We read with interest the article "Endoscopic resection of high-risk T1 colorectal carcinoma prior to surgical resection has no adverse effect on long-term outcomes" by Overwater et al., which was published in Gut (1). Endoscopic resection, including polypectomy and endoscopic mucosal resection (EMR), is a widely recognized treatment for early gastrointestinal malignancies. Endoscopic submucosal dissection (ESD) is accepted as a minimally invasive treatment for early-stage colorectal cancer (CRC), and this approach enables en bloc resection of a specimen (2). In certain cases, endoscopic treatment alone is insufficient for disease control, and additional surgical treatment after EMR is recommended for patients with high-risk T1 CRC (3,4). However, endoscopic resection of T1 CRC prior to surgical resection might worsen oncologic outcomes by accelerating the growth of the remaining tumor and promoting cancer cell dissemination and metastasis. For high-risk T1 CRC, relatively little is known about whether endoscopic resection before surgery influences lymph node metastasis (LNM), recurrence, or long-term survival.Prior studies showed that the recurrence rate of endoscopically treated T1 CRC is 2.3-7.3% and that the duration of recurrence is 19.7-38.3 months (3,5-7). Asayama et al. reported recurrence rates of 4.3% and 6.6% in primary surgery and secondary surgery (endoscopic resection with additional surgical resection) groups, respectively, although this difference was not significant (7). However, previous investigations have exhibited several limitations, including the examination of a small number of patients, short follow-up periods, and a lack of data regarding pathological findings.The aforementioned study by Overwater et al. was the largest multicenter observational study to evaluate longterm outcomes after surgical resection of high-risk T1 CRC with or without prior endoscopic resection in Western countries. This retrospective study involved 602 patients diagnosed with T1 CRC with one or more histological risk factors for LNM who were treated via primary or secondary surgery between 2000 and 2014 at 13 hospitals in the Netherlands. High-risk T1-CRC was defined as CRC with poorly differentiated histology, positive resection margins, deep submucosal invasion depth (defined as a submucosal invasion depth ≥1,000 μm, Sm2/Sm3 stage for sessile T1 CRC and Haggitt level 3-4 for pedunculated T1 CRC) or the presence of vascular or lymphatic invasion. The present study is particularly important because it was limited to analyzing high-risk T1 CRC for both primary surgical resection and secondary surgical resection (endoscopic resection with additional surgical resection). No differences were observed between primary and secondary surgery with respect to the presence of LNM (OR 0.97; 95% CI: 0.49 to 1.93; P=0.94) or recurrence during followup (HR 0.97; 95% CI: 0.41 to 2.34; P=0.954). In the aforementioned study by Overwater et al., recurrence rates Editorial