A large-scale multicenter study of long-term outcomes after endoscopic resection for submucosal invasive colorectal cancer

 

 Buy Article Permissions and Reprints

Background and study aims: Patients with submucosal invasive colorectal cancer (SM-CRC) treated with endoscopic resection who are at low risk of lymph node metastasis and local recurrence may be followed up with observation alone, while additional surgery is recommended for those with high risk features. However, the long-term outcomes that these strategies offer are still unclear. The objective of our study was to retrospectively evaluate the long-term outcomes of patients with SM-CRC managed with endoscopic resection.

Patients and methods: We retrospectively analyzed all patients with SM-CRC treated by endoscopic resection at six institutions between 2000 and 2007. SM-CRCs with (i) negative vertical margin, (ii) well or moderately differentiated adenocarcinoma, (iii) absence of lymphovascular invasion, and (iv) invasion depth < 1000 µm were classified as low risk. Patients with SM-CRCs without these characteristics were classified as high risk. Outcomes were assessed by 5-year recurrence-free survival (RFS) and recurrence rate.

Results: During the study period, 428 patients with SM-CRC (low risk, 126; high risk, 302) who underwent endoscopic resection as their first treatment were enrolled (median follow-up 61 months). Among the 120 patients with low risk features treated by endoscopic resection alone, the 5-year RFS and recurrence rates were 98 % and 0.8 %, respectively. Of the 302 patients with high risk features, 196 underwent additional surgery and 106 were managed with endoscopic resection alone. For those who underwent additional surgery, the 5-year RFS and recurrence rates were 97 % and 3.6 %, respectively. Among the 106 patients managed with endoscopic resection alone, RFS and recurrence rates were 89 % (P < 0.05 vs. low risk patients treated by endoscopic resection alone) and 6.6 % (P < 0.05), respectively.

Conclusions: Endoscopic resection alone is adequate for the management of patients with SM-CRC and low risk features. However, in those patients with SM-CRC and high risk features, surgery should be considered in addition to endoscopic resection.

• References

• 1 Coverlizza S, Risio M, Ferrari A et al. Colorectal adenomas containing invasive carcinoma. Pathologic assessment of lymph node metastatic potential. Cancer 1989; 64: 1937-1947
  CrossrefPubMedGoogle Scholar
• 2 Morson BC, Whiteway JE, Jones EA et al. Histopathology and prognosis of malignant colorectal polyps treated by endoscopic polypectomy. Gut 1984; 25: 437-444
  CrossrefPubMedGoogle Scholar
• 3 Wilcox GM, Anderson PB, Colacchio TA. Early invasive carcinoma in colonic polyps. A review of the literature with emphasis on the assessment of the risk of metastasis. Cancer 1986; 57: 160-171
  CrossrefPubMedGoogle Scholar
• 4 Cooper HS. Surgical pathology of endoscopically removed malignant polyps of the colon and rectum. Am J Surg Pathol 1983; 7: 613-623
  CrossrefPubMedGoogle Scholar
• 5 Tanaka S, Haruma K, Teixeira CR et al. Endoscopic treatment of submucosal invasive colorectal carcinoma with special reference to risk factors for lymph node metastasis. J Gastroenterol 1995; 30: 710-717
  CrossrefPubMedGoogle Scholar
• 6 Colacchio TA, Forde KA, Scantlebury VP. Endoscopic polypectomy: inadequate treatment for invasive colorectal carcinoma. Ann Surg 1981; 194: 704-707
  CrossrefPubMedGoogle Scholar
• 7 Nascimbeni R, Burgart LJ, Nivatvongs S et al. Risk of lymph node metastasis in T1 carcinoma of the colon and rectum. Dis Colon Rectum 2002; 45: 200-206
  CrossrefPubMedGoogle Scholar
• 8 Muller S, Chesner IM, Egan MJ et al. Significance of venous and lymphatic invasion in malignant polyps of the colon and rectum. Gut 1989; 30: 1385-1391
  CrossrefPubMedGoogle Scholar
• 9 Ueno H, Mochizuki H, Hashiguchi Y et al. Risk factors for an adverse outcome in early invasive colorectal carcinoma. Gastroenterology 2004; 127: 385-394
  CrossrefPubMedGoogle Scholar
• 10 The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointest Endosc 2003; 58: 3-S43
  CrossrefPubMedGoogle Scholar
• 11 Watanabe T, Itabashi M, Shimada Y et al. Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2010 for the treatment of colorectal cancer. Int J Clin Oncol 2012; 17: 1-29
  CrossrefPubMedGoogle Scholar
• 12 Kudo S, Tamura S, Nakajima T et al. Diagnosis of colorectal tumorous lesions by magnifying endoscopy. Gastrointest Endosc 1996; 44: 8-14
  CrossrefPubMedGoogle Scholar
• 13 Matsuda T, Fujii T, Saito Y et al. Efficacy of the invasive/non-invasive pattern by magnifying chromoendoscopy to estimate the depth of invasion of early colorectal neoplasms. Am J Gastroenterol 2008; 103: 2700-2706
  CrossrefPubMedGoogle Scholar
• 14 Choi DH, Sohn DK, Chang HJ et al. Indications for subsequent surgery after endoscopic resection of submucosally invasive colorectal carcinomas: a prospective cohort study. Dis Colon Rectum 2009; 52: 438-445
  CrossrefPubMedGoogle Scholar
• 15 Bories E, Pesenti C, Monges G et al. Endoscopic mucosal resection for advanced sessile adenoma and early-stage colorectal carcinoma. Endoscopy 2006; 38: 231-235
  Article in Thieme ConnectPubMedGoogle Scholar
• 16 Di Gregorio C, Bonetti LR, de Gaetani C et al. Clinical outcome of low- and high-risk malignant colorectal polyps: results of a population-based study and meta-analysis of the available literature. Intern Emerg Med 2012; [Epub ahead of print]. DOI: DOI: 10.1007/s11739-012-0772-2.
  PubMedGoogle Scholar
• 17 Kudo S. Endoscopic mucosal resection of flat and depressed types of early colorectal cancer. Endoscopy 1993; 25: 455-461
  Article in Thieme ConnectPubMedGoogle Scholar
• 18 Kikuchi R, Takano M, Takagi K et al. Management of early invasive colorectal cancer. Risk of recurrence and clinical guidelines. Dis Colon Rectum 1995; 38: 1286-1295
  CrossrefPubMedGoogle Scholar
• 19 Kitajima K, Fujimori T, Fujii S et al. Correlations between lymph node metastasis and depth of submucosal invasion in submucosal invasive colorectal carcinoma: a Japanese collaborative study. J Gastroenterol 2004; 39: 534-543
  PubMedGoogle Scholar
• 20 Seitz U, Bohnacker S, Seewald S et al. Is endoscopic polypectomy an adequate therapy for malignant colorectal adenomas? Presentation of 114 patients and review of the literature. Dis Colon Rectum 2004; 47: 1789-1796
  CrossrefPubMedGoogle Scholar
• 21 Ikematsu H, Matsuda T, Emura F et al. Efficacy of capillary pattern type IIIA/IIIB by magnifying narrow band imaging for estimating depth of invasion of early colorectal neoplasms. BMC Gastroenterol 2010; 10: 33
  CrossrefPubMedGoogle Scholar
• 22 Weiser MR, Landmann RG, Wong WD et al. Surgical salvage of recurrent rectal cancer after transanal excision. Dis Colon Rectum 2005; 48: 1169-1175
  CrossrefPubMedGoogle Scholar
• 23 Waye JD, Braunfeld S. Surveillance intervals after colonoscopic polypectomy. Endoscopy 1982; 14: 79-81
  Article in Thieme ConnectPubMedGoogle Scholar
• 24 Patchett SE, Mulcahy HE, O’Donoghue DP. Colonoscopic surveillance after curative resection for colorectal cancer. Br J Surg 1993; 80: 1330-1332
  CrossrefPubMedGoogle Scholar
• 25 Fujimori T, Fujii S, Saito N et al. Pathological diagnosis of early colorectal carcinoma and its clinical implications. Digestion 2009; 79: 40-51
  PubMedGoogle Scholar
• 26 Shimomura T, Ishiguro S, Konishi H et al. New indication for endoscopic treatment of colorectal carcinoma with submucosal invasion. J Gastroenterol Hepatol 2004; 19: 48-55
  CrossrefPubMedGoogle Scholar