Endoscopic Management of Large (≥2 cm) Non-pedunculated Colorectal Polyps: Impact of Polyp Morphology on Outcomes

Obesity-Associated Colorectal Cancer

Colorectal cancer (CRC) affects approximately 2 million people worldwide. Obesity is the major risk factor for CRC. In addition, obesity contributes to a chronic inflammatory stage that enhances tumor progression through the secretion of proinflammatory cytokines. In addition to an increased inflammatory response, obesity-associated cancer presents accrued molecular factors related to cancer characteristics, such as genome instability, sustained cell proliferation, telomere dysfunctions, angiogenesis, and microbial alteration, among others. Despite the evidence accumulated over the last few years, the treatments for obesity-associated CRC do not differ from the CRC treatments in normal-weight individuals. In this review, we summarize the current knowledge on obesity-associated cancer, including its epidemiology, risk factors, molecular factors, and current treatments. Finally, we enumerate possible new therapeutic targets that may improve the conditions of obese CRC patients. Obesity is key for the development of CRC, and treatments resulting in the reversal of obesity should be considered as a strategy for improving antineoplastic CRC therapies.

Evaluation of polypectomy quality indicators of large nonpedunculated colorectal polyps in a nonexpert, bowel cancer screening cohort

BACKGROUND AND AIMS

With the introduction of the national bowel cancer screening program, the detection of sessile and flat colonic lesions ≥20 mm in size, defined as large nonpedunculated colorectal polyps (LNPCPs), has increased. The aim of this study was to examine the quality of endoscopic treatment of LNPCPs in the Dutch screening program.

METHODS

This investigation comprised 2 related, but separate, substudies (1 with a cross-sectional design and 1 with a longitudinal design). The first examined prevalence and characteristics of LNPCPs in data from the national Dutch screening cohort from February 2014 until January 2017. The second, with screening data from 5 endoscopy units in the Southern part of the Netherlands from February 2014 until August 2015, examined performance on important quality indicators (technical and clinical successes, recurrence rate, adverse event rate, and surgery referral rate). All patients were part of the national Dutch screening cohort.

RESULTS

In the national cohort, an LNPCP was detected in 8% of participants. Technical and clinical success decreased with increasing LNPCP size, from 93% and 96% in 20- to 29-mm lesions to 85% and 86% in 30- to 39-mm lesions and to 74% and 81% in ≥40-mm lesions (P < .001; P = .034). The cumulative recurrence rate at 12 months increased with LNPCP size, from 9% to 22% and 26% in the respective size groups (P = .095). The adverse event rate was 5%. The overall surgical referral rate for noninvasive LNPCPs was 7%.

CONCLUSIONS

In this performance of 2 substudies, it was shown that quality parameters for endoscopic resection of large polyps in the Dutch screening cohort are not reached, especially in ≥30-mm polyps. Endoscopic resection of large polyps could benefit from additional training, quality monitoring, and centralization either within or between centers.

Evaluation of recurrence and surgical complementation rates after endoscopic resection of large colorectal non-pedunculated lesions

BACKGROUND AND AIM

the process that leads to the development of colorectal cancer takes many years and most tumors originate from polyps and non-polypoid lesions. Techniques of endoscopic resection are surgical treatment options, even in case of large lesions or with initial invasion. This study aimed to evaluate the recurrence and surgical complementation rates after endoscopic resection of large colorectal non-pedunculated lesions.

METHODS

a retrospective, longitudinal and descriptive trial was performed via an analysis of colonoscopies with the resection of non-pedunculated lesions larger than 3 cm, performed between 2014 and 2017.

RESULTS

sixty-two lesions were included from 61 patients and 32 (52.5 %) were female. The age ranged from 36 to 89 years, with a mean age of 60.5 years. Lesions had an average diameter of 40.08 mm, ranging from 30 to 80 mm. Regarding the location of the lesions, the most frequent colonic segments were the ascending and rectum, both accounting for 22.6 %. Considering the morphologic endoscopic classification, 67.7 % were granular laterally spreading tumors (LST), 38.8 % were homogeneous granular and 29 % were mixed granular. The most frequent histological types were tubulovillous adenoma (30.7 %) and intramucosal adenocarcinoma (29 %). The resection technique was piecemeal mucosectomy in 85.5 %. Five lesions were removed by en bloc mucosectomy, two (3.2 %) by endoscopic submucosal dissection (ESD) and two (3.2 %) by a hybrid technique. The recurrence rate was 25.8 %. Three patients needed complementary surgical treatment and the clinical success of endoscopic treatment was 95.1 %.

CONCLUSION

recurrence rate after endoscopic resection of large colorectal lesions was 25.8 % and surgical complementation rate due to failure in the endoscopic treatment of recurrence was 4.8 %.

Incidence and risk factors of advanced neoplasia after endoscopic mucosal resection of colonic laterally spreading lesions

PURPOSE

To investigate advanced neoplasia (AN) after endoscopic mucosal resection (EMR) of colonic laterally spreading lesions (LSLs).

METHODS

A retrospective study of patients who underwent injection-assisted EMR of colonic LSLs ≥ 10 mm was performed. Primary outcome was overall rate of AN at initial surveillance colonoscopy. Secondary outcomes were the rates of residual AN (rAN) at the EMR site and metachronous AN (mAN), and analysis of risk factors for AN, including effect of surveillance guidance.

RESULTS

Three hundred seventy-four patients underwent successful EMR for 388 LSLs. AN occurred in 66/374 (17.6%) patients on initial surveillance colonoscopy at median follow-up of 364.5 days. Two patients had both rAN and mAN, for a total of 68 instances of AN, including 30/374 (8.0%) cases of rAN and 38/374 (10.2%) cases of mAN. On multivariate analysis, use of piecemeal resection was associated with increased likelihood of residual AN (P = 0.003, OR 9.2, 95% CI 2.1-33.3). Twenty-nine out of thirty cases (96.7%) of rAN were successfully endoscopically managed at surveillance colonoscopy.

CONCLUSIONS

AN occurred in 17.6% of all patients at initial surveillance colonoscopy at a median of 1 year after EMR. Roughly half of the instances of AN were metachronous lesions. Our data support a 1-year surveillance interval after EMR of LSLs ≥ 10 mm with careful inspection of the entire colon, not just the prior resection site.

Management of Large Cecal Polyps: When Can the Ileocecal Valve Be Spared?

BACKGROUND

Endoscopic mucosal resection comprises the first-line treatment for large cecal polyps. With up to 14% of unresectable colonic polyps harboring malignancy, the management of endoscopically unresectable cecal polyps remains an oncologic right hemicolectomy, which can be associated with substantial postoperative morbidity.

OBJECTIVE

This study compares the outcomes of patients with cecal polyps who underwent either endoscopic mucosal resection, a cecectomy, or a right hemicolectomy.

DATA SOURCES

Patients undergoing either endoscopic mucosal resection, partial cecectomy, or right hemicolectomy from 2008 to 2017 at a single tertiary care institution were selected.

STUDY SELECTION

This was a retrospective cohort study.

MAIN OUTCOME MEASURES

The primary outcomes measured were the rate of malignancy, complication rate, estimated blood loss, and hospital length of stay between surgical cohorts.

RESULTS

One hundred twenty-nine patients with cecal polyps were identified, of which 52 were referred for surgery. Nineteen underwent partial cecectomy and 33 (27.3%) underwent right hemicolectomy. Two patients undergoing cecectomy required conversion to hemicolectomy because the resected specimen did not contain the polyp. The 2 surgical cohorts did not differ significantly regarding age, sex, or ASA classification. Procedural complication rates were higher among those undergoing hemicolectomy compared with those undergoing cecectomy (37.1% versus 5.9%, p = 0.02). Estimated blood loss (50 vs 10 mL, p = 0.02), operative duration (98 vs 76 minutes, p = 0.009), and length of stay (4 vs 2 days, p < 0.001) were higher in patients undergoing hemicolectomy than in those undergoing cecectomy. No invasive malignancies were identified on final pathology within the cecectomy cohort.

LIMITATIONS

Single-institution data and retrospective design were limitations of this study.

CONCLUSIONS

In tertiary centers, the majority of large cecal polyps are benign and can be addressed by using endoscopic mucosal resection. When involvement of the appendiceal orifice or ileocecal valve precludes endoscopic treatment, surgical resection is the standard of care. In the subset of cases not involving the ileocecal valve and without preoperative evidence of malignancy, partial cecectomy spares the ileocecal valve and can offer reduced postoperative morbidity compared with a formal right hemicolectomy. See Video Abstract at http://links.lww.com/DCR/A674.

Endoscopic resection of large colorectal adenomas - clinical experience of a tertiary referral centre

AIM

Colorectal cancer is a leading cause of cancer-related mortality. Adenomatous polyps are typically resected endoscopically to prevent cancer while giant and complex polyps are managed surgically. No criteria clearly define the indications for surgical vs endoscopic resection. Our aim was to evaluate factors associated with the short-term efficacy and safety of endoscopic resection of large (≥ 20 mm) and giant (≥ 40 mm) adenomas.

METHOD

Consecutive cases with colonic adenomas larger than 20 mm resected endoscopically were included. Endoscopic, clinical and histological details of polyps were recorded as well as the need for surgical resection.

RESULT

A total of 351 resections were included. The average adenoma diameter was 30.34 ± 10.66 mm. Surgery was recommended in 21 (5.98%) cases. In a multivariate analysis for efficacy, two variables were independent risk factors for surgery: adenoma size [OR 1.08 (95% CI: 1.04-1.12)] and caecal location [5.97(1.60-22.33)]. Postpolypectomy complications were documented in 85 (24.2%) cases: bleeding 69 (19.7%), perforations 8(2.3%) and significant discomfort 15(4.3%). Twenty-one patients (6.0%) developed serious complications requiring further hospitalization. In multivariate analysis for safety, independent risk factors for postpolypectomy complications included adenoma size [1.04 (1.06-1.01)], polyp morphology [sessile 2.55 (1.45-4.51), flat 2.40 (1.04-5.52)] and submucosal adrenaline injection [1.87 (1.11-3.20)]. Increments of 1 mm in adenoma diameter beyond 20 mm increased the need for surgery by 8% and the risk of complications by 4%.

CONCLUSION

Resection of large or giant adenomas is generally a safe procedure. Although adenoma size and morphology are significant predictors of efficacy and safety, each case should be individually evaluated in a specialist unit for feasibility of endoscopic resection.