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Giuliani O, Baldacchini F, Bucchi L, Mancini S, Ravaioli A, Vattiato R, Zamagni F, Sassatelli R, Triossi O, Trande P, Palmonari C, Mussetto A, Fabbri C, Giovanardi M, de Padova A, Falcini F. Factors affecting treatment decisions for endoscopically resected low- and high-risk malignant colorectal polyps in a screening setting. Dig Liver Dis 2024:S1590-8658(24)01002-8. [PMID: 39327146 DOI: 10.1016/j.dld.2024.08.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 08/22/2024] [Accepted: 08/30/2024] [Indexed: 09/28/2024]
Abstract
INTRODUCTION The European Guidelines for colorectal cancer screening of 2006 state that only high-risk endoscopically resected malignant colorectal polyps (MCPs), defined as poor/no differentiation or positive resection margins or lymphovascular invasion, require colonic resection. METHODS A multicentre series of 954 patients with screen-detected MCP (northern Italy, 2005-2016, age 50-69) was studied to identify (1) the factors affecting the choice of colonic resection, and (2) the factors associated with deviation from the European Guidelines for low- and high-risk patients. Data analysis was based on multilevel logistic regression models. RESULTS Five hundred sixty-four (59.1 %) patients underwent colonic resection. The factors significantly associated with surgical referral included: distal and rectal versus proximal tumour site (inverse association); sessile and flat versus pedunculated morphology (direct association); tumour size (direct); moderate/poor versus good differentiation (direct); adenocarcinoma of not otherwise specified type versus adenocarcinoma with a residual adenoma component (direct); positive versus negative resection margins (direct); lymphovascular invasion (direct); and high-grade versus low-grade/absent tumour budding (direct). In low-risk MCPs, tumour budding encouraged strongly the decision for surgery. In high-risk MCPs, a distal/rectal tumour site encouraged the follow-up option. CONCLUSION The identification of factors associated with treatment choices other than those currently recommended may help prioritise the clinical questions in the development of future guidelines.
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Affiliation(s)
- Orietta Giuliani
- Emilia-Romagna Cancer Registry, Romagna Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) Dino Amadori, Meldola, Forlì, Italy
| | - Flavia Baldacchini
- Emilia-Romagna Cancer Registry, Romagna Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) Dino Amadori, Meldola, Forlì, Italy
| | - Lauro Bucchi
- Emilia-Romagna Cancer Registry, Romagna Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) Dino Amadori, Meldola, Forlì, Italy.
| | - Silvia Mancini
- Emilia-Romagna Cancer Registry, Romagna Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) Dino Amadori, Meldola, Forlì, Italy
| | - Alessandra Ravaioli
- Emilia-Romagna Cancer Registry, Romagna Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) Dino Amadori, Meldola, Forlì, Italy
| | - Rosa Vattiato
- Emilia-Romagna Cancer Registry, Romagna Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) Dino Amadori, Meldola, Forlì, Italy
| | - Federica Zamagni
- Emilia-Romagna Cancer Registry, Romagna Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) Dino Amadori, Meldola, Forlì, Italy
| | - Romano Sassatelli
- Unit of Gastroenterology and Digestive Endoscopy, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Omero Triossi
- Gastroenterology Unit, Local Health Authority, Santa Maria delle Croci Hospital, Ravenna, Italy
| | - Paolo Trande
- Struttura Semplice Dipartimentale Screening del Colon-Retto, AUSL di Modena, Modena, Italy
| | - Caterina Palmonari
- Western Health District and UOSD Management, Epidemiology, Oncologic screening, Health promotion programmes, AUSL Ferrara, Ferrara, Italy
| | - Alessandro Mussetto
- Gastroenterology Unit, Local Health Authority, Santa Maria delle Croci Hospital, Ravenna, Italy
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Local Health Authority, Forlì-Cesena, Italy
| | - Mauro Giovanardi
- Gastroenterology and Digestive Endoscopy Unit, Local Health Authority, Rimini, Italy
| | - Angelo de Padova
- Gastroenterology and Digestive Endoscopy Unit, Local Health Authority, Rimini, Italy
| | - Fabio Falcini
- Emilia-Romagna Cancer Registry, Romagna Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) Dino Amadori, Meldola, Forlì, Italy; Cancer Prevention Unit, Local Health Authority, Forlì, Italy
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2
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van der Schee L, Haasnoot KJC, Elias SG, Gijsbers KM, Alderlieste YA, Backes Y, van Berkel AM, Boersma F, Ter Borg F, Breekveldt ECH, Kessels K, Koopman M, Lansdorp-Vogelaar I, van Leerdam ME, Rasschaert G, Schreuder RM, Schrauwen RWM, Seerden TCJ, Spanier MBW, Terhaar Sive Droste JS, Toes-Zoutendijk E, Tuynman JB, Vink GR, de Vos Tot Nederveen Cappel WH, Vleggaar FP, Laclé MM, Moons LMG. Oncologic outcomes of screen-detected and non-screen-detected T1 colorectal cancers. Endoscopy 2024; 56:484-493. [PMID: 38325403 DOI: 10.1055/a-2263-2841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
BACKGROUND The incidence of T1 colorectal cancer (CRC) has increased with the implementation of CRC screening programs. It is unknown whether the outcomes and risk models for T1 CRC based on non-screen-detected patients can be extrapolated to screen-detected T1 CRC. This study aimed to compare the stage distribution and oncologic outcomes of T1 CRC patients within and outside the screening program. METHODS Data from T1 CRC patients diagnosed between 2014 and 2017 were collected from 12 hospitals in the Netherlands. The presence of lymph node metastasis (LNM) at diagnosis was compared between screen-detected and non-screen-detected patients using multivariable logistic regression. Cox proportional hazard regression was used to analyze differences in the time to recurrence (TTR), metastasis-free survival (MFS), cancer-specific survival (CSS), and overall survival. Additionally, the performance of conventional risk factors for LNM was evaluated across the groups. RESULTS 1803 patients were included (1114 [62%] screen-detected), with median follow-up of 51 months (interquartile range 30). The proportion of LNM did not significantly differ between screen- and non-screen-detected patients (12.6% vs. 8.9%; odds ratio 1.41; 95%CI 0.89-2.23); a prediction model for LNM performed equally in both groups. The 3- and 5-year TTR, MFS, and CSS were similar for patients within and outside the screening program. However, overall survival was significantly longer in screen-detected T1 CRC patients (adjusted hazard ratio 0.51; 95%CI 0.38-0.68). CONCLUSIONS Screen-detected and non-screen-detected T1 CRCs have similar stage distributions and oncologic outcomes and can therefore be treated equally. However, screen-detected T1 CRC patients exhibit a lower rate of non-CRC-related mortality, resulting in longer overall survival.
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Affiliation(s)
- Lisa van der Schee
- Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, Netherlands
- Pathology, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Krijn J C Haasnoot
- Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Sjoerd G Elias
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Kim M Gijsbers
- Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, Netherlands
- Gastroenterology and Hepatology, Deventer Hospital, Deventer, Netherlands
| | | | - Yara Backes
- Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, Netherlands
| | | | - Femke Boersma
- Gastroenterology and Hepatology, Gelre Hospitals, Apeldoorn, Netherlands
| | - Frank Ter Borg
- Gastroenterology and Hepatology, Deventer Hospital, Deventer, Netherlands
| | - Emilie C H Breekveldt
- Public Health, Erasmus MC, Rotterdam, Netherlands
- Gastrointestinal Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Koen Kessels
- Gastroenterology and Hepatology, Sint Antonius Ziekenhuis, Nieuwegein, Netherlands
| | - Miriam Koopman
- Medical Oncology, University Medical Centre Utrecht, Utrecht, Netherlands
| | | | - Monique E van Leerdam
- Gastrointestinal Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, Netherlands
| | | | | | - Ruud W M Schrauwen
- Gastroenterology and Hepatology, Bernhoven Hospital Location Uden, Uden, Netherlands
| | - Tom C J Seerden
- Gastroenterology and Hepatology, Amphia Hospital, Breda, Netherlands
| | - Marcel B W Spanier
- Gastroenterology and Hepatology, Rijnstate Hospital Arnhem Branch, Arnhem, Netherlands
| | | | | | | | - Geraldine R Vink
- Medical Oncology, University Medical Centre Utrecht, Utrecht, Netherlands
- Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, Netherlands
| | | | - Frank P Vleggaar
- Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Miangela M Laclé
- Pathology, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Leon M G Moons
- Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, Netherlands
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Zammit AP, Panahi SE, Brown I, Hooper JD, Clark DA, Riddell AD. Management of high and low risk malignant polyps: a population-wide analysis. Colorectal Dis 2023; 25:66-74. [PMID: 36088629 PMCID: PMC10087765 DOI: 10.1111/codi.16328] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 08/22/2022] [Accepted: 09/01/2022] [Indexed: 02/02/2023]
Abstract
AIM The management of malignant polyps is a treatment dilemma in selecting between polypectomy and colorectal resection. To assist clinicians, guidelines have been developed by the Association of Coloproctology of Great Britain and Ireland (ACPGBI) to provide treatment recommendations. METHODS This study compared management strategy based on the ACPGBI risk categorization for malignant polyps. Univariable and multivariable statistical analysis was undertaken to assess the factors predicting management strategy. A population-wide analysis was performed of 1646 malignant polyps and the factors that predicted their management strategy, from Queensland, Australia, from 2011 to 2019. RESULTS Overall, 31.55% of patients with very low or low risk disease proceeded to resection. Of those with high or very high risk disease, 36.69% did not proceed to resection. In very low and low risk polyps, age (P = 0.003) and polyp location (P < 0.001) were significantly different between the colorectal resection group and the polypectomy alone group. In those with very high or high risk polyps age (P < 0.001), type of facility (public or private) for the colonoscopy (P = 0.037), right colonic polyps compared to left colonic polyps (P = 0.015) and rectal polyps (P < 0.001) and mismatch repair mutations present (P = 0.027) were predictive of resection in high risk disease using a multivariable model. CONCLUSION Over 30% of patients with very low and low risk malignant polyps proceeded to resection, against the advice of guidelines. Furthermore, over 35% of patients with very high or high risk malignant polyps did not proceed to resection. Education strategies may improve management decision choices. Furthermore, improvements in data collation will improve the understanding of management choices in the future.
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Affiliation(s)
- Andrew P Zammit
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Seyed E Panahi
- Sydney Local Health District, Sydney, New South Wales, Australia
| | - Ian Brown
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Envoi Specialist Pathologists, Brisbane, Queensland, Australia.,Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - John D Hooper
- Mater Research, Translational Research Institute, Brisbane, Queensland, Australia
| | - David A Clark
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine and Health, University of Sydney and Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,St Vincent's Private Hospital Northside, Brisbane, Queensland, Australia
| | - Andrew D Riddell
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Redcliffe Hospital, Redcliffe, Queensland, Australia
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4
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Zammit AP, Lyons NJ, Chatfield MD, Hooper JD, Brown I, Clark DA, Riddell AD. Patient and pathological predictors of management strategy for malignant polyps following polypectomy: a systematic review and meta-analysis. Int J Colorectal Dis 2022; 37:1035-1047. [PMID: 35394561 PMCID: PMC9072497 DOI: 10.1007/s00384-022-04142-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/29/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Malignant polyps present a treatment dilemma for clinicians and patients. This meta-analysis sought to identify the factors that predicted the management strategy for patients diagnosed with a malignant polyp. METHODS A literature search was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Cochrane Collaboration prognostic studies guidelines. Reports from 1985 onwards were included, data on patient and pathological factors were extracted and random effects meta-analysis models were used. RESULTS Fifteen studies were included. Seven studies evaluated lymphovascular invasion (LVI). The odds of surgery were significantly higher in malignant polyps with LVI (OR 2.20, 95% CI 1.36-3.55). Ten studies revealed the odds of surgery were significantly higher with positive polypectomy margins (OR 8.09, 95% CI 4.88-13.40). Tumour differentiation was compared in eight studies. There were significantly lower odds of surgery in malignant polyps with well/moderate differentiation compared with poor differentiation (OR 0.31, 95% CI 0.21-0.46). There were non-significant trends favouring surgical resection in younger patients, males and Haggitt 4/Kikuchi Sm3 lesions. There was considerable heterogeneity in the meta-analyses for the variables age, gender, polyp morphology and Haggitt/Kikuchi level (I2 > 75%). CONCLUSION This meta-analysis has demonstrated that LVI, positive polypectomy resection margins, and poor tumour differentiation significantly predict malignant polypectomy patients who underwent subsequent surgery. Age and gender were important factors predicting management, but not consistently across studies, whilst polyp morphology and Haggitt/Kikuchi levels did not significantly predict the management strategy. Further research may assist in understanding the management preferences.
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Affiliation(s)
- Andrew P. Zammit
- Faculty of Medicine, University of Queensland, Brisbane, QLD Australia
| | - Nicholas J. Lyons
- Mater Research Institute, The University of Queensland, Brisbane, QLD Australia
| | - Mark D. Chatfield
- Faculty of Medicine, University of Queensland, Brisbane, QLD Australia
| | - John D. Hooper
- Mater Research Institute, The University of Queensland, Brisbane, QLD Australia
| | - Ian Brown
- Faculty of Medicine, University of Queensland, Brisbane, QLD Australia ,Envoi Specialist Pathologists, Brisbane, QLD Australia ,Royal Brisbane and Women’s Hospital, Brisbane, QLD Australia
| | - David A. Clark
- Faculty of Medicine, University of Queensland, Brisbane, QLD Australia ,Royal Brisbane and Women’s Hospital, Brisbane, QLD Australia ,Faculty of Medicine and Health, University of Sydney and Surgical Outcomes Research Centre (SOuRCe), Sydney, NSW Australia ,St Vincent’s Private Hospital Northside, Brisbane, QLD Australia
| | - Andrew D. Riddell
- Faculty of Medicine, University of Queensland, Brisbane, QLD Australia ,Redcliffe Hospital, Redcliffe, QLD Australia
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Cazacu SM, Săftoiu A, Iordache S, Ghiluşi MC, Georgescu CV, Iovănescu VF, Neagoe CD, Streba L, Caliţa M, Burtea ED, Cârţu D, Leru PM. Factors predicting occurrence and therapeutic choice in malignant colorectal polyps: a study of 13 years of colonoscopic polypectomy. ROMANIAN JOURNAL OF MORPHOLOGY AND EMBRYOLOGY = REVUE ROUMAINE DE MORPHOLOGIE ET EMBRYOLOGIE 2021; 62:917-928. [PMID: 35673811 PMCID: PMC9289694 DOI: 10.47162/rjme.62.4.04] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Colorectal carcinoma represents a major cause of mortality and 0.2–12% of resected colonic polyps have malignant cells inside. We performed a retrospective study of patients with resected polyps during a period of 13 years. A total of 905 patients had 2033 polyps removed; 122 polyps (109 patients) had malignant cells. Prevalence of malignant polyps with submucosal invasion was 1.23% and for all polyps with malignant cells was 6%; malignant polyps had a larger size (23.44 mm mean diameter) vs benign polyps (9.63 mm); the risk of malignancy was increased in polyps larger than 10 mm, in lateral spreading lesions and in Paris types 0-Ip, 0-Isp, in sigmoid, descending colon and rectum, in sessile serrated adenoma and traditional serrate adenoma subtypes of serrated lesions and in tubulovillous and villous adenoma. In 18 cases surgery was performed, in 62 patients only colonoscopic follow-up was made and in 35 patients no colonoscopic follow-up was recorded. From initially endoscopic resected polyps, recurrence was noted in seven (11.3%) cases; there was a trend toward association with depth of invasion, piecemeal resection, right and rectum location, sessile and lateral spreading type and pathological subtype. In surgical group, post-therapeutic staging was available in 11 cases; nodal involvement was noted in three (27.27%) cases; none had lymphatic or vascular invasion in endoscopically resected polyps. Four patients with no macroscopic local recurrence underwent surgery with no residual tumor. The rate of metastasis was 16.67% in surgical group and 1.61% in endoscopic group. Evaluation of lymph node (LN) invasion was available for 11 operated patients, with LN invasion (N1) in three patients, local residual tumoral tissue in one patient with incomplete resection and no residual tumor (R0 resection) in four patients with endoscopic resection before surgery.
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Affiliation(s)
- Sergiu Marian Cazacu
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, Romania; ,
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Rex DK, Risio M, Hassan C. Prioritizing an oncologic approach to endoscopic resection of pedunculated colorectal polyps. Gastrointest Endosc 2021; 94:155-159. [PMID: 33931206 DOI: 10.1016/j.gie.2021.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 03/05/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mauro Risio
- Institute for Cancer Research and Treatment, Candiolo (Torino), Italy
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Grainville T, Bretagne JF, Piette C, Rousseau C, Bordet M, Cosson M, Lièvre A. Management of T1 colorectal cancers detected at screening colonoscopy: A study from the French national screening programme. Dig Liver Dis 2020; 52:909-917. [PMID: 32505572 DOI: 10.1016/j.dld.2020.04.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/07/2020] [Accepted: 04/17/2020] [Indexed: 02/07/2023]
Abstract
AIM The main aim of this study was to examine the management strategies that were used and to determine the outcomes (survival and recurrence rate) of screen-detected T1-CRC. METHODS Medical records from 207 patients with T1-CRC diagnosed through the French national screening programme in one district from 2003 to 2015 were analysed. The 5-year overall, CRC-specific and CRC-free survival were calculated for the whole cohort and for the 3 groups treated by endoscopic resection (ER) alone, ER followed by subsequent surgery (ERSS), and primary surgery (PS). RESULTS Of the 207 patients, 81 (39%) underwent PS, and 126 (61%) underwent primary ER, of whom 82 (64%) underwent subsequent surgery. The 5-year overall and cancer-specific survival rates were 95.5% (95% CI, 90.8; 97.9) and 98.8% (95% CI, 95.4; 99.7%), respectively. Long-term cancer-specific mortality and recurrence crude rates were 2.4% and 5.6%, respectively. The 5-year CRC-free survival rate was 96.1% (95% CI, 91.8; 98.1%) and did not differ amongst the 3 groups (ER alone, ERSS and PS). CONCLUSION This study demonstrates the good prognosis of screen-detected T1-CRC, regardless of the treatment strategy used. But, there is a room to improve the screening programme quality with regard to the management of screen-detected CRC.
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Affiliation(s)
- Thomas Grainville
- Department of Gastroenterology, University Hospital, 35033, Rennes, France
| | | | - Christine Piette
- ADECI 35 (Association pour le Dépistage des Cancers en Ille-et-Vilaine), 35040, Rennes, France
| | - Chloé Rousseau
- Department of Biostastics, University Hospital, 35033, Rennes, France
| | - Martin Bordet
- Department of Gastroenterology, University Hospital, 35033, Rennes, France
| | - Mathilde Cosson
- ADECI 35 (Association pour le Dépistage des Cancers en Ille-et-Vilaine), 35040, Rennes, France
| | - Astrid Lièvre
- Department of Gastroenterology, University Hospital, 35033, Rennes, France; Rennes 1 University, 35000, Rennes, France; ADECI 35 (Association pour le Dépistage des Cancers en Ille-et-Vilaine), 35040, Rennes, France; COSS (Chemistry Oncogenesis Stress Signaling), UMR_S 1242, Rennes, France
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Antonelli G, Berardi G, Rampioni Vinciguerra GL, Brescia A, Ruggeri M, Mercantini P, Corleto VD, D’Ambra G, Pilozzi E, Hassan C, Angeletti S, Di Giulio E. Clinical management of endoscopically resected pT1 colorectal cancer. Endosc Int Open 2018; 6:E1462-E1469. [PMID: 30574536 PMCID: PMC6291400 DOI: 10.1055/a-0781-2293] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 05/14/2018] [Indexed: 02/06/2023] Open
Abstract
Background Implementation of colorectal cancer (CRC) screening programs increases endoscopic resection of polyps with early invasive CRC (pT1). Risk of lymph node metastasis often leads to additional surgery, but despite guidelines, correct management remains unclear. Our aim was to assess the factors affecting the decision-making process in endoscopically resected pT1-CRCs in an academic center. Methods We retrospectively reviewed patients undergoing endoscopic resection of pT1 CRC from 2006 to 2016. Clinical, endoscopic, surgical treatment, and follow-up data were collected and analyzed. Lesions were categorized according to endoscopic/histological risk-factors into low and high risk groups. Comorbidities were classified according to the Charlson comorbidity index (CCI). Surgical referral for each group was computed, and dissociation from current European CRC screening guidelines recorded. Multivariate analysis for factors affecting the post-endoscopic surgery referral was performed. Results Seventy-two patients with endoscopically resected pT1-CRC were included. Overall, 20 (27.7 %) and 52 (72.3 %) were classified as low and high risk, respectively. In the low risk group, 11 (55 %) were referred to surgery, representing over-treatment compared with current guidelines. In the high risk group, nonsurgical endoscopic surveillance was performed in 20 (38.5 %) cases, representing potential under-treatment. After a median follow-up of 30 (6 - 130) months, no patients developed tumor recurrence. At multivariate analysis, age (OR 1.21, 95 %CI 1.02 - 1.42; P = 0.02) and CCI (OR 1.67, 95 %CI 1.12 - 3.14; P = 0.04) were independent predictors for subsequent surgery. Conclusions A substantial rate of inappropriate post-endoscopic treatment of pT1-CRC was observed when compared with current guidelines. This was apparently related to an overestimation of patient-related factors rather than endoscopically or histologically related factors.
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Affiliation(s)
- Giulio Antonelli
- Endoscopy Unit, Azienda Ospedaliera Sant’Andrea, “Sapienza” University of Rome, Rome, Italy,Corresponding author Giulio Antonelli, MD Digestive Endoscopy UnitSant’Andrea Hospital“Sapienza” University of RomeVia di Grottarossa 1035-103900189RomeItaly+39-06-33776692
| | - Giammauro Berardi
- General Surgery Unit, Azienda Ospedaliera Sant’Andrea, “Sapienza” University of Rome, Rome, Italy
| | | | - Antonio Brescia
- General Surgery Unit, Azienda Ospedaliera Sant’Andrea, “Sapienza” University of Rome, Rome, Italy
| | - Maurizio Ruggeri
- Endoscopy Unit, Azienda Ospedaliera Sant’Andrea, “Sapienza” University of Rome, Rome, Italy
| | - Paolo Mercantini
- General Surgery Unit, Azienda Ospedaliera Sant’Andrea, “Sapienza” University of Rome, Rome, Italy
| | - Vito Domenico Corleto
- Endoscopy Unit, Azienda Ospedaliera Sant’Andrea, “Sapienza” University of Rome, Rome, Italy
| | - Giancarlo D’Ambra
- Endoscopy Unit, Azienda Ospedaliera Sant’Andrea, “Sapienza” University of Rome, Rome, Italy
| | - Emanuela Pilozzi
- Pathology Unit, Azienda Ospedaliera Sant’Andrea, “Sapienza” University of Rome, Rome, Italy
| | - Cesare Hassan
- Endoscopy Unit, Azienda Ospedaliera Sant’Andrea, “Sapienza” University of Rome, Rome, Italy
| | - Stefano Angeletti
- Endoscopy Unit, Azienda Ospedaliera Sant’Andrea, “Sapienza” University of Rome, Rome, Italy
| | - Emilio Di Giulio
- Endoscopy Unit, Azienda Ospedaliera Sant’Andrea, “Sapienza” University of Rome, Rome, Italy
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Senore C, Giovo I, Ribaldone DG, Ciancio A, Cassoni P, Arrigoni A, Fracchia M, Silvani M, Segnan N, Saracco GM. Management of Pt1 tumours removed by endoscopy during colorectal cancer screening: Outcome and treatment quality indicators. Eur J Surg Oncol 2018; 44:1873-1879. [PMID: 30343994 DOI: 10.1016/j.ejso.2018.09.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 08/22/2018] [Accepted: 09/02/2018] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Limited information is available about outcomes of patients with malignant adenomas endoscopically resected at screening. The aim of the study was to evaluate diagnostic and therapeutic quality indicators and to correlate them with clinical and surgical outcomes. MATERIALS AND METHODS We reviewed endoscopic and histology characteristics of all pT1 tumours endoscopically removed at the time of colonoscopy assessment in subjects with a positive screening test result in the context of a population-based program. RESULTS 392 pT1 tumours were completely removed by endoscopy (en-bloc = 86.7%, piecemeal = 13.3%) and the histology report was considered complete in 83.2% of cases. Treatment was limited to endoscopic excision for 120 patients (30.7%, Group 1), 272 (69.3%, Group 2) underwent radicalisation surgery. In patients who had at least 1 lymph node examined, the rate of nodal involvement was 5.4% (13/239); no metastatic node was found in the 21 (27.6%) out of 76 patients with low-risk adenomas, who underwent surgery. CONCLUSION Risk of nodal involvement in colorectal pT1 tumours is well predicted by known histologic features also in a screening setting, although it was lower than among patients from clinical series. Surgical overtreatment is still significantly present and there is ample room for improvement regarding diagnostic and therapeutic flow-chart.
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Affiliation(s)
- Carlo Senore
- Cancer Epidemiology Unit, CPO Piemonte, AOU Città della Salute e della Scienza, Turin, Italy
| | - Ilaria Giovo
- Division of Gastroenterology, Department of Medical Sciences, Molinette Hospital, University of Turin, Italy
| | - Davide Giuseppe Ribaldone
- Division of Gastroenterology, Department of Medical Sciences, Molinette Hospital, University of Turin, Italy.
| | - Alessia Ciancio
- Division of Gastroenterology, Department of Medical Sciences, Molinette Hospital, University of Turin, Italy
| | - Paola Cassoni
- Pathology Unit, Department of Medical Sciences, Molinette Hospital, University of Turin, Italy
| | - Arrigo Arrigoni
- Division of Gastroenterology, Department of Medical Sciences, Molinette Hospital, University of Turin, Italy
| | - Mario Fracchia
- Division of Gastroenterology, Mauriziano Hospital, Turin, Italy
| | - Marco Silvani
- Cancer Epidemiology Unit, CPO Piemonte, AOU Città della Salute e della Scienza, Turin, Italy
| | - Nereo Segnan
- Cancer Epidemiology Unit, CPO Piemonte, AOU Città della Salute e della Scienza, Turin, Italy
| | - Giorgio Maria Saracco
- Division of Gastroenterology, Department of Medical Sciences, Molinette Hospital, University of Turin, Italy
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Levic K, Bulut O, Hansen TP, Gögenur I, Bisgaard T. Malignant colorectal polyps: endoscopic polypectomy and watchful waiting is not inferior to subsequent bowel resection. A nationwide propensity score-based analysis. Langenbecks Arch Surg 2018; 404:231-242. [PMID: 30206683 DOI: 10.1007/s00423-018-1706-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 08/28/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS The optimal treatment of patients with malignant colorectal polyps is unsettled. The surgical dilemma following polypectomy is selecting between watchful waiting (WW) and subsequent bowel resection (SBR), but the long-term survival outcomes have not been established yet. This nationwide study compared survival of patients after WW or SBR. METHODS Danish nationwide study with 100% follow-up of all patients with malignant colorectal polyps (the Danish Colorectal Cancer Group database) in a 10-year period from 2001 to 2011. All patients' charts and histological reports were individually reviewed. Survival rates were calculated with Cox proportional hazard model after propensity score matching. RESULTS A total of 692 patients were included (WW, 424 (61.3%), SBR, 268 (38.7%)) with a mean follow-up of 7.5 years (3-188 months). Following propensity score matching, there was no significant difference in overall or disease-free survival (p = 0.344 and p = 0.184) or rate of local recurrence (WW, 7.2%, SBR, 2%, p = 0.052) or distant metastases (WW, 3.3%, SBR, 4.6%, p = 0.77). In the SBR group, there was no residual tumor or lymph node metastases in the resected specimen in 82.5% of the patients. CONCLUSION Subsequent bowel resection may not be superior to endoscopic polypectomy and watchful waiting with regard to overall and disease-free survival in patients with malignant colorectal polyps.
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Affiliation(s)
- Katarina Levic
- Gastrounit-Surgical Division, Center for Surgical Research, Copenhagen University Hospital Hvidovre, Kettegaards Allé 30, DK-2650 Hvidovre, Copenhagen, Denmark.
| | - Orhan Bulut
- Gastrounit-Surgical Division, Center for Surgical Research, Copenhagen University Hospital Hvidovre, Kettegaards Allé 30, DK-2650 Hvidovre, Copenhagen, Denmark
- Institution of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Tine Plato Hansen
- Institution of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Pathology, Herlev University Hospital, Copenhagen, Denmark
- Danish Colorectal Cancer Group, Copenhagen, Denmark
| | - Ismail Gögenur
- Institution of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Køge, Denmark
- Danish Colorectal Cancer Group, Copenhagen, Denmark
| | - Thue Bisgaard
- Gastrounit-Surgical Division, Center for Surgical Research, Copenhagen University Hospital Hvidovre, Kettegaards Allé 30, DK-2650 Hvidovre, Copenhagen, Denmark
- Institution of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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