Management of non-curative endoscopic resection of T1 colon cancer

Endoscopic resection techniques enable en-bloc resection of T1 colon cancers. A complete removal of T1 colon cancer can be considered curative when histologic examination of the specimens shows none of the high-risk factors for lymph nodes metastases. Criteria predicting lymph nodes metastases include deep submucosal invasion, poor differentiation, lymphovascular invasion, and high-grade tumor budding. In these cases, complete (R0), local endoscopic resection is considered sufficient as negligible risk of lymph nodes metastases does not outweigh morbidity and mortality associated with surgical resection. Challenges arise when endoscopic resection is incomplete (RX/R1) or high-risk histological features are present. The risk of lymph node metastasis in T1 CRC ranges from 1% to 36.4%, depending on histologic risk factors. Presence of any risk factor labels the patient "high risk," warranting oncologic surgery with mesocolic lymphadenectomy. However, even if 70%-80% of T1-CRC patients are classified as high-risk, more than 90% are without lymph node involvement after oncological surgery. Surgical overtreatment in T1 CRC is a challenge, requiring a balance between oncologic safety and minimizing morbidity/mortality. This narrative review explores the landscape of managing non-curative T1 colon cancer, focusing on the choice between advanced endoscopic resection techniques and surgical interventions. We discuss surveillance strategies and shared decision-making, emphasizing the importance of a multidisciplinary approach.

Management of malignant colonic polyps

With the implementation of colorectal cancer screening programs, there has been an increasing incidence of malignant colonic polyps (MP). The attending surgeon is often faced with the management dilemma of whether polypectomy can be considered adequate treatment or if formal oncological resection is required. While endoscopic therapy avoids the risks and morbidity of surgery, there is a potential trade-off of under-staging and inadequate treatment. Surgery, on the other hand confers the benefits of clear resection margins, nodal staging and the ability to prognosticate and guide the decision for adjuvant therapy. This article sets out to review the histopathologic prognostic factors of MP and the various management and surveillance strategies.