Clinical outcomes and factors related to resectability and curability of EMR for early colorectal cancer

T1 colorectal cancer management in the era of minimally invasive endoscopic resection

T1 colorectal cancer (CRC), defined by tumor invasion confined to the submucosa, has historically been managed by surgery. Improved understanding of recurrence and lymph node metastases risk, coupled with advances in endoscopic resection techniques, have led to an increasing capacity for organ-sparing local excision. Minimally invasive management of T1 CRC begins with optical evaluation of the lesion to diagnose invasive disease and quantify depth of invasion, which informs therapeutic decision making. Modality selection between various available endoscopic resection techniques depends upon lesion characteristics, technique risk-benefit profiles, and location-specific implications. Following endoscopic resection, established histopathology features determine the risk of recurrence and subsequent management including surveillance or adjuvant surgical excision. The management of non-operative candidates deviates from conventional recommendations with emerging treatment strategies in select populations.

Molecular and clinicopathological differences between depressed and protruded T2 colorectal cancer

Background

Colorectal cancer (CRC) can be classified into four consensus molecular subtypes (CMS) according to genomic aberrations and gene expression profiles. CMS is expected to be useful in predicting prognosis and selecting chemotherapy regimens. However, there are still no reports on the relationship between the morphology and CMS.

Methods

This retrospective study included 55 subjects with T2 CRC undergoing surgical resection, of whom 30 had the depressed type and 25 the protruded type. In the classification of the CMS, we first defined cases with deficient mismatch repair as CMS1. And then, CMS2/3 and CMS4 were classified using an online classifier developed by Trinh et al. The staining intensity of CDX2, HTR2B, FRMD6, ZEB1, and KER and the percentage contents of CDX2, FRMD6, and KER are input into the classifier to obtain automatic output classifying the specimen as CMS2/3 or CMS4.

Results

According to the results yielded by the online classifier, of the 30 depressed-type cases, 15 (50%) were classified as CMS2/3 and 15 (50%) as CMS4. Of the 25 protruded-type cases, 3 (12%) were classified as CMS1 and 22 (88%) as CMS2/3. All of the T2 CRCs classified as CMS4 were depressed CRCs. More malignant pathological findings such as lymphatic invasion were associated with the depressed rather than protruded T2 CRC cases.

Conclusions

Depressed-type T2 CRC had a significant association with CMS4, showing more malignant pathological findings such as lymphatic invasion than the protruded-type, which could explain the reported association between CMS4 CRC and poor prognosis.

Risk Stratification of Endoscopic Submucosal Dissection in Colon Tumors

Background: Endoscopic submucosal dissection (ESD) is a technique proven effective in the treatment of early neoplastic lesions in the gastrointestinal tract. However, in the case of colon lesions, many doubts remain. The purpose of our study is to stratify the success rates of the ESD procedure in the colon. Materials and Methods: A retrospective analysis of 601 patients who underwent ESD procedure for colorectal neoplasm from 2016 to 2019 in Center of Bowel Treatment, Brzeziny, Poland. Excluding 335 rectal neoplasms, we selected 266 patients with lesions located in the colon. Results: Lesions located in the left colon were characterized by the statistically higher en bloc resection and success rate, compared with the right colon—87.76% vs. 73.95% (p = 0.004) and 83.67% vs. 69.75% (p = 0.007), respectively. The success rate was significantly lower in lesions with submucosal cancer, compared to low- and high-grade dysplasia (p < 0.001). Polyps located in the right colon were characterized by a slightly higher complication rate compared to the left colon, without statistical significance—13.45% vs. 9.52% (p = 0.315). Conclusions: Our results show that colonic ESD has a high success rate, especially in the left colon, with a low risk of complications, slightly higher than in the right colon.

Colorectal malignant polyps: a modern approach

Colorectal malignant polyps (MP) are polyps with invasive cancer into the submucosa harboring a variable risk of lymph node involvement, which can be estimated through evaluation of morphological, endoscopic, and histologic features. The recent advances in imaging endoscopic techniques have led to the possibility of performing an optical diagnosis of T1 colorectal cancer, allowing the selection of the best therapeutic modality to optimize outcomes for the patient. When MP are diagnosed after endoscopic removal, their management can be challenging. Differentiating low- and high-risk histologic features that influence the possibility of residual tumor, the risk of recurrence and the risk of lymph node metastasis, is crucial to further optimize treatment and surveillance plans. While the presence of high-risk features indicates a need for surgery in the majority of cases, location, comorbidities and the patient’s preference should be taken in account when making the final decision. This is a particularly important issue in the management of low rectal MP presenting with high-risk features, where chemoradiotherapy followed by a watch-and-wait strategy has demonstrated promising results. In this review we discuss the important prognostic features of MP and the most modern approaches regarding their management.

Risk factors of recurrence in T1 colorectal cancers treated by endoscopic resection alone or surgical resection with lymph node dissection

PURPOSE

The recurrence of T1 colorectal cancers is relatively rare, and the prognostic factors still remain obscure. This study aimed to clarify the risk factors for recurrence in patients with T1 colorectal cancers treated by endoscopic resection (ER) alone or surgical resection (SR) with lymph node dissection, respectively.

METHODS

We reviewed 930 patients with resected T1 colorectal cancers (mean follow-up, 52.3 months). Patients were divided into two groups: those who underwent ER alone (298 cases), and those who underwent initial or additional SR with lymph node dissection (632 cases). Group differences in recurrence-free survival were evaluated using the Kaplan-Meier method and log-rank test. Associations between recurrence and clinicopathological features were evaluated in Cox regression analyses; hazard ratios (HRs) were calculated for the total population and each group.

RESULTS

Recurrence occurred in four cases (1.34%) in the ER group and six cases (0.95%) in the SR group (p = 0.32). Endoscopic resection, rectal location, and poor or mucinous (Por/Muc) differentiation were prognostic factors for recurrence in the total population. Por/Muc differentiation was prognostic factor in both groups. Female sex, depressed-type morphology, and lymphatic invasion were also prognostic factors in the ER group, but not in the SR group.

CONCLUSIONS

Endoscopic resection, rectal location, and Por/Muc differentiation are prognostic factors in the total population. For patients who undergo ER alone, female sex, depressed-type morphology, and lymphatic invasion are also risk factors for recurrence. For such patients, regional en-bloc surgery with lymph node dissection could reduce the risk of recurrence.

Clinical utility of the SMSA grading tool for the management of colonic neoplastic lesions

BACKGROUND

Whilst polyp size has been traditionally used as a predictor of the complexity of endoscopic resection, the influence of other factors is increasingly recognised. The SMSA grading system takes into account polyp Site, Morphology, Size and Access, with higher scores correlating with increased technical difficulty.

AIMS

To evaluate whether the SMSA grading tool correlates with endoscopic and clinical outcomes.

METHODS

This retrospective study was conducted at two high volume centres in the United Kingdom and Italy. All polyps identified at colonoscopy were included in this study and classified as per the SMSA grading system.

RESULTS

A total of 1668 lesions were resected in 1016 patients. There was a positive correlation between increasing SMSA level and the inability to resect lesions "en bloc" (p<0.001). Histologically complete clearance was higher in the lower SMSA groups (p<0.0001). Additional endoscopic therapies, were more commonly required with the higher SMSA groups to achieve histological clearance (p<0.0001). Moreover, advanced histology in resection specimens and procedural complications were significantly less common in SMSA level 1 lesions compared to level 3 or 4 lesions (p<0.0001).

CONCLUSIONS

The SMSA grading tool is a useful predictor of outcome following the resection of colonic neoplastic lesions.

Colonoscopy: Advanced and Emerging Techniques-A Review of Colonoscopic Approaches to Colorectal Conditions

A complete colonoscopy is key in the diagnostic and therapeutic approaches to a variety of colorectal diseases. Major challenges are incomplete polyp removal and missed polyps, particularly in the setting of a difficult colonoscopy. There are a variety of both well-established and newer techniques that have been developed to optimize polyp detection, perform complete polypectomy, and endoscopically treat various complications and conditions such as strictures and perforations. The objective of this article is to familiarize the colorectal surgeon with techniques utilized by advanced endoscopists.

Colon carcinoma staging by endoscopic ultrasonography miniprobes

Background and Objectives:

Due to the increasing use of endoscopic techniques for colon cancer resection, pretreatment locoregional staging may gain critical interest. The use of endoscopic ultrasonography (EUS) miniprobes in this context has been seldom reported. Our aim was to determine the accuracy of EUS miniprobes for colon cancer staging.

Materials and Methods:

Forty patients with colon cancer (2 in the cecum, 9 in the ascending colon, 5 in the transverse colon, 5 in the descending colon, and 19 in the sigmoid colon) were submitted to staging using 12 MHz EUS miniprobes. EUS and the anatomopathological results were compared with regard to the T and N stages. It was assessed if the location, longitudinal extension, or circumferential extension of the tumor had any influence on the accuracy in EUS staging.

Results:

Tumor staging was feasible in 39 (98%) patients except in one case with a stenosing tumor (out of 6). Globally, T stage was accurately determined in 88% of the cases. In the assessment of the presence or absence of lymph node metastasis, miniprobes presented an accuracy of 82% with a sensitivity of 67%. These results were neither affected by the location nor by the longitudinal or circumferential extension of the tumor.

Conclusions:

EUS miniprobes may play an important role in assessing T and N stages in colon cancer and may represent an incentive to the research of new therapeutic areas for this disease.

Endoscopic Approach for Superficial Colorectal Neoplasms

BACKGROUND

Colorectal cancer (CRC) is the third most commonly diagnosed cancer in males and the second in females, with an estimated 1.4 million cases and 693,900 deaths in 2012. Colonoscopy is the cornerstone for the detection and prevention of CRC. In addition, endoscopic treatment for CRC at an early stage can effectively improve patients' quality of life and cure rate.

SUMMARY

This review focuses on endoscopic approaches, including white light endoscopy, chromoendoscopy, magnifying endoscopy and therapeutic endoscopy, for the evaluation and treatment of superficial colorectal neoplasms.

KEY MESSAGE

Understanding the preoperative evaluation, indications and techniques of endoscopic mucosal resection/endoscopic submucosal dissection as well as postoperative surveillance for superficial colorectal neoplasms is critical for providing appropriate management to the patients.

PRACTICAL IMPLICATIONS

Endoscopic therapy, a method preserving organ function and improving quality of life, is a widely applied microinvasive treatment for superficial colorectal neoplasms. This review describes the basics and developments of endoscopic approaches and may facilitate daily practice for superficial colorectal neoplasms.

The risk of lymph node metastasis makes it unsafe to expand the conventional indications for endoscopic treatment of T1 colorectal cancer: A retrospective study of 428 patients

Though endoscopic treatment is an option for T1 colorectal cancer (CRC), the optimal indications and long-term outcomes of this strategy need to be validated. Therefore, the aim of this study is to investigate long-term outcomes of endoscopy versus surgery and optimal indications for endoscopic treatment of T1 CRC.This retrospective study included 428 T1 CRC patients treated with initial endoscopy (n = 224) or surgery (n = 204) at Severance Hospital between 2005 and 2012. Patients were subdivided into 4 groups according to conventional indications (CIs) for endoscopic treatment: negative lateral/vertical margins; submucosal invasion depth within 1000 μm; no lymphovascular invasion (LVI); well or moderately differentiated. For prognosis evaluation, short-term outcomes (resection margin and complications) and long-term outcomes (recurrence and cancer-specific mortality) were evaluated.Endoscopic treatment achieved en bloc resection in 86.6% of 224 patients. Recurrence and mortality did not differ between the endoscopy and surgery groups with or without CIs. For patients with CIs, although 80 patients were treated endoscopically with 1 (1.3%) recurrence and 0 mortality, 75 patients were treated surgically with 2 (2.7%) recurrence and 1 (1.3%) mortality. Multivariate analysis revealed that LVI positivity and poorly differentiated histology were independently associated with lymph node metastasis (LNM; P < 0.001 and P = 0.001, respectively).To determine whether the depth of submucosal invasion among criteria of CIs could be extended for endoscopic treatment, LNM was analyzed by extending the depth of submucosal invasion. There was no LNM in 155 patients within conventional indication. When the depth of submucosal invasion was extended up to 1500 μm, LNM was occurred (1/197 patient [0.5%]). In addition, when the depth of submucosal invasion was extended up to 2000 μm, LNM was increased (4/271 patient [1.5%]).Endoscopic treatment is safe, effective, and is associated with favorable long-term outcomes compared to surgery for initial treatment of T1 CRC patients with CIs. However, the risk of LNM makes it unsafe to extend the CIs for endoscopic therapy in these patients.

What is the best therapeutic strategy for colonoscopy of colorectal neoplasia? Future perspectives from the East

Development and improvement of endoscopic techniques and devices have changed the treatment of colorectal tumors over the last decade. For the treatment of diminutive polyps, the cold snare technique of the West is becoming a promising treatment in the East because of its short procedure time and low rate of delayed bleeding by eliminating the delayed effect of electrocautery. Rather than using piecemeal endoscopic mucosal resection or surgical resection for the treatment of large superficial tumors, the technique of the East of endoscopic submucosal dissection (ESD) achieves a high success rate of en bloc R0 resection, enabling detailed pathological evaluation with less invasive treatment. This procedure should also be useful in the West where large colorectal tumors are more frequent than in the East. Regarding outcomes, however, in the literature, the definition of 'curative resection' remains somewhat inconsistent and long-term outcomes of patients with deep submucosal and/or lymphovascular invasion in the en bloc specimen have not yet been determined. Large prospective, as well as retrospective, studies of these patients are warranted. When colorectal ESD is difficult because of size or location, the pocket-creation method and/or double-balloon-assisted technique may be useful. In the East, high-quality magnified chromoendoscopy is widely available, and endoscopists try to identify focal submucosal invasion. In the West, a systematic evaluation of surveillance for the prevention of colorectal cancer has been done and is highly refined. The East and West have much to learn from each other.

Management of colorectal T1 carcinoma treated by endoscopic resection from the Western perspective

Detection of early colorectal cancer is expected to rise in light of national colorectal cancer screening programs. This The present review article delineates current endoscopic risk assessments, differentiating invasive from non-invasive neoplasia, for high likelihood of lymph node metastasis in early colorectal cancer, also termed high-risk early colorectal cancer, and endoscopic and surgical resection methods from a Western hemisphere perspective.

Recurrent colorectal cancer after endoscopic resection when additional surgery was recommended

AIM: To evaluate the type of recurrence after endoscopic resection in colorectal cancer patients and whether rescue was possible by salvage operation.

METHODS: Among 4972 patients who underwent surgical resection at our institution for primary or recurrent colorectal cancers from January 2005 to February 2015, we experienced eight recurrent colorectal cancers after endoscopic resection when additional surgical resection was recommended.

RESULTS: The recurrence patterns were: intramural local recurrence (five cases), regional lymph node recurrence (three cases), and associated with simultaneous distant metastasis (three cases). Among five cases with lymphatic invasion observed histologically in endoscopic resected specimens, four cases recurred with lymph node metastasis or distant metastasis. All cases were treated laparoscopically and curative surgery was achieved in six cases. Among four cases located in the rectum, three cases achieved preservation of the anus. Postoperative complications occurred in two cases (enteritis).

CONCLUSION: For high-risk submucosal invasive colorectal cancers after endoscopic resection, additional surgical resection with lymphadenectomy is recommended, particularly in cases with lymphovascular invasion.

British Society of Gastroenterology/Association of Coloproctologists of Great Britain and Ireland guidelines for the management of large non-pedunculated colorectal polyps

These guidelines provide an evidence-based framework for the management of patients with large non-pedunculated colorectal polyps (LNPCPs), in addition to identifying key performance indicators (KPIs) that permit the audit of quality outcomes. These are areas not previously covered by British Society of Gastroenterology (BSG) Guidelines.A National Institute of Health and Care Excellence (NICE) compliant BSG guideline development process was used throughout and the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool was used to structure the guideline development process. A systematic review of literature was conducted for English language articles up to May 2014 concerning the assessment and management of LNPCPs. Quality of evaluated studies was assessed using the Scottish Intercollegiate Guidelines Network (SIGN) Methodology Checklist System. Proposed recommendation statements were evaluated by each member of the Guideline Development Group (GDG) on a scale from 1 (strongly agree) to 5 (strongly disagree) with >80% agreement required for consensus to be reached. Where consensus was not reached a modified Delphi process was used to re-evaluate and modify proposed statements until consensus was reached or the statement discarded. A round table meeting was subsequently held to finalise recommendations and to evaluate the strength of evidence discussed. The GRADE tool was used to assess the strength of evidence and strength of recommendation for finalised statements.KPIs, a training framework and potential research questions for the management of LNPCPs were also developed. It is hoped that these guidelines will improve the assessment and management of LNPCPs.

Endoscopic resection of tumors in the lower digestive tract

As endoscopic technology has developed and matured, the endoscopic resection of gastrointestinal tract polyps has become a widely used treatment. Colorectal polyps are the most common type of polyp, which are best managed by early resection before the polyp undergoes malignant transformation. Methods for treating colorectal tumors are numerous, including argon plasma coagulation, endoscopic mucosal resection, endoscopic submucosal dissection, and laparoscopic-endoscopic cooperative surgery. In this review, we will highlight several currently used clinical endoscopic resection methods and how they are selected based on the characteristics of the targeted tumor. Specifically, we will focus on laparoscopic-endoscopic cooperative surgery.

Practice parameters for early colon cancer management: Italian Society of Colorectal Surgery (Società Italiana di Chirurgia Colo-Rettale; SICCR) guidelines

Early colon cancer (ECC) has been defined as a carcinoma with invasion limited to the submucosa regardless of lymph node status and according to the Royal College of Pathologists as TNM stage T1 NX M0. As the potential risk of lymph node metastasis ranges from 6 to 17% and the preoperative assessment of lymph node metastasis is not reliable, the management of ECC is still controversial, varying from endoscopic to radical resection. A meeting on recent advances on the management of colorectal polyps endorsed by the Italian Society of Colorectal Surgery (SICCR) took place in April 2014, in Genoa (Italy). Based on this material the SICCR decided to issue guidelines updating the evidence and to write a position statement paper in order to define the diagnostic and therapeutic strategy for ECC treatment in context of the Italian healthcare system.

Complete resection of colorectal adenomas: what are the important factors in fellow training?

BACKGROUND

The complete removal of adenomatous polyps is important for reducing interval cancer after colonoscopy.

AIMS

To identify factors affecting the completeness of colonoscopic polypectomies and to evaluate the experience level of fellows who achieve competence compared with that of experts.

METHODS

Medical records of 1,860 patients who underwent at least one polypectomy for an adenomatous polyp at Seoul National University Hospital between March 2011 and February 2013 were retrospectively reviewed. A total of 3,469 adenomatous polyps were included. The lateral and deep margins of the resected polyps were evaluated to check the resection completeness.

RESULTS

Of the 3,469 adenomatous polyps, 1,389 (40.0 %) were removed by two experts and 2,080 (60.0 %) were removed by seven fellows. In the expert-treated group, larger size [odds ratio (OR) 2.81 for ≥20 mm, 95 % confidence interval (CI) 1.64-4.84, P < 0.001] and right-sided location (OR 1.31, 95 % CI 1.05-1.63, P = 0.019) were associated with incomplete resection. In the fellow-treated group, not only polyp characteristics [right-sided location (OR 1.41, 95 % CI 1.18-1.69, P < 0.001)], but also the cumulative number of procedures was also related to resection completeness. After 300 polypectomies, the complete resection rate of the fellows was comparable to that of the experts.

CONCLUSIONS

In the fellow-treated group, the level of procedure experience was closely associated with the polypectomy outcomes. Meticulous attention is critical to ensure the completeness of polypectomies performed by trainee endoscopists during the training program.

Effect of prior biopsy sampling, tattoo placement, and snare sampling on endoscopic resection of large nonpedunculated colorectal lesions

BACKGROUND

Endoscopic manipulations, including biopsy sampling, tattoo application on the lesion itself, and sampling of the lesion with a polypectomy snare, are frequently performed on large nonpedunculated colorectal lesions ≥ 20 mm (LNCL) before referral for endoscopic resection.

OBJECTIVE

To assess the effect of prior manipulations on the technical difficulty and recurrence rates of subsequent endoscopic treatment.

DESIGN

Retrospective study.

SETTING

Two referral centers.

PATIENTS

Patients with LNCL referred for endoscopic resection.

INTERVENTIONS

Endoscopic resection.

MAIN OUTCOME MEASUREMENT

En-bloc resection rate, rate of successful complete endoscopic resection without the need for ablation of visible residual, recurrence rate on follow-up, independent predictive factors for en-bloc resection, complete resection without ablation of visible residual, and recurrence.

RESULTS

A total of 132 lesions was analyzed: 46 lesions without any prior manipulation, 44 with prior biopsy sampling only, and 42 with prior advanced manipulation including tattoo and/or snare sampling. The en-bloc resection rate was 34.8% for nonmanipulated lesions, 15.9% for lesions with prior biopsy sampling, and 4.8% for lesions with prior advanced manipulation (P = .001). Complete endoscopic resection without the need for ablation of visible residual was performed in 93.5% of nonmanipulated lesions, 68.2% of lesions with prior biopsy sampling, and 50% of lesions with prior advanced manipulation (P < .001). Recurrence rates were 7.7%, 40.7%, and 53.8% in the 3 groups (P = .001). In multivariate analysis, prior biopsy sampling was an independent predictor for inability to perform complete resection without ablation of visible residual (odds ratio .24, P < .05) and for recurrence (odds ratio 11.5, P = .004) compared with nonmanipulated lesions. Prior advanced manipulation was an independent predictor for inability to perform en-bloc resection (odds ratio .024, P = .001), for inability to perform complete resection without ablation of visible residual (odds ratio .081, P < .001), and for recurrence (odds ratio 18.8, P = .001).

LIMITATIONS

Retrospective study.

CONCLUSIONS

Prior biopsy sampling and advanced manipulation have significant deleterious effects on endoscopic treatment of LNCL.

Facilitating endoscopic submucosal dissection: the suture-pulley method significantly improves procedure time and minimizes technical difficulty compared with conventional technique: an ex vivo study (with video)

BACKGROUND

The lack of countertraction in endoscopic submucosal dissection (ESD) results in increased technical demand and procedure time. Although the suture-pulley method for countertraction has been reported, its effectiveness compared with the traditional ESD technique remains unclear.

OBJECTIVE

To objectively analyze efficacy of countertraction using the suture-pulley method for ESD.

DESIGN

Prospective ex vivo animal study.

SETTING

Animal laboratory.

INTERVENTIONS

Twenty simulated gastric lesions were created in porcine stomachs by using a standard circular template 30 mm in diameter. In the control arm (n = 10), ESD was performed by using the standard technique. In the suture-pulley arm (N = 10), a circumferential incision was made, and an endoscopic suturing device was used to place the suture pulley.

MAIN OUTCOME MEASUREMENTS

The primary outcome of this study was total procedure time.

RESULTS

The median total procedure time with the suture-pulley method was significantly shorter than the traditional ESD technique (median, 25% to 75%, interquartile range [IQR]: 531 seconds [474.3-549.3 seconds] vs 845 seconds [656.3-1547.5 seconds], P < .001). The median time (IQR) for suture-pulley placement was 160.5 seconds (150.0-168.8 seconds). Although there was a significantly longer procedure time for proximal versus middle/lower stomach lesions with traditional ESD (median, 1601 seconds; IQR, 1547.5-1708.8 seconds vs median, 663 seconds; IQR, 627.5-681.8 seconds; P = .01), there was no significant difference in procedure time for lesions of various locations when using the suture-pulley method. Compared with traditional ESD, the suture-pulley method was less demanding in all categories evaluated by the NASA Task Load Index.

LIMITATIONS

Ex vivo study.

CONCLUSIONS

The suture-pulley method facilitates direct visualization of the submucosal layer during ESD and significantly reduces procedure time and technical difficulty. In addition, the benefit of the suture-pulley method was seen for both simple and more complicated ESDs.

Advances, problems, and complications of polypectomy

The major role of colonoscopy with polypectomy in reducing the incidence of and mortality from colorectal cancer has been firmly established. Yet there is cause to be uneasy. One of the most striking recent findings is that there is an alarmingly high incomplete polyp removal rate. This phenomenon, together with missed polyps during screening colonoscopy, is thought to be responsible for the majority of interval cancers. Knowledge of serrated polyps needs to broaden as well, since they are quite often missed or incompletely removed. Removal of small and diminutive polyps is almost devoid of complications. Cold snare polypectomy seems to be the best approach for these lesions, with biopsy forcep removal reserved only for the tiniest of polyps. Hot snare or hot biopsy forcep removal of these lesions is no longer recommended. Endoscopic mucosal resection and endoscopic submucosal dissection have proven to be effective in the removal of large colorectal lesions, avoiding surgery in the majority of patients, with acceptably low complication rates. Variants of these approaches, as well as new hybrid techniques, are being currently tested. In this paper, we review the current status of the different approaches in removing polypoid and nonpolypoid lesions of the colon, their complications, and future directions in the prevention of colorectal cancer.

Oncologic colorectal resection after endoscopic treatment of malignant polyps: does endoscopy have an adverse effect on oncologic and surgical outcomes?

BACKGROUND

Early colorectal cancer is increasingly treated by endoscopic removal. In cases of incomplete resection or high-risk carcinoma, additional surgery is necessary.

OBJECTIVE

To evaluate the frequency of subsequent oncologic surgery after endoscopic resection of colorectal cancer, the rate of lymph node metastasis, residual cancer, and morbidity and mortality rates of the operation. Any eventual adverse effect of the prior endoscopic therapy on the surgical and oncologic outcome was assessed.

DESIGN

Retrospective review of prospectively collected data.

SETTING

University hospital.

PATIENTS

Sixty-six consecutive patients with incomplete endoscopic treatment and need for additional surgery between 2004 and 2011.

INTERVENTION

The data of these patients were compared with those of a group of patients with surgery for early colorectal cancer during the same period without prior endoscopic resection as the control group.

MAIN OUTCOME MEASUREMENTS

Rate of lymph node metastasis and residual cancer, perioperative morbidity and mortality.

RESULTS

The lymph node metastasis rate after oncologic resection was 8.6%, and the residual cancer rate was 41%. Risk factors for residual cancer were macroscopic incomplete resection (P < .0001), positive resection margins (P = .03), and piecemeal resection (P = .004). No mortality was observed. Perioperative morbidity, mortality, and oncologic outcome were not significantly different in the group with prior endoscopic resection compared with the primarily operated group.

LIMITATIONS

Retrospective study.

CONCLUSION

Endoscopic treatment of malignant polyps does not worsen surgical and oncologic outcomes in cases of subsequent surgery. Because mortality and morbidity are low, oncologic resection generally should be done in the presence of risk factors for residual cancer.

Endoscopic resection for superficial colorectal neoplasia in Italy: a prospective multicentre study

BACKGROUND

Since there are few prospective studies on colorectal endoscopic resection to date, we aimed to prospectively assess safety and efficacy of endoscopic resection in a cohort of Italian patients.

METHODS

Prospective multicentre assessment of resection of sessile polyps or non-polypoid lesions ≥10mm in size or smaller (if depressed). Outcome measures included complete excision, morbidity, mortality, and residual/recurrence at 12 months.

RESULTS

Overall, 1012 resections in 928 patients were analysed (62.4% sessile polyps, 28.8% laterally spreading tumours, 8.7% depressed non-polypoid lesions). Lesions were prevalent in the proximal colon. En bloc resection was possible in 715/1012 cases (70.7%), whereas piecemeal resection was required in 297 (29.3%). Endoscopically complete excision was achieved in 866 cases (85.6%). Adverse events occurred in 83 (8.2%), and no deaths occurred. Independent predictors of 12-month residual/recurrence were the location of the lesion in the proximal colon (OR 2.22 [95% CI 1.16-4.26]; p=0.015) and piecemeal endoscopic resection (OR 2.76 [95% CI 1.56-4.87]; p=0.0005). Limitations of the study were: potential expertise bias, no data on eligible and potentially resectable excluded lesions, high percentage of lesions<20mm, follow-up limited to 1 year.

CONCLUSION

In this registry study the endoscopic resection of colorectal lesions was safe and achieved high rates of long-term endoscopic clearance.

Mini-probe ultrasonography for the staging of colon cancer: a systematic review and meta-analysis

AIM

With an increasing array of treatment modalities available for colon cancer, it is increasingly important to stage tumours accurately to allocate the appropriate management. This study evaluated the accuracy of mini-probe endoscopic ultrasound (EUS) in assigning clinical stage to colon cancer.

METHOD

An electronic search was performed in January 2013 using the Embase, MEDLINE and Cochrane databases. This was supplemented by a hand search of published abstracts from scientific meetings. Trials evaluating the accuracy of the mini-probe EUS compared with histopathological grade in determining the clinical stage of colon cancer were included in this pooled analysis. The main outcome measures included accuracy, sensitivity and specificity for T and N staging.

RESULTS

Ten studies were identified which compared the mini-probe EUS staging of 642 colon or rectal cancers with the histopathological specimen. The pooled sensitivity and specificity for staging were 0.91 and 0.98 for T1 tumours, 0.78 and 0.94 for T2 tumours, 0.97 and 0.90 for T3/T4 tumours and 0.63 and 0.82 for nodal staging. Eight per cent of T1/T2 tumours were upstaged to T3/T4 tumours and 5% of T3/T4 tumours were downstaged.

CONCLUSION

Mini-probe EUS is highly effective for assigning clinical stage in colon cancer and in identifying patients who may be suitable for nonsurgical treatment including neoadjuvant chemotherapy or endoscopic resection.

Re-evaluation of indications and outcomes of endoscopic excision procedures for colorectal tumors: a review

Endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) are useful therapeutic techniques for colorectal tumors. Currently, new techniques based on these procedures are available, such as endoscopic submucosal dissection with snare (ESD-S) and endoscopic mucosal resection with pre-cutting (EMR-P). For the excision of colorectal tumors, each of these techniques has been characterized as having a high total resection rate, low recurrence rate or low complication rate. In this study, we analysed clinical trials that had recently been published, to search for the most appropriate endoscopic treatment for colorectal tumors. Our search results revealed the following: for a tumor with a diameter less than 20 mm, the surgeon should choose ESD, ESD-S, EMR-P or EMR, depending on the condition of the tumor. On the other hand, to excise a tumor larger than 20 mm in diameter, ESD and ESD-S should be the first choices. However, if the patient has a high risk of complications due to ESD or ESD-S, the use of EMR-P would be suitable. Because of the high possibility of canceration in a tumor larger than 20 mm in diameter, EMR is not the optimal endoscopic treatment for the excision of a colorectal tumor, due to a low total resection rate and a high recurrence rate.

A comparative study of colorectal surgical outcome in a national audit separated by 15 years

AIM

The Wales-Trent Bowel Cancer Audit (WTBA) was carried out in 1993, and since 2001 Welsh Bowel Cancer Audits (WBCA) have taken place annually. Screening for bowel cancer in Wales was introduced in 2008. This study compared patient variables, the role of surgery and operative mortality rates over the 15-year interval between the WTBA and the last WBCA before the introduction of population screening.

METHOD

Data from the WTBA in 1993 were compared with those of the WBCA including patients diagnosed between April 2007 and March 2008.

RESULTS

In 1993, 1536 patients were diagnosed with colorectal cancer (CRC) compared with 1793 in 2007-2008. Patient demographics and American Society of Anesthesiology (ASA) score did not change during these periods. Surgical treatment for CRC decreased (93% in 1993 vs 80% in 2007-2008; P < 0.001) particularly in the use of resectional surgery (84% in 1993 vs 71% in 2007-2008; P < 0.001). The 30-day postoperative mortality rate fell from 7.4% in 1993 to 5.9% in 2007-2008 (P = 0.097). Advanced disease at operation was more prevalent in the WTBA (25% of all operated patients were Stage IV in 1993 vs 13% in 2007-2008; P < 0.001). The use of surgery in patients with metastatic disease also declined over this period.

CONCLUSION

Surgery is used less frequently in the management of CRC compared with 15 years previously, and is a factor in the reduction of the interpreted 30-day operative mortality.

Warning for unprincipled colorectal endoscopic submucosal dissection: accurate diagnosis and reasonable treatment strategy

Piecemeal endoscopic mucosal resection (EMR) is generally indicated for laterally spreading tumors (LST) >2 cm in diameter. However, the segmentation of adenomatous parts does not affect the histopathological diagnosis and completeness of cure. Thus, possible indications for piecemeal EMR are both adenomatous homogenous-type granular-type LST (LST-G) and LST-G as carcinoma in adenoma without segmentalizing the carcinomatous part. Diagnosis of the pit pattern using magnifying endoscopy is essential for determining the correct treatment and setting segmentation borders. In contrast, endoscopic submucosal dissection (ESD) is indicated for lesions requiring endoscopic en bloc excision, as it is difficult to use the snare technique for en bloc excisions such as in non-granular-type LST (LST-NG), especially for the pseudodepressed type, tumors with a type VI pit pattern, shallow invasive submucosal carcinoma, largedepressed tumors and large elevated lesions, which are often malignant (e.g. nodular mixed-type LST-G). Other lesions, such as intramucosal tumor accompanied by submucosal fibrosis, induced by biopsy or peristalsis of the lesion; sporadic localized tumors that occur due to chronic inflammation, including ulcerative colitis; and local residual early carcinoma after endoscopic treatment, are also indications for ESD. In clinical practice, an efficient endoscopic treatment with segregation of ESD from piecemeal EMR should be carried out after a comprehensive evaluation of the completeness of cure, safety, clinical simplicity, and cost-benefit, based on an accurate preoperative diagnosis.