Low value of second-look endoscopy for detecting residual colorectal cancer after endoscopic removal

Gijsbers, Kim; Post, Zoë; Schrauwen, Ruud; Tang, Thjon J.; Bisseling, Tanya M.; Bac, Dirk Jan; Veenstra, Renzo P.; Schreuder, Ramon-Michel; Stippel, Ludger S.M. Epping; Cappel, Wouter H. de Vos tot Nederveen; Slangen, Rob M.E.; Lelyveld, Niels van; Witteman, E. M.; Wit, Marc A.W.M. van Milligen de; Honkoop, Pieter; Alderlieste, Yasser A.; Borg, Pieter J.C. ter; Roermund, Rolf van; Schmittgens, S.; Dekker, Evelien; Leeuwenburgh, Ivonne; Ridder, Rogier J J de; Zonneveld, Anke M.; Hadithi, Muhammed; Leerdam, Monique E. van; Bruno, Marco J.; Vleggaar, Frank P.; Moons, Leon M.G.; Koch, Arjun D.; Borg, Frank ter

doi:10.1016/j.gie.2020.01.056

Cited by 6 publications

(9 citation statements)

References 19 publications

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“…To the best of our knowledge, this is the first study comparing the oncological outcome of FTRS for R1/Rx resected T1 CRC without LVI and poor differentiation with conventional CS. We found a higher rate of LNM (8.5%) than expected in these patients, confirming the observation made in the SCAPURA trial (13). The 5-year DFS was lower in the FTRS group (89.9% vs 96.8%), but because 63% of recurrences in this group could be treated with curative intent, the 5-year OS and MFS were similar between both treatment strategies (94.4% vs 95.6% and 92.1% vs 96.8%, respectively).…”

Section: Discussionsupporting

confidence: 91%

“…Our study shows that cases with LIRC (of whom 11.0% underwent FTRS) show higher risks of an adverse oncological event (27.3%) and are likely to benefit from CS. The problem is that LIRC is hard to detect during endoscopy with biopsies of the postendoscopic resection scar alone (13). However, the risk of adverse oncological events is equal in patients with recognized and unrecognized LIRC.…”

Section: Discussionmentioning

confidence: 99%

“…A higher risk of LNM in endoscopically excised T1 CRC with positive resection margins has been shown compared with T1 CRC with a free resection margin (11,12). Furthermore, in a recent prospective study on T1 CRC with R1/ Rx resection margins without other histological risk factors of LNM, an unexpected high rate of LNM (8.3%) was detected during CS in cases without LIRC (13). Moreover, a study on transanal endoscopic microsurgery (TEM) without LIRC after endoscopic excision reported 9.4% recurrences in patients with R1/Rx resection margins (9).…”

Section: Introductionmentioning

confidence: 97%

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Full-Thickness Scar Resection After R1/Rx Excised T1 Colorectal Cancers as an Alternative to Completion Surgery

et al. 2021

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INTRODUCTION:Local full-thickness resections of the scar (FTRS) after local excision of a T1 colorectal cancer (CRC) with uncertain resection margins is proposed as an alternative strategy to completion surgery (CS), provided that no local intramural residual cancer (LIRC) is found. However, a comparison on long-term oncological outcome between both strategies is missing.METHODS:A large cohort of patients with consecutive T1 CRC between 2000 and 2017 was used. Patients were selected if they underwent a macroscopically complete local excision of a T1 CRC but positive or unassessable (R1/Rx) resection margins at histology and without lymphovascular invasion or poor differentiation. Patients treated with CS or FTRS were compared on the presence of CRC recurrence, a 5-year overall survival, disease-free survival, and metastasis-free survival.RESULTS:Of 3,697 patients with a T1 CRC, 434 met the inclusion criteria (mean age 66 years, 61% men). Three hundred thirty-four patients underwent CS, and 100 patients underwent FTRS. The median follow-up period was 64 months. CRC recurrence was seen in 7 patients who underwent CS (2.2%, 95% CI 0.9%–4.6%) and in 8 patients who underwent FTRS (9.0%, 95% CI 3.9%–17.7%). Disease-free survival was lower in FTRS strategy (96.8% vs 89.9%, P = 0.019), but 5 of the 8 FTRS recurrences could be treated with salvage surgery. The metastasis-free survival (CS 96.8% vs FTRS 92.1%, P = 0.10) and overall survival (CS 95.6% vs FTRS 94.4%, P = 0.55) did not differ significantly between both strategies.DISCUSSION:FTRS after local excision of a T1 CRC with R1/Rx resection margins as a sole risk factor, followed by surveillance and salvage surgery in case of CRC recurrence, could be a valid alternative strategy to CS.

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Section: Discussionsupporting

confidence: 91%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 97%

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Full-Thickness Scar Resection After R1/Rx Excised T1 Colorectal Cancers as an Alternative to Completion Surgery

et al. 2021

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“…Thirty-three per cent of cases had residual tumour at time of surgical resection. A large study quoted a much lower rate of 3.4%,21 with other studies also observing lower rates ranging between 4% and 7%,22 23 while a meta-analysis quoted a rate of 14% 24. None of the aforementioned studies evaluated only LNPCPs resected by pEMR and this has likely had a major impact on higher rates observed in our study.…”

Section: Discussioncontrasting

confidence: 57%

“…The cohort of conservatively managed cases is likely too small to draw firm conclusions, as a large meta-analysis of over 1000 high risk conservatively managed cases quoted a malignant recurrent risk of 7%,27 and it is clear that in our study the conservatively managed group had a lower risk histological profile compared with the surgical cohort. Furthermore, submucosal recurrence could have been present despite no endoscopic evidence of recurrence,21 as biopsies of the scar may not aid in detection of recurrence22 in such circumstances, although an experienced endoscopists is likely to recognise the signs of submucosal recurrence.…”

Section: Discussionmentioning

confidence: 99%

Oncological outcomes after piecemeal endoscopic mucosal resection of large non-pedunculated colorectal polyps with covert submucosal invasive cancer

Gibson

Sidhu

Zanati

et al. 2022

Gut

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ObjectiveManagement of covert submucosal invasive cancer (SMIC) discovered after piecemeal endoscopic mucosal resection (pEMR) of large (>20 mm) non-pedunculated colorectal polyps is challenging. The residual cancer risk is largely unknown. We sought to evaluate this in a large tertiary referral cohort.DesignCases of covert SMIC following pEMR were identified and followed. Oncological outcomes after surgery were divided based on residual intramural cancer, lymph node metastases (LNM) or both. Risk factors for residual intramural cancer and LNM were analysed based on the original pEMR histological variables. Risk parameters were analysed with respect to low and high-risk variables for residual intramural cancer and LNM.ResultsAmong 3372 cases of large non-pedunculated colorectal polyps, 143 cases of covert SMIC (4.2%) were identified. 109 underwent surgical resection. Histological analysis of pEMR histology was available in 98 of 109 (90%) cases. 62 cases (63%) had no residual malignancy. 36 cases had residual malignancy (residual intramural cancer n=24; LNM n=5; both n=7). All cases of residual intramural cancer could be identified by a R1 histological deep margin. Cases with poor differentiation (PD) and/or lymphovascular invasion (LVI) had a high risk of LNM (12/33), with a very low risk without these criteria (<1%; 0/65). Cases at low risk for LNM with R0 deep margin have a low risk of residual intramural cancer (<1%; 0/35).ConclusionThe majority of cases of large non-pedunculated colorectal polyps with covert SMIC following pEMR will have no residual malignancy. The risk of residual malignancy can be ascertained from three key variables: PD, LVI and R1 deep margin.

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Management of non-curative endoscopic resection of T1 colon cancer

Bernklev,

Nilsen,

Augestad

et al. 2024

Best Practice & Research Clinical Gastroenterology

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Low value of second-look endoscopy for detecting residual colorectal cancer after endoscopic removal

Cited by 6 publications

References 19 publications

Full-Thickness Scar Resection After R1/Rx Excised T1 Colorectal Cancers as an Alternative to Completion Surgery

Full-Thickness Scar Resection After R1/Rx Excised T1 Colorectal Cancers as an Alternative to Completion Surgery

Oncological outcomes after piecemeal endoscopic mucosal resection of large non-pedunculated colorectal polyps with covert submucosal invasive cancer

Management of non-curative endoscopic resection of T1 colon cancer

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