Long-Term Outcomes of T1 Colorectal Cancer after Endoscopic Resection

Risk of recurrence in high-risk T1 colon cancer following endoscopic and surgical resection: registry-based cohort study

BACKGROUND

Endoscopic resection of T1 colon cancer (CC) is currently limited by guidelines related to risk of lymph node metastases. However, clinical outcome following endoscopic and surgical resection is poorly investigated.

METHOD

A retrospective multicentre national cohort study was conducted on prospectively collected data from the Swedish colorectal cancer registry on all non-pedunculated T1 CC patients undergoing surgical and endoscopic resection between 2009 and 2021. Patients were categorized on the basis of deep submucosal invasion (Sm2-3), lymphovascular invasion (LVI), poor tumour differentiation, and R1/Rx into low- and high-risk cases. The primary outcomes of interest were recurrence rates and disease-free interval (DFI, defined as time from treatment to date of recurrence) according to resection methods and risk factors (sex, age at diagnosis, histologic grade, LVI, perineural invasion, mucinous subtype, submucosal invasion, tumour location, resection margin and nodal positivity in the surgical group).

RESULTS

In total, 1805 patients undergoing endoscopic (488) and surgical (1317) resection with 60.0 months median follow-up were included. Recurrence occurred in 18 (3.7%) endoscopically and 48 (3.6%) surgically resected patients. Adjuvant treatment was administered in 7.4% and 0.2% of the cases respectively in the surgical and endoscopically treated patients. Five-year DFI was 95.6% after endoscopic and 96.2% after surgical resection, with no significant difference when adjusting for confounding factors (HR 1.03, 95% c.i. 0.56 to 1.91, P = 0.920). There were no statistically significant differences in recurrence comparing endoscopic (1.7%) versus surgical (3.6%) low-risk and endoscopic (5.4%) versus surgical (3.8%) high-risk cases. LVI was the only significant risk factor for recurrence in multivariate Cox regression (HR 3.73, 95% c.i. 1.76 to 7.92, P < 0.001).

CONCLUSIONS

This study shows no difference in recurrence after endoscopic and surgical resection in high-risk T1 CC. Although it was not possible to match groups according to treatment, the multivariate analysis showed that lymphovascular invasion was the only independent risk factor for recurrence.

Long-term outcomes of endoscopic or surgical resection in T1 colorectal cancer patients: a retrospective cohort study

BACKGROUND

The personalized treatments of T1 colorectal cancer (CRC) remains controversial. We compared the long-term outcomes of T1 CRC patients after endoscopic resection (ER) and surgery, and evaluated the risk factors for the long-term prognosis.

METHODS

T1 CRCs after resection at the Cancer Hospital, Chines Academy of Medical Sciences from June 2011 to November 2021 were reviewed. High-risk factors included positive resection margin, poor differentiation, deep submucosal invasion (DSI ≥ 1000 μm), lymphovascular invasion and intermediate/high tumor budding. Comparative analyses were conducted based on three treatment methods: follow-up after ER (Group A), additional surgery after ER (Group B) and initial surgery (Group C). The primary endpoints included recurrence-free survival (RFS) and overall survival (OS). Cox proportional hazard regression models were constructed to identify risk factors for RFS and OS.

RESULTS

A total of 528 patients were enrolled (173 patients in Group A, 102 patients in Group B, 253 patients in Group C). The 3-year RFS, 5-year RFS, 3-year OS, and 5-year OS rates were 96.7%, 94.7%, 99.1%, and 97.8%, respectively. In the absence of other high-risk factors, RFS (P = 0.321) and OS (P = 0.155) of patients with DSI after ER were not inferior to those after surgery. Multivariate analyses identified sex (HR 0.379; 95% CI 0.160-0.894), Charlson comorbidities index (CCI) (HR 3.330; 95% CI 1.571-7.062), margin (HR 8.212; 95% CI 2.325-29.006), and budding (HR 3.794; 95% CI 1.686-8.541) as independent predictive factors of RFS, and identified CCI (HR 10.266; 95% CI 2.856-36.899) as an independent predictive factor of OS.

CONCLUSION

The long-term outcomes of ER are comparable to those of surgery in T1 CRC patients with DSI when other high-risk factors are negative. Resection margin, tumor budding, sex, and CCI may be the most important long-term prognostic factors for T1 CRC patients.

Long-term outcomes of local resection versus surgical resection for high-risk T1 colorectal cancer: a systematic review and meta-analysis

BACKGROUND AND AIMS

Patients with T1 colorectal cancer (CRC) are at high risk for lymph node metastasis and recurrence after local resection (LR) and need surgical resection (SR) for additional lymph node dissection to improve prognosis. However, the net benefits of SR and LR are still unquantified.

METHODS

We conducted a systematic search for studies in which survival analysis among high-risk T1 CRC patients undergoing LR and SR was performed. Overall survival (OS), recurrence-free survival (RFS), and disease-specific survival (DSS) data were extracted. Hazard ratios (HRs) and fitted survival curves for OS, RFS, and DSS were used to estimate the long-term clinical outcomes of patients in the 2 groups.

RESULTS

This meta-analysis included 12 studies. Compared with those in the SR group, patients in the LR group had higher risks of death (HR, 2.06; 95% confidence interval [CI], 1.59-2.65), recurrence (HR, 3.51; 95% CI, 2.51-4.93), and cancer-related mortality (HR, 2.31; 95% CI, 1.17-4.54) in the long term. Fitted survival curves for the LR and SR groups revealed the 5-year, 10-year, and 20-year rates for OS (86.3% and 94.5%, 72.9% and 84.4%, and 61.8% and 71.1%), RFS (89.9% and 96.9%, 83.3% and 93.9%, and 29.6% and 90.8%), and DSS (96.7% and 98.3%, 86.9% and 97.1%, and 86.9% and 96.4%). Log-rank tests showed significant differences among all outcomes except 5-year DSS.

CONCLUSIONS

For high-risk T1 CRC patients, the net benefit of DSS appears to be significant when the observation period exceeds 10 years. A long-term net benefit may exist but may not be applicable to all patients, especially high-risk patients with comorbidities. Therefore, LR may be a reasonable alternative for individualized treatment for some high-risk T1 CRC patients.

A DNA Methylation-based Epigenetic Signature for the Identification of Lymph Node Metastasis in T1 Colorectal Cancer

OBJECTIVE

This study aimed to unravel the lymph node metastasis (LNM)-related methylated DNA (mDNA) landscape and develop a mDNA signature to identify LNM in patients with T1 colorectal cancers (T1 CRC).

BACKGROUND

Considering the invasiveness of T1 CRC, current guidelines recommend endoscopic resection in patients with LNM-negative, and radical surgical resection only for high-risk LNM-positive patients. Unfortunately, the clinicopathological criteria for LNM risk stratification are imperfect, resulting in frequent misdiagnosis leading to unnecessary radical surgeries and postsurgical complications.

METHODS

We conducted genome-wide methylation profiling of 39 T1 CRC specimens to identify differentially methylated CpGs between LNM-positive and LNM-negative, and performed quantitative pyrosequencing analysis in 235 specimens from 3 independent patient cohorts, including 195 resected tissues (training cohort: n=128, validation cohort: n=67) and 40 pretreatment biopsies.

RESULTS

Using logistic regression analysis, we developed a 9-CpG signature to distinguish LNM-positive versus LNM-negative surgical specimens in the training cohort [area under the curve (AUC)=0.831, 95% confidence interval (CI)=0.755-0.892; P <0.0001], which was subsequently validated in additional surgical specimens (AUC=0.825; 95% CI=0.696-0.955; P =0.003) and pretreatment biopsies (AUC=0.836; 95% CI=0.640-1.000, P =0.0036). This diagnostic power was further improved by combining the signature with conventional clinicopathological features.

CONCLUSIONS

We established a novel epigenetic signature that can robustly identify LNM in surgical specimens and even pretreatment biopsies from patients with T1 CRC. Our signature has strong translational potential to improve the selection of high-risk patients who require radical surgery while sparing others from its complications and expense.

Risk of recurrence after endoscopic resection of nonpedunculated T1 colorectal cancer

BACKGROUND

The long-term outcome after local excision of T1 colorectal cancer (CRC) remains unknown. The aim of this study was to examine clinical and histopathological risk factors for recurrence in patients with T1 CRC undergoing endoscopic resection.

METHODS

This was a retrospective registry-based population study on prospectively collected data of all patients with nonpedunculated T1 CRC undergoing only local excision (no salvage surgery) in Sweden between 2009 and 2018. Potential risk factors for recurrence, including age, sex, tumor location, resection margins, lymphovascular, perineural, and submucosal invasion, grade of differentiation, and mucinous subtype, were analyzed using univariate and multivariate cox regression.

RESULTS

Median follow-up time was 60 months, and 28 /602 patients (4.7 %) had a recurrence (13 local and 18 distant). Recurrence rate stratified by submucosal invasion was: Sm1 3.5 % (14 /397), Sm2 6.0 % (8 /133), and Sm3 8.3 % (6 /72), with no significant differences. Resection margins, lymphovascular and perineural invasion, grade of differentiation, mucinous subtype, and age were not significant risk factors for recurrence. In contrast, rectal location was found to be a significant risk factor for tumor recurrence in multivariate analysis (hazard ratio 3.08, P = 0.006). The 3- and 5-year disease-free survival was 96.2 % and 91.1 %, respectively, in T1 CRC patients undergoing endoscopic resection.

CONCLUSION

Tumor recurrence was rare (4.7 %) in this large population-based study on recurrence after local excision of nonpedunculated T1 CRC. Rectal location was an independent risk factor for recurrence, suggesting the need for strict surveillance after endoscopic resection of early rectal cancer.

Clinical outcome of local treatment and radical resection for pT1 rectal cancer

BACKGROUND

Rectal cancer is mainly cured by radical resection with neoadjuvant chemoradiation or adjuvant chemotherapy. Pathological T1 lesions can be managed by local treatment and radiotherapy thereafter. Lower morbidity is the key benefit of these local treatments. Since nodal metastasis is important for staging, radical resection (RR) is suggested. Rectal cancer has higher surgical morbidity than colon cancer; local treatment has been the preferred choice by patients.

METHODS

We retrospectively enrolled data of 244 patients with pT1 rectal adenocarcinoma. A total of 202 patients (82.8%) underwent RR, including low anterior resection (LAR) and abdomino-perineal resection (APR), and 42 patients (17.2%) underwent LT, including transanal excision and colonoscopic polypectomy.

RESULTS

In our study, seven patients (16.7%) had loco-regional recurrence and distant metastasis from the LT group while eight patients (4.0%) had distant metastasis without loco-regional recurrence from the RR group. The lymph node metastasis rate in RR group was 8.4%. Forty-seven patients (24.2%) underwent LAR with temporary stoma, and its reversal rate was 100%. In the RR group, postoperative complication rate was 10.4% with a mortality rate of 0.5%. Recurrence-free survival (RFS) was 95.7% for RR and 80.2% for LT (P = 0.001), and overall survival (OS) was 93.7% for RR and 70.0% for LT (P = 0.001).

CONCLUSION

This study found that RFS and OS in patients of pT1 rectal adenocarcinoma that had received RR were better than receiving LT. Further adjuvant chemotherapy was possible for some RR patients. A higher recurrence rate after LT must be balanced against the morbidity and mortality associated with RR.

Endoscopic full-thickness resection of T1 colorectal cancers: a retrospective analysis from a multicenter Dutch eFTR registry

BACKGROUND

Complete endoscopic resection and accurate histological evaluation for T1 colorectal cancer (CRC) are critical in determining subsequent treatment. Endoscopic full-thickness resection (eFTR) is a new treatment option for T1 CRC < 2 cm. We aimed to report clinical outcomes and short-term results.

METHODS

Consecutive eFTR procedures for T1 CRC, prospectively recorded in our national registry between November 2015 and April 2020, were retrospectively analyzed. Primary outcomes were technical success and R0 resection. Secondary outcomes were histological risk assessment, curative resection, adverse events, and short-term outcomes.

RESULTS

We included 330 procedures: 132 primary resections and 198 secondary scar resections after incomplete T1 CRC resection. Overall technical success, R0 resection, and curative resection rates were 87.0 % (95 % confidence interval [CI] 82.7 %-90.3 %), 85.6 % (95 %CI 81.2 %-89.2 %), and 60.3 % (95 %CI 54.7 %-65.7 %). Curative resection rate was 23.7 % (95 %CI 15.9 %-33.6 %) for primary resection of T1 CRC and 60.8 % (95 %CI 50.4 %-70.4 %) after excluding deep submucosal invasion as a risk factor. Risk stratification was possible in 99.3 %. The severe adverse event rate was 2.2 %. Additional oncological surgery was performed in 49/320 (15.3 %), with residual cancer in 11/49 (22.4 %). Endoscopic follow-up was available in 200/242 (82.6 %), with a median of 4 months and residual cancer in 1 (0.5 %) following an incomplete resection.

CONCLUSIONS

eFTR is relatively safe and effective for resection of small T1 CRC, both as primary and secondary treatment. eFTR can expand endoscopic treatment options for T1 CRC and could help to reduce surgical overtreatment. Future studies should focus on long-term outcomes.

Patient outcomes after non-curative endoscopic submucosal dissection for early colorectal cancer: a single-center, retrospective cohort study

Background

The treatment patterns and outcomes for patients after non-curative endoscopic submucosal dissection (ESD) remain controversial, particularly among those requiring preservation of the anal sphincter or advanced age. This retrospective study aimed to investigate the treatment patterns and outcomes in patients after non-curative ESD for early colorectal cancer (CRC).

Methods

This was a retrospective review in Chinese patients who received non-curative ESD for early CRC, and who were treated in the Cancer Hospital at the Chinese Academy of Medical Sciences from 2010 to 2019. Demographic parameters, clinicopathologic features, treatment patterns, and clinical outcomes were analyzed.

Results

Of the 180 patients who received non-curative ESD, 85 received additional surgery; the remaining 95 patients were kept under surveillance only. Patients in the surveillance-only group tended to be older than those in the additional surgery group. Furthermore, tumors in the surveillance-only group were located in the rectum significantly more often, were better differentiated with a shallower depth of invasion and less perineuronal invasion than in the additional surgery group; there were fewer high-risk factors for residual cancer or lymph node (LN) metastasis in the surveillance-only group compared with the additional surgery group. There was no significant difference in 5-year overall survival (OS) (92.6% versus 92.7%, P=0.355), 5-year disease-free survival (DFS) (94.7% versus 91.9%, P=0.340), 5-year cancer-specific survival (CSS) (93.8% versus 92.7%, P=0.791), or total recurrence rates (4.7% versus 9.5%, P=0.217) between the additional surgery and surveillance-only groups, respectively.

Conclusions

ESD results in favorable outcomes for patients with early CRC. Surveillance in patients who receive non-curative ESD may be an alternative option for those with advanced age and fewer high-risk factors for residual cancer or LN metastasis.

Supervised Learning Based Systemic Inflammatory Markers Enable Accurate Additional Surgery for pT1NxM0 Colorectal Cancer: A Comparative Analysis of Two Practical Prediction Models for Lymph Node Metastasis

Purpose

Predicting lymph node metastasis (LNM) after endoscopic resection is crucial in determining whether patients with pT1NxM0 colorectal cancer (CRC) should undergo additional surgery. This study was aimed to develop a predictive model that can be used to reduce the current likelihood of overtreatment.

Patients and Methods

We recruited a total of 1194 consecutive CRC patients with pT1NxM0 who underwent endoscopic or surgical resection at the Gezhouba Central Hospital of Sinopharm between January 1, 2006, and August 31, 2021. The random forest classifier (RFC) and generalized linear algorithm (GLM) were used to screen out the variables that greatly affected the LNM prediction, respectively. The area under the curve (AUC) and decision curve analysis (DCA) were applied to assess the accuracy of predictive models.

Results

Analysis identified the top 10 candidate factors including depth of submucosal invasion, neutrophil-lymphocyte ratio (NLR), platelet lymphocyte ratio (PLR), platelet-to-neutrophil ratio(PNR), venous invasion, poorly differentiated clusters, tumor budding, grade, lymphatic vascular invasion, and background adenoma. The performance of the GLM achieved the highest AUC of 0.79 (95% confidence interval [CI]: 0.30 to 1.28) in the training cohort and robust AUC of 0.80 (95% confidence interval [CI]: 0.36 to 1.24) in the validation cohort. Meanwhile, the RFC exhibited a robust AUC of 0.84 (95% confidence interval [CI]: 0.40 to 1.28) in the training cohort and a high AUC of 0.85 (95% CI: 0.41 to 1.29) in the validation cohort. DCAs also showed that the RFC had superior predictive ability.

Conclusion

Our supervised learning-based model incorporating histopathologic parameters and inflammatory markers showed a more accurate predictive performance compared to the GLM. This newly supervised learning-based predictive model can be used to determine an individually tailored treatment strategy.

Role of barium enema examination for the diagnosis of submucosal invasion depth in T1 colorectal cancers

BACKGROUND

The indication for endoscopic resection for submucosally invasive colorectal cancer (T1-CRC) depends on the preoperative diagnosis of invasion depth. The aim of this investigation was to evaluate the association between barium enema examination (BE) profile views and depth of submucosal (SM) invasion in CRCs.

METHODS

We reviewed the radiographic and endoscopic findings of 145 T1-CRCs diagnosed from 2008 to 2019. We measured the widths of horizontal and vertical rigidity under a BE profile view corresponding to CRC and compared the values with SM invasion depth. Horizontal rigidity was defined as the horizontal length and vertical rigidity as the vertical width of the barium defect corresponding to each target lesion. The most appropriate cut-off values for predicting SM invasion ≥1.8 mm were calculated by receiver operating characteristic curve analysis.

RESULTS

Values of horizontal rigidity (r = 0.626, P < 0.05) and vertical rigidity (r = 0.482, P < 0.05) correlated significantly with SM invasion depth. The most appropriate cut-off values for the prediction of SM invasion depth ≥ 1.8 mm were 4.5 mm for horizontal rigidity, with an accuracy of 80.7%; and 0.7 mm for vertical rigidity, with an accuracy of 77.9%. The prevalence of lympho-vascular invasion was significantly different when those cut-off values were applied (43.2% vs. 17.5% for horizontal rigidity, P < 0.005).

CONCLUSIONS

In T1-CRC, values of horizontal and vertical rigidities under a BE profile view were correlated with SM invasion depth. While the accuracy of the rigidities for the prediction of SM invasion depth ≥ 1.8 mm was not high, horizontal rigidity may be predictive of lympho-vascular invasion, thus aiding in therapeutic decision-making.