 μm and high-grade budding/sprouting are powerful predictive parameters for lymph node metastasis in T1 colorectal cancer. This three-tier risk classification system will facilitate the decision for additional major surgery for T1 colorectal cancer patients after successful endoscopic treatment.

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Section: Discussionmentioning

confidence: 99%

A three-tier classification system based on the depth of submucosal invasion and budding/sprouting can improve the treatment strategy for T1 colorectal cancer: a retrospective multicenter study

et al. 2015

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“…Many studies attempted the definition of potential predictors for locoregional residual disease, however the indications for subsequent colectomy versus follow-up remain controversial and still not properly established, persisting a surgical overtreatment rate that can achieve 80 % (13,14). In our 40 studied patients, only 15 had residual disease, thus 63 % of our population was "cured" at colonoscopy.…”

Section: Discussionmentioning

confidence: 90%

“…Endoscopic resection affords patients with the typical advantages of minimally invasive procedures, but in T1 (tumor invading submucosa) colorectal cancers it should be used selectively because of decreased certainty regarding oncologic outcomes when local recurrence or LNM is considered (14,18). Many studies attempted the definition of potential predictors for locoregional residual disease, however the indications for subsequent colectomy versus follow-up remain controversial and still not properly established, persisting a surgical overtreatment rate that can achieve 80 % (13,14).…”

Section: Discussionmentioning

confidence: 99%

“…These factors include deep submucosal invasion, poor or undifferentiation, lymphovascular invasion, and positive resection margins (6,10,(13)(14)(15). Nevertheless, the identification of those patients remains a challenge, in fact even in the presence of high-risk features residual disease is noted in 15-20 % of the operated cases, and nodal disease is detected in a smaller proportion (13).…”

Section: Introductionmentioning

confidence: 99%

“…Nevertheless, the identification of those patients remains a challenge, in fact even in the presence of high-risk features residual disease is noted in 15-20 % of the operated cases, and nodal disease is detected in a smaller proportion (13). Thus, around 84 % of patients may be undergoing significant morbidity due to unnecessary surgical interventions after endoscopic resection (14).…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Oncological outcomes after endoscopic removal of malignant colorectal polyps

Gonçalves

Fontainhas

Caetano

et al. 2013

Rev. esp. enferm. dig.

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Objective: malignant colorectal polyp, defined by submucosally invasive adenocarcinoma, is the earliest form of clinically relevant colorectal cancer (CRC). After endoscopic resection additional surgery may be necessary, although decision criteria remain debatable. The objective of this study was to assess oncologic outcomes in terms of locoregional disease and to identify areas of improvement that may facilitate patients' management.Methods: retrospective study of 40 patients with T1 CRC endoscopically resected between 2007 and 2012. Clinicopathological features were assessed and correlated with residual disease (RD), defined as presence of adenocarcinoma in intestinal wall and/ or lymph nodes.Results: thirty-one patients underwent surgery while 9 were followed-up. After surgery, RD was confirmed in 15 (48.4 %) patients: 8 (53.3 %) wall disease, 5 (33 %) nodal metastasis, and 2 (13.3 %) with both. No recurrence was detected in the follow-up group. The characteristics of the lesions that were associated with DR were sessile configuration (p = 0.03), the degree of differentiation G3 (p = 0.01) and intercepted/indeterminate margins (p = 0.01). Twenty-two patients were operated because of inadequate evaluation, mainly due to piecemeal resection, and half of them were disease free. Postoperative complications were found in 9 (30 %) patients, mainly anastomotic leakage that was associated with rectum anterior resection (p = 0.03).Conclusions: surgery should be considered in the presence of any risk factor for residual disease, while follow-up can be offered in low risk settings. Was also demonstrated a clear need for technical improvement in endoscopic resection and pathology evaluation in order to prevent unnecessary surgeries.

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Local recurrence after local excision of early rectal cancer: a meta-analysis of completion TME, adjuvant (chemo)radiation, or no additional treatment

Oostendorp

Smits

Vroom

et al. 2020

British Journal of Surgery

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Background: The risks of local recurrence and treatment-related morbidity need to be balanced after local excision of early rectal cancer. The aim of this meta-analysis was to determine oncological outcomes after local excision of pT1-2 rectal cancer followed by no additional treatment (NAT), completion total mesorectal excision (cTME) or adjuvant (chemo)radiotherapy (aCRT). Methods: A systematic search was conducted in PubMed, Embase and the Cochrane Library. The primary outcome was local recurrence. Statistical analysis included calculation of the weighted average of proportions. Results: Some 73 studies comprising 4674 patients were included in the analysis. Sixty-two evaluated NAT, 13 cTME and 28 aCRT. The local recurrence rate for NAT among low-risk pT1 tumours was 6⋅7 (95 per cent c.i. 4⋅8 to 9⋅3) per cent. There were no local recurrences of low-risk pT1 tumours after cTME or aCRT. The local recurrence rate for high-risk pT1 tumours was 13⋅6 (8⋅0 to 22⋅0) per cent for local excision only, 4⋅1 (1⋅7 to 9⋅4) per cent for cTME and 3⋅9 (2⋅0 to 7⋅5) per cent for aCRT. Local recurrence rates for pT2 tumours were 28⋅9 (22⋅3 to 36⋅4) per cent with NAT, 4 (1 to 13) per cent after cTME and 14⋅7 (11⋅2 to 19⋅0) per cent after aCRT. Conclusion: There is a substantial risk of local recurrence in patients who receive no additional treatment after local excision, especially those with high-risk pT1 and pT2 rectal cancer. The lowest recurrence risk is provided by cTME; aCRT has outcomes comparable to those of cTME for high-risk pT1 tumours, but shows a higher risk for pT2 tumours.

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Indications for Subsequent Surgery After Endoscopic Resection of Submucosally Invasive Colorectal Carcinomas

Cited by 95 publications

References 22 publications

A three-tier classification system based on the depth of submucosal invasion and budding/sprouting can improve the treatment strategy for T1 colorectal cancer: a retrospective multicenter study

A three-tier classification system based on the depth of submucosal invasion and budding/sprouting can improve the treatment strategy for T1 colorectal cancer: a retrospective multicenter study

Oncological outcomes after endoscopic removal of malignant colorectal polyps

Local recurrence after local excision of early rectal cancer: a meta-analysis of completion TME, adjuvant (chemo)radiation, or no additional treatment

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