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  • Oncological outcomes after piecemeal endoscopic mucosal resection of large non-pedunculated colorectal polyps with covert submucosal invasive cancer

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Endoscopy
Original research
Oncological outcomes after piecemeal endoscopic mucosal resection of large non-pedunculated colorectal polyps with covert submucosal invasive cancer
  1. Dave J Gibson1,
  2. Mayenaaz Sidhu2,3,
  3. Simon Zanati4,
  4. David J Tate2,
  5. Dileep Mangira4,
  6. Alan Moss5,
  7. Rajvinder Singh6,
  8. Luke F Hourigan7,
  9. Spiro Raftopoulos8,
  10. Alan Pham9,
  11. Phil Kostos10,
  12. M Priyanthi Kumarasinghe11,
  13. Andrew Ruszkiewicz12,
  14. Duncan McLeod13,
  15. Gregor J E Brown1,
  16. Michael J Bourke2,3
  1. 1 Gastroenterology, Alfred Health, Melbourne, Victoria, Australia
  2. 2 Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
  3. 3 Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
  4. 4 Gastroenterology, Western Health, Footscray, Victoria, Australia
  5. 5 Department of Gastroenterology, Western Hospital, Footscray, Victoria, Australia
  6. 6 Gastroenterology, Lyell McEwin Hospital, Adelaide, South Australia, Australia
  7. 7 Gastroenterology, Greenslopes Private Hospital, Brisbane, Queensland, Australia
  8. 8 Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
  9. 9 Anatomical Pathology, Alfred Hospital, Melbourne, Victoria, Australia
  10. 10 Pathology, Western Health, Footscray, Victoria, Australia
  11. 11 Department of Anatomical Pathology, PathWest, QEII Medical Centre, Perth, Western Australia, Australia
  12. 12 Pathology, Lyell McEwin Hospital, Adelaide, South Australia, Australia
  13. 13 Institute of Clinical Pathology and Medical Research, Westmead Millennium Institute and Westmead Hospital, University of Sydney, Australia, Westmead Hospital, Westmead, New South Wales, Australia
  1. Correspondence to Dr Dave J Gibson, Gastroenterology, Alfred Health, Melbourne, Victoria, Australia; D.Gibson{at}alfred.org.au

Abstract

Objective Management of covert submucosal invasive cancer (SMIC) discovered after piecemeal endoscopic mucosal resection (pEMR) of large (>20 mm) non-pedunculated colorectal polyps is challenging. The residual cancer risk is largely unknown. We sought to evaluate this in a large tertiary referral cohort.

Design Cases of covert SMIC following pEMR were identified and followed. Oncological outcomes after surgery were divided based on residual intramural cancer, lymph node metastases (LNM) or both. Risk factors for residual intramural cancer and LNM were analysed based on the original pEMR histological variables. Risk parameters were analysed with respect to low and high-risk variables for residual intramural cancer and LNM.

Results Among 3372 cases of large non-pedunculated colorectal polyps, 143 cases of covert SMIC (4.2%) were identified. 109 underwent surgical resection. Histological analysis of pEMR histology was available in 98 of 109 (90%) cases. 62 cases (63%) had no residual malignancy. 36 cases had residual malignancy (residual intramural cancer n=24; LNM n=5; both n=7). All cases of residual intramural cancer could be identified by a R1 histological deep margin. Cases with poor differentiation (PD) and/or lymphovascular invasion (LVI) had a high risk of LNM (12/33), with a very low risk without these criteria (<1%; 0/65). Cases at low risk for LNM with R0 deep margin have a low risk of residual intramural cancer (<1%; 0/35).

Conclusion The majority of cases of large non-pedunculated colorectal polyps with covert SMIC following pEMR will have no residual malignancy. The risk of residual malignancy can be ascertained from three key variables: PD, LVI and R1 deep margin.

  • colonoscopy
  • colonic polyps
  • colonic neoplasms
  • endoscopic polypectomy

Data availability statement

Data are available upon reasonable request.

https://doi.org/10.1136/gutjnl-2020-323666

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    Data availability statement

    Data are available upon reasonable request.

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    Footnotes

    • Contributors DJG, GJEB and MJB were involved in study concept all design. All other authors were involved in patient recruitment, endoscopy or pathological analysis. DJG is guarantor.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.