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Viktil E, Hanekamp BA, Nesbakken A, Løberg EM, Sjo OH, Negård A, Dormagen JB, Schulz A. MRI of early rectal cancer; bisacodyl micro-enema increases submucosal width, reader confidence, and tumor conspicuity. Abdom Radiol (NY) 2025; 50:2401-2413. [PMID: 39645641 PMCID: PMC12069511 DOI: 10.1007/s00261-024-04701-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2024] [Revised: 11/11/2024] [Accepted: 11/13/2024] [Indexed: 12/09/2024]
Abstract
PURPOSE To investigate the influence of a micro-enema on diagnostic performance, submucosal width, reader confidence, and tumor conspicuity using MRI to stage early rectal cancers (ERC). METHODS In this single-center study, we consecutively included 50 participants with assumed ERC who all completed MRI with (MRin) and without (MRex) a micro-enema. The diagnostic performance was recorded for two experienced radiologists using histopathology as the gold standard. In addition, the width of the submucosa in the tumor-bearing wall, reader confidence for T-staging, and tumor conspicuity were assessed. Significance levels were calculated using McNemar's test (diagnostic performance) and Wilcoxon's signed-rank test (reader confidence, submucosal width, and conspicuity). Interreader agreement was assessed using kappa statistics. RESULTS Sensitivity/specificity were for Reader1 91%/87% for both MRex and MRin and for Reader2 74%/87% and 89%/87%, both readers p > 0.05. The micro-enema induced a significant widening of the submucosa, p < 0.001, with a mean increase of 2.2/2.8 mm measured by Reader1/Reader2. Reader confidence in T-staging and tumor conspicuity increased for both readers, p < 0.005. The proportion of tumors with both correct staging and high reader confidence increased from 58% (29/50) to 80% (40/50) (p = 0.04) for Reader1 and from 42% (21/50) to 72% (36/50) (p = 0.002) for Reader2. Interreader agreement increased from moderate (kappa 0.58) to good (kappa 0.68). CONCLUSION The micro-enema significantly increased the submucosal width in the tumor-bearing wall, reader confidence, and tumor conspicuity and improved interreader agreement from moderate to good. Sensitivity and specificity in T-staging did not improve, but there was a significant increase in the proportion of tumors staged with both high confidence and correct T-stage.
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Affiliation(s)
- Ellen Viktil
- Department of Radiology, Oslo University Hospital Ullevål, Oslo, Norway.
- Institution of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Bettina Andrea Hanekamp
- Department of Radiology, Oslo University Hospital Ullevål, Oslo, Norway
- Institution of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Arild Nesbakken
- Institution of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Gastrointestinal Surgery, Oslo University Hospital Ullevål, Oslo, Norway
| | - Else Marit Løberg
- Institution of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Pathology, Oslo University Hospital Ullevål, Oslo, Norway
| | - Ole Helmer Sjo
- Department of Gastrointestinal Surgery, Oslo University Hospital Ullevål, Oslo, Norway
| | - Anne Negård
- Institution of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Radiology, Akershus University Hospital, Lørenskog, Norway
| | | | - Anselm Schulz
- Department of Radiology, Oslo University Hospital Ullevål, Oslo, Norway
- Institution of Clinical Medicine, University of Oslo, Oslo, Norway
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Hochberger J, Loss M, Kruse E, Kouladouros K. Endoscopic Resection Techniques for Widespread Precancerous Lesions and Early Carcinomas in the Rectum. J Clin Med 2025; 14:3322. [PMID: 40429318 PMCID: PMC12112218 DOI: 10.3390/jcm14103322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2025] [Revised: 03/15/2025] [Accepted: 04/16/2025] [Indexed: 05/29/2025] Open
Abstract
Today, endoscopy plays a crucial role not only in the detection of precancerous and malignant colorectal lesions, but also in the treatment of even widespread adenomas and T1 early cancers. In addition to classic polypectomy and endoscopic mucosal resection (EMR) using a snare, in recent years, endoscopic submucosal dissection (ESD) has become increasingly important. Marking, submucosal injection, circumferential incision of the mucosa around the lesion, tunneling, and submucosal dissection using a short diathermic knife facilitate the 'en bloc' resection of lesions larger than 3 cm, difficult to resect in one piece using a snare. Lesions with high-grade dysplasia or mucosal carcinoma are other good candidates aside from widespread adenomata with a high risk of recurrence after piecemeal resection. ESD allows R0 resection rates of more than 90% in specialized centers. Lesions of 20 cm have been removed 'en bloc' by expert endoscopists. ESD provides an optimal histopathologic yield and has a risk of recurrence as low as 3%. Endoscopic full-thickness resection using a special device (eFTRD) is another addition to the resection armamentarium. It is especially suitable for circumscribed lesions up to 2 cm in the middle and upper rectum. Endoscopic intermuscular dissection (EID) is a recent modification of ESD primarily in the rectum, including the inner, circular muscular layer into the resection specimen. In this way, it allows a histopathologic analysis of the entire submucosa beyond the mucosal and upper submucosal layer such as in ESD. This is especially important for T1 cancers invading the submucosa without any other risk factors of invasion.
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Affiliation(s)
- Juergen Hochberger
- Department of Medicine, Hepatology and Gastroenterology, Campus Virchow Klinikum, Charité University Medicine, 13353 Berlin, Germany;
- Department of Gastroenterology, Vivantes Klinikum im Friedrichshain, 10249 Berlin, Germany
- Medical Clinic I—Gastroenterology, Friedrich-Alexander University Erlangen-Nuremberg, 91054 Erlangen, Germany
| | - Martin Loss
- Department of General and Visceral Surgery, Vivantes Klinikum im Friedrichshain, 10249 Berlin, Germany;
| | - Elena Kruse
- Department of Gastroenterology and Hepatology, Asklepios Westklinikum, 22559 Hamburg, Germany
| | - Konstantinos Kouladouros
- Department of Medicine, Hepatology and Gastroenterology, Campus Virchow Klinikum, Charité University Medicine, 13353 Berlin, Germany;
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Hanevelt J, Brohet RM, Moons LMG, Laclé MM, Vleggaar FP, van Westreenen HL, de Vos Tot Nederveen Cappel WH. ASO Author Reflections: Pushing the Boundaries of Local Excision: How Does the Risk of Lymph Node Metastases Compare to Those Associated with Major Surgery in T2 Colon Cancer Patients? Ann Surg Oncol 2025; 32:3106-3107. [PMID: 39948310 DOI: 10.1245/s10434-025-16997-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2025] [Accepted: 01/23/2025] [Indexed: 04/24/2025]
Affiliation(s)
- Julia Hanevelt
- Department of Gastroenterology and Hepatology, Isala, Zwolle, The Netherlands.
| | - Richard M Brohet
- Department of Epidemiology and Statistics, Isala, Zwolle, The Netherlands
| | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - Miangela M Laclé
- Department of Pathology, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
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Hanevelt J, Brohet RM, Moons LMG, Laclé MM, Vleggaar FP, van Westreenen HL, de Vos Tot Nederveen Cappel WH. Risk of Lymph Node Metastasis in T2 Colon Cancer: A Nationwide Population-Based Cohort Study. Ann Surg Oncol 2025; 32:3078-3088. [PMID: 39847281 DOI: 10.1245/s10434-025-16921-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2024] [Accepted: 01/04/2025] [Indexed: 01/24/2025]
Abstract
BACKGROUND Similar to T1 colon cancer (CC), risk stratification may guide T2 CC treatment and reduce unnecessary major surgery. In this study, prediction models were developed that could identify T2 CC patients with a lower risk of lymph node metastasis (LNM) for whom (intensive) follow-up after local treatment could be considered. METHODS A nationwide cohort study was performed involving pT2 CC patients who underwent surgery between 2012 and 2020, using data from the Dutch ColoRectal Audit, which were linked to the Nationwide Pathology Databank. Four machine learning models were evaluated to predict LNM. RESULTS LNMs were found in 1877/9803 patients (19.1%). Independent risk factors included (younger) age (odds ratio [OR] 0.98, 95% confidence interval [CI] 0.979-0.990), left-sided CC (OR 1.5, 95% CI 1.4-1.7), poor differentiation (OR 1.7, 95% CI 1.4-2.2), and lymphovascular invasion (LVI; OR 4.1, 95% CI 3.6-4.7). A deficient mismatch repair (MMR) status significantly lowered the risk of LNM (OR 0.3, 95% CI 0.2-0.5). The general linear model demonstrated the highest prediction accuracy, achieving area under the receiver operating characteristic curves of 0.67 and 0.68, with good calibration. In the absence of risk factors, elderly patients (≥74 years of age) had a predicted risk of LNM of 10.7%, yet up to 30% experienced postoperative complications, with mortality rates reaching up to 3.5%. Patients with a deficient MMR status had a predicted risk of LNM of 6.1% if LVI was absent and the tumor was well-differentiated. CONCLUSIONS The risk of LNM should be weighed against surgical risks. The findings of this study will enable clinicians to make more deliberate considerations about these competing risks before making a shared decision.
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Affiliation(s)
- Julia Hanevelt
- Department of Gastroenterology and Hepatology, Isala, Zwolle, The Netherlands.
| | - Richard M Brohet
- Department of Epidemiology and Statistics, Isala, Zwolle, The Netherlands
| | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - Miangela M Laclé
- Department of Pathology, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
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Glorieux R, Hanevelt J, van der Wel MJ, de Vos Tot Nederveen Cappel WH, van Westreenen HL. The Outcome of Colonoscopy-Assisted Laparoscopic Wedge Resections (CAL-WR) for Colon Cancer: A Retrospective Cohort Study. Cancers (Basel) 2025; 17:1466. [PMID: 40361393 PMCID: PMC12070948 DOI: 10.3390/cancers17091466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2025] [Revised: 04/16/2025] [Accepted: 04/25/2025] [Indexed: 05/15/2025] Open
Abstract
Local excision is gaining acceptance as standard treatment for T1 colon cancer (CC); however, not all patients are eligible for endoscopic resection. Colonoscopy-assisted laparoscopic wedge resection (CAL-WR) is a relatively new technique that could fill the gap between endoscopic resection and major surgery. The aim of this study was to analyze the oncological safety of CAL-WR for CC. METHODS A retrospective cohort study was performed, including patients that underwent CAL-WR for CC. Exclusion criteria were double tumors, <1 year follow-up, previous other colorectal malignancy, inflammatory bowel disease or synchronous metastases. The primary outcome was disease recurrence and the secondary outcome was overall survival. RESULTS Fifty-three patients were included; 35 patients were diagnosed with T1 CC. CAL-WR was radical (R0) for all T1 CC in 94.3% and 94.7% for tumors with deep submucosal invasion (sm2-3 Kikuchi). The mean follow-up was 3.3 years (Q1: 2.0; Q3: 4.3) for disease recurrence and 4.2 years (Q1: 2.8; Q3: 5.2) for overall survival. None of the patients with T1 CC had disease recurrence or died due to their malignancy. There were 14 patients with a T2 and 4 patients with a T3 CC, 17/18 patients underwent completion surgery. Three patients with T2 and one with T3 CC developed a locoregional recurrence (peritoneal). One patient with T3 CC developed lung metastases. Two patients with T3 and one with T2 CC died due to their malignancy. CONCLUSIONS This study suggests that CAL-WR is oncologically safe as treatment for T1 CC. The safety of incidental CAL-WR for >T1 CC, followed by completion surgery, remains unclear. Prospective studies are needed to evaluate these results.
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Affiliation(s)
- Robin Glorieux
- Department of Surgery, Isala, Dokter van Heesweg 2, 8025 AB Zwolle, The Netherlands;
| | - Julia Hanevelt
- Department of Gastroenterology and Hepatology, Isala, Dokter van Heesweg 2, 8025 AB Zwolle, The Netherlands; (J.H.); (W.H.d.V.T.N.C.)
| | - Myrtle J. van der Wel
- Department of Pathology, Isala, Dokter van Heesweg 2, 8025 AB Zwolle, The Netherlands;
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Argenziano ME, Sorge A, Hoorens A, Montori M, Poortmans PJ, Smeets S, Tornai T, Debels LK, Desomer L, Tate DJ. Knife-assisted full-thickness resection guided by the pocket-detection method for posterior deeply invasive rectal cancer: A novel endoscopic approach (with video). DEN OPEN 2025; 5:e70116. [PMID: 40271449 PMCID: PMC12014851 DOI: 10.1002/deo2.70116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2024] [Revised: 03/25/2025] [Accepted: 04/06/2025] [Indexed: 04/25/2025]
Abstract
Local full-thickness resection techniques for rectal cancer are limited by lesion size, location, or poor margin delineation. We aimed to evaluate the feasibility of endoscopic knife-assisted full-thickness resection (kFTR) guided by the pocket-detection method (PDM) for deeply invasive rectal cancer. Consecutive posterior-lateral rectal lesions suspected of deep submucosal invasion treated at a tertiary care center from February to October 2024 were retrospectively included. kFTR guided by PDM involved creating a submucosal pocket to detect and isolate the suspected invasive component (muscle-retracting sign), followed by muscularis propria incision and full-thickness resection. Technical success, accuracy of detecting deep submucosal invasion, and en-bloc resection rates were 100%. The median procedure time was 141.5 [IQR 123.7-179.5] minutes and the median hospitalization was 1 [IQR 1-7] day. No adverse events occurred. Histopathology showed R1-vertical margin in patient 1 (pT2 adenocarcinoma) and R0 resection in patients 2, 3, and 4 (pT1bsm3) after refinement of the procedure to include a ≥3 mm muscularis propria margin around the suspected invasive component. There was no recurrence at the first endoscopic follow-up of patients 1, 2, and 4. Patient 3 was sent to surgical low anterior resection due to multiple high-risk histological features. The previous kFTR did not impair surgery (no residual rectal carcinoma and 1/17 positive lymph nodes). Endoscopic kFTR guided by the PDM may be a feasible organ-preserving treatment for the detection and resection of deeply invasive posterior rectal cancer. Future studies are needed to ascertain whether rectal kFTR could represent a viable alternative to conventional surgical local excision techniques.
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Affiliation(s)
- Maria Eva Argenziano
- Department of Gastroenterology & HepatologyUniversity Hospital Ghent (UZ Ghent)GhentBelgium
- Faculty of Medicine and Health SciencesUniversity of GhentGhentBelgium
- Clinic of Gastroenterology, Hepatology and Emergency Digestive EndoscopyUniversità Politecnica delle MarcheAnconaItaly
| | - Andrea Sorge
- Department of Gastroenterology & HepatologyUniversity Hospital Ghent (UZ Ghent)GhentBelgium
- Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly
| | - Anne Hoorens
- Department of PathologyUniversity Hospital of Ghent (UZ Ghent)GhentBelgium
| | - Michele Montori
- Department of Gastroenterology & HepatologyUniversity Hospital Ghent (UZ Ghent)GhentBelgium
- Clinic of Gastroenterology, Hepatology and Emergency Digestive EndoscopyUniversità Politecnica delle MarcheAnconaItaly
| | - Pieter Jan Poortmans
- Department of Gastroenterology & HepatologyUniversity Hospital Ghent (UZ Ghent)GhentBelgium
- Faculty of Medicine and Health SciencesUniversity of GhentGhentBelgium
- Department of Gastroenterology & HepatologyUniversity Hospital Brussels (UZ Brussels)BrusselsBelgium
| | - Sander Smeets
- Department of Gastroenterology & HepatologyUniversity Hospital Ghent (UZ Ghent)GhentBelgium
- Faculty of Medicine and Health SciencesUniversity of GhentGhentBelgium
| | - Tamas Tornai
- Department of Gastroenterology & HepatologyUniversity Hospital Ghent (UZ Ghent)GhentBelgium
| | - Lynn K. Debels
- Department of Gastroenterology & HepatologyUniversity Hospital Ghent (UZ Ghent)GhentBelgium
- Faculty of Medicine and Health SciencesUniversity of GhentGhentBelgium
- Department of Gastroenterology & HepatologyUniversity Hospital Brussels (UZ Brussels)BrusselsBelgium
| | - Lobke Desomer
- Department of Gastroenterology & HepatologyUniversity Hospital Ghent (UZ Ghent)GhentBelgium
- Department of Gastroenterology & HepatologyRoeselareBelgium
| | - David J. Tate
- Department of Gastroenterology & HepatologyUniversity Hospital Ghent (UZ Ghent)GhentBelgium
- Faculty of Medicine and Health SciencesUniversity of GhentGhentBelgium
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Badia-Closa J, Campana JP, Rossi GL, Serra-Aracil X. Local resection in rectal cancer: When, who and how? Cir Esp 2025; 103:244-253. [PMID: 39848575 DOI: 10.1016/j.cireng.2024.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2024] [Accepted: 11/15/2024] [Indexed: 01/25/2025]
Abstract
Local resection (LR) in rectal cancer is indicated in stage T1N0M0 without unfavorable pathological factors, achieving oncologically satisfactory outcomes through transanal endoscopic surgery techniques. However, the initial step involves accurate staging and selection of these tumors through specific tests conducted in specialized colorectal units. For T2N0M0 tumors and T1 tumors with poor prognostic factors, the standard treatment is total mesorectal excision (TME), a procedure associated with high postoperative morbidity and mortality, functional impairments, and reduced quality of life. Therefore, new organ-preservation strategies are being explored as alternatives to TME. These include neoadjuvant therapy combined with LR, which has shown promising results, and neoadjuvant therapy followed by a "Watch and Wait" approach -where patients with complete clinical response are selected for strict surveillance- as an ideal future treatment, although there are still current challenges to be addressed.
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Affiliation(s)
- Jesus Badia-Closa
- Unidad Colorrectal, Servicio de Cirugía General y Digestiva, Hospital de Sant Joan Despí Moisès Broggi, Barcelona, Spain
| | - Juan Pablo Campana
- Sección de Cirugía Colorrectal, Servicio de Cirugía General, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Gustavo Leandro Rossi
- Sección de Cirugía Colorrectal, Servicio de Cirugía General, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Xavier Serra-Aracil
- Unidad de Coloproctología, Hospital Universitario Parc Tauli, Sabadell. Institut d'investigació i innovació Parc Tauli I3PT-CERCA, Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain.
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van der Schee L, Snaebjornsson P, Laclé MM. Response to Letter to the Editor. United European Gastroenterol J 2025; 13:280-281. [PMID: 39761003 PMCID: PMC11975608 DOI: 10.1002/ueg2.12742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2024] [Accepted: 12/12/2024] [Indexed: 01/07/2025] Open
Affiliation(s)
- Lisa van der Schee
- Department of PathologyUniversity Medical Center UtrechtUtrechtthe Netherlands
| | - Petur Snaebjornsson
- Department of PathologyThe Netherlands Cancer InstituteAmsterdamthe Netherlands
| | - Miangela M. Laclé
- Department of PathologyUniversity Medical Center UtrechtUtrechtthe Netherlands
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Erkaya M, Ulkucu A, Erozkan K, Catalano B, Allende D, Steele S, Sommovilla J, Gorgun E. Is endoscopic submucosal dissection safe in the management of early-stage colorectal cancers? Am J Surg 2025; 241:116159. [PMID: 39732030 DOI: 10.1016/j.amjsurg.2024.116159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2024] [Revised: 11/26/2024] [Accepted: 12/19/2024] [Indexed: 12/30/2024]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) is increasingly being adopted for the treatment of early-stage colorectal cancer (CRC) lesions. METHODS We retrospectively analyzed patients with early-stage CRC treated between 2015 and 2023, using ESD and colectomy databases, categorizing them into three groups: ESD only (n = 24), oncological colorectal resection (OCR) only (n = 90), and OCR after ESD (n = 59). We compared pathological and oncological outcomes among these groups. RESULTS The OCR after ESD group demonstrated higher non-granular lesions, and deeper submucosal invasion compared to ESD only group. The primary OCR group showed higher 2-year overall survival compared to ESD-only group (98.9 % vs 85.6 %, p = 0.01), with no colorectal cancer-related mortality in any of the groups. Notably, 2-year disease-free survival rates were comparable across all groups (93.8 % ESD only, 88.0 % primary OCR only, and 97.8 % for OCR after ESD, p = 0.27). CONCLUSION The current study highlights feasibility the promising potential and oncologic safety of ESD in carefully selected patients with early malignant lesions.
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Affiliation(s)
- Metincan Erkaya
- Department of Colorectal Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Attila Ulkucu
- Department of Colorectal Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Kamil Erozkan
- Department of Colorectal Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Brogan Catalano
- Department of Colorectal Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Daniela Allende
- Department of Pathology, Pathology & Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Scott Steele
- Department of Colorectal Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Joshua Sommovilla
- Department of Colorectal Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Emre Gorgun
- Department of Colorectal Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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Gauci JL, Whitfield A, Medas R, Kerrison C, Mandarino FV, Gibson D, O'Sullivan T, Cronin O, Gupta S, Lam B, Perananthan V, Hourigan L, Zanati S, Singh R, Raftopoulos S, Moss A, Brown G, Klein A, Desomer L, Tate DJ, Williams SJ, Lee EY, Burgess N, Bourke MJ. Prevalence of Endoscopically Curable Low-Risk Cancer Among Large (≥20 mm) Nonpedunculated Polyps in the Right Colon. Clin Gastroenterol Hepatol 2025; 23:555-563.e1. [PMID: 39089517 DOI: 10.1016/j.cgh.2024.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Revised: 07/07/2024] [Accepted: 07/08/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND AND AIMS Endoscopic submucosal dissection is increasingly promoted for the treatment of all large nonpedunculated colorectal polyps (LNPCPs) to cure potential low-risk cancers (superficial submucosal invasion without additional high-risk histopathologic features). The effect of a universal en bloc strategy on oncologic outcomes for the treatment of LNPCPs in the right colon is unknown. We evaluated this in a large Western population. METHODS A prospective cohort of patients referred for endoscopic resection (ER) of LNPCPs was analyzed. Patients found to have cancer after ER and those referred directly to surgery were included. The primary outcome was to determine the proportion of right colon LNPCPs with low-risk cancer. RESULTS Over 180 months until June 2023, 3294 sporadic right colon LNPCPs in 2956 patients were referred for ER at 7 sites (median size 30 [interquartile range 22.5-37.5] mm). A total of 63 (2.1%) patients were referred directly to surgery, and cancer was proven in 56 (88.9%). A total of 2851 (96.4%) of 2956 LNPCPs underwent ER (median size 35 [interquartile range 25-45] mm), of which 75 (2.6%) were cancers. The overall prevalence of cancer in the right colon was 4.4% (n = 131 of 2956). Detailed histopathologic analysis was possible in 115 (88%) of 131 cancers (71 after ER, 44 direct to surgery). After excluding missing histopathologic data, 23 (0.78%) of 2940 sporadic right colon LNPCPs were low-risk cancers. CONCLUSIONS The proportion of right colon LNPCPs referred for ER containing low-risk cancer amenable to endoscopic cure was <1%, in a large, multicenter Western cohort. A universal endoscopic submucosal dissection strategy for the management of right colon LNPCPs is unlikely to yield improved patient outcomes given the minimal impact on oncologic outcomes. CLINICALTRIALS gov, Numbers: NCT01368289, NCT02000141.
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Affiliation(s)
- Julia L Gauci
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - Anthony Whitfield
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia; Westmead Clinical School of Medicine, University of Sydney, Sydney, Australia
| | - Renato Medas
- Gastroenterology Department, Centro Hospitalar e Universitario São João, Porto, Portugal; Faculty of Medicine, University of Porto, Porto, Portugal
| | - Clarence Kerrison
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia; Westmead Clinical School of Medicine, University of Sydney, Sydney, Australia
| | | | - David Gibson
- Department of Gastroenterology and Hepatology, Alfred Hospital, Melbourne, Australia; Department of Gastroenterology and Hepatology, Epworth Hospital, Melbourne, Australia
| | - Timothy O'Sullivan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia; Westmead Clinical School of Medicine, University of Sydney, Sydney, Australia
| | - Oliver Cronin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia; Westmead Clinical School of Medicine, University of Sydney, Sydney, Australia
| | - Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia; Westmead Clinical School of Medicine, University of Sydney, Sydney, Australia
| | - Brian Lam
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - Varan Perananthan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - Luke Hourigan
- Department of Gastroenterology, Princess Alexandra Hospital (Queensland Health), Brisbane, Australia
| | - Simon Zanati
- Department of Gastroenterology and Hepatology, Alfred Hospital, Melbourne, Australia; Department of Gastroenterology and Hepatology, Epworth Hospital, Melbourne, Australia
| | - Rajvinder Singh
- Department of Gastroenterology and Hepatology, Lyell McEwan Hospital, Adelaide, Australia
| | - Spiro Raftopoulos
- Department of Gastroenterology, Sir Charles Gairdner Hospital, Perth, Australia
| | - Alan Moss
- Department of Gastroenterology and Hepatology, Alfred Hospital, Melbourne, Australia; Department of Gastroenterology and Hepatology, Epworth Hospital, Melbourne, Australia
| | - Gregor Brown
- Department of Gastroenterology and Hepatology, Alfred Hospital, Melbourne, Australia; Department of Gastroenterology and Hepatology, Epworth Hospital, Melbourne, Australia
| | - Amir Klein
- Department of Medicine, Ambam Heath Care Campus, Technion Institute of Technology, Haifa, Israel; Faculty of Medicine, Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel
| | - Lobke Desomer
- Department of Gastroenterology, AZ Delta Roeselare, University Hospital Ghent, Ghent, Belgium
| | - David J Tate
- Department of Gastroenterology and Hepatology, University Hospital of Ghent, Ghent, Belgium; Faculty of Medicine, University of Ghent, Ghent, Belgium
| | - Steven J Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - Eric Y Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia; Westmead Clinical School of Medicine, University of Sydney, Sydney, Australia
| | - Nicholas Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia; Westmead Clinical School of Medicine, University of Sydney, Sydney, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia; Westmead Clinical School of Medicine, University of Sydney, Sydney, Australia.
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11
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Li L, He J, Hu H, Wang Y, Li W, Huang S, Rownoak J, Xu S, Xie F, Wang J, Mi W, Cai J, Ye Y, Liu S, Wang J, Li Y. Linear-Array Endoscopic Ultrasound and Narrow-Band Imaging Measure the Invasion Depth of Nonpedunculated Rectal Lesions With Comparable Accuracy Based on a Randomized Controlled Trial. Am J Gastroenterol 2025; 120:562-569. [PMID: 39051647 DOI: 10.14309/ajg.0000000000002975] [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] [Received: 12/21/2023] [Accepted: 07/03/2024] [Indexed: 07/27/2024]
Abstract
INTRODUCTION Linear-array endoscopic ultrasound (EUS) and narrow-band imaging (NBI) are both used to estimate the invasion depth of nonpedunculated rectal lesions (NPRLs). However, it is unclear which procedure is more accurate. This randomized controlled trial aimed to compare the diagnostic accuracy of linear EUS and NBI for estimating the invasion depth of NPRLs. METHODS This study is a single-center, randomized, tandem trial. Eligible patients with NPRLs were randomly assigned to A group (assessment with EUS followed by NBI) or B group (assessment with NBI followed by EUS). The invasion depth of each lesion was independently measured by each procedure and categorized as mucosal to slight submucosal (M-SM s , invasion depth <1,000 μm) or deep submucosal (SM d , invasion depth ≥1,000 μm) invasion, with postoperative pathology as the standard of measurement. The primary outcome was diagnostic accuracy, and secondary outcomes included sensitivity, specificity, and procedure time. RESULTS Eighty-six patients with NPRLs were enrolled, and 79 patients were finally analyzed, including 39 cases in the A group and 40 cases in the B group. Comparable diagnostic accuracies were observed between EUS and NBI (96.2% vs 93.7%, P = 0.625). EUS identified lesions with deep submucosal invasion with 81.8% sensitivity while that of NBI was 63.6% ( P = 0.500). The specificity of both EUS and NBI was 98.5%. The procedure time was also similar between EUS and NBI (5.90 ± 3.44 vs 6.4 ± 3.94 minutes, P = 0.450). Furthermore, the combined use of EUS and NBI did not improve diagnostic accuracy compared with EUS or NBI alone (94.9% vs 96.2% vs 93.7%, P = 0.333). DISCUSSION Linear EUS and NBI measure the invasion depth of NPRLs with comparable accuracy. The combination of the 2 methods does not improve the diagnostic accuracy. Single NBI should be preferred, considering its simplicity and convenience in clinical practice.
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Affiliation(s)
- Lingzhi Li
- Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jiaming He
- Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Haiyan Hu
- Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yingying Wang
- Economics of Global Health and Infectious Diseases Unit, Melbourne Health Economics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
| | - Weixin Li
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shaohui Huang
- Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jahan Rownoak
- Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shenglin Xu
- Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Fang Xie
- Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Junfen Wang
- Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wenting Mi
- Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jianqun Cai
- Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yaping Ye
- Department of Pathology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Side Liu
- Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jing Wang
- Department of Pathology, The First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| | - Yue Li
- Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Department of Gastroenterology, Zhongshan Torch Development Hospital, Zhongshan, China
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12
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Ulkucu A, Erkaya M, Erozkan K, Catalano B, Liska D, Allende D, Steele SR, Sommovilla J, Gorgun E. Should endoscopic submucosal dissection be offered to patients with early colorectal cancer? Surgery 2025; 179:109030. [PMID: 39732557 DOI: 10.1016/j.surg.2024.109030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Revised: 11/25/2024] [Accepted: 12/05/2024] [Indexed: 12/30/2024]
Abstract
BACKGROUND Endoscopic submucosal dissection is increasingly used to treat early-stage colorectal cancer. This study evaluated the feasibility of endoscopic submucosal dissection in this setting and the determinants of lymph node metastasis. METHODS We reviewed patients who underwent colorectal endoscopic submucosal dissection for early-stage colorectal cancer at a tertiary center between 2011 and 2023. The primary outcome was the identification of high-risk pathologic features predictive of lymph node metastasis in patients undergoing oncologic colon resection following endoscopic submucosal dissection. RESULTS We reviewed 1,398 patients who underwent endoscopic submucosal dissection, and 83 (6%) had colorectal cancer. Twenty-four patients (29%) were closely monitored after endoscopic submucosal dissection, and 59 (71%) underwent oncologic colon resection because of high-risk pathologies of the endoscopic submucosal dissection specimen. In the oncologic colon resection group, the mean age was 62.7 years (±10.2), with 56% male predominance, and 14% showed positive lymph nodes in the final pathology. Analysis comparing patients with and without lymph node metastasis showed significant differences in sex, lesion size, submucosal invasion depth, and budding scores. Multivariate analysis showed that lesions with a submucosal invasion depth ≥2.00 mm of the endoscopic submucosal dissection resection specimen had higher odds of lymph node metastasis (odds ratio 18.7, P = .028), whereas lesions with a diameter >20 mm were associated with a lower likelihood of lymph node metastasis (odds ratio 0.07, P = .036). CONCLUSION The study highlights the oncologic safety of early-stage endoscopic submucosal dissection as a viable treatment option for carefully selected patients with colorectal cancer. After tissue resection with endoscopic submucosal dissection, if the lesion size is less than 20 mm, depth of invasion up to 2 mm may be considered safe in the absence of other high-risk pathologic factors.
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Affiliation(s)
- Attila Ulkucu
- Department of Colorectal Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH. https://twitter.com/AttilaUlkucu
| | - Metincan Erkaya
- Department of Colorectal Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH. https://twitter.com/MetinErkayaMD
| | - Kamil Erozkan
- Department of Colorectal Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Brogan Catalano
- Department of Colorectal Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - David Liska
- Department of Colorectal Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH. https://twitter.com/DavidLiskaMD
| | - Daniela Allende
- Department of Pathology, Pathology & Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH. https://twitter.com/ScottRSteeleMD
| | - Joshua Sommovilla
- Department of Colorectal Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Emre Gorgun
- Department of Colorectal Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH.
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13
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Ichimasa K, Kudo S, Misawa M. T1 Colorectal Cancer: What Are the Barriers to Minimizing Unnecessary Surgical Interventions? United European Gastroenterol J 2025; 13:278-279. [PMID: 39621361 PMCID: PMC11975604 DOI: 10.1002/ueg2.12729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2024] [Accepted: 11/24/2024] [Indexed: 04/09/2025] Open
Affiliation(s)
- Katsuro Ichimasa
- Digestive Disease CenterShowa University Northern Yokohama HospitalYokohamaJapan
- Yong Loo Lin School of MedicineNational University of SingaporeSingaporeSingapore
| | - Shin‐ei Kudo
- Digestive Disease CenterShowa University Northern Yokohama HospitalYokohamaJapan
| | - Masashi Misawa
- Digestive Disease CenterShowa University Northern Yokohama HospitalYokohamaJapan
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14
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Giri B. The scalpel or the scope? Balancing Prudence and Practicality for endoscopic submucosal dissection in early colorectal cancer. Am J Surg 2025; 241:116171. [PMID: 39788819 DOI: 10.1016/j.amjsurg.2024.116171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2024] [Revised: 12/26/2024] [Accepted: 12/28/2024] [Indexed: 01/12/2025]
Affiliation(s)
- Bhuwan Giri
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, AL, USA.
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15
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Norton EJ, Bateman AC. Pitfalls during histological assessment in locally resected pT1 colorectal cancer. Histopathology 2025. [PMID: 39939288 DOI: 10.1111/his.15425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2024] [Revised: 01/06/2025] [Accepted: 01/27/2025] [Indexed: 02/14/2025]
Abstract
Colorectal cancer (CRC) is a common malignancy worldwide, and the stage of the tumour is closely related to clinical outcome. Bowel cancer screening programmes have resulted in the identification of colorectal cancer at earlier stages. Approximately 10% of patients with the earliest stage of CRC (i.e. pT1) will possess regional lymph node metastases (LNM). Therefore, if these patients have initially been treated by local resection (e.g. polypectomy), this subgroup will require surgical resection. Identification of pathological risk factors for LNM within locally resected pT1 CRC is a very important process during the histological assessment of these lesions. This paper describes the most commonly encountered and clinically significant difficulties in the histological assessment of these cases. These pitfalls are illustrated using four examples of locally resected pT1 CRC that were received by our department during routine diagnostic practice.
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Affiliation(s)
- Emma J Norton
- Department of Cellular Pathology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Adrian C Bateman
- Department of Cellular Pathology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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16
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Alfarone L, Maselli R, Hassan C, Spaggiari P, Spadaccini M, Capogreco A, Massimi D, De Sire R, Mastrorocco E, Repici A. Endoscopic submucosal dissection for proximal colonic lesions: An effective therapeutic option. Endosc Int Open 2025; 13:a24431609. [PMID: 40109311 PMCID: PMC11922310 DOI: 10.1055/a-2443-1609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2024] [Accepted: 10/16/2024] [Indexed: 03/22/2025] Open
Abstract
Background and study aims Due to the greater risks of adverse events (AEs) and the lower rate of submucosal invasive cancer (SMIC), large proximal colonic polyps are frequently treated by piecemeal endoscopic mucosal resection (EMR) in the West. However, this implies the risk of surgery to radicalize non-curative endoscopic resection in case of early colorectal cancer (CRC). We evaluated procedure outcomes in patients undergoing ESD for proximal colonic lesions at risk of SMIC. Patients and methods All consecutive patients with lesions at risk of SMIC proximal to splenic flexure referred for ESD at a tertiary center were prospectively included from 2019 to 2021. En bloc, R0, and curative resection rates were primary outcomes, while length of hospitalization, AEs, need for surgery due to AEs, and recurrence rates were secondary outcomes. Results A total of 116 patients (mean age: 68.4±10.91 years; men: 69.8%) were included. En bloc, R0, and curative resection rates were 84.5%, 78.4%, and 72.4%, respectively. T1 adenocarcinoma was reported in 25% of lesions (29/116). Eleven patients (9.5%) underwent secondary surgery due to non-curative resections; residual disease was found in one patient. Most frequent AE was intra-procedural perforation (9.9%); no AE required surgery. Median follow-up was 36 months; three of 97 recurrences (3.1%) at 6 months and one of 85 recurrence (1.2%) at 36 months were reported, which were all endoscopically treated. Conclusions In expert hands, ESD is effective and safe for proximal colonic lesions at risk of SMIC for the favorable balance between risk of AEs and benefit of avoiding unnecessary surgery, even for early CRC.
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Affiliation(s)
| | - Roberta Maselli
- Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Cesare Hassan
- Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Paola Spaggiari
- Pathology Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Marco Spadaccini
- Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | | | - Davide Massimi
- Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Roberto De Sire
- Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Gastroenterology, IBD Unit, Department of Clinical Medicine and Surgery, Università degli Studi di Napoli Federico II, Napoli, Italy
| | - Elisabetta Mastrorocco
- Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Alessandro Repici
- Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
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17
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Kim J, Gweon TG, Kwak MS, Kim SY, Kim SJ, Kim HG, Hong SN, Kim ES, Moon CM, Myung DS, Baek DH, Oh SJ, Lee HJ, Lee JY, Jung Y, Chun J, Yang DH, Kim ER, Intestinal Tumor Research Group of the Korean Association for the Study of Intestinal Diseases (KASID). Survey of the Actual Practices Used for Endoscopic Removal of Colon Polyps in Korea: A Comparison with the Current Guidelines. Gut Liver 2025; 19:77-86. [PMID: 39748649 PMCID: PMC11736314 DOI: 10.5009/gnl240217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 07/25/2024] [Accepted: 07/31/2024] [Indexed: 01/04/2025] Open
Abstract
Background/Aims We investigated the clinical practice patterns of Korean endoscopists for the endoscopic resection of colorectal polyps. Methods From September to November 2021, an online survey was conducted regarding the preferred resection methods for colorectal polyps, and responses were compared with the international guidelines. Results Among 246 respondents, those with <4 years, 4-9 years, and ≥10 years of experience in colonoscopy practices accounted for 25.6%, 34.1%, and 40.2% of endoscopists, respectively. The most preferred resection methods for non-pedunculated lesions were cold forceps polypectomy for ≤3 mm lesions (81.7%), cold snare polypectomy for 4-5 mm (61.0%) and 6-9 mm (43.5%) lesions, hot endoscopic mucosal resection (EMR) for 10-19 mm lesions (72.0%), precut EMR for 20-25 mm lesions (22.0%), and endoscopic submucosal dissection (ESD) for ≥26 mm lesions (29.3%). Hot EMR was favored for pedunculated lesions with a head size <20 mm and stalk size <10 mm (75.6%) and for those with a head size ≥20 mm or stalk size ≥10 mm (58.5%). For suspected superficial and deep submucosal lesions measuring 10-19 mm and ≥20 mm, ESD (26.0% and 38.6%) and surgery (36.6% and 46.3%) were preferred, respectively. The adherence rate to the guidelines ranged from 11.2% to 96.9%, depending on the size, shape, and histology of the lesions. Conclusions Adherence to the guidelines for endoscopic resection techniques varied depending on the characteristics of colorectal polyps. Thus, an individualized approach is required to increase adherence to the guidelines.
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Affiliation(s)
- Jeongseok Kim
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Tae-Geun Gweon
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Min Seob Kwak
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Su Young Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seong Jung Kim
- Department of Internal Medicine, Chosun University College of Medicine, Gwangju, Korea
| | - Hyun Gun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Sung Noh Hong
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun Sun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Institute of Digestive Disease and Nutrition, Korea University College of Medicine, Seoul, Korea
| | - Chang Mo Moon
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Dae Seong Myung
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Dong-Hoon Baek
- Department of Internal Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Shin Ju Oh
- Department of Gastroenterology, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Hyun Jung Lee
- Department of Internal Medicine, Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Ji Young Lee
- Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yunho Jung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Jaeyoung Chun
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong-Hoon Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Ran Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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18
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Gonçalves AR, Azevedo Silva M, Sequeira C, Mascarenhas A, Costa M, Pinto Pais T, Barreiro P, Almeida N, Rama N, Fernandes A, Eliseu L, Dinis-Ribeiro M, Vasconcelos H. Applicability of the Scottish screen-detected polyp cancer study (SSPoCS) algorithm in a multicentric cohort in the management of malignant colorectal polyps. Scand J Gastroenterol 2025; 60:122-129. [PMID: 39711172 DOI: 10.1080/00365521.2024.2445699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2024] [Revised: 12/09/2024] [Accepted: 12/17/2024] [Indexed: 12/24/2024]
Abstract
BACKGROUND/OBJECTIVES Robust evidence regarding the management after endoscopic resection of malignant colorectal polyps (MCP) is lacking. Inconsistencies in reporting on potential prognostic factors hinder the decision process. To address these issues, the Scottish Screen-detected Polyp Cancer Study (SSPoCS) introduced an algorithm based in two easily obtainable variables: resection margin and lymphovascular invasion. This study aims to assess the applicability of the SSPoCS algorithm in a Portuguese multicentric cohort. METHODS Endoscopically resected MCP in five centers were included. The main outcome was residual/recurrent malignancy (RRM), defined as any of the following: (1) residual intramural or lymph node malignancy in the surgical specimen after completion surgery; (2) local or systemic recurrent disease in conservatively managed patients. RESULTS Two-hundred and eleven patients were included (mean age: 68.6 ± 10.4 years; male participants: 65.4%); 121 underwent completion surgery while 90 remained in surveillance. Thirty-two patients (15.2%) experienced RRM: 27 displayed residual malignancy in the surgical specimen and five developed recurrent disease. According to the SSPoCS algorithm: 120 patients were classified as having low-risk of residual disease, six of whom displayed RRM (5.0%); 10 as medium-risk, with one having RRM (10.0%); and 81 as high-risk, 25 of whom experienced RRM (30.9%). Lesions classified as low risk showed a negative predictive value (NPV) of 95.0% to exclude RRM. The algorithm demonstrated good accuracy in predicting RRM in a Receiver Operating Characteristic curve analysis (AUC: 0.74; 95% CI: 0.65-0.83; p < 0.001). CONCLUSIONS The SSPoCS algorithm revealed good accuracy in predicting residual/recurrent malignancy with a NPV of 95.0% to exclude RRM in low-risk lesions.
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Affiliation(s)
| | | | - Cristiana Sequeira
- Gastroenterology Department, Centro Hospitalar de Setúbal, Setúbal, Portugal
| | - André Mascarenhas
- Gastroenterology Department, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
| | - Mara Costa
- Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Teresa Pinto Pais
- Gastroenterology Department, Instituto Português de Oncologia do Porto, Porto, Portugal
| | - Pedro Barreiro
- Gastroenterology Department, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
- Lisbon Advanced Endoscopic Center, Hospital Lusíadas, Lisboa, Portugal
| | - Nuno Almeida
- Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Nuno Rama
- General Surgery Department, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | | | - Liliana Eliseu
- Gastroenterology Department, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Mário Dinis-Ribeiro
- Gastroenterology Department, Instituto Português de Oncologia do Porto, Porto, Portugal
- MEDCIDS, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Helena Vasconcelos
- Gastroenterology Department, Centro Hospitalar de Leiria, Leiria, Portugal
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19
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Cao Z, Zhao J, Liu J, Tian X, Shi Y, Zhang J, Hu J, Liu F. Long-term outcomes of endoscopic submucosal dissection for T1b colorectal cancer. J Cancer Res Ther 2024; 20:2055-2060. [PMID: 39792415 DOI: 10.4103/jcrt.jcrt_515_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 11/23/2024] [Indexed: 01/12/2025]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) is a standardized procedure for intramucosal and slightly invasive submucosal colorectal cancers (CRC). However, the role of ESD for T1b (depth of submucosal invasion: ≥1,000 μm) CRC remains unclear. This study aimed to investigate the long-term efficacy and safety of ESD for T1b CRC. METHODS This study involved 50 patients with T1b CRC who underwent ESD, including 31 who received subsequent surgery (ESD + surgery group) and 19 who reported comorbidities or refused subsequent surgery (ESD-alone group). The clinical outcomes, lymph node metastasis (LNM) rate, and recurrence and survival rates were determined. RESULTS All the patients achieved en-bloc resection, and 41 patients achieved R0 resection. The mean tumor diameter was 31.2 ± 11.9 mm. LNM was detected in 3 (6%) cases, demonstrating high-grade tumor budding (Bd 2/3) and invasion depth of >1,500 um. LNM was significantly correlated with tumor budding (P = 0.030). The overall median follow-up period was 41.00 ± 27.69 months and 33.16 ± 19.05 months in the ESD-alone and ESD + surgery groups, respectively (P = 0.241). Two patients in the ESD group had local recurrence and two patients died. Patients in the ESD + surgery group reported no local recurrence, distant metastasis, or disease-related death. Recurrence (P = 0.074) and survival rates (P = 0.072) were not significantly different between the two groups. CONCLUSIONS The LNM rate was exceedingly low in patients with T1b. ESD is an effective and safe method for these patients. The necessity of additional surgical treatment after ESD should be comprehensively determined following the patient's characteristics.
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Affiliation(s)
- Zhixin Cao
- Department of Pathology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, P. R. China
| | - Jingfang Zhao
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, P. R. China
| | - Juan Liu
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, P. R. China
| | - Xiangguo Tian
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, P. R. China
| | - Yongjun Shi
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, P. R. China
| | - Junyong Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, P. R. China
| | - Jinhua Hu
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, P. R. China
| | - Fuli Liu
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, P. R. China
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20
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Inaba A, Ikematsu H, Kojima M, Sakamoto N, Wakabayashi M, Sunakawa H, Nakajo K, Murano T, Kadota T, Shinmura K, Yano T. Association between pathological T1 colorectal cancer with lymphoid follicular replacement and risk of lymph node metastasis. J Gastroenterol Hepatol 2024; 39:2631-2638. [PMID: 39307824 DOI: 10.1111/jgh.16745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 08/05/2024] [Accepted: 08/31/2024] [Indexed: 12/21/2024]
Abstract
BACKGROUND AND AIM Endoscopic resection (ER) is widely performed to treat early colorectal cancer. However, additional surgery for pathological T1 colorectal cancer (pT1CRC) after ER is controversial because of the imprecise prediction of lymph node metastasis (LNM). Recently, several patients of pT1CRC with lymphoid follicular replacement (LFR) without LNM have been reported. This study aimed to investigate the clinicopathological features and risk of LNM in patients with pT1CRC with LFR. METHODS We retrospectively analyzed patients who underwent ER or surgical resection and were diagnosed with pT1CRC between January 2010 and December 2020. We defined pT1CRC with LFR as the replacement of a part of the lymphoid follicular component within the submucosal area by adenocarcinoma, with no invasion into other submucosal areas. RESULTS Among the 600 eligible patients, the incidence rate of pT1CRC with LFR was 6.7% (40/600). Patients with pT1CRC with LFR represented 14.3% (37/258) of the endoscopically treated patients and 0.9% (3/342) of the surgically treated patients. For patients with pT1CRC with LFR, 80.0% (32/40) had flat and depressed lesions, and 35.0% (14/40) had submucosal invasion depth ≥1000 μm. Patients with pT1CRC with LFR had negative lymphovascular invasion, differentiated type, and budding grade 1. In the median follow-up of 61 months, patients with pT1CRC with LFR had no LNM. CONCLUSIONS The presence of LFR in pT1CRC may be associated with a low risk of LNM. In patients with pT1CRC with LFR, follow-up without additional surgery is possible even if the submucosal invasion depth is ≥1000 μm.
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Affiliation(s)
- Atsushi Inaba
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Kashiwa, Japan
| | - Hiroaki Ikematsu
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Kashiwa, Japan
- Medical Device Innovation Center, National Cancer Center Hospital East, Kashiwa, Japan
| | - Motohiro Kojima
- Division of Pathology, Exploratory Oncology Research and Clinical Trial Center, National Cancer Center, Kashiwa, Japan
| | - Naoya Sakamoto
- Division of Pathology, Exploratory Oncology Research and Clinical Trial Center, National Cancer Center, Kashiwa, Japan
| | - Masashi Wakabayashi
- Biostatistics Division, Center for Research Administration and Support, National Cancer Center, Tokyo, Japan
| | - Hironori Sunakawa
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Kashiwa, Japan
- Medical Device Innovation Center, National Cancer Center Hospital East, Kashiwa, Japan
| | - Keiichiro Nakajo
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Kashiwa, Japan
| | - Tatsuro Murano
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Kashiwa, Japan
| | - Tomohiro Kadota
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Kashiwa, Japan
| | - Kensuke Shinmura
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Kashiwa, Japan
| | - Tomonori Yano
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Kashiwa, Japan
- Medical Device Innovation Center, National Cancer Center Hospital East, Kashiwa, Japan
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21
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Tsuji S, Doyama H, Kobayashi N, Ohata K, Takeuchi Y, Chino A, Takamaru H, Tsuji Y, Hotta K, Harada K, Ikematsu H, Uraoka T, Murakami T, Katagiri A, Hori S, Michida T, Suzuki T, Fukuzawa M, Kiriyama S, Fukase K, Murakami Y, Ishikawa H, Saito Y. Outcomes of noncurative endoscopic submucosal dissection for T1 colorectal cancer: Prospective, multicenter, cohort study in Japan. Dig Endosc 2024; 36:1369-1379. [PMID: 39117368 DOI: 10.1111/den.14878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 06/10/2024] [Indexed: 08/10/2024]
Abstract
OBJECTIVES This study investigated the incidence of lymph node metastasis and long-term outcomes in patients with T1 colorectal cancer where endoscopic submucosal dissection (ESD) resulted in noncurative treatment. It is focused on those with deep submucosal invasion, a factor considered a weak predictor of lymph node metastasis in the absence of other risk factors. METHODS This nationwide, multicenter, prospective study conducted a post-hoc analysis of 141 patients with T1 colorectal cancer ≥20 mm where ESD of the lesion resulted in noncurative outcomes, characterized by poor differentiation, deep submucosal invasion (≥1000 μm), lymphovascular invasion, high-grade tumor budding, or positive vertical margins. Clinicopathologic features and patient prognoses focusing on lesion sites and additional surgery requirements were evaluated. Lymph node metastasis incidence in the low-risk T1 group, identified by deep submucosal invasion as the sole high-risk histological feature, was assessed. RESULTS Lymph node metastasis occurred in 14% of patients undergoing additional surgery post-noncurative endoscopic submucosal dissection for T1 colorectal cancer. In the low-risk T1 group, in the absence of other risk factors, the frequency was 9.7%. The lymph node metastasis rates in patients with T1 colon and rectal cancers did not differ significantly (14% vs. 16%). Distant recurrence was observed in one patient (2.3%) in the ESD only group and in one (1.0%) in the additional surgery group, both of whom had had rectal cancer removed. CONCLUSION The risk of lymph node metastasis or distant occurrence was not negligible, even in the low-risk T1 group. The findings suggest the need for considering additional surgery, particularly for rectal lesions (Clinical Trial Registration: UMIN000010136).
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Affiliation(s)
- Shigetsugu Tsuji
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Ishikawa, Japan
| | - Hisashi Doyama
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Ishikawa, Japan
| | - Nozomu Kobayashi
- Department of Gastroenterology, Tochigi Cancer Center, Tochigi, Japan
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Ken Ohata
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Yoji Takeuchi
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Akiko Chino
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | | | - Yosuke Tsuji
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kinichi Hotta
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Keita Harada
- Department of Gastroenterology, Okayama University Hospital, Okayama, Japan
- Department of Gastroenterology, Okayama Saiseikai General Hospital, Okayama, Japan
| | - Hiroaki Ikematsu
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Chiba, Japan
| | - Toshio Uraoka
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Takashi Murakami
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Atsushi Katagiri
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Shinichiro Hori
- Department of Gastroenterology, NHO Shikoku Cancer Center, Ehime, Japan
- Department of Gastrointestinal Medicine, Japan Red Cross Society Himeji Hospital, Hyogo, Japan
| | - Tomoki Michida
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
- Department of Internal Medicine, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
| | - Takuto Suzuki
- Department of Gastroenterology, Chiba Cancer Center, Chiba, Japan
| | - Masakatsu Fukuzawa
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Shinsuke Kiriyama
- Department of Surgery, Japan Community Healthcare Organization Gunma Central Hospital, Gunma, Japan
| | - Kazutoshi Fukase
- Department of Internal Medicine, Yamagata Prefectural Central Hospital, Yamagata, Japan
- Department of Internal Medicine, Yamagata Prefectural Kahoku Hospital, Yamagata, Japan
| | | | - Hideki Ishikawa
- Department of Molecular-Targeting Prevention, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
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22
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Xu J, Yin F, Ren L, Xu Y, Min C, Zhang P, Cao M, Li X, Tian Z, Mao T. The risk factors of lymph node metastasis in early colorectal cancer: a predictive nomogram and risk assessment. Int J Colorectal Dis 2024; 39:191. [PMID: 39607559 PMCID: PMC11604734 DOI: 10.1007/s00384-024-04760-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/11/2024] [Indexed: 11/29/2024]
Abstract
PURPOSE Endoscopic procedures and surgery are common treatments for early colorectal cancer (CRC). However, only approximately 10% of patients who undergo surgery have lymph node metastases (LNM) detected on postoperative pathology, which often leads to overtreatment. This study aims to comprehensively analyze the risk factors for LNM in early CRC patients, establishing a predictive model to aid in treatment decisions. METHODS This study reviewed the clinicopathologic data of patients with early CRC who underwent surgery from January 2015 to June 2023. Univariate and multivariate logistic regression analyses were employed to identify LNM risk factors. The receiver operating characteristic (ROC) analysis and calibration curves were also constructed to verify the model's discrimination and calibration. A simplified scale was calculated to promote the risk stratification for LNM. RESULTS The study analyzed medical records of 375 patients. Of these, 37 (9.9%) cases had LNM. Univariate analysis identified age, nerve invasion, depth of submucosal invasion, histologic grade, LVI, and tumor budding as risk factors. The multivariate analysis confirmed histologic grade (OR, 13.403; 95% CI, 1.415-126.979; P = 0.024), LVI (OR, 6.703; 95% CI, 2.600-17.284; P < 0.001), and tumor budding (OR, 3.090; 95% CI, 1.082-8.820; P = 0.035) as independent predictors. The optimal nomogram, incorporating six risk factors, demonstrated strong predictability with an area under the ROC curve (AUC) of 0.837 (95% CI, 0.762-0.912). A simplified risk assessment scale with a total score of 19 points was developed. CONCLUSION The study developed a nomogram and a simplified risk assessment scale to predict LNM risk, potentially optimizing the management of early CRC patients.
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Affiliation(s)
- Jiahui Xu
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, No. 16, Jiangsu Road, Qingdao, 266000, Shandong Province, China
| | - Fan Yin
- Teaching and Research Department, Qingdao Municipal Center for Disease Control and Prevention, Qingdao, Shandong Province, China
| | - Linlin Ren
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, No. 16, Jiangsu Road, Qingdao, 266000, Shandong Province, China
| | - Yushuang Xu
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, No. 16, Jiangsu Road, Qingdao, 266000, Shandong Province, China
| | - Congcong Min
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, No. 16, Jiangsu Road, Qingdao, 266000, Shandong Province, China
| | - Peng Zhang
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, No. 16, Jiangsu Road, Qingdao, 266000, Shandong Province, China
| | - Mengyu Cao
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, No. 16, Jiangsu Road, Qingdao, 266000, Shandong Province, China
| | - Xiaoyu Li
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, No. 16, Jiangsu Road, Qingdao, 266000, Shandong Province, China
| | - Zibin Tian
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, No. 16, Jiangsu Road, Qingdao, 266000, Shandong Province, China
| | - Tao Mao
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, No. 16, Jiangsu Road, Qingdao, 266000, Shandong Province, China.
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23
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Park JH, Kim JH, Ko SH, Park SJ. Combining Endoscopic Submucosal Dissection and Adjuvant Chemoradiotherapy or Radiotherapy for Effective Management of Rectal Cancer with Deep Submucosal Invasion: A Case Series. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2024; 84:230-234. [PMID: 39582311 DOI: 10.4166/kjg.2024.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2024] [Revised: 10/18/2024] [Accepted: 10/24/2024] [Indexed: 11/26/2024]
Abstract
Rectal cancer is one of the most prevalent malignancies worldwide, and the introduction of an endoscopic submucosal dissection (ESD) has offered minimally invasive management for early colorectal cancers. On the other hand, a post-ESD pathological examination showed that the risk of lymph node metastasis increases with deep submucosal (SM) invasion, positive lymphovascular invasion, grade 2/3 tumor budding, and certain histological types. An intestinal resection with a lymph node dissection is recommended in these cases, and chemoradiotherapy (CRT) is also effective adjuvant therapy. This paper reports a case series of patients who underwent ESD for rectal cancer and received concurrent CRT because of pathologically confirmed deep SM invasion.
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Affiliation(s)
- Ji Hye Park
- Division of Gastroenterology, Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Jae Hyun Kim
- Division of Gastroenterology, Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Sung Hyun Ko
- Division of Gastroenterology, Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Seun Ja Park
- Division of Gastroenterology, Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
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24
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Wong NACS. My approach to assessing for colorectal polyp cancer. J Clin Pathol 2024; 77:793-801. [PMID: 39074975 DOI: 10.1136/jcp-2024-209604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 07/10/2024] [Indexed: 07/31/2024]
Abstract
Assessing a locally excised colorectal adenoma for malignancy is a common but often challenging scenario. This article outlines a simple, stepwise approach to this diagnostic assessment. The first steps are to assess for high-grade dysplasia and, if present, to determine whether any neoplastic glands lie within the submucosa. If so, a distinction must then be made between epithelial misplacement and adenocarcinoma; this process is aided by certain clinical and endoscopic data together with assessment of six key histological features. If adenocarcinoma is diagnosed, a final step is to report the presence/absence of high-risk features of polyp cancers because this will then determine if further surgical resection is required for that malignancy. Caveats, uncertainties and newly introduced concepts exist at several steps of the assessment pathway presented and are therefore discussed in detail throughout the article.
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25
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Tribonias G, Papaefthymiou A, Zormpas P, Seewald S, Zachou M, Barbaro F, Kahaleh M, Andrisani G, Elkholy S, El-Sherbiny M, Komeda Y, Yarlagadda R, Tziatzios G, Essam K, Haggag H, Paspatis G, Mavrogenis G. Endoscopic Local Excision (ELE) with Knife-Assisted Resection (KAR) Techniques Followed by Adjuvant Radiotherapy and/or Chemotherapy for Invasive (T1bsm2,3/T2) Early Rectal Cancer: A Multicenter Retrospective Cohort. J Clin Med 2024; 13:6951. [PMID: 39598095 PMCID: PMC11594537 DOI: 10.3390/jcm13226951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2024] [Revised: 11/02/2024] [Accepted: 11/16/2024] [Indexed: 11/29/2024] Open
Abstract
Background: Resected rectal polyps with deep invasion into the submucosa (pT1b-sm2,3) or the muscle layer (pT2) are currently confronted with surgery due to non-curative resection. Aims: We evaluated the efficacy, safety, and locoregional control of adjuvant radiotherapy (RT) and/or chemotherapy (CT) following endoscopic KAR (knife-assisted resection) in patients with invasive early rectal cancers who are unwilling or unsuitable for additional surgical resection. Methods: Fifty-one patients with early rectal cancers, pT1b or pT2, underwent post-resection adjuvant RT and/or CT in 15 centers worldwide. "En bloc" macroscopic resection, R0 resection, recurrence rate, and adverse events following resection and adjuvant therapy were recorded in a multicenter retrospective cohort study. Results: Diagnostic staging (38/51, 75%) was the main reason for ELE. Macroscopic "en bloc" resection was demonstrated in 50/51 (98%), with an average follow-up of 20.6 months. Endoscopic recurrence occurred in 7/51 (13.7%) of patients, with mean time for diagnosis of recurrence at 8.9 months. Adjuvant therapy consisted of RT in 49.0% (25/51), CT in 11.8% (6/51), and combined CRT in 39.2% (20/51) of the cases. Perforation, severe post-procedural bleeding, and incontinence were the most frequent complications. The absence of superficial ulceration was associated with macroscopic complete resection, while the lesions with lower budding stage, clear lateral margins, lesion size < 40 mm, and needle-type knife used were associated with less endoscopic recurrencies. Conclusions: Our data investigated adjuvant RT and/or CT after endoscopic KAR of infiltrative rectal cancers (pT1bsm2,3-pT2) as being safe and effective for locoregional control and providing a non-surgical treatment option for patients with a non-curative resection.
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Affiliation(s)
- George Tribonias
- Department of Gastroenterology, Red Cross Hospital, 11526 Athens, Greece
| | | | - Petros Zormpas
- Department of Gastroenterology, Red Cross Hospital, 11526 Athens, Greece
| | - Stefan Seewald
- Center for Gastroenterology, Hirslanden Clinic Zurich, 8032 Zurich, Switzerland
| | - Maria Zachou
- Department of Gastroenterology, “Sismanogleio” General Hospital, 15126 Athens, Greece
| | - Federico Barbaro
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Michel Kahaleh
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical School New Brunswick, New Brunswick, NJ 08901, USA
| | - Gianluca Andrisani
- Digestive Endoscopy Unit, Campus Bio-Medico, University of Rome, 00128 Rome, Italy
| | - Shaimaa Elkholy
- Gastroenterology Division, Internal Medicine Department, Faculty of Medicine, Cairo University Kasr Alainy, Cairo 4240310, Egypt
| | - Mohamed El-Sherbiny
- Department of Basic Medical Sciences, College of Medicine, AlMaarefa University, Riyadh 13713, Saudi Arabia
| | - Yoriaki Komeda
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, Osaka-Sayama 589-0014, Japan
| | | | - Georgios Tziatzios
- Department of Gastroenterology, “Konstantopoulio-Patision” General Hospital, 14233 Athens, Greece
| | - Kareem Essam
- Gastroenterology Division, Department of Internal Medicine, Faculty of Medicine, Cairo University, Cairo 4240310, Egypt
| | - Hany Haggag
- Gastroenterology Division, Internal Medicine Department, Faculty of Medicine, Cairo University Kasr Alainy, Cairo 4240310, Egypt
| | - Gregorios Paspatis
- Department of Gastroenterology, Venizeleion General Hospital, 71409 Heraklion, Greece
| | - Georgios Mavrogenis
- Unit of Hybrid Interventional Endoscopy, Department of Gastroenterology, Mediterraneo Hospital, 16675 Athens, Greece
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26
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Djinbachian R, Rex DK, Chiu HM, Fukami N, Aihara H, Bastiaansen BAJ, Bechara R, Bhandari P, Bhatt A, Bourke MJ, Byeon JS, Cardoso D, Chino A, Chiu PWY, Dekker E, Draganov PV, Elkholy S, Emura F, Goldblum J, Haji A, Ho SH, Jung Y, Kawachi H, Khashab M, Khomvilai S, Kim ER, Maselli R, Messmann H, Moons L, Mori Y, Nakanishi Y, Ngamruengphong S, Parra-Blanco A, Pellisé M, Pinto RC, Pioche M, Pohl H, Rastogi A, Repici A, Sethi A, Singh R, Suzuki N, Tanaka S, Vieth M, Yamamoto H, Yang DH, Yokoi C, Saito Y, von Renteln D. International consensus on the management of large (≥20 mm) colorectal laterally spreading tumors: World Endoscopy Organization Delphi study. Dig Endosc 2024; 36:1253-1268. [PMID: 38934243 DOI: 10.1111/den.14826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 05/07/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVES There have been significant advances in the management of large (≥20 mm) laterally spreading tumors (LSTs) or nonpedunculated colorectal polyps; however, there is a lack of clear consensus on the management of these lesions with significant geographic variability especially between Eastern and Western paradigms. We aimed to provide an international consensus to better guide management and attempt to homogenize practices. METHODS Two experts in interventional endoscopy spearheaded an evidence-based Delphi study on behalf of the World Endoscopy Organization Colorectal Cancer Screening Committee. A steering committee comprising six members devised 51 statements, and 43 experts from 18 countries on six continents participated in a three-round voting process. The Grading of Recommendations, Assessment, Development and Evaluations tool was used to assess evidence quality and recommendation strength. Consensus was defined as ≥80% agreement (strongly agree or agree) on a 5-point Likert scale. RESULTS Forty-two statements reached consensus after three rounds of voting. Recommendations included: three statements on training and competency; 10 statements on preresection evaluation, including optical diagnosis, classification, and staging of LSTs; 14 statements on endoscopic resection indications and technique, including statements on en bloc and piecemeal resection decision-making; seven statements on postresection evaluation; and eight statements on postresection care. CONCLUSIONS An international expert consensus based on the current available evidence has been developed to guide the evaluation, resection, and follow-up of LSTs. This may provide guiding principles for the global management of these lesions and standardize current practices.
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Affiliation(s)
- Roupen Djinbachian
- Montreal University Hospital Research Center, Montreal, Canada
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Douglas K Rex
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, USA
| | - Han-Mo Chiu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Norio Fukami
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, USA
| | - Hiroyuki Aihara
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, USA
- Department of Medicine, Harvard Medical School, Boston, USA
| | - Barbara A J Bastiaansen
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Robert Bechara
- Division of Gastroenterology, Kingston Health Sciences Centre, Queen's University, Kingston General Hospital, Kingston, ON, Canada
| | | | - Amit Bhatt
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases Institute, Cleveland Clinic, Cleveland, USA
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Daniela Cardoso
- Institute of Digestive Apparatus, Oncological Surgery, Goiâsnia, Brazil
| | - Akiko Chino
- Department of Gastroenterology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Philip W Y Chiu
- Division of Upper GI Surgery, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, USA
| | - Shaimaa Elkholy
- Gastroenterology Division, Internal Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Fabian Emura
- Gastroenterology Division, de La Sabana University, Chia, Colombia
- Advanced GI Endoscopy, EmuraCenter LatinoAmerica, Bogotá, Colombia
| | - John Goldblum
- Department of Anatomic Pathology, Cleveland Clinic, Cleveland, USA
| | - Amyn Haji
- King's Institute of Therapeutic Endoscopy, King's College Hospital, London, UK
| | - Shiaw-Hooi Ho
- Department of Medicine, Malaya University, Kuala Lumpur, Malaysia
| | - Yunho Jung
- Division of Gastroenterology, Department of Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Hiroshi Kawachi
- Department of Pathology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Mouen Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, USA
| | - Supakij Khomvilai
- Surgical Endoscopy Colorectal Division, Department of Surgery Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Eun Ran Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Roberta Maselli
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Division of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Helmut Messmann
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Leon Moons
- Departments of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Yuichi Mori
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Kanagawa, Japan
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway
| | | | | | - Adolfo Parra-Blanco
- NHR Nottingham Biomedical Research Centre, Department of Gastroenterology, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Division of Gastroenterology, University of Nottingham, Nottingham, UK
| | - María Pellisé
- Department of Gastroenterology, Hospital Clinic of Barcelona, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- Hospital Clinic of Barcelona, Biomedical Research Center in Hepatic and Digestive Diseases (CIBERehd), University of Barcelona, Barcelona, Spain
| | | | - Mathieu Pioche
- Endoscopic Division, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Heiko Pohl
- Department of Gastroenterology, VA Medical Center, White River Junction, USA
- Dartmouth-Hitchcock Medical Center, White River Junction, USA
| | - Amit Rastogi
- Division of Gastroenterology, University of Kansas Medical Center, Kansas City, USA
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Division of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Amrita Sethi
- Division of Digestive and Liver Disease, Columbia University Irving Medical Center, New York City, USA
| | - Rajvinder Singh
- Gastroenterology Unit, Division of Surgery, Northern Adelaide Local Health Area Network, Adelaide, Australia
- Department of Gastroenterology, University of Adelaide, Adelaide, Australia
| | - Noriko Suzuki
- Wolfson Unit for Endoscopy, St. Mark's Hospital, London, UK
| | - Shinji Tanaka
- Gastroenterology Division, JA Onomichi General Hospital, Hiroshima, Japan
| | - Michael Vieth
- Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg, Klinikum Bayreuth, Bayreuth, Germany
| | - Hironori Yamamoto
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan
| | - Dong-Hoon Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chizu Yokoi
- Department of Gastroenterology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Daniel von Renteln
- Montreal University Hospital Research Center, Montreal, Canada
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
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Tanino F, Yamashita K, Morimoto S, Takehara Y, Yamamoto N, Kamigaichi Y, Nishimura T, Tanaka H, Takigawa H, Urabe Y, Kuwai T, Shimamoto F, Oka S. Comparative prediction of lymph node metastasis in pT1 colorectal cancer among Western and Japanese guidelines. Front Oncol 2024; 14:1475270. [PMID: 39544306 PMCID: PMC11560900 DOI: 10.3389/fonc.2024.1475270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2024] [Accepted: 10/04/2024] [Indexed: 11/17/2024] Open
Abstract
Background Additional surgery with lymph node (LN) dissection is recommended for pT1 colorectal carcinoma (CRC) resected by endoscopy, based on pathological risk factors for LN metastasis (LNM), according to guidelines by the Japanese Society for Cancer of the Colon and Rectum (JSCCR), National Comprehensive Cancer Network (NCCN), and European Society for Medical Oncology (ESMO). Methods We retrospectively analyzed 560 consecutive patients with T1 CRC who underwent endoscopic resection alone (n=190) or initial or additional surgery with LN dissection (n=370) between 1992 and 2017 at Hiroshima University Hospital. Patients were classified into LNM low- and high-risk groups according to guidelines by the JSCCR, NCCN, and ESMO as follows. Patients without any specified pathological LNM risk factor were included in the LNM low-risk group, while the high-risk group comprised all other patients. We analyzed the LNM predictive ability of each guideline. Results The LNM high-risk rate, sensitivity, specificity, positive and negative predictive values, accuracy of LNM risk, and AUC for LNM predictive ability were 82%, 100%, 19%, 9%, 100%, 26% and 0.596 in the JSCCR guidelines; 52%, 98%, 52%, 15%, 99%, 56%, and 0.749 in the NCCN; and 54%, 98%, 50%, 15%, 99%, 54%, and 0.743 in the ESMO, respectively. Conclusions The JSCCR guidelines could diagnose LNM in all cases but had the highest false-positive rate. It is important to reduce unnecessary additional surgeries for pT1 CRCs after ER.
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Affiliation(s)
- Fumiaki Tanino
- Department of Gastroenterology, Hiroshima University, Hiroshima, Japan
| | - Ken Yamashita
- Department of Gastroenterology, Hiroshima University, Hiroshima, Japan
| | - Shin Morimoto
- Department of Gastroenterology, Hiroshima University, Hiroshima, Japan
| | - Yudai Takehara
- Department of Gastroenterology, Hiroshima University, Hiroshima, Japan
| | - Noriko Yamamoto
- Department of Gastroenterology, Hiroshima University, Hiroshima, Japan
| | - Yuki Kamigaichi
- Department of Gastroenterology, Hiroshima University, Hiroshima, Japan
| | | | - Hidenori Tanaka
- Department of Gastroenterology, Hiroshima University, Hiroshima, Japan
| | - Hidehiko Takigawa
- Department of Gastroenterology, Hiroshima University, Hiroshima, Japan
| | - Yuji Urabe
- Department of Gastroenterology, Hiroshima University, Hiroshima, Japan
| | - Toshio Kuwai
- Department of Gastrointestinal Endoscopy and Medicine, Hiroshima University, Hiroshima, Japan
| | - Fumio Shimamoto
- Department of Health Sciences, Hiroshima Cosmopolitan University, Hiroshima, Japan
| | - Shiro Oka
- Department of Gastroenterology, Hiroshima University, Hiroshima, Japan
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Yue B, Jia M, Xu R, Chen GY, Jin ML. Histological Risk Factors for Lymph Node Metastasis in pT1 Colorectal Cancer: Does Submucosal Invasion Depth Really Matter? Curr Med Sci 2024; 44:1026-1035. [PMID: 39390217 DOI: 10.1007/s11596-024-2926-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 08/18/2024] [Indexed: 10/12/2024]
Abstract
OBJECTIVE After endoscopic resection of colorectal cancer with submucosal invasion (pT1 CRC), additional surgical treatment is recommended if deep submucosal invasion (DSI) is present. This study aimed to further elucidate the risk factors for lymph node metastasis (LNM) in patients with pT1 CRC, especially the effect of DSI on LNM. METHODS Patients with pT1 CRC who underwent lymph node dissection were selected. The Chi-square test and multivariate logistic regression were used to analyze the relationship between clinicopathological characteristics and LNM. The submucosal invasion depth (SID) was measured via 4 methods and analyzed with 3 cut-off values. RESULTS Twenty-eight of the 239 patients presented with LNM (11.7%), and the independent risk factors for LNM included high histological grade (P=0.003), lymphovascular invasion (LVI) (P=0.004), intermediate to high budding (Bd 2/3) (P=0.008), and cancer gland rupture (CGR) (P=0.008). Moreover, the SID, width of submucosal invasion (WSI), and area of submucosal invasion (ASI) were not significantly different. When one, two, three or more risk factors were identified, the LNM rates were 1.1% (1/95), 12.5% (7/56), and 48.8% (20/41), respectively. CONCLUSION Indicators such as the SID, WSI, and ASI are not risk factors for LNM and are subjective in their measurement, which renders them relatively inconvenient to apply in clinical practice. In contrast, histological grade, LVI, tumor budding and CGR are relatively straightforward to identify and have been demonstrated to be statistically significant. It would be prudent to focus on these histological factors rather than subjective measurements.
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Affiliation(s)
- Bing Yue
- Department of Pathology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
- Department of Pathology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100015, China
| | - Mei Jia
- Department of Pathology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Rui Xu
- Department of Pathology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Guang-Yong Chen
- Department of Pathology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China.
| | - Mu-Lan Jin
- Department of Pathology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100015, China.
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Meulen LW, Haasnoot KJ, Vlug MS, Wolfhagen FH, Baven-Pronk MA, van der Voorn MP, Schwartz MP, Vogelaar L, de Vos tot Nederveen Cappel WH, Seerden TC, Hazen WL, Schrauwen RW, Alvarez-Herrero L, Schreuder RM, van Nunen AB, Stoop E, de Bruin GJ, Bos P, Marsman WA, Kuiper E, de Bièvre M, Alderlieste YA, Roomer R, Groen J, Bigirwamungu-Bargeman M, Siersema PD, Elias SG, Masclee AA, Moons LM, on behalf of the OPTICAL-STAR study team and the Dutch T1 CRC Working Group . Effect of optical diagnosis training on recognition and treatment of submucosal invasive colorectal cancer in community hospitals: a prospective multicenter intervention study. Endoscopy 2024; 56:770-779. [PMID: 38657659 PMCID: PMC11436291 DOI: 10.1055/a-2313-4996] [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] [Received: 04/07/2023] [Accepted: 04/24/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Recognition of submucosal invasive colorectal cancer (T1 CRC) is difficult, with sensitivities of 35 %-60 % in Western countries. We evaluated the real-life effects of training in the OPTICAL model, a recently developed structured and validated prediction model, in Dutch community hospitals. METHODS In this prospective multicenter study (OPTICAL II), 383 endoscopists from 40 hospitals were invited to follow an e-learning program on the OPTICAL model, to increase sensitivity in detecting T1 CRC in nonpedunculated polyps. Real-life recognition of T1 CRC was then evaluated in 25 hospitals. Endoscopic and pathologic reports of T1 CRCs detected during the next year were collected retrospectively, with endoscopists unaware of this evaluation. Sensitivity for T1 CRC recognition, R0 resection rate, and treatment modality were compared for trained vs. untrained endoscopists. RESULTS 1 year after e-learning, 528 nonpedunculated T1 CRCs were recorded for endoscopies performed by 251 endoscopists (118 [47 %] trained). Median T1 CRC size was 20 mm. Lesions were mainly located in the distal colorectum (66 %). Trained endoscopists recognized T1 CRCs more frequently than untrained endoscopists (sensitivity 74 % vs. 62 %; mixed model analysis odds ratio [OR] 2.90, 95 %CI 1.54-5.45). R0 resection rate was higher for T1 CRCs detected by trained endoscopists (69 % vs. 56 %; OR 1.73, 95 %CI 1.03-2.91). CONCLUSION Training in optical recognition of T1 CRCs in community hospitals was associated with increased recognition of T1 CRCs, leading to higher en bloc and R0 resection rates. This may be an important step toward more organ-preserving strategies.
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Affiliation(s)
- Lonne W.T. Meulen
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands
- GROW, School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Krijn J.C. Haasnoot
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Marije S. Vlug
- Department of Gastroenterology and Hepatology, Dijklander Hospital, Hoorn, The Netherlands
| | - Frank H.J. Wolfhagen
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | | | | | - Matthijs P. Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands
| | - Lauran Vogelaar
- Department of Gastroenterology and Hepatology, Diakonessenhuis, Utrecht, The Netherlands
| | | | - Tom C.J. Seerden
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, The Netherlands
| | - Wouter L. Hazen
- Department of Gastroenterology and Hepatology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Ruud W.M. Schrauwen
- Department of Gastroenterology and Hepatology, Bernhoven, Uden, The Netherlands
| | - Lorenza Alvarez-Herrero
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Ramon-Michel Schreuder
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Annick B. van Nunen
- Department of Gastroenterology and Hepatology, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
| | - Esther Stoop
- Department of Gastroenterology and Hepatology, Haaglanden Medical Center, Den Haag, The Netherlands
| | - Gijs J. de Bruin
- Department of Gastroenterology and Hepatology, Tergooi Hospital, Hilversum, The Netherlands
| | - Philip Bos
- Department of Gastroenterology and Hepatology, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Willem A. Marsman
- Department of Gastroenterology and Hepatology, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Edith Kuiper
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Marc de Bièvre
- Department of Gastroenterology and Hepatology, Viecuri Medical Center, Venlo, The Netherlands
| | | | - Robert Roomer
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis, Rotterdam, The Netherlands
| | - John Groen
- Department of Gastroenterology and Hepatology, Sint Jansdal Hospital, Harderwijk, The Netherlands
| | | | - Peter D. Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sjoerd G. Elias
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ad A.M. Masclee
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Leon M.G. Moons
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
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Liu C, Ye L, Peng T, Chen L, Zhang Y, Zhou Y, Du J, Bai S, Luo Y, Zhang W, Li J, Zhang Y, Wen W, Chen Z, Liu Y, Sun Z, Pan F, Yuan X, Liu W, Mou Y, Zhang Q, Hu B. Correlation between tumor budding and the long-term follow-up outcomes after endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma. Surg Endosc 2024; 38:5575-5583. [PMID: 39090202 DOI: 10.1007/s00464-024-11124-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 07/27/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND The effect of tumor budding (TB) on the prognosis of patients with esophageal squamous cell carcinoma (ESCC) after endoscopic submucosal dissection (ESD) remains unclear. We evaluated the long-term outcomes of patients with superficial ESCC after ESD and the risk factors of TB for the long-term prognosis. METHODS We conducted a retrospective study in a Chinese hospital. All patients with ESCC treated by ESD and reported TB were included consecutively. Comparative analyses were conducted in three parts: specimen analysis, follow-up analyses of unmatched patients, and propensity score-matched (PSM) patients. Cox proportional hazard regression models were constructed to identify risk factors for overall survival and recurrence-free survival (RFS). RESULTS A total of 437 patients were enrolled [154 TB and 283 no tumor budding (NTB)], and 258 patients (52 TB and 206 NTB) were included in the follow-up analysis. Results showed that the invasion depth, differentiation type, and positive vascular invasion (all p < 0.001) of the TB group were significantly different from the NTB group. The all-cause mortality and the median RFS time between the two groups were comparable. RFS rate at 5 years were 84.6% and 80.6%, respectively (p = 0.43). Cox analyses identified that having other cancers but not TB, as a risk factor independently associated with overall survival and RFS after ESD. CONCLUSION TB tends to be associated with invasion depth, differentiation type, and positive vascular invasion. However, it might not affect the long-term outcomes of patients with superficial ESCC after ESD when other high-risk factors are negative.
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Affiliation(s)
- Cenqin Liu
- Department of Gastroenterology and Hepatology/Digestive Endoscopy Medical Engineering Research Laboratory, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Liansong Ye
- Department of Gastroenterology and Hepatology/Digestive Endoscopy Medical Engineering Research Laboratory, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Tingfa Peng
- Department of Gastroenterology, Armed Police Forces Hospital of Sichuan, Leshan, China
| | - Liuxiang Chen
- Department of Gastroenterology and Hepatology/Digestive Endoscopy Medical Engineering Research Laboratory, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Yuhang Zhang
- Department of Gastroenterology and Hepatology/Digestive Endoscopy Medical Engineering Research Laboratory, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Yang Zhou
- Department of Gastroenterology and Hepatology/Digestive Endoscopy Medical Engineering Research Laboratory, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Jiang Du
- Department of Gastroenterology and Hepatology/Digestive Endoscopy Medical Engineering Research Laboratory, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Shuai Bai
- Department of Gastroenterology and Hepatology/Digestive Endoscopy Medical Engineering Research Laboratory, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Yonghong Luo
- Department of Gastroenterology and Hepatology/Digestive Endoscopy Medical Engineering Research Laboratory, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Wanhong Zhang
- Department of Gastroenterology, Cangxi People's Hospital, Guangyuan, China
| | - Jia Li
- Department of Gastroenterology, Cangxi People's Hospital, Guangyuan, China
| | - Yingjie Zhang
- Department of Gastroenterology, Chengdu Second People's Hospital, Chengdu, China
| | - Wu Wen
- Department of Gastroenterology, Chengdu Second People's Hospital, Chengdu, China
| | - Zonghua Chen
- Department of Gastroenterology, Yibin Second People's Hospital, Yibin, China
| | - Yi Liu
- Department of Gastroenterology, Yibin Second People's Hospital, Yibin, China
| | - Zhongshang Sun
- Department of Gastroenterology, Huai'an First People's Hospital, Huai'an, China
| | - Feng Pan
- Department of Gastroenterology, Huai'an First People's Hospital, Huai'an, China
| | - Xianglei Yuan
- Department of Gastroenterology and Hepatology/Digestive Endoscopy Medical Engineering Research Laboratory, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Wei Liu
- Department of Gastroenterology and Hepatology/Digestive Endoscopy Medical Engineering Research Laboratory, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Yi Mou
- Department of Gastroenterology and Hepatology/Digestive Endoscopy Medical Engineering Research Laboratory, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Qiongying Zhang
- Department of Gastroenterology and Hepatology/Digestive Endoscopy Medical Engineering Research Laboratory, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Bing Hu
- Department of Gastroenterology and Hepatology/Digestive Endoscopy Medical Engineering Research Laboratory, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, 610041, Sichuan, China.
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Cheong C, Kim NW, Lee HS, Kang J. Application of machine learning for predicting lymph node metastasis in T1 colorectal cancer: a systematic review and meta-analysis. Langenbecks Arch Surg 2024; 409:287. [PMID: 39311932 DOI: 10.1007/s00423-024-03476-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 09/12/2024] [Indexed: 10/15/2024]
Abstract
BACKGROUND We review and analyze research on the application of machine learning (ML) and deep learning (DL) models to lymph node metastasis (LNM) prediction in patients with T1 colorectal cancer (CRC). Predicting LNM before radical surgery is important in patients with T1 CRC. However, current surgical treatment guidelines are limited. LNM prediction using ML or DL may improve predictive accuracy. The diagnostic accuracy of LNM prediction using ML- and DL-based models for patients with CRC was assessed. METHODS We performed a comprehensive search of the PubMed, Embase, and Cochrane databases (inception to April 30th of 2022) for studies that applied ML or DL to LNM prediction in T1 CRC patients specifically to compare with histopathological findings and not related to radiological aspects. RESULTS 33,199 T1 CRC patients enrolled across seven studies with a retrospective design were included. LNM was observed in 3,173 (9.6%) patients. Overall, the ML- and DL-based model exhibited a sensitivity of 0.944 and specificity of 0.877 for the prediction of LNM in patients with T1 CRC. Six different types of ML and DL models were used across the studies included in this meta-analysis. Therefore, a high degree of heterogeneity was observed. CONCLUSIONS The ML and DL models provided high sensitivity and specificity for predicting LNM in patients with T1 CRC, and the heterogeneity between studies was significant. These results suggest the potential of ML or DL as diagnostic tools. However, more reliable algorithms should be developed for predicting LNM before surgery in patients with T1 CRC.
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Affiliation(s)
- Chinock Cheong
- Department of Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Na Won Kim
- Yonsei University Medical Library, Seoul, Republic of Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jeonghyun Kang
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Mateos Sanchez C, Quintanilla Lazaro E, Rabago LR. How secure can we expect the surveillance policies to be after the implementation in T1 polyps with carcinoma? World J Gastrointest Endosc 2024; 16:502-508. [PMID: 39351175 PMCID: PMC11438583 DOI: 10.4253/wjge.v16.i9.502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 08/08/2024] [Accepted: 08/20/2024] [Indexed: 09/12/2024] Open
Abstract
Approximately 7% of the polyps resected endoscopically have an adenocarcinoma focus, with no previous endoscopic evidence of malignancy. This raises the question of whether endoscopic resection has been curative. Furthermore, there is no consensus on what the endoscopic and histological criteria for good prognosis are, the appropriate follow-up strategy and what are the long-term results. The aim of the retrospective study by Fábián et al was to evaluate the occurrence of local relapse or distant metastasis in those tumors that were resected endoscopically compared to those that underwent oncologic surgery. They concluded that, regardless of the treatment strategy chosen, there was a higher recurrence rate than described in the literature and that adherence to follow-up was poor. The management approach for an endoscopically benign polyp histologically confirmed as adenocarcinoma depends on the presence of any of the previously described poor prognostic histological factors. If none of these factors are present and the polyp has been completely resected en bloc (R0), active surveillance is considered appropriate as endoscopic resection is deemed curative. These results highlight, once again, the need for further multicentric clinical practice studies to obtain more evidence for the purpose of establishing appropriate treatment and follow-up strategies.
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Affiliation(s)
| | | | - Luis Ramon Rabago
- Department of Gastroenterology, San Rafael Hospital, Madrid 28016, Spain
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Ichimasa K, Kudo SE, Misawa M, Yeoh KG, Nemoto T, Kouyama Y, Takashina Y, Miyachi H. Accuracy Goals in Predicting Preoperative Lymph Node Metastasis for T1 Colorectal Cancer Resected Endoscopically. Gut Liver 2024; 18:803-806. [PMID: 39049721 PMCID: PMC11391136 DOI: 10.5009/gnl240081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 04/27/2024] [Accepted: 05/07/2024] [Indexed: 07/27/2024] Open
Abstract
Submucosal invasive (T1) colorectal cancer is a significant clinical management challenge, with an estimated 10% of patients developing extraintestinal lymph node metastasis. This condition necessitates surgical resection along with lymph node dissection to achieve a curative outcome. Thus, the precise preoperative assessment of lymph node metastasis risk is crucial to guide treatment decisions after endoscopic resection. Contemporary clinical guidelines strive to identify a low-risk cohort for whom endoscopic resection will suffice, applying stringent criteria to maximize patient safety. Those failing to meet these criteria are often recommended for surgical resection, with its associated mortality risks although it may still include patients with a low risk of metastasis. In the quest to enhance the precision of preoperative lymph node metastasis risk prediction, innovative models leveraging artificial intelligence or nomograms are being developed. Nevertheless, the debate over the ideal sensitivity and specificity for such models persists, with no consensus on target metrics. This review puts forth postoperative mortality rates as a practical benchmark for the sensitivity of predictive models. We underscore the importance of this method and advocate for research to amass data on surgical mortality in T1 colorectal cancer. Establishing specific benchmarks for predictive accuracy in lymph node metastasis risk assessment will hopefully optimize the treatment of T1 colorectal cancer.
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Affiliation(s)
- Katsuro Ichimasa
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Shin-ei Kudo
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Masashi Misawa
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Khay Guan Yeoh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tetsuo Nemoto
- Department of Pathology and Laboratory Medicine, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Yuta Kouyama
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Yuki Takashina
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Hideyuki Miyachi
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
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Tovar Pérez R, Cerdán Santacruz C, Cano-Valderrama Ó, Jiménez Escovar F, Flor Lorente B, Perez RO, García Septiem J. Local Excision for organ preservation in early REctal cancer with No Adjuvant treatment (LORENA Trial): prospective observational study protocol. Cir Esp 2024; 102:506-512. [PMID: 38763491 DOI: 10.1016/j.cireng.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 04/12/2024] [Indexed: 05/21/2024]
Abstract
INTRODUCTION Local resection (LR) is an alternative to total mesorectal excision (TME) that avoids its associated morbidity to the detriment of oncological radicality in early stages of rectal cancer. There are several conditioning factors for the success of this strategy, such as poor prognosis histological factors (PPHF), involvement of resection margins, clinical under staging, or complications that may lead to the indication for radical surgery with TME. PATIENTS AND METHOD An international multicenter prospective observational open-label study has been designed. Consecutive patients diagnosed with early rectal cancer (cT1N0 on MRI +/- endorectal ultrasound) whose lower limit is a maximum of 2 cm proximal to the ano-rectal junction will be included. The primary objective of the study is to determine the overall prevalence of PPHF after LR and requiring TME or postoperative radio-chemotherapy. DISCUSSION The prevalence of PPHF conditioning the success of LR in early distal rectal cancer has been scarcely studied in the literature, and there are very few prospective data. Considering the increasing interest in the watch and wait strategy in rectal cancer and its possible application in early-stage tumors, it seems necessary to know this information. The results of this study will help guide clinical practice in patients with early distal rectal cancer. It will also provide quality information for the design of future comparative studies to improve organ preservation success in these patients. TRIAL REGISTRATION NUMBER NCT05927584.
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Affiliation(s)
- Rodrigo Tovar Pérez
- General and Digestive Surgery Department, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Carlos Cerdán Santacruz
- Colorectal Surgery Department, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain; Colorectal Surgery Department, Clínica Santa Elena, Madrid, Spain.
| | - Óscar Cano-Valderrama
- Colorectal Surgery Department, Complejo Hospitalario Universitario de Vigo, Vigo, Spain
| | | | - Blas Flor Lorente
- Colorectal Surgery Department, Hospital Polite´cnico Universitario la Fe, Valencia, Spain
| | - Rodrigo O Perez
- Department of Surgical Oncology, Hospital Beneficencia Portuguesa, São Paulo, Brasil; Division of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brasil; Angelita and Joaquim Gama Institute, São Paulo, Brasil
| | - Javier García Septiem
- Colorectal Surgery Department, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain
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Medic S, Nilsson E, Rönnow CF, Thorlacius H. Lymphovascular invasion is a dominant risk factor for lymph node metastasis in T2 rectal cancer. Endosc Int Open 2024; 12:E1056-E1062. [PMID: 39268155 PMCID: PMC11392589 DOI: 10.1055/a-2405-1117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 07/11/2024] [Indexed: 09/15/2024] Open
Abstract
Background and study aims Surgical resection is standard treatment of T2 rectal cancer due to risk of concomitant lymph node metastases (LNM). Local resection could potentially be an alternative to surgical treatment in a subgroup of patients with low risk of LNM. The aim of this study was to identify clinical and histopathological risk factors of LNM in T2 rectal cancer. Patients and methods This was a retrospective registry-based population study on prospectively collected data on all patients with T2 rectal cancer undergoing surgical resection in Sweden between 2009 and 2021. Potential risk factors of LNM, including age, gender, resection margin, lymphovascular invasion (LVI), histologic grade, mucinous cancer, and perineural invasion (PNI) were analyzed using univariate and multivariate logistic regression. Results Of 1607 patients, 343 (21%) with T2 rectal cancer had LNM. LVI (odds ratio [OR] = 4.21, P < 0.001) and age < 60 years (OR = 1.80, P < 0.001) were significant and independent risk factors. However, PNI (OR = 1.50, P = 0.15), mucinous cancer (OR = 1.14, P = 0.60), histologic grade (OR = 1.47, P = 0.07) and non-radical resection margin (OR = 1.64, P = 0.38) were not significant risk factors for LNM in multivariate analyses. The incidence of LNM was 15% in the absence of any risk factor. Conclusions This was a large study on LNM in T2 rectal cancer which showed that LVI is the dominant risk factor. Moreover, low age constituted an independent risk factor, whereas gender, resection margin, PNI, histologic grade, and mucinous cancer were not independent risk factors of LNM. Thus, these findings may provide a useful basis for management of patients after local resection of early rectal cancer.
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Affiliation(s)
- Selma Medic
- Department of Clinical Sciences, Lund University Surgery, Malmö, Sweden
| | - Emelie Nilsson
- Clinical Sciences and Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
| | | | - Henrik Thorlacius
- Clinical Sciences and Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
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O’Sullivan T, Bourke MJ. Endoscopic Resection of Neoplasia in the Lower GI Tract: A Clinical Algorithm. Visc Med 2024; 40:217-227. [PMID: 39157731 PMCID: PMC11326768 DOI: 10.1159/000539219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 05/03/2024] [Indexed: 08/20/2024] Open
Abstract
Background Colorectal cancer is a highly prevalent malignancy and a significant driver of cancer mortality and health-related expenditure worldwide. Polyp removal reduces the incidence and mortality of colorectal cancer. In 2024, endoscopists have an array of resection modalities at their disposal. Each technique requires a unique skillset and has individual advantages and limitations. Consequently, resection in the colorectum requires an evidence-based algorithm approach that considers these factors. Summary A literature review of endoscopic resection for colonic neoplasia was conducted. Best supporting scientific evidence was summarized for the endoscopic resection of diminutive polyps, large ≥20 mm lesions and polyps containing invasive cancer. Factors including resection modality, complications and lesion selection were explored to inform an algorithm approach to colorectal resection. Key Messages Endoscopic resection in the colorectum is not a one-size-fits-all approach. Detailed understanding of polyp size, location, morphology and predicted histology are critical factors that inform appropriate endoscopic resection practice.
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Affiliation(s)
- Timothy O’Sullivan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
- University of Sydney, Westmead Clinical School, Westmead, NSW, Australia
| | - Michael J. Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
- University of Sydney, Westmead Clinical School, Westmead, NSW, Australia
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Song X, Li J, Zhu J, Kong YF, Zhou YH, Wang ZK, Zhang J. Predictors of early colorectal cancer metastasis to lymph nodes: providing rationale for therapy decisions. Front Oncol 2024; 14:1371599. [PMID: 39035744 PMCID: PMC11257837 DOI: 10.3389/fonc.2024.1371599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 06/24/2024] [Indexed: 07/23/2024] Open
Abstract
With the improvement of national health awareness and the popularization of a series of screening methods, the number of patients with early colorectal cancer is gradually increasing, and accurate prediction of lymph node metastasis of T1 colorectal cancer is the key to determining the optimal therapeutic solutions. Whether patients with T1 colorectal cancer undergoing endoscopic resection require additional surgery and regional lymph node dissection is inconclusive in current guidelines. However, we can be sure that in early colorectal cancer without lymph node metastasis, endoscopic resection alone does not affect the prognosis, and it greatly improves the quality of life and reduces the incidence of surgical complications while preserving organ integrity. Therefore, it is vital to discriminate patients without lymph node metastasis in T1 colorectal cancer, and this requires accurate predictors. This paper briefly explains the significance and shortcomings of traditional pathological factors, then extends and states the new pathological factors, clinical test factors, molecular biomarkers, and the risk assessment models of lymph node metastasis based on artificial intelligence.
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Affiliation(s)
| | | | | | | | | | | | - Jin Zhang
- Department of General Surgery, Affiliated Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
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38
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Jung Y. Approaches and considerations in the endoscopic treatment of T1 colorectal cancer. Korean J Intern Med 2024; 39:563-576. [PMID: 38742279 PMCID: PMC11236804 DOI: 10.3904/kjim.2023.487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 12/12/2023] [Accepted: 12/27/2023] [Indexed: 05/16/2024] Open
Abstract
The detection of early colorectal cancer (CRC) is increasing through the implementation of screening programs. This increased detection enhances the likelihood of minimally invasive surgery and significantly lowers the risk of recurrence, thereby improving patient survival and reducing mortality rates. T1 CRC, the earliest stage, is treated endoscopically in cases with a low risk of lymph node metastasis (LNM). The advantages of endoscopic treatment compared with surgery include minimal invasiveness and limited tissue disruption, which reduce morbidity and mortality, preserve bowel function to avoid colectomy, accelerate recovery, and improve cost-effectiveness. However, T1 CRC has a risk of LNM. Thus, selection of the appropriate treatment between endoscopic treatment and surgery, while avoiding overtreatment, is challenging considering the potential for complete resection, LNM, and recurrence risk.
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Affiliation(s)
- Yunho Jung
- Division of Gastroenterology, Department of Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
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39
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Watanabe J, Ichimasa K, Kudo SE, Mochizuki K, Tan KK, Kataoka Y, Tahara M, Kubota T, Takashina Y, Yeoh KG. Risk factors for lymph node metastasis in T2 colorectal cancer: a systematic review and meta-analysis. Int J Clin Oncol 2024; 29:921-931. [PMID: 38709424 DOI: 10.1007/s10147-024-02547-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 04/30/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND Lymph node metastasis (LNM) occurs in 20-25% of patients with T2 colorectal cancer (CRC). Identification of risk factors for LNM in T2 CRC may help identify patients who are at low risk and thereby potential candidates for endoscopic full-thickness resection. We examined risk factors for LNM in T2 CRC with the goal of establishing further criteria of the indications for endoscopic resection. METHODS MEDLINE, CENTRAL, and EMBASE were systematically searched from inception to November 2023. Studies that investigated the association between the presence of LNM and the clinical and pathological factors of T2 CRC were included. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Certainty of evidence (CoE) was assessed using the GRADE approach. RESULTS Fourteen studies (8349 patients) were included. Overall, the proportion of LNM was 22%. The meta-analysis revealed that the presence of lymphovascular invasion (OR, 5.5; 95% CI 3.7-8.3; high CoE), high-grade tumor budding (OR, 2.4; 95% CI 1.5-3.7; moderate CoE), poor differentiation (OR, 2.2; 95% CI 1.8-2.7; moderate CoE), and female sex (OR, 1.3; 95% CI 1.1-1.7; high CoE) were associated with LNM in T2 CRC. Lymphatic invasion (OR, 5.0; 95% CI 3.3-7.6) was a stronger predictor of LNM than vascular invasion (OR, 2.4; 95% CI 2.1-2.8). CONCLUSIONS Lymphovascular invasion, high-grade tumor budding, poor differentiation, and female sex were risk factors for LNM in T2 CRC. Endoscopic resection of T2 CRC in patients with very low risk for LNM may become an alternative to conventional surgical resection. TRIAL REGISTRATION PROSPERO, CRD42022316545.
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Affiliation(s)
- Jun Watanabe
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
- Division of Community and Family Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Katsuro Ichimasa
- Digestive Disease Center, Showa University Northern Yokohama Hospital, 35-1 Chigasaki-chuo, Tsuzuki, Yokohama, 224-8503, Japan.
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
| | - Shin-Ei Kudo
- Digestive Disease Center, Showa University Northern Yokohama Hospital, 35-1 Chigasaki-chuo, Tsuzuki, Yokohama, 224-8503, Japan
| | - Kenichi Mochizuki
- Digestive Disease Center, Showa University Northern Yokohama Hospital, 35-1 Chigasaki-chuo, Tsuzuki, Yokohama, 224-8503, Japan
| | - Ker-Kan Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Surgery, National University Hospital, Singapore, Singapore
| | - Yuki Kataoka
- Department of Internal Medicine, Kyoto Min-Iren Asukai Hospital, Kyoto, Japan
- Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan
- Department of Healthcare Epidemiology, Graduate School of Medicine / School of Public Health, Kyoto University, Kyoto, Japan
| | - Makiko Tahara
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Takafumi Kubota
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan
- Department of Neurology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Yuki Takashina
- Digestive Disease Center, Showa University Northern Yokohama Hospital, 35-1 Chigasaki-chuo, Tsuzuki, Yokohama, 224-8503, Japan
| | - Khay Guan Yeoh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Gastroenterology and Hepatology, National University Hospital, Singapore, Singapore
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40
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Martínez de Juan F, Navarro S, Machado I. Refining Risk Criteria May Substantially Reduce Unnecessary Additional Surgeries after Local Resection of T1 Colorectal Cancer. Cancers (Basel) 2024; 16:2321. [PMID: 39001382 PMCID: PMC11240655 DOI: 10.3390/cancers16132321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 06/20/2024] [Accepted: 06/21/2024] [Indexed: 07/16/2024] Open
Abstract
BACKGROUND The low positive predictive value for lymph node metastases (LNM) of common practice risk criteria (CPRC) in T1 colorectal carcinoma (CRC) leads to manyunnecessary additional surgeries following local resection. This study aimed to identify criteria that may improve on the CPRC. METHODS Logistic regression analysis was performed to determine the association of diverse variables with LNM or 'poor outcome' (LNM and/or distant metastases and/or recurrence) in a single center T1 CRC cohort. The diagnostic capacity of the set of variables obtained was compared with that of the CPRC. RESULTS The study comprised 161 cases. Poorly differentiated clusters (PDC) and tumor budding grade > 1 (TB > 1) were the only independent variables associated with LNM. The area under the curve (AUC) for these criteria was 0.808 (CI 95% 0.717-0.880) compared to 0.582 (CI 95% 0.479-0.680) for CPRC. TB > 1 and lymphovascular invasion (LVI) were independently associated with 'poor outcome', with an AUC of 0.801 (CI 95% 0.731-0.859), while the AUC for CPRC was 0.691 (CI 95% 0.603-0.752). TB > 1, combined either with PDC or LVI, would reduce false positives between 41.5% and 45% without significantly increasing false negatives. CONCLUSIONS Indicating additional surgery in T1 CRC only when either TB > 1, PDC, or LVI are present could reduce unnecessary surgeries significantly.
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Affiliation(s)
- Fernando Martínez de Juan
- Unit of Gastroenterology and Digestive Endoscopy, Instituto Valenciano de Oncología, 46009 Valencia, Spain
| | - Samuel Navarro
- Department of Pathology, Universidad de Valencia, 46010 Valencia, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), 46009 Valencia, Spain
| | - Isidro Machado
- Department of Pathology, Universidad de Valencia, 46010 Valencia, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), 46009 Valencia, Spain
- Department of Pathology, Instituto Valenciano de Oncología, 46009 Valencia, Spain
- Patologika Laboratory, Hospital Quirón-Salud, 46010 Valencia, Spain
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41
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Jiang SX, Zarrin A, Shahidi N. T1 colorectal cancer management in the era of minimally invasive endoscopic resection. World J Gastrointest Oncol 2024; 16:2284-2294. [PMID: 38994167 PMCID: PMC11236244 DOI: 10.4251/wjgo.v16.i6.2284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 04/02/2024] [Accepted: 04/24/2024] [Indexed: 06/13/2024] Open
Abstract
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.
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Affiliation(s)
- Shirley Xue Jiang
- Department of Medicine, University of British Columbia, Vancouver V6Z2K5, British Columbia, Canada
| | - Aein Zarrin
- Department of Medicine, University of British Columbia, Vancouver V6Z2K5, British Columbia, Canada
| | - Neal Shahidi
- Department of Medicine, University of British Columbia, Vancouver V6Z2K5, British Columbia, Canada
- Division of Gastroenterology, St. Paul’s Hospital, Vancouver V6Z2K5, British Columbia, Canada
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42
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Labiad C, Alric H, Barret M, Cazelles A, Rahmi G, Karoui M, Manceau G. Management after local excision of small rectal cancers. Indications for completion total mesorectal excision and possible alternatives. J Visc Surg 2024; 161:173-181. [PMID: 38448362 DOI: 10.1016/j.jviscsurg.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
The treatment of superficial rectal cancers (local excision, or proctectomy with total mesorectal excision (TME) remains controversial. Endoscopy and endorectal ultrasonography are essential for the precise initial definition of these small cancers. During endoscopy, the depth of the lesion can be estimated using virtual chromoendoscopy with magnification, thereby aiding the assessment of the possibilities of local excision. Current international recommendations indicate completion proctectomy after wide local excision for cases where the pathologic examination reveals poorly-differentiated lesions, lymphovascular invasion, grade 2 or 3 tumor budding, and incomplete resection. But debate persists regarding whether the depth of submucosal invasion can accurately predict the risk of lymph node spread. Recent data from the literature suggest that the depth of submucosal invasion should no longer, by itself, be an indication for additional oncological surgery. Adjuvant radio-chemotherapy could be an alternative to completion proctectomy in patients with pT1 rectal cancer and unfavorable histopathological criteria. A Dutch randomized controlled trial is underway to validate this strategy.
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Affiliation(s)
- Camélia Labiad
- Digestive and Oncological Surgery Department, Assistance publique-Hôpitaux de Paris, hôpital européen Georges-Pompidou, université Paris Cité, 20, rue Leblanc, 75015 Paris, France
| | - Hadrien Alric
- Gastroenterology Department, Assistance publique-Hôpitaux de Paris, hôpital européen Georges-Pompidou, université Paris Cité, Paris, France
| | - Maximilien Barret
- Gastroenterology Department, Assistance publique-Hôpitaux de Paris, hôpital Cochin, université Paris Cité, Paris, France
| | - Antoine Cazelles
- Digestive and Oncological Surgery Department, Assistance publique-Hôpitaux de Paris, hôpital européen Georges-Pompidou, université Paris Cité, 20, rue Leblanc, 75015 Paris, France
| | - Gabriel Rahmi
- Gastroenterology Department, Assistance publique-Hôpitaux de Paris, hôpital européen Georges-Pompidou, université Paris Cité, Paris, France
| | - Mehdi Karoui
- Digestive and Oncological Surgery Department, Assistance publique-Hôpitaux de Paris, hôpital européen Georges-Pompidou, université Paris Cité, 20, rue Leblanc, 75015 Paris, France
| | - Gilles Manceau
- Digestive and Oncological Surgery Department, Assistance publique-Hôpitaux de Paris, hôpital européen Georges-Pompidou, université Paris Cité, 20, rue Leblanc, 75015 Paris, France.
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43
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Kouladouros K, Bourke MJ. Endoscopy First: The Best Choice to Optimize Outcomes for Early Gastrointestinal Malignancy. Visc Med 2024; 40:107-109. [PMID: 38873628 PMCID: PMC11166897 DOI: 10.1159/000539178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 05/01/2024] [Indexed: 06/15/2024] Open
Affiliation(s)
- Konstantinos Kouladouros
- Central Interdisciplinary Endoscopy, Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Michael J. Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
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Baral JEM, Kouladouros K. Completion Surgery after Non-Curative Local Resection of Early Rectal Cancer. Visc Med 2024; 40:144-149. [PMID: 38873629 PMCID: PMC11166898 DOI: 10.1159/000538840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 04/10/2024] [Indexed: 06/15/2024] Open
Abstract
Background The expanding indications of local - endoscopic and transanal surgical - resection of early rectal cancer has led to their increased popularity and inclusion in the treatment guidelines. The accuracy of the current diagnostic tools in identifying the low-risk T1 tumors that can be curatively treated with a local resection is low, and thus several patients require additional oncologic surgery with total mesorectal excision (TME). An efficient clinical strategy which avoids overtreatment and obstacle surgical procedures is under debate between different disciplines. Summary Completion surgery has comparable outcomes to primary surgery regarding perioperative morbidity and mortality but also recurrence rates and overall survival. However, local scarring in the mesorectum can make mesorectal excision technically challenging, especially after full-thickness resections, and has been associated with increased rates of permanent ostomy and worse quality of the TME specimen. This risk seems to be lower after muscle-sparing procedures like endoscopic submucosal dissection, which seem to show a benefit in comparison to full-thickness resections. Key Messages Completion surgery after non-curative local resection of gastrointestinal malignancies is safe and feasible. Full-thickness resection techniques can cause scarring of the mesorectum; therefore, muscle-sparing procedures should be preferred.
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Affiliation(s)
| | - Konstantinos Kouladouros
- Central Interdisciplinary Endoscopy, Department of Hepatology and Gastroenterology, Charité University Hospital Berlin – Campus Virchow Klinikum, Berlin, Germany
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45
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Ebigbo A, Nagl S. Endoscopic Assessment of Local Resectability of Colorectal Malignancies. Visc Med 2024; 40:110-115. [PMID: 38873626 PMCID: PMC11166904 DOI: 10.1159/000538317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 03/11/2024] [Indexed: 06/15/2024] Open
Abstract
Background The endoscopic assessment of colorectal malignancies primarily aims at deciding on the local resectability. Local resectability is defined by the risk of lymphonodal metastasis. Summary The gross morphology as well as the surface and vessel patterns provide valuable information prior to endoscopic resection. Various classifications have been standardized to assist endoscopists during endoscopic assessment. Key Message The macroscopic assessment of colorectal malignancies should include the Paris and laterally spreading tumor (LST) classification as well as chromoendoscopic assessments such as Kudo's pit pattern and the Japanese NBI Expert Team classifications to describe the vessel and surface patterns.
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Affiliation(s)
- Alanna Ebigbo
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Sandra Nagl
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
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46
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Chaussade S, Corre F, Pellat A, Coriat R, Terris B. Comment on "How Does Omitting Additional Surgery After Local Excision Affect the Prognostic Outcome of Patients With High-Risk T1 Colorectal Cancer?". ANNALS OF SURGERY OPEN 2024; 5:e441. [PMID: 38911637 PMCID: PMC11191945 DOI: 10.1097/as9.0000000000000441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 04/21/2024] [Indexed: 06/25/2024] Open
Affiliation(s)
- Stanislas Chaussade
- From the Department of Gastroenterology, Digestive Oncology and Endoscopy, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Félix Corre
- From the Department of Gastroenterology, Digestive Oncology and Endoscopy, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Anna Pellat
- From the Department of Gastroenterology, Digestive Oncology and Endoscopy, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Romain Coriat
- From the Department of Gastroenterology, Digestive Oncology and Endoscopy, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Benoit Terris
- Department of Pathology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
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47
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Nilsson E, Wetterholm E, Syk I, Thorlacius H, Rönnow CF. Risk of recurrence in high-risk T1 colon cancer following endoscopic and surgical resection: registry-based cohort study. BJS Open 2024; 8:zrae053. [PMID: 38869239 PMCID: PMC11170496 DOI: 10.1093/bjsopen/zrae053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 04/01/2024] [Accepted: 04/07/2024] [Indexed: 06/14/2024] Open
Abstract
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.
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Affiliation(s)
- Emelie Nilsson
- Department of Clinical Sciences, Division of Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Erik Wetterholm
- Department of Clinical Sciences, Division of Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Ingvar Syk
- Department of Clinical Sciences, Division of Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Henrik Thorlacius
- Department of Clinical Sciences, Division of Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Carl-Fredrik Rönnow
- Department of Clinical Sciences, Division of Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
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48
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Watanabe J, Ichimasa K, Kataoka Y, Miki A, Someko H, Honda M, Tahara M, Yamashina T, Yeoh KG, Kawai S, Kotani K, Sata N. Additional staining for lymphovascular invasion is associated with increased estimation of lymph node metastasis in patients with T1 colorectal cancer: Systematic review and meta-analysis. Dig Endosc 2024; 36:533-545. [PMID: 37746764 DOI: 10.1111/den.14691] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 09/20/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVES Lymphovascular invasion (LVI) is a critical risk factor for lymph node metastasis (LNM), which requires additional surgery after endoscopic resection of T1 colorectal cancer (CRC). However, the impact of additional staining on estimating LNM is unclear. This systematic review aimed to evaluate the impact of additional staining on determining LNM in T1 CRC. METHODS We searched five electronic databases. Outcomes were diagnostic odds ratio (DOR), assessed using hierarchical summary receiver operating characteristic curves, and interobserver agreement among pathologists for positive LVI, assessed using Kappa coefficients (κ). We performed a subgroup analysis of studies that simultaneously included a multivariable analysis for other risk factors (deep submucosal invasion, poor differentiation, and tumor budding). RESULTS Among the 64 studies (18,097 patients) identified, hematoxylin-eosin (HE) and additional staining for LVI had pooled sensitivities of 0.45 (95% confidence interval [CI] 0.32-0.58) and 0.68 (95% CI 0.44-0.86), specificities of 0.88 (95% CI 0.78-0.94) and 0.76 (95% CI 0.62-0.86), and DORs of 6.26 (95% CI 3.73-10.53) and 6.47 (95% CI 3.40-12.32) for determining LNM, respectively. In multivariable analysis, the DOR of additional staining for LNM (DOR 5.95; 95% CI 2.87-12.33) was higher than that of HE staining (DOR 1.89; 95% CI 1.13-3.16) (P = 0.01). Pooled κ values were 0.37 (95% CI 0.22-0.52) and 0.62 (95% CI 0.04-0.99) for HE and additional staining for LVI, respectively. CONCLUSION Additional staining for LVI may increase the DOR for LNM and interobserver agreement for positive LVI among pathologists.
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Affiliation(s)
- Jun Watanabe
- Division of Gastroenterological, General and Transplant Surgery, Department of Surgery, Jichi Medical University, Tochigi, Japan
- Division of Community and Family Medicine, Jichi Medical University, Tochigi, Japan
| | - Katsuro Ichimasa
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Kanagawa, Japan
- Department of Medicine, National University of Singapore, Singapore City, Singapore
| | - Yuki Kataoka
- Department of Internal Medicine, Kyoto Min-iren Asukai Hospital, Kyoto, Japan
- Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine/Public Health, Kyoto, Japan
- Scientific Research WorkS Peer Support Group, Osaka, Japan
| | - Atsushi Miki
- Division of Gastroenterological, General and Transplant Surgery, Department of Surgery, Jichi Medical University, Tochigi, Japan
| | - Hidehiro Someko
- Scientific Research WorkS Peer Support Group, Osaka, Japan
- General Internal Medicine, Asahi General Hospital, Chiba, Japan
| | - Munenori Honda
- Department of Gastroenterology and Hepatology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Makiko Tahara
- Division of Gastroenterological, General and Transplant Surgery, Department of Surgery, Jichi Medical University, Tochigi, Japan
| | - Takeshi Yamashina
- Division of Gastroenterology and Hepatology, Kansai Medical University Medical Center, Osaka, Japan
| | - Khay Guan Yeoh
- Department of Medicine, National University of Singapore, Singapore City, Singapore
- Department of Gastroenterology and Hepatology, National University Hospital, Singapore City, Singapore
| | - Shigeo Kawai
- Department of Diagnostic Pathology, Tochigi Medical Center Shimotsuga, Tochigi, Japan
| | - Kazuhiko Kotani
- Division of Community and Family Medicine, Jichi Medical University, Tochigi, Japan
| | - Naohiro Sata
- Division of Gastroenterological, General and Transplant Surgery, Department of Surgery, Jichi Medical University, Tochigi, Japan
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Wang K, He H, Lin Y, Zhang Y, Chen J, Hu J, He X. A new clinical model for predicting lymph node metastasis in T1 colorectal cancer. Int J Colorectal Dis 2024; 39:46. [PMID: 38565736 PMCID: PMC10987358 DOI: 10.1007/s00384-024-04621-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/22/2024] [Indexed: 04/04/2024]
Abstract
PURPOSE Lymph node metastasis (LNM) is a crucial factor that determines the prognosis of T1 colorectal cancer (CRC) patients. We aimed to develop a practical prediction model for LNM in T1 CRC. METHODS We conducted a retrospective analysis of data from 825 patients with T1 CRC who underwent radical resection at a single center in China. All enrolled patients were randomly divided into a training set and a validation set at a ratio of 7:3 using R software. Risk factors for LNM were identified through multivariate logistic regression analyses. Subsequently, a prediction model was developed using the selected variables. RESULTS The lymph node metastasis (LNM) rate was 10.1% in the training cohort and 9.3% in the validation cohort. In the training set, risk factors for LNM in T1 CRC were identified, including depressed endoscopic gross appearance, sex, submucosal invasion combined with tumor grade (DSI-TG), lymphovascular invasion (LVI), and tumor budding. LVI emerged as the most potent predictor for LNM. The prediction model based on these factors exhibited good discrimination ability in the validation sets (AUC: 79.3%). Compared to current guidelines, the model could potentially reduce over-surgery by 48.9%. Interestingly, we observed that sex had a differential impact on LNM between early-onset and late-onset CRC patients. CONCLUSIONS We developed a clinical prediction model for LNM in T1 CRC using five factors that are easily accessible in clinical practice. The model has better predictive performance and practicality than the current guidelines and can assist clinicians in making treatment decisions for T1 CRC patients.
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Affiliation(s)
- Kai Wang
- Department of Anaesthesia, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Hui He
- Department of General Surgery (Colorectal Surgery), The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yanyun Lin
- Department of General Surgery (Colorectal Surgery), The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yanhong Zhang
- Department of General Surgery (Colorectal Surgery), The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Junguo Chen
- Department of General Surgery (Colorectal Surgery), The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
- Department of Thoracic Surgery, Thoracic Cancer Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jiancong Hu
- Department of General Surgery (Colorectal Surgery), The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.
| | - Xiaosheng He
- Department of General Surgery (Colorectal Surgery), The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.
- Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.
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50
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Dawson H, Bokhorst J, Studer L, Vieth M, Oguz Erdogan AS, Kus Öztürk S, Kirsch R, Brockmoeller S, Cathomas G, Buslei R, Fink D, Roumet M, Zlobec I, van der Laak J, Nagtegaal ID, Lugli A. Lymph node metastases and recurrence in pT1 colorectal cancer: Prediction with the International Budding Consortium Score-A retrospective, multi-centric study. United European Gastroenterol J 2024; 12:299-308. [PMID: 38193866 PMCID: PMC11017758 DOI: 10.1002/ueg2.12521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 11/03/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND The International Collaboration on Cancer Reporting proposes histological tumour type, lymphovascular invasion, tumour grade, perineural invasion, extent, and dimensions of invasion as risk factors for lymph node metastases and tumour progression in completely endoscopically resected pT1 colorectal cancer (CRC). OBJECTIVE The aim of the study was to propose a predictive and reliable score to optimise the clinical management of endoscopically resected pT1 CRC patients. METHODS This multi-centric, retrospective International Budding Consortium (IBC) study included an international pT1 CRC cohort of 565 patients. All cases were reviewed by eight expert gastrointestinal pathologists. All risk factors were reported according to international guidelines. Tumour budding and immune response (CD8+ T-cells) were assessed with automated models using artificial intelligence. We used the information on risk factors and least absolute shrinkage and selection operator logistic regression to develop a prediction model and generate a score to predict the occurrence of lymph node metastasis or cancer recurrence. RESULTS The IBC prediction score included the following parameters: lymphovascular invasion, tumour buds, infiltration depth and tumour grade. The score has an acceptable discrimination power (area under the curve of 0.68 [95% confidence intervals (CI) 0.61-0.75]; 0.64 [95% CI 0.57-0.71] after internal validation). At a cut-off of 6.8 points to discriminate high-and low-risk patients, the score had a sensitivity and specificity of 0.9 [95% CI 0.8-0.95] and 0.26 [95% 0.22, 0.3], respectively. CONCLUSION The IBC score is based on well-established risk factors and is a promising tool with clinical utility to support the management of pT1 CRC patients.
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Affiliation(s)
- Heather Dawson
- Institute of Tissue Medicine and PathologyUniversity of BernBernSwitzerland
| | | | - Linda Studer
- Institute of Tissue Medicine and PathologyUniversity of BernBernSwitzerland
- Institute of Artificial Intelligence and Complex SystemsUniversity of Applied Sciences and Arts Western SwitzerlandFribourgSwitzerland
| | - Michael Vieth
- Institute of PathologyFriedrich‐Alexander‐University Erlangen‐NurembergKlinikum BayreuthBayreuthGermany
| | | | | | - Richard Kirsch
- Pathology and Laboratory MedicineMount Sinai HospitalUniversity of TorontoTorontoOntarioCanada
| | - Scarlett Brockmoeller
- Pathology and Data AnalyticsLeeds Institute of Medical Research at St. James's School of MedicineLeedsUK
| | - Gieri Cathomas
- Institute of PathologyKantonsspital BasellandLiestalSwitzerland
- Present address:
Institute of Tissue Medicine and PathologyUniversity of BernBernSwitzerland.
| | - Rolf Buslei
- Institut und Praxis für Pathologie, Neuropathologie, Molekulare Diagnostik und ZytologieSozialstiftung BambergBambergGermany
| | - David Fink
- Department of Pathology and ImmunologyBaylor College of MedicineHoustonTexasUSA
| | - Marie Roumet
- Clinical Trials UnitUniversity of BernBernSwitzerland
| | - Inti Zlobec
- Institute of Tissue Medicine and PathologyUniversity of BernBernSwitzerland
| | | | | | - Alessandro Lugli
- Institute of Tissue Medicine and PathologyUniversity of BernBernSwitzerland
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