Indications and outcomes of endoscopic resection for non-pedunculated colorectal lesions: A narrative review

Table 1 Diagnostic performance for the histological prediction of underlying malignancy of colorectal lesions according to their morphological pattern as well as to Kudo pit pattern, narrow-band imaging international colorectal endoscopic, and Japan narrow-band imaging expert team classifications

Variables	Sensitivity	Specificity	PPV	NPV	Accuracy
Morphological pattern1
0-IIa G	5.7%	70.0%	1.7%	89.1%	64.6%
0-Is G	11.5%	83.2%	5.8%	91.2%	77.3%
0-IIa + Is G	22.9%	77.4%	8.4%	91.7%	72.8%
0-IIa NG	27.4%	79.5%	10.8%	92.4%	75.2%
0-Is NG	16.6%	95.5%	25.0%	92.7%	89.0%
0-IIa + Is NG	15.9%	94.5%	20.7%	92.6%	88.0%
Kudo pit pattern (NBI)2	73.3%-93.7%3	89.2%-100%3	93.7%-100%3	89.2%-96.4%3	92.0%-96.7%3
NICE classification4
Type 1	82.1%-84.6%	93.8%-94.9%	65.9%-92.5%	60.4-98.2%	93.9%-97.8%
Type 2	89.8%-91.4%	84.3%-86.3%	89.1%-90.7%	97.3-97.7%	56.6%-61.2%
Type 3	83.3%-91.7%	96.4%-97.0%	96.0%-96.8%	45.8-54.0%	99.4%-99.7%
JNET classification5
Type 1	73.0%-87.1%	96.0%-99.5%	73.4%-92.3%	96%-98.9%	93.0%-98.5%
Type 2A	82.5%-96.0%	70.0%-91.1%	90.3%-96.7%	62.1%-92.1%	84.5%-90.9%
Type 2B	42.0%-75.6%	84.2%-95.0%	26.0%-67.3%	92.2%-98.0%	81.3%-93.0%
Type 3	35.0%-91.7%	98.1%-100%	63.2%-100%	93.8%-99.7%	94.0%-98.0%

¹Diagnostic performance of lesion classification types according to Paris classification for covert submucosal invasive cancer (SMIC) (SMIC that is not visible on endoscopic inspection).

²Narrow-band imaging.

³These percentages refer to the ability of preoperative magnifying chromoendoscopy (Kudo pit pattern classification by narrow-band imaging assessment of mucosal surface) to predict depth of submucosal invasion for large colorectal lesions.

⁴Narrow-band imaging international colorectal endoscopic (NICE) classification, NICE type 1: hyperplastic polyps, NICE type 2: adenomas (with/without risk of a superficial SMIC), NICE type 3: strongly predictive of cancers with deep SMIC.

⁵Japan narrow-band imaging expert team classification (JNET), JNET type 1: predictive of hyperplastic/sessile serrated polyps, JNET type 2A: predictive of neoplasia with low/high-grade intramucosal neoplasia, JNET type 2B: predictive of high-grade intramucosal neoplasia/shallow submucosal invasive cancer, JNET type 3: predictive of cancer with deep SMIC. PPV: Positive predictive value; NPV: Negative predictive value; NBI: Narrow-band imaging; JNET: Japan Narrow-band imaging expert team classification; NICE: Narrow-band imaging international colorectal endoscopic; NG: Non-granular; G: Granular.

Table 2 Characteristics of the seven included systematic reviews and meta-analyses on the comparison between the outcomes for endoscopic mucosal resection and endoscopic submucosal dissection procedures

Ref.	Study	Nations	N patients/lesions	Type of colorectal lesions	Lesion size	Procedural time1	En bloc resection1	R01	Perforation1	Bleeding1		Surgery1	Recurrence1
Zhong et al[134], 2013	Systematic review with meta-analysis of 4 retrospective studies	Japan, Korea, China	243 patients/245 lesions (EMR: 106; ESD: 139)	Sessile (carcinoids)	< 15 mm	19.1 ± 11.1 vs 8.1 ± 9.4	92% vs 100%	69.1% vs 87.7%	2.8% vs 0.7%	2.8% vs 3.6%		0.7% vs 0%	2.9% vs 0%
Wang et al[135], 2014	Meta-analysis of 6 studies (case-control)	Japan, Korea	893 patients/1642 lesions (EMR: 866; ESD: 776)	Sessile or flat	≥ 10 mm	Range, 29.0-29.4 vs 87.2-108.0 min	44.5% vs 87.9%	65.5% vs 83.8%	5.8% vs 8.9% (overall complications)			NA	12.70% vs 0.98%
Wang et al[136], 2016	Systematic review with meta-analysis of 4 retrospective studies	Brazil, Korea, Japan, China	216 patients/216 lesions (EMR: 109; ESD: 107)	Rectal carcinoids (lesion morphology not specified)	≥ 10 mm	(150.0 ± 66.3/116.0 ± 58.5 ± 3.6/63.0 ± 54.0/50.0 ± 589.2) vs (133.0 ± 94.8/84.0 ± 51.2/131.0 ± 100.0/78 ± 176.7) min	93.6% vs 90.6%	78% vs 79.4%	10.3% vs 18.3% (overall complications)			NA	6.4% vs 0.9%
Chao et al[137], 2016	Meta-analysis of 17 studies (retrospective)	China	2003 patients/2003 lesions (EMR: 1054; ESD: 949)	Sessile: carcinoids (11 studies) or carcinomas (5 studies); LST (1 study)	≥ 5 mm	Range, 15.0-65.9 vs 3.5-29.4 min	89.8% vs 92.0%	61.4% vs 86.5%	1.5% vs 5.9 %		3.3% vs 3.7%	NA	9.9% vs 1.0%
Fujiya et al[103], 2015	Meta-analysis of 8 studies (non-randomized, 6 cohort and 2 case-control)	Japan	1262 patients (EMR: 634; ESD: 628)/1763 lesions (EMR: 949; ESD: 814)	Morphological features of lesions in 7 studies were2, in the EMR group: 0-I (269 cases) and 0-II (679 cases); in the ESD group: 0-I (125 cases) and 0-II (680 cases); 576 adenomas and 380 carcinomas	≥ 20 mm (5 studies), ≥ 10 mm (1 study), > 5 mm (1 study)	Range, 29.0-30.0 vs 65.9-108.0 min	46.7% vs 91.7%	42.3% vs 80.3%	0% vs 8.5%		3.5% vs 2.0%	5.8% vs 9.9%	12.2% vs 0.9%
Arezzo et al[138], 2016	Systematic review with meta-analysis of 11 studies (10 retrospective and 1 case-control)	Japan, Korea, France	4678 patients/4678 lesions (EMR: 3161; ESD: 1517)	Sessile (LST-NG and LST-G were also included in 3 studies): adenomas, carcinomas in situ, invasive cancers or carcinoids	≥ 20 mm (except in 3 studies)	29.1 vs 66.5 min	34.9% vs 89.9%	36.2% vs 79.6%	0.9% vs 4.9%		2.9% vs 1.9%	3.0% vs 7.8%	12.7% vs 0.7%
De Ceglie et al[107], 2016	Systematic review of 66 studies (3 RCTs; 22 prospective and 41 retrospective)	Germany, Taiwan, France, Japan, Greece, Great Britain, Czech Republic, Malaysia, Australia, Italy, China, United States, Brazil, Korea, Portugal, Serbia	13659 patients (EMR: 8660; ESD: 4999)/17950 lesions (EMR: 11.873; ESD: 6077)	Sessile or LST	LST-NG ≥ 20 mm and for LST-G ≥ 30 mm or ≥ 40 mm	NA	62.8% vs 90.5%	92.0% vs 82.1%	0.9% vs 4.8%		2.3% vs 2.0%	NA	10.4% (3.0% in en bloc and 12% in piecemeal) vs 1.2%

¹Endoscopic mucosal resection vs Endoscopic submucosal dissection.

²According to Paris classification. EMR: Endoscopic mucosal resection; ESD: Endoscopic submucosal dissection; LST: Laterally spreading tumor; NG: Non-granular type; G: Granular type; RCT: Randomized controlled trial; NA: Not available.