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Dang H, Verhoeven DA, Boonstra JJ, van Leerdam ME. Management after non-curative endoscopic resection of T1 rectal cancer. Best Pract Res Clin Gastroenterol 2024; 68:101895. [PMID: 38522888 DOI: 10.1016/j.bpg.2024.101895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 02/03/2024] [Accepted: 02/15/2024] [Indexed: 03/26/2024]
Abstract
Since the introduction of population-based screening, increasing numbers of T1 rectal cancers are detected and removed by local endoscopic resection. Patients can be cured with endoscopic resection alone, but there is a possibility of residual tumor cells remaining after the initial resection. These can be located intraluminally at the resection site or extraluminally in the form of (lymph node) metastases. To decrease the risk of residual cells progressing towards more advanced disease, additional treatment is usually needed. However, with the currently available risk stratification models, it remains challenging to determine who should and should not be further treated after non-curative endoscopic resection. In this review, the different management strategies for patients with non-curatively treated T1 rectal cancers are discussed, along with the available evidence for each strategy and relevant considerations for clinical decision making. Furthermore, we provide practical guidance on the management and surveillance following non-curative endoscopic resection of T1 rectal cancer.
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Affiliation(s)
- Hao Dang
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands.
| | - Daan A Verhoeven
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jurjen J Boonstra
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Monique E van Leerdam
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
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2
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Zwager LW, Moons LMG, Farina Sarasqueta A, Laclé MM, Albers SC, Hompes R, Peeters KCMJ, Bekkering FC, Boonstra JJ, Ter Borg F, Bos PR, Bulte GJ, Gielisse EAR, Hazen WL, Ten Hove WR, Houben MHMG, Mundt MW, Nagengast WB, Perk LE, Quispel R, Rietdijk ST, Rando Munoz FJ, de Ridder RJJ, Schwartz MP, Schreuder RM, Seerden TCJ, van der Sluis H, van der Spek BW, Straathof JWA, Terhaar Sive Droste JS, Vlug MS, van de Vrie W, Weusten BLAM, de Wijkerslooth TD, Wolters HJ, Fockens P, Dekker E, Bastiaansen BAJ. Long-term oncological outcomes of endoscopic full-thickness resection after previous incomplete resection of low-risk T1 CRC (LOCAL-study): study protocol of a national prospective cohort study. BMC Gastroenterol 2022; 22:516. [PMID: 36513968 DOI: 10.1186/s12876-022-02591-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 11/21/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND T1 colorectal cancer (CRC) without histological high-risk factors for lymph node metastasis (LNM) can potentially be cured by endoscopic resection, which is associated with significantly lower morbidity, mortality and costs compared to radical surgery. An important prerequisite for endoscopic resection as definite treatment is the histological confirmation of tumour-free resection margins. Incomplete resection with involved (R1) or indeterminate (Rx) margins is considered a strong risk factor for residual disease and local recurrence. Therefore, international guidelines recommend additional surgery in case of R1/Rx resection, even in absence of high-risk factors for LNM. Endoscopic full-thickness resection (eFTR) is a relatively new technique that allows transmural resection of colorectal lesions. Local scar excision after prior R1/Rx resection of low-risk T1 CRC could offer an attractive minimal invasive strategy to achieve confirmation about radicality of the previous resection or a second attempt for radical resection of residual luminal cancer. However, oncologic safety has not been established and long-term data are lacking. Besides, surveillance varies widely and requires standardization. METHODS/DESIGN In this nationwide, multicenter, prospective cohort study we aim to assess feasibility and oncological safety of completion eFTR following incomplete resection of low-risk T1 CRC. The primary endpoint is to assess the 2 and 5 year luminal local tumor recurrence rate. Secondary study endpoints are to assess feasibility, percentage of curative eFTR-resections, presence of scar tissue and/or complete scar excision at histopathology, safety of eFTR compared to surgery, 2 and 5 year nodal and/or distant tumor recurrence rate and 5-year disease-specific and overall-survival rate. DISCUSSION Since the implementation of CRC screening programs, the diagnostic rate of T1 CRC is steadily increasing. A significant proportion is not recognized as cancer before endoscopic resection and is therefore resected through conventional techniques primarily reserved for benign polyps. As such, precise histological assessment is often hampered due to cauterization and fragmentation and frequently leads to treatment dilemmas. This first prospective trial will potentially demonstrate the effectiveness and oncological safety of completion eFTR for patients who have undergone a previous incomplete T1 CRC resection. Hereby, substantial surgical overtreatment may be avoided, leading to treatment optimization and organ preservation. Trial registration Nederlands Trial Register, NL 7879, 16 July 2019 ( https://trialregister.nl/trial/7879 ).
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Affiliation(s)
- L W Zwager
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.,Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands.,Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - L M G Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - A Farina Sarasqueta
- Department of Pathology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - M M Laclé
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - S C Albers
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.,Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands.,Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - R Hompes
- Department of Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - K C M J Peeters
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - F C Bekkering
- Department of Gastroenterology and Hepatology, IJsselland Hospital, Capelle Aan Den Ijssel, The Netherlands
| | - J J Boonstra
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - F Ter Borg
- Department of Gastroenterology and Hepatology, Deventer Hospital, Deventer, The Netherlands
| | - P R Bos
- Department of Gastroenterology and Hepatology, Gelderse Vallei, Ede, The Netherlands
| | - G J Bulte
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - E A R Gielisse
- Department of Gastroenterology and Hepatology, Rode Kruis Hospital, Beverwijk, The Netherlands
| | - W L Hazen
- Department of Gastroenterology and Hepatology, Elisabeth Tweesteden Hospital, Tilburg, The Netherlands
| | - W R Ten Hove
- Department of Gastroenterology and Hepatology, Alrijne Medical Group, Leiden, The Netherlands
| | - M H M G Houben
- Department of Gastroenterology and Hepatology, Haga Teaching Hospital, the Hague, The Netherlands
| | - M W Mundt
- Department of Gastroenterology and Hepatology, Flevoziekenhuis, Almere, The Netherlands
| | - W B Nagengast
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, The Netherlands
| | - L E Perk
- Department of Gastroenterology and Hepatology, Haaglanden Medical Center, The Hague, The Netherlands
| | - R Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf, Delft, The Netherlands
| | - S T Rietdijk
- Department of Gastroenterology and Hepatology, OLVG, Amsterdam, The Netherlands
| | - F J Rando Munoz
- Department of Gastroenterology and Hepatology, Nij Smellinghe Hospital, Drachten, The Netherlands
| | - R J J de Ridder
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - M P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands
| | - R M Schreuder
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, The Netherlands
| | - T C J Seerden
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, The Netherlands
| | - H van der Sluis
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, The Netherlands
| | - B W van der Spek
- Department of Gastroenterology and Hepatology, Noordwest Hospital Group, Alkmaar, The Netherlands
| | - J W A Straathof
- Department of Gastroenterology and Hepatology, Màxima Medical Center, Veldhoven, The Netherlands
| | - J S Terhaar Sive Droste
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, S' Hertogenbosch, The Netherlands
| | - M S Vlug
- Department of Gastroenterology and Hepatology, Dijklander Hospital, Hoorn, The Netherlands
| | - W van de Vrie
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - B L A M Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - T D de Wijkerslooth
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute/Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - H J Wolters
- Department of Gastroenterology and Hepatology, Martini Hospital, Groningen, The Netherlands
| | - P Fockens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.,Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands.,Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - E Dekker
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.,Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands.,Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - B A J Bastiaansen
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands. .,Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands. .,Cancer Center Amsterdam, Amsterdam, The Netherlands.
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3
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Dekkers N, Dang H, van der Kraan J, le Cessie S, Oldenburg PP, Schoones JW, Langers AMJ, van Leerdam ME, van Hooft JE, Backes Y, Levic K, Meining A, Saracco GM, Holman FA, Peeters KCMJ, Moons LMG, Doornebosch PG, Hardwick JCH, Boonstra JJ. Risk of recurrence after local resection of T1 rectal cancer: a meta-analysis with meta-regression. Surg Endosc 2022; 36:9156-9168. [PMID: 35773606 PMCID: PMC9652303 DOI: 10.1007/s00464-022-09396-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 06/06/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND T1 rectal cancer (RC) patients are increasingly being treated by local resection alone but uniform surveillance strategies thereafter are lacking. To determine whether different local resection techniques influence the risk of recurrence and cancer-related mortality, a meta-analysis was performed. METHODS A systematic search was conducted for T1RC patients treated with local surgical resection. The primary outcome was the risk of RC recurrence and RC-related mortality. Pooled estimates were calculated using mixed-effect logistic regression. We also systematically searched and evaluated endoscopically treated T1RC patients in a similar manner. RESULTS In 2585 unique T1RC patients (86 studies) undergoing local surgical resection, the overall pooled cumulative incidence of recurrence was 9.1% (302 events, 95% CI 7.3-11.4%; I2 = 68.3%). In meta-regression, the recurrence risk was associated with histological risk status (p < 0.005; low-risk 6.6%, 95% CI 4.4-9.7% vs. high-risk 28.2%, 95% CI 19-39.7%) and local surgical resection technique (p < 0.005; TEM/TAMIS 7.7%, 95% CI 5.3-11.0% vs. other local surgical excisions 10.8%, 95% CI 6.7-16.8%). In 641 unique T1RC patients treated with flexible endoscopic excision (16 studies), the risk of recurrence (7.7%, 95% CI 5.2-11.2%), cancer-related mortality (2.3%, 95% CI 1.1-4.9), and cancer-related mortality among patients with recurrence (30.0%, 95% CI 14.7-49.4%) were comparable to outcomes after TEM/TAMIS (risk of recurrence 7.7%, 95% CI 5.3-11.0%, cancer-related mortality 2.8%, 95% CI 1.2-6.2% and among patients with recurrence 35.6%, 95% CI 21.9-51.2%). CONCLUSIONS Patients with T1 rectal cancer may have a significantly lower recurrence risk after TEM/TAMIS compared to other local surgical resection techniques. After TEM/TAMIS and endoscopic resection the recurrence risk, cancer-related mortality and cancer-related mortality among patients with recurrence were comparable. Recurrence was mainly dependent on histological risk status.
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Affiliation(s)
- Nik Dekkers
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
| | - Hao Dang
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Jolein van der Kraan
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Saskia le Cessie
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Philip P Oldenburg
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Jan W Schoones
- Directorate of Research Policy (Formerly: Walaeus Library), Leiden University Medical Center, Leiden, The Netherlands
| | - Alexandra M J Langers
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Monique E van Leerdam
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Yara Backes
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Katarina Levic
- Gastrounit-Surgical Division, Center for Surgical Research, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Alexander Meining
- Department of Gastroenterology, University Hospital of Würzburg, Würzburg, Germany
| | - Giorgio M Saracco
- Division of Gastroenterology, Department of Medical Sciences, Molinette Hospital, University of Turin, Turin, Italy
| | - Fabian A Holman
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Koen C M J Peeters
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Pascal G Doornebosch
- Department of Surgery, IJsselland Hospital, Capelle Aan Den IJssel, The Netherlands
| | - James C H Hardwick
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Jurjen J Boonstra
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
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4
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Dang H, Dekkers N, le Cessie S, van Hooft JE, van Leerdam ME, Oldenburg PP, Flothuis L, Schoones JW, Langers AMJ, Hardwick JCH, van der Kraan J, Boonstra JJ. Risk and Time Pattern of Recurrences After Local Endoscopic Resection of T1 Colorectal Cancer: A Meta-analysis. Clin Gastroenterol Hepatol 2022; 20:e298-e314. [PMID: 33271339 DOI: 10.1016/j.cgh.2020.11.032] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/02/2020] [Accepted: 11/06/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Growing numbers of patients with T1 CRC are being treated with local endoscopic resection only and as a result, the need for optimization of surveillance strategies for these patients also increases. We aimed to estimate the cumulative incidence and time pattern of CRC recurrences for endoscopically treated patients with T1 CRC. METHODS Using a systematic literature search in PubMed, EMBASE, Web of Science and Cochrane Library (from inception till 15 May 2020), we identified and extracted data from studies describing the cumulative incidence of local or distant CRC recurrence for patients with T1 CRC treated with local endoscopic resection only. Pooled estimates were calculated using mixed-effect logistic regression models. RESULTS Seventy-one studies with 5167 unique, endoscopically treated patients with T1 CRC were included. The pooled cumulative incidence of any CRC recurrence was 3.3% (209 events; 95% CI, 2.6%-4.3%; I2 = 54.9%), with local and distant recurrences being found at comparable rates (pooled incidences 1.9% and 1.6%, respectively). CRC-related mortality was observed in 42 out of 2519 patients (35 studies; pooled incidence 1.7%, 95% CI, 1.2%-2.2%; I2 = 0%), and the CRC-related mortality rate among patients with recurrence was 40.8% (42/103 patients). The vast majority of recurrences (95.6%) occurred within 72 months of follow-up. Pooled incidences of any CRC recurrence were 7.0% for high-risk T1 CRCs (28 studies; 95% CI, 4.9%-9.9%; I2 = 48.1%) and 0.7% (36 studies; 95% CI, 0.4%-1.2%; I2 = 0%) for low-risk T1 CRCs. CONCLUSIONS Our meta-analysis provides quantitative outcome measures which are relevant to guidelines on surveillance after local endoscopic resection of T1 CRC.
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Affiliation(s)
- Hao Dang
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands.
| | - Nik Dekkers
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Saskia le Cessie
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Monique E van Leerdam
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Philip P Oldenburg
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Louis Flothuis
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jan W Schoones
- Walaeus Library, Leiden University Medical Center, Leiden, The Netherlands
| | - Alexandra M J Langers
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - James C H Hardwick
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jolein van der Kraan
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jurjen J Boonstra
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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5
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Takamaru H, Saito Y, Sekiguchi M, Yamada M, Sakamoto T, Matsuda T, Sekine S, Ochiai H, Tsukamoto S, Shida D, Kanemitsu Y. Endoscopic Resection Before Surgery Does Not Affect the Recurrence Rate in Patients With High-Risk T1 Colorectal Cancer. Clin Transl Gastroenterol 2021; 12:e00336. [PMID: 33843782 PMCID: PMC8043730 DOI: 10.14309/ctg.0000000000000336] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 03/05/2021] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Patients with high-risk T1 colorectal cancer (CRC) after endoscopic resection (ER) should undergo surgery in view of the risk of lymph node metastasis. Although additional surgery can potentially prevent recurrence, there is a paucity of data and longitudinal studies exploring this potential. Hence, this study aimed to evaluate the prolonged influence of ER before additional surgery on recurrence in T1 CRC. METHODS Between January 2004 and October 2015, 162 patients who underwent secondary surgery (SS) after ER ([ER + SS] group) and 392 consecutive patients with T1 CRC who underwent primary surgery at our institution were retrospectively analyzed. Recurrence was analyzed in these 2 groups. High-risk CRC patients were histologically defined according to the Japanese Society for Cancer of the Colon and Rectum guidelines (2016) for the treatment of CRC. Data were analyzed based on clinical and histological features, including lymph node metastasis, and the number of lymph nodes evaluated. RESULTS The recurrence rate was comparable between the ER + SS and primary surgery groups, with no significant difference (P = 0.625, log-rank test). There was no significant difference in the recurrence in patients receiving adjuvant chemotherapy in both groups (7.4% vs 10.4%, P = 0.27). The difference in the mean number of lymph nodes dissected between both groups was also not significant (24.3 vs 25.3, P = 0.43). DISCUSSION There was no significant difference in recurrence rates between patients undergoing ER before surgery and those undergoing primary surgery for high-risk T1 CRC. Hence, ER may be acceptable for high-risk T1 CRC.
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Affiliation(s)
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Masau Sekiguchi
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
- Cancer Screening Center, National Cancer Center, Tokyo, Japan
| | - Masayoshi Yamada
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Taku Sakamoto
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Takahisa Matsuda
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
- Cancer Screening Center, National Cancer Center, Tokyo, Japan
| | - Shigeki Sekine
- Pathology Division, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroki Ochiai
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Shunsuke Tsukamoto
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Dai Shida
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Yukihide Kanemitsu
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
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6
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Gijsbers K, de Graaf W, Moons LM, ter Borg F. High practice variation in risk stratification, baseline oncological staging, and follow-up strategies for T1 colorectal cancers in the Netherlands. Endosc Int Open 2020; 8:E1117-E1122. [PMID: 32904821 PMCID: PMC7458727 DOI: 10.1055/a-1192-3545] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 05/05/2020] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Based on pathology, locally resected T1 colorectal cancer (T1-CRC) can be classified as having low- or high-risk for irradicality and/or lymph node metastasis, the latter requiring adjuvant surgery. Reporting and application of pathological high-risk criteria is likely variable, with inherited variation regarding baseline oncological staging, treatment and surveillance. Methods We assessed practice variation using an online survey among gastroenterologists and surgeons participating in the Dutch T1-CRC Working Group. Results Of the 130 invited physicians, 53 % participated. Regarding high-risk T1-CRC criteria, lymphangio-invasion is used by 100 %, positive or indeterminable margins by 93 %, poor differentiation by 90 %, tumor-free margin ≤ 1 mm by 78 %, tumor budding by 57 % and submucosal invasion > 1000 µm by 47 %. Fifty-two percent of the respondents do not perform baseline staging in locally resected low-risk T1-CRC. In case of unoperated high-risk patients, we recorded 61 different surveillance strategies in 63 participants, using 19 different combinations of diagnostic tests. Endoscopy is used in all schedules. Mean follow-up time is 36 months for endoscopy, 26 months for rectal MRI and 30 months for abdominal CT (all varying 3-60 months). Conclusion We found variable use of pathological high-risk T1-CRC criteria, creating risk for misclassification as low-risk T1-CRC. This has serious implications, as most participants will not proceed to oncological staging in low-risk patients and adjuvant surgery nor radiological surveillance is considered. On the other hand, oncological surveillance in patients with a locally resected high-risk T1-CRC who do not wish adjuvant surgery is highly variable emphasizing the need for a uniform surveillance protocol.
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Affiliation(s)
- Kim Gijsbers
- Department of Gastroenterology and Hepatology, Deventer Hospital, Deventer, The Netherlands,Department of Gastroenterology and Hepatology, UMC Utrecht, Utrecht, The Netherlands
| | - Wilmar de Graaf
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Leon M.G. Moons
- Department of Gastroenterology and Hepatology, UMC Utrecht, Utrecht, The Netherlands
| | - F. ter Borg
- Department of Gastroenterology and Hepatology, Deventer Hospital, Deventer, The Netherlands
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7
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Low value of second-look endoscopy for detecting residual colorectal cancer after endoscopic removal. Gastrointest Endosc 2020; 92:166-172. [PMID: 32105713 DOI: 10.1016/j.gie.2020.01.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 01/22/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endoscopic resection is often feasible for submucosal invasive colorectal cancers (T1 CRCs) and usually judged as complete. If histology casts doubt on the radicality of resection margins, adjuvant surgical resection is advised, although residual intramural cancer is found in only 5% to 15% of patients. We assessed the sensitivity of biopsy specimens from the resection area for residual intramural cancer as a potential tool to estimate the preoperative risk of residual intramural cancer in patients without risk factors for lymph node metastasis (LNM). METHODS In this multicenter prospective cohort study, patients with complete endoscopic resection of T1 CRC, scheduled for adjuvant resection due to pathologically unclear resection margins, but absent risk factors for LNM, were asked to consent to second-look endoscopy with biopsies. The results were compared with the pathology results of the surgical resection specimen (criterion standard). RESULTS One hundred three patients were included. In total, 85% of resected lesions were unexpectedly malignant, and 45% were removed using a piecemeal resection technique. Sixty-four adjuvant surgical resections and 39 local full-thickness resections were performed. Residual intramural cancer was found in 7 patients (6.8%). Two of these patients had cancer in second-look biopsy specimens, resulting in a sensitivity of 28% (95% confidence interval, <58%). The preoperative risk of residual intramural cancer in the case of negative biopsy specimens was not significantly reduced (P = .61). CONCLUSIONS The sensitivity of second-look endoscopy with biopsies for residual intramural cancer after endoscopic resection of CRC is low. Therefore, it should not be used in the decision whether or not to perform adjuvant resection. (Clinical trial registration number: NCT02328664.).
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8
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Surgery Versus Endoscopic Mucosal Resection Versus Endoscopic Submucosal Dissection for Large Polyps: Making Sense of When to Use Which Approach. Gastrointest Endosc Clin N Am 2019; 29:675-685. [PMID: 31445690 DOI: 10.1016/j.giec.2019.06.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Endoscopic resection for large colorectal lesion is effective and cost-saving than surgery. Piecemeal resections are often effective if applied meticulously but endoscopic submucosal dissection (ESD) allows meritorious removal of large lesions in one piece. For rectal lesions, transanal endoscopic microsurgery or transanal minimally invasive surgery offers more radical transmural resection but ESD is also effective for removal of complex rectal lesions. Surgical resection with lymph node dissection is the gold standard for invasive cancer; however, the management of low-risk early-stage colorectal cancer is worth debating. Treatment selection for large colorectal lesions is discussed based on lesion factor and treatment outcomes.
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9
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Yasue C, Chino A, Takamatsu M, Namikawa K, Ide D, Saito S, Igarashi M, Fujisaki J. Pathological risk factors and predictive endoscopic factors for lymph node metastasis of T1 colorectal cancer: a single-center study of 846 lesions. J Gastroenterol 2019; 54:708-717. [PMID: 30810812 DOI: 10.1007/s00535-019-01564-y] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 02/20/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Determining the depth of invasion of early stage colorectal cancer has been emphasized as a means of improving endoscopic diagnostic accuracy. Recent studies have focused on other pathological risk factors for lymph node metastasis (LNM). We investigated the significance of depth of invasion and predictive properties of other endoscopic findings. METHODS We retrospectively investigated 846 patients with submucosal invasive (T1) colorectal cancer who received an accurate pathological diagnosis and were treated between January 2005 and December 2016. Pathological risk factors associated with LNM were reviewed. We divided patients into groups: low-risk T1 colorectal cancer (LRC; no risk factors) and high-risk T1 colorectal cancer (HRC; exhibiting lymphovascular invasion, tumor budding grade of 2/3, and/or poor differentiation) and studied predictive endoscopic factors for HRC. RESULTS Significant risk factors for LNM in multivariate analysis were lymphovascular invasion [odds ratio (OR) 8.09; 95% confidence interval (CI) 3.84-17.1], tumor budding (OR 1.89; 95% CI 1.09-3.29), and histological differentiation (OR 2.09; 95% CI 1.12-3.89). The LNM-positive rate with only deep submucosal invasion was 1.6%. Significant predictive factors for HRC in multivariate analysis identified rectal tumor location (OR 1.92; 95% CI 1.35 -2.72, depression (OR 2.73; 95% CI 1.96 -3.80), protuberance within the depression (OR 2.58; 95% CI 1.39- 4.78), expansiveness (OR 2.39; 95% CI 1.27- 4.50), and loss of mucosal patterns (OR 1.90; 95% CI 1.20 -3.01) as significant factors. CONCLUSIONS Rectal tumor location, depression, protuberance within the depression, expansiveness, and loss of mucosal patterns could be predictive factors for HRC.
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Affiliation(s)
- Chihiro Yasue
- Department of Gastroenterology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| | - Akiko Chino
- Department of Gastroenterology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Manabu Takamatsu
- Department of Pathology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Ken Namikawa
- Department of Gastroenterology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Daisuke Ide
- Department of Gastroenterology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Shoichi Saito
- Department of Gastroenterology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Masahiro Igarashi
- Department of Gastroenterology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Junko Fujisaki
- Department of Gastroenterology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
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10
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Chromoendoscopy: Coloring the Colon to Predict Submucosal Invasive Colon Cancer. Dis Colon Rectum 2019; 62:389-391. [PMID: 30844964 DOI: 10.1097/dcr.0000000000001344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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11
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Vermeer NCA, Bahadoer RR, Bastiaannet E, Holman FA, Meershoek-Klein Kranenbarg E, Liefers GJ, van de Velde CJH, Peeters KCMJ. Introduction of a colorectal cancer screening programme: results from a single-centre study. Colorectal Dis 2018; 20:O239-O247. [PMID: 29917325 DOI: 10.1111/codi.14313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 06/06/2018] [Indexed: 02/08/2023]
Abstract
AIM In 2014, a national colorectal cancer (CRC) screening programme was launched in the Netherlands. It is difficult to assess for the individual patients with CRC whether the oncological benefits of surgery will outweigh the morbidity of the procedure, especially in early lesions. This study compares patient and tumour characteristics between screen-detected and nonscreen-detected patients. Also, we present an overview of treatment options and clinical dilemmas when treating patients with early-stage colorectal disease. METHOD Between January 2014 and December 2016, all patients with nonmalignant polyps or CRC who were referred to the Department of Surgery of the Leiden University Medical Centre in the Netherlands were included. Baseline characteristics, type of treatment and short-term outcomes of patients with screen-detected and nonscreen-detected colorectal tumours were compared. RESULTS A total of 426 patients were included, of whom 240 (56.3%) were identified by screening. Nonscreen-detected patients more often had comorbidity (P = 0.03), the primary tumour was more often located in the rectum (P = 0.001) and there was a higher rate of metastatic disease (P < 0.001). Of 354 surgically treated patients, postoperative adverse events did not significantly differ between the two groups (P = 0.38). Of 46 patients with T1 CRC in the endoscopic resection specimen, 23 underwent surgical resection of whom only 30.4% had residual invasive disease at colectomy. CONCLUSION Despite differences in comorbidity, stage and surgical outcome of patients with screen-detected tumours compared to nonscreen-detected tumours were not significantly different. Considering its limited oncological benefits as well as the rate of adverse events, surgery for nonmalignant polyps and T1 CRC should be considered carefully.
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Affiliation(s)
- N C A Vermeer
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - R R Bahadoer
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - E Bastiaannet
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands.,Department of Medical Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | - F A Holman
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - G J Liefers
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - C J H van de Velde
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - K C M J Peeters
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
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12
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Sakamoto T, Nakajima T, Matsuda T, Murakami Y, Ishikawa H, Yao K, Saito Y. Comparison of the diagnostic performance between magnifying chromoendoscopy and magnifying narrow-band imaging for superficial colorectal neoplasms: an online survey. Gastrointest Endosc 2018; 87:1318-1323. [PMID: 29309778 DOI: 10.1016/j.gie.2017.12.021] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 12/03/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Magnifying narrow-band imaging (mag-NBI) and magnifying chromoendoscopy using crystal violet staining for pit pattern analysis (pit pattern) is highly accurate for diagnosing invasion depth of superficial colorectal neoplasms. However, NBI and pit pattern have not been compared. METHODS We conducted an online survey of endoscopists interested in image-enhanced endoscopy. Still images using white light, mag-NBI, and pit pattern were collected from lesions diagnosed at the National Cancer Center Hospital (NCCH), Tokyo, Japan. Sixty endoscopists from outside NCCH who typically use magnifying endoscopy were recruited for this survey. We assessed the diagnostic accuracy using receiver operating characteristic (ROC) analysis based on a calculation of the area under the ROC curve. RESULTS One hundred early colorectal neoplasms were selected for this survey. Histopathology revealed that, although 67 of the lesions had high-grade dysplasia or carcinoma with superficial submucosal (SM-s) invasion, the other 33 lesions had a carcinoma with deep submucosal invasion (SM-d). Comparing the area under the ROC curve from mag-NBI with that of pit pattern, the latter showed significantly higher diagnostic accuracy for depth invasion (0.83 [95% CI, 0.81-0.85] for mag-NBI, 0.88 [95% CI, 0.85-0.89] for pit pattern, P = .013). CONCLUSIONS Pit pattern should be the first choice for diagnosing invasion depth as the most reliable modality rather than mag-NBI.
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Affiliation(s)
- Taku Sakamoto
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Takeshi Nakajima
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Takahisa Matsuda
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan; Division of Screening Technology, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan
| | | | - Hideki Ishikawa
- Department of Molecular-Targeting Cancer Prevention, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kenshi Yao
- Department of Endoscopy Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
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13
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Inoki K, Sakamoto T, Takamaru H, Sekiguchi M, Yamada M, Nakajima T, Matsuda T, Taniguchi H, Sekine S, Kanemitsu Y, Ohe Y, Saito Y. Predictive relevance of lymphovascular invasion in T1 colorectal cancer before endoscopic treatment. Endosc Int Open 2017; 5:E1278-E1283. [PMID: 29218320 PMCID: PMC5718905 DOI: 10.1055/s-0043-117952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 06/26/2017] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND AND AIM The depth of tumor invasion is currently the only reliable predictive risk factor for lymph node metastasis before endoscopic treatment for colorectal cancer. However, the most important factor to predict lymph node metastasis has been suggested to be lymphovascular invasion rather than the depth of invasion. Thus, the aim of this study was to investigate the predictive relevance of lymphovascular invasion before endoscopic treatment. METHODS The data on pT1 colorectal cancers that were resected endoscopically or surgically from 2007 to 2015 were retrospectively reviewed. The cases were categorized into two groups: positive or negative for lymphovascular invasion. The following factors were evaluated by univariate and multivariate analyses: age and sex of the patients; location, size, and morphology of the lesion; and depth of invasion. RESULTS The positive and negative groups included 229 and 457 cases, respectively. Younger age ( P < 0.01), smaller lesion size ( P = 0.01), non-LST (LST: laterally spreading tumor) ( P < 0.01), presence of depression ( P < 0.01), and pT1b ( P < 0.01) were associated with lymphovascular invasion. In multivariate analysis, younger age (comparing patients aged ≤ 64 years with those aged > 65 years, OR, 1.81; 95 %CI, 1.29 - 2.53), presence of depression (OR, 1.97; CI, 1.40 - 2.77), non-LST features (OR, 1.50; CI, 1.04 - 2.15), and pT1b (OR, 3.08; CI, 1.91 - 4.97) were associated with lymphovascular invasion. CONCLUSION Younger age, presence of depression, T1b, and non-LST are associated with lymphovascular invasion. Therefore, careful pathological diagnosis and surveillance are necessary for lesions demonstrating any of these four factors.
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Affiliation(s)
- Kazuya Inoki
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan,Course of Advanced Clinical Research of Cancer, Juntendo University Graduate School of Medicine, National Cancer Center Hospital, Tokyo, Japan
| | - Taku Sakamoto
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan,Corresponding author Taku Sakamoto, MD National Cancer Center Hospital5-1-1 TsukijiChuo-kuTokyo104-0045Japan+81-3-35423815
| | | | - Masau Sekiguchi
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Masayoshi Yamada
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Takeshi Nakajima
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Takahisa Matsuda
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Hirokazu Taniguchi
- Pathology and Clinical Laboratory Division, National Cancer Center Hospital, Tokyo, Japan
| | - Shigeki Sekine
- Pathology and Clinical Laboratory Division, National Cancer Center Hospital, Tokyo, Japan
| | - Yukihide Kanemitsu
- Colorectal Surgery Division, National Cancer Center Hospital, Tokyo, Japan
| | - Yuichiro Ohe
- Course of Advanced Clinical Research of Cancer, Juntendo University Graduate School of Medicine, National Cancer Center Hospital, Tokyo, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
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14
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van der Stok EP, Spaander MCW, Grünhagen DJ, Verhoef C, Kuipers EJ. Surveillance after curative treatment for colorectal cancer. Nat Rev Clin Oncol 2016; 14:297-315. [DOI: 10.1038/nrclinonc.2016.199] [Citation(s) in RCA: 118] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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15
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Nam MJ, Han KS, Kim BC, Hong CW, Sohn DK, Chang HJ, Kim MJ, Kim SY, Baek JY, Park SC, Oh JH. Long-term outcomes of locally or radically resected T1 colorectal cancer. Colorectal Dis 2016; 18:852-60. [PMID: 26589573 DOI: 10.1111/codi.13221] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 10/08/2015] [Indexed: 12/11/2022]
Abstract
AIM Little is known about the long-term outcome of T1 colorectal cancer (CRC) following curative resection. The present study addressed the long-term outcome of locally or radically resected T1 CRCs. METHOD A total of 430 patients with T1 CRC who underwent local or radical resection were considered. Unfavourable histological factors were defined as positive resection margin, deep submucosal invasion, vascular invasion, Grade 3 and budding. The patients were classified as low-risk (unfavourable histological factor negative, n = 65) or high-risk (unfavourable histological factor positive, n = 365). RESULTS Over a median follow-up of 78.4 months, disease recurred in 16 (3.7%) patients in the high-risk group, and no recurrence in the low-risk group. Resection type and vascular invasion were significantly associated with recurrence. In the vascular invasion (+) high-risk group, both 5-year disease-free survival rate and 5-year overall survival rate were significantly associated with resection type (radical 94.6%, local 43.8%, P < 0.001, and radical 99.1%, local 66.7%, P < 0.001). In the vascular invasion (-) high-risk group, 5-year disease-free survival rate was also significantly associated with resection type (radical 98.9%, local 84.7%, P = 0.001). However, 5-year overall survival rate was not associated with resection type (radical 98.9%, local 95.2%, P = 0.816). CONCLUSION Local resection may be effective and oncologically safe in low-risk T1 CRC. Although additional surgery should be recommended for the locally resected high-risk T1 CRC cases, intensive surveillance without additional surgery and timely salvage operation may offer another treatment option, if vascular invasion is negative.
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Affiliation(s)
- M J Nam
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - K S Han
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea.,Center for Cancer Prevention and Early Detection, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - B C Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea.,Center for Cancer Prevention and Early Detection, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - C W Hong
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea.,Center for Cancer Prevention and Early Detection, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - D K Sohn
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea.,Center for Cancer Prevention and Early Detection, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - H J Chang
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - M J Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - S Y Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - J Y Baek
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - S C Park
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - J H Oh
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
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16
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Saitoh Y, Inaba Y, Sasaki T, Sugiyama R, Sukegawa R, Fujiya M. Management of colorectal T1 carcinoma treated by endoscopic resection. Dig Endosc 2016; 28:324-9. [PMID: 26076802 DOI: 10.1111/den.12503] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 06/05/2015] [Accepted: 06/08/2015] [Indexed: 12/28/2022]
Abstract
As a result of recent advances in endoscopic therapeutic technology, the number of endoscopic resections carried out in the treatment of early colorectal carcinomas with little risk of lymph node metastasis has increased. There are no reports of lymph node metastasis in intramucosal (Tis) carcinomas, whereas lymph node metastasis occurs in 6.8-17.8% of submucosal (T1) carcinomas. Three clinical guidelines have been published in Japan and the management strategy for early colorectal tumors has been demonstrated. According to the 2014 Japanese Society for Cancer of the Colon and Rectum (JSCCR) Guidelines for the Treatment of Colorectal Cancer, additional surgery should be done in cases of endoscopically resected T1 carcinoma with a histologically diagnosed positive vertical margin. Additional surgery may also be considered when one of the following histological findings is detected: (i) SM invasion depth ≥1000 µm; (ii) histological type por., sig., or muc.; (iii) grade 2-3 tumor budding; and (iv) positive vascular permeation. A resected lesion that is histologically diagnosed as a T1 carcinoma without any of the above-mentioned findings can be followed up without additional surgery. As for the prognosis of endoscopically resected T1 carcinomas, the relapse ratio of approximately 3.4% (44/1312) is relatively low. However, relapse is associated with a poor prognosis, with 72 cancer-related deaths reported out of 134 relapsed cases (54%). A more detailed stratification of the lymph node metastasis risk after endoscopic resection for T1 carcinomas and the prognosis of relapsed cases will be elucidated through prospective studies. Thereafter, the appropriate indications and safe and secure endoscopic resection for T1 carcinomas will be established.
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Affiliation(s)
- Yusuke Saitoh
- Digestive Disease Center, Asahikawa City Hospital, Japan
| | - Yuhei Inaba
- Digestive Disease Center, Asahikawa City Hospital, Japan
| | | | - Ryuji Sugiyama
- Digestive Disease Center, Asahikawa City Hospital, Japan
| | - Ryuji Sukegawa
- Digestive Disease Center, Asahikawa City Hospital, Japan
| | - Mikihiro Fujiya
- Division of Gastroenterology and Hematology/Oncology, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
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17
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Endoscopic Resection of Malignant Colonic Polyps: Why Clinicopathological Correlation (CPC) Is Needed for Optimal Treatment of CRC? Dig Dis Sci 2015. [PMID: 26195309 DOI: 10.1007/s10620-015-3617-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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18
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Kim JB, Lee HS, Lee HJ, Kim J, Yang DH, Yu CS, Kim JC, Byeon JS. Long-Term Outcomes of Endoscopic Versus Surgical Resection of Superficial Submucosal Colorectal Cancer. Dig Dis Sci 2015; 60:2785-92. [PMID: 25586088 DOI: 10.1007/s10620-015-3530-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 01/07/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND The long-term outcomes of endoscopic resection of superficial submucosal colorectal cancer (CRC) had not been adequately compared with those of surgical resection. AIMS We aimed to compare the long-term clinical outcomes of endoscopic resection of superficial submucosal CRC to those of surgical resection. METHODS Submucosal CRC patients with a tumor depth of sm1 or less than 1 mm from the muscularis mucosa were enrolled. Patients with unfavorable histology, such as poorly differentiated cancer or lymphovascular invasion, were excluded. Recurrence-free survival and overall survival were investigated in 87 patients who underwent endoscopic resection and in 171 patients who underwent surgical resection. RESULTS The mean ages of the endoscopic and surgical resection groups were 59.7 and 59.8 years, respectively. Hospital stay was shorter in the endoscopic resection group (1.7 ± 1.6 vs. 8.6 ± 3.8 days; p < 0.001). The 3- and 5-year recurrence-free survival rates were 98.7 and 96.7 % in the endoscopic resection group and 98.7 and 97.5 % in the surgical resection group, respectively (p = 0.837). The 3- and 5-year overall survival rates were 100.0 and 95.2 % in the endoscopic resection group and 98.7 and 92.8 % in the surgical resection group, respectively (p = 0.928). Recurred cases showed an unfavorable histology that was overlooked at the time of initial resection. CONCLUSIONS Long-term outcomes after endoscopic resection of superficial submucosal CRC are comparable to those after surgical resection. Thorough initial histopathological evaluations are needed to guarantee the correct indication for endoscopic resection of submucosal CRC.
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Affiliation(s)
- Ji-Beom Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
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19
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Abstract
Most colorectal cancer arises from adenomatous polyps. This gradual process may be interrupted by screening and treatment using colonoscopy and polypectomy. Advances in imaging platforms have led to classification systems that facilitate prediction of histologic type and both stratification for and prediction of the risk of invasion. Endoscopic treatment should be the standard of care even for extensive advanced mucosal neoplasm. Technique selection is influenced by lesion features, location, patient factors, and local expertise. Postprocedural complications are more common following advanced resection and endoscopists should be familiar with risk factors, early detection methods, and management.
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Affiliation(s)
- Amir Klein
- Department of Gastroenterology and Hepatology, Westmead Hospital, Crn Hawkesbury & Darcy Rds, Sydney, Westmead New South Wales 2145, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, University of Sydney, Crn Hawkesbury & Darcy Rds, Sydney, Westmead New South Wales 2145, Australia.
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20
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Tanaka S, Saitoh Y, Matsuda T, Igarashi M, Matsumoto T, Iwao Y, Suzuki Y, Nishida H, Watanabe T, Sugai T, Sugihara KI, Tsuruta O, Hirata I, Hiwatashi N, Saito H, Watanabe M, Sugano K, Shimosegawa T. Evidence-based clinical practice guidelines for management of colorectal polyps. J Gastroenterol 2015; 50:252-60. [PMID: 25559129 DOI: 10.1007/s00535-014-1021-4] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 11/07/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND Recently in Japan, the morbidity of colorectal polyp has been increasing. As a result, a large number of cases of colorectal polyps that are diagnosed and treated using colonoscopy has now increased, and clinical guidelines are needed for endoscopic management and surveillance after treatment. METHODS Three committees [the professional committee for making clinical questions (CQs) and statements by Japanese specialists, the expert panelist committee for rating statements by the modified Delphi method, and the evaluating committee by moderators] were organized. Ten specialists for colorectal polyp management extracted the specific clinical statements from articles published between 1983 and September 2011 obtained from PubMed and a secondary database, and developed the CQs and statements. Basically, statements were made according to the GRADE system. The expert panel individually rated the clinical statements using a modified Delphi approach, in which a clinical statement receiving a median score greater than seven on a nine-point scale from the panel was regarded as valid. RESULTS The professional committee created 91CQs and statements for the current concept and diagnosis/treatment of various colorectal polyps including epidemiology, screening, pathophysiology, definition and classification, diagnosis, treatment/management, practical treatment, complications and surveillance after treatment, and other colorectal lesions (submucosal tumors, nonneoplastic polyps, polyposis, hereditary tumors, ulcerative colitis-associated tumor/carcinoma). CONCLUSIONS After evaluation by the moderators, evidence-based clinical guidelines for management of colorectal polyps have been proposed for 2014.
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Affiliation(s)
- Shinji Tanaka
- Guidelines Committee for creating and evaluating the "Evidence-based clinical practice guidelines for management of colorectal polyps", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13 Ginza, Chuo, Tokyo, 104-0061, Japan,
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21
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Mounzer R, Das A, Yen RD, Rastogi A, Bansal A, Hosford L, Wani S. Endoscopic and surgical treatment of malignant colorectal polyps: a population-based comparative study. Gastrointest Endosc 2015; 81:733-740.e2. [PMID: 25708762 DOI: 10.1016/j.gie.2014.11.049] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 11/21/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Long-term population-based data comparing endoscopic therapy (ET) and surgery for management of malignant colorectal polyps (MCPs) are limited. OBJECTIVE To compare colorectal cancer (CRC)-specific survival with ET and surgery. DESIGN AND SETTING Population-based study. PATIENTS Patients with stage 0 and stage 1 MCPs were identified from the Surveillance Epidemiology and End Results (SEER) database (1998-2009). Demographic characteristics, tumor size, location, treatment modality, and survival were compared. Propensity-score matching and Cox proportional hazards regression models were used to evaluate the association between treatment and CRC-specific survival. INTERVENTIONS ET and surgery. MAIN OUTCOME MEASUREMENTS Mid-term (2.5 years) and long-term (5 years) CRC-free survival rates and independent predictors of CRC-specific mortality. RESULTS Of 10,403 patients with MCPs, 2688 (26%) underwent ET and 7715 (74%) underwent surgery. Patients undergoing ET were more likely to be older white men with stage 0 disease. Surgical patients had more right-sided lesions, larger MCPs, and stage 1 disease. There was no difference in the 2.5-year and 5-year CRC-free survival rates between the 2 groups in stage 0 disease. Surgical resection led to higher 2.5-year (97.8% vs 93.2%; P < .001) and 5-year (96.6% vs 89.8%; P < .001) CRC-free survival in stage 1 disease. These results were confirmed by propensity-score matching. ET was a significant predictor for CRC-specific mortality in stage 1 disease (hazard ratio 2.40; 95% confidence interval, 1.75-3.29; P < .001). LIMITATIONS Comorbidity index not available, selection bias. CONCLUSIONS ET and surgery had comparable mid- and long-term CRC-free survival rates in stage 0 disease. Surgical resection is the recommended treatment modality for MCPs with submucosal invasion.
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Affiliation(s)
- Rawad Mounzer
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Ananya Das
- Arizona Center for Digestive Health, Gilbert, Arizona, USA
| | - Roy D Yen
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Amit Rastogi
- University of Kansas School of Medicine and Veterans Affairs Medical Center, Kansas City, Missouri, USA
| | - Ajay Bansal
- University of Kansas School of Medicine and Veterans Affairs Medical Center, Kansas City, Missouri, USA
| | - Lindsay Hosford
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA; Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center, Denver, Colorado, USA
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Factors associated with risk for colorectal cancer recurrence after endoscopic resection of T1 tumors. Clin Gastroenterol Hepatol 2014; 12:292-302.e3. [PMID: 23962552 DOI: 10.1016/j.cgh.2013.08.008] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 07/16/2013] [Accepted: 08/05/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS More information is needed on the long-term outcomes of patients who undergo endoscopic resection of colorectal tumors. We evaluated recurrence of colorectal cancer (CRC) after endoscopic resection or a combination of endoscopic research and surgery for T1 colorectal tumors. METHODS We conducted a retrospective study of 389 patients with T1 CRC treated by endoscopic resection from January 1989 to December 2008 in Sapporo, Japan. We compared outcomes between patients who underwent subsequent surgery (ER + SURG, n = 205) and those who did not (ER only, n = 184) and statistically adjusted baseline differences between the groups according to the propensity scores. RESULTS There was almost no risk of cancer recurrence among patients without indications for surgery recommended by the Japanese Society for Cancer of the Colon and Rectum (these indications include tumors with vertical margins, deep submucosal invasion, lymphatic or venous invasion, poor differentiation, or high-grade budding). Among patients with indications for surgery, the cumulative risks of recurrence (CRRs) were 3.7% in the ER + SURG group and 20.1% in the ER only group (P = .001). However, the patients with only deep submucosal invasion had a low CRR, even without surgery (2.3% in the ER + SURG group and 3.4% in the ER only groups, P = .867). In contrast, patients with indications for surgery other than deep submucosal invasion (high-risk patients) had much better outcomes when they also underwent surgery (CRRs: 5.8% in the ER + SURG group vs 58.0% in the ER only group, P < .001). CONCLUSIONS On the basis of a retrospective study of patients who underwent endoscopic resection for T1 CRC, those with tumors with only submucosal invasion are at low risk for cancer recurrence. However, patients with other high-risk tumor features have greater risks for cancer recurrence and benefit from subsequent surgery.
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Tutticci N, Bourke MJ. Advanced endoscopic resection in the colon: recent innovations, current limitations and future directions. Expert Rev Gastroenterol Hepatol 2014; 8:161-77. [PMID: 24308750 DOI: 10.1586/17474124.2014.866894] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The major health burden of colorectal cancer is reduced by colonoscopic polypectomy. The majority of polyps encountered are diminutive in size and easily removed; however, endoscopic removal of lesions >20 mm in size is also effective and safe. Techniques have progressed, advancing the boundaries of endoscopic therapy to include resection of circumferential lesions and selected submucosal invasive cancers. While there are cost and safety advantages over surgical management, specific limitations of endoscopic resection remain, chiefly bleeding, perforation and recurrence. Recent studies highlight the utility of risk stratification and demonstrate the effectiveness of endoscopic treatment of complications; however, strategies for prevention remain elusive. Prediction of submucosal invasive cancers through systematic assessment of lesion morphology and surface pattern is now established. Harnessing submucosal invasive cancer prediction and risk stratification allows a shift toward lesion-specific therapy, the next paradigm in the management of advanced colonic lesions.
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Affiliation(s)
- Nicholas Tutticci
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
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Transanal endoscopic microsurgery after endoscopic resection of malignant rectal polyps: a useful technique for indication to radical treatment. Surg Endosc 2013; 28:1136-40. [PMID: 24170069 DOI: 10.1007/s00464-013-3290-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 10/11/2013] [Indexed: 12/29/2022]
Abstract
BACKGROUND Management of malignant rectal polyps (MRPs) after endoscopic polypectomy (EP) is still debated. It is sometimes difficult to decide whether to simply follow-up (FU) or to treat such a removed lesion. Transanal endoscopic microsurgery (TEM) could have a role both in T staging and in treating MRPs after EP. METHODS Patients who underwent a full-thickness TEM within 3 months after an EP between January 2008 and October 2012 were retrospectively analyzed. If post-TEM histology showed locally advanced rectal cancer, patients underwent a total mesorectal excision (TME) within 4-6 weeks. Patients without malignant disease or pT1sm1 cancers at post-TEM histology were followed up every 3 months for 2 years with clinical examination, flexible rectal endoscopy, and neoplastic markers monitoring. RESULTS A total of 39 patients were included. Post-EP histology was adenocarcinoma in 27/39 cases (69.2 %) and adenoma in 12/39. Mean operative time was 64.2 min; no 30-day mortality occurred; 30-day morbidity was 2.7 % (rectal bleeding in 1/39 cases). Post-TEM histology showed a T2 cancer in 5/39 patients, four with and one without a previous cancer diagnosis, who were further treated by TME (four RARs and one APR) and are disease free with a mean FU of 24.2 months. Post-TEM histology showed adenoma in 10/39 cases and fibrosis in 24/39. These patients are disease free with a mean FU of 13 months. CONCLUSIONS A full-thickness TEM after EP of MRPs can establish the presence of residual malignant disease and its depth of invasion, precisely defining the indication to TME. In event of benign post-EP histology, TEM must be performed in presence of macroscopic residual disease, in order to obtain an RO resection and finally exclude cancer, while, in absence of macroscopic residual disease, only close FU is required.
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Wani S, Rastogi A. Narrow-band imaging in the prediction of submucosal invasive colon cancer: how "NICE" is it? Gastrointest Endosc 2013; 78:633-6. [PMID: 24054741 DOI: 10.1016/j.gie.2013.06.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 06/19/2013] [Indexed: 02/08/2023]
Affiliation(s)
- Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA; Division of Gastroenterology and Hepatology, Department of Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado, USA
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Hayashi N, Tanaka S, Hewett DG, Kaltenbach TR, Sano Y, Ponchon T, Saunders BP, Rex DK, Soetikno RM. Endoscopic prediction of deep submucosal invasive carcinoma: validation of the narrow-band imaging international colorectal endoscopic (NICE) classification. Gastrointest Endosc 2013; 78:625-32. [PMID: 23910062 DOI: 10.1016/j.gie.2013.04.185] [Citation(s) in RCA: 289] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Accepted: 04/20/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND A simple endoscopic classification to accurately predict deep submucosal invasive (SM-d) carcinoma would be clinically useful. OBJECTIVE To develop and assess the validity of the NBI international colorectal endoscopic (NICE) classification for the characterization of SM-d carcinoma. DESIGN The study was conducted in 4 phases: (1) evaluation of endoscopic differentiation by NBI-experienced colonoscopists; (2) extension of the NICE classification to incorporate SM-d (type 3) by using a modified Delphi method; (3) prospective validation of the individual criteria by inexperienced participants, by using high-definition still images without magnification of known histology; and (4) prospective validation of the individual criteria and overall classification by inexperienced participants after training. SETTING Japanese academic unit. MAIN OUTCOME MEASUREMENTS Performance characteristics of the NICE criteria (phase 3) and overall classification (phase 4) for SM-d carcinoma; sensitivity, specificity, predictive values, and accuracy. RESULTS We expanded the NICE classification for the endoscopic diagnosis of SM-d carcinoma (type 3) and established the predictive validity of its individual components. The negative predictive values of the individual criteria for diagnosis of SM-d carcinoma were 76.2% (color), 88.5% (vessels), and 79.1% (surface pattern). When any 1 of the 3 SM-d criteria was present, the sensitivity was 94.9%, and the negative predictive value was 95.9%. The overall sensitivity and negative predictive value of a global, high-confidence prediction of SM-d carcinoma was 92%. Interobserver agreement for an overall SM-d carcinoma prediction was substantial (kappa 0.70). LIMITATIONS Single Japanese center, use of still images without prospective clinical evaluation. CONCLUSION The NICE classification is a valid tool for predicting SM-d carcinomas in colorectal tumors.
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Affiliation(s)
- Nana Hayashi
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
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Endoscopic submucosal dissection for nonpedunculated submucosal invasive colorectal cancer: is it feasible? Eur J Gastroenterol Hepatol 2013; 25:1051-9. [PMID: 23660936 DOI: 10.1097/meg.0b013e328361dd39] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND/AIMS There have been no definite indications for additional surgical resection after endoscopic submucosal dissection (ESD) of submucosal invasive colorectal cancer (SICC). The aims of this study were to evaluate the feasibility of ESD for nonpedunculated SICC and to determine the need for subsequent surgery after ESD. PATIENTS AND METHODS A total of 150 patients with nonpedunculated SICC in resected specimens after ESD were analyzed. Among them, 75 patients underwent subsequent surgery after ESD. Clinical outcomes of ESD and histopathological risk factors for lymph node (LN) metastasis were evaluated. RESULTS The en-bloc resection and complete resection (R0) rates of ESD were 98% (147/150) and 95.3% (143/150), respectively. None of the patients had delayed bleeding after ESD. Perforations occurred in seven patients (4.7%), which were successfully treated by endoscopic clipping. After subsequent surgery for 75 patients, LN metastases were found in 10 cases (13.3%). The incidence of LN metastasis was significantly higher in tumors featuring submucosal invasion of at least 1500 μm, lymphovascular invasion, and tumor budding. Multivariate analysis showed that lymphovascular invasion (P=0.034) and tumor budding (P=0.015) were significantly associated with LN metastasis. Among the 150 patients, no local recurrence or distant metastasis was detected, except one patient with risk factors and who refused subsequent surgery, during the overall median follow-up of 34 months (range, 5-63 months). CONCLUSION ESD is feasible and may be considered as an alternative treatment option for carefully selected cases of nonpedunculated SICC, provided that the appropriate histopathological curative criteria are fulfilled in completely resectable ESD specimens.
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Fukami N. Determining the benefits of oncologic surgery after endoscopic removal of submucosal invasive colorectal carcinoma. Clin Gastroenterol Hepatol 2011; 9:539-40. [PMID: 21558019 DOI: 10.1016/j.cgh.2011.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Accepted: 04/18/2011] [Indexed: 02/07/2023]
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