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

doi:10.1016/j.gie.2011.07.069

Gastrointestinal Endoscopy

Volume 74, Issue 6, December 2011, Pages 1337-1346

https://doi.org/10.1016/j.gie.2011.07.069 Get rights and content

Background

EMR has emerged as an alternative therapeutic option for selected cases of early colorectal cancer (ECC). However, the factors associated with resectability and curability of EMR for ECC remain unknown.

Objective

To investigate clinical outcomes and factors related to resectability and curability in ECC cases treated with EMR.

Design

Retrospective study.

Setting

Tertiary-care academic medical center.

Patients

This study involved all patients in whom EMR was performed for ECC at Severance Hospital between March 1997 and August 2007. A total of 236 cases of ECC occurring in 231 patients (66.2% men) were enrolled.

Intervention

EMR. Curative surgical resection and lymph node dissection were used in cases that were incompletely cured by EMR.

Main Outcome Measurements

Resectability, curability, and recurrence.

Results

Complete cure was achieved for 162 lesions (68.6%). Of the remaining 74 cases (31.4%), 69 (29.2%) were incompletely cured, and the other 5 (2.1%) had an undetermined resection status and ultimately required supplementary surgical resection for curative treatment. Location on the right side of the colon, piecemeal resection, and submucosal carcinoma were independently associated with incomplete resection, whereas depressed tumor type was independently related to incomplete cure. Among the ECC cases completely cured by EMR and followed for more than a year (n = 118), local recurrence was observed in one case (0.8%) during the median follow-up period of 39.4 months (range 12.4-123.1 months).

Limitations

Single-center, retrospective study.

Conclusion

Our data show that EMR is feasible and could be an effective option for treatment of ECC if the technique is applied with the appropriate indications.

Section snippets

Patients

All EMRs for ECC performed at Severance Hospital, Yonsei University School of Medicine, between March 1997 and August 2007 were initially considered for enrollment in this study. Patients with synchronous advanced colorectal cancers, familial colorectal cancers, and inflammatory bowel diseases were excluded. Pre- and post-EMR clinicopathologic data were collected retrospectively. ECC was defined according to the Japanese classification of colorectal carcinoma⁸ as limited to the mucosa or

EMR

Second-stage planned endoscopic resection was performed on 208 (88.1%) cases, whereas only 28 (11.9%) cases were endoscopically resected at the time of initial identification. Endoscopic resection was performed with or without saline solution-epinephrine injection at the discretion of the endoscopist. Usually, injection was used for flat, depressed, or protruding lesion types but not for pedunculated lesions. In cases of endoscopic piecemeal mucosal resection, endoscopists attempted to take

Baseline characteristics of study patients

A total of 236 lesions from 231 patients were included in the study. The number of cancerous lesions was 1 in 226 patients (97.8%) and 2 in 5 patients (2.2%). The baseline characteristics of the patients and the tumors are summarized in Table 1. Forty-two cases (17.8%) were lost to follow-up. Among patients with more than a year of follow-up, the median follow-up period was 42.1 months (range 12.4-123.1 months; interquartile range [IQR] 27.1-54.5 months).

Techniques of EMR

EMR included snaring polypectomy without

Discussion

EMR has emerged as a curative treatment for colorectal cancer in the mucosa or with superficial invasion of the submucosa.¹⁴ There have been many studies evaluating the efficacy and safety of EMR for ECC.10, 15, 16, 17, 18, 19, 20 However, most of these studies have limitations in terms of the small number of ECC cases and the varying criteria for complete cure between studies. Therefore, clinicopathologic factors associated with resectability and curability of endoscopic resection for ECC have

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The size of neoplastic lesions has traditionally been used as a main factor to predict complexity of ER. However, an increasing body of evidence has suggested the influence of other parameters such as location of the lesion, ease of access to the lesion itself, pit pattern, operator experience, morphology or type of ER technique [22–28]. The SMSA score includes four variables: location, morphology, size and access.
Whilst polyp size has been traditionally used as a predictor of the complexity of endoscopic resection, the influence of other factors is increasingly recognised. The SMSA grading system takes into account polyp Site, Morphology, Size and Access, with higher scores correlating with increased technical difficulty.
To evaluate whether the SMSA grading tool correlates with endoscopic and clinical outcomes.
This retrospective study was conducted at two high volume centres in the United Kingdom and Italy. All polyps identified at colonoscopy were included in this study and classified as per the SMSA grading system.
A total of 1668 lesions were resected in 1016 patients. There was a positive correlation between increasing SMSA level and the inability to resect lesions “en bloc” (p < 0.001). Histologically complete clearance was higher in the lower SMSA groups (p < 0.0001). Additional endoscopic therapies, were more commonly required with the higher SMSA groups to achieve histological clearance (p < 0.0001). Moreover, advanced histology in resection specimens and procedural complications were significantly less common in SMSA level 1 lesions compared to level 3 or 4 lesions (p < 0.0001).
The SMSA grading tool is a useful predictor of outcome following the resection of colonic neoplastic lesions.
Effect of prior biopsy sampling, tattoo placement, and snare sampling on endoscopic resection of large nonpedunculated colorectal lesions
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Endoscopic manipulations, including biopsy sampling, tattoo application on the lesion itself, and sampling of the lesion with a polypectomy snare, are frequently performed on large nonpedunculated colorectal lesions ≥ 20 mm (LNCL) before referral for endoscopic resection.
To assess the effect of prior manipulations on the technical difficulty and recurrence rates of subsequent endoscopic treatment.
Retrospective study.
Two referral centers.
Patients with LNCL referred for endoscopic resection.
Endoscopic resection.
En-bloc resection rate, rate of successful complete endoscopic resection without the need for ablation of visible residual, recurrence rate on follow-up, independent predictive factors for en-bloc resection, complete resection without ablation of visible residual, and recurrence.
A total of 132 lesions was analyzed: 46 lesions without any prior manipulation, 44 with prior biopsy sampling only, and 42 with prior advanced manipulation including tattoo and/or snare sampling. The en-bloc resection rate was 34.8% for nonmanipulated lesions, 15.9% for lesions with prior biopsy sampling, and 4.8% for lesions with prior advanced manipulation (P = .001). Complete endoscopic resection without the need for ablation of visible residual was performed in 93.5% of nonmanipulated lesions, 68.2% of lesions with prior biopsy sampling, and 50% of lesions with prior advanced manipulation (P < .001). Recurrence rates were 7.7%, 40.7%, and 53.8% in the 3 groups (P = .001). In multivariate analysis, prior biopsy sampling was an independent predictor for inability to perform complete resection without ablation of visible residual (odds ratio .24, P < .05) and for recurrence (odds ratio 11.5, P = .004) compared with nonmanipulated lesions. Prior advanced manipulation was an independent predictor for inability to perform en-bloc resection (odds ratio .024, P = .001), for inability to perform complete resection without ablation of visible residual (odds ratio .081, P < .001), and for recurrence (odds ratio 18.8, P = .001).
Retrospective study.
Prior biopsy sampling and advanced manipulation have significant deleterious effects on endoscopic treatment of LNCL.
Facilitating endoscopic submucosal dissection: The suture-pulley method significantly improves procedure time and minimizes technical difficulty compared with conventional technique: An ex vivo study (with video)
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Most laterally spreading colorectal tumors are still treated with endoscopic piecemeal resection or referred for surgery. However, endoscopic piecemeal resection for such lesions is associated with less R0 resection (68.6%)6 and a higher local recurrence rate (12%)7 compared with high R0 resection rate (88%) and low local recurrence rate (0.07%) after en bloc resection with ESD.8 Although surgical en bloc GI resection could be curative, in many cases, it would be overtreatment from an oncologic, economic, and perhaps ethical point of view.
The lack of countertraction in endoscopic submucosal dissection (ESD) results in increased technical demand and procedure time. Although the suture-pulley method for countertraction has been reported, its effectiveness compared with the traditional ESD technique remains unclear.
To objectively analyze efficacy of countertraction using the suture-pulley method for ESD.
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Twenty simulated gastric lesions were created in porcine stomachs by using a standard circular template 30 mm in diameter. In the control arm (n = 10), ESD was performed by using the standard technique. In the suture-pulley arm (N = 10), a circumferential incision was made, and an endoscopic suturing device was used to place the suture pulley.
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Ex vivo study.
The suture-pulley method facilitates direct visualization of the submucosal layer during ESD and significantly reduces procedure time and technical difficulty. In addition, the benefit of the suture-pulley method was seen for both simple and more complicated ESDs.
Endoscopic resection for superficial colorectal neoplasia in Italy: A prospective multicentre study
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The overwhelming preference for the piecemeal technique recorded herein is in agreement with previous data showing a low adherence of Western endoscopists to ESD in the colorectum [3,11,29]. Although associated with a higher risk of incomplete resection compared to ESD, Italian endoscopists feel more confident with multi-step piecemeal resection, an established procedure that has demonstrated to be safe and effective, also in the long-term [13–15,30–32]. If the dimensional criterion guides the decision as to what type of resection, the suspicion of deep submucosal infiltration should determine the treatment strategy.
Since there are few prospective studies on colorectal endoscopic resection to date, we aimed to prospectively assess safety and efficacy of endoscopic resection in a cohort of Italian patients.
Prospective multicentre assessment of resection of sessile polyps or non-polypoid lesions ≥ 10 mm in size or smaller (if depressed). Outcome measures included complete excision, morbidity, mortality, and residual/recurrence at 12 months.
Overall, 1012 resections in 928 patients were analysed (62.4% sessile polyps, 28.8% laterally spreading tumours, 8.7% depressed non-polypoid lesions). Lesions were prevalent in the proximal colon. Enbloc resection was possible in 715/1012 cases (70.7%), whereas piecemeal resection was required in 297 (29.3%). Endoscopically complete excision was achieved in 866 cases (85.6%). Adverse events occurred in 83 (8.2%), and no deaths occurred. Independent predictors of 12-month residual/recurrence were the location of the lesion in the proximal colon (OR 2.22 [95% CI 1.16–4.26]; p = 0.015) and piecemeal endoscopic resection (OR 2.76 [95% CI 1.56–4.87]; p = 0.0005). Limitations of the study were: potential expertise bias, no data on eligible and potentially resectable excluded lesions, high percentage of lesions < 20 mm, follow-up limited to 1 year.
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: DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.

: If you would like to chat with an author of this article, you may contact Dr Cheon at [email protected].

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Original articleClinical endoscopyClinical outcomes and factors related to resectability and curability of EMR for early colorectal cancer

Background

Objective

Design

Setting

Patients

Intervention

Main Outcome Measurements

Results

Limitations

Conclusion

Section snippets

Patients

EMR

Baseline characteristics of study patients

Techniques of EMR

Discussion

Lancet Oncol

Gastroenterology

Gastrointest Endosc Clin N Am

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Clin Gastroenterol Hepatol

Gastrointest Endosc

Gastrointest Endosc Clin N Am

Cancer statistics, 2010

CA Cancer J Clin

Epidemiology of colorectal cancer: the 21-year experience of a specialised registry

Intern Emerg Med

Screening for early colorectal cancer

World J Surg

Review article: Population screening for colorectal cancer

Aliment Pharmacol Ther

Early detection of and screening for colorectal neoplasia

Gut Liver

Endoscopic findings and management

Endoscopic mucosal resection for early colorectal neoplasia: pathologic basis, procedures, and outcomes

Dis Colon Rectum

Endoscopic mucosal resection of flat and depressed types of early colorectal cancer

Endoscopy

Overview of colorectal cancer in Japan: report from the Registry of the Japanese Society for Cancer of the Colon and Rectum

Dis Colon Rectum

The Vienna classification of gastrointestinal epithelial neoplasia

Gut

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