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Original research
Clinical outcome of non-curative endoscopic submucosal dissection for early colorectal cancer
  1. Marco Spadaccini1,2,
  2. Michael J Bourke3,4,
  3. Roberta Maselli1,2,
  4. Marhieu Pioche5,
  5. Pradeep Bhandari6,
  6. Jérémie Jacques7,
  7. Amyn Haji8,
  8. Dennis Yang9,
  9. Eduardo Albéniz10,
  10. Michal Filip Kaminski11,12,
  11. Helmut Messmann13,
  12. Alberto Herreros de Tejada14,
  13. Sandro Sferrazza15,
  14. Boris Pekarek16,
  15. Jerome Rivory5,
  16. Sophie Geyl7,
  17. Shraddha Gulati8,
  18. Peter Draganov9,
  19. Neal Shahidi3,4,
  20. Ejaz Hossain6,
  21. Carola Fleischmann13,
  22. Edoardo Vespa1,2,
  23. Andrea Iannone17,
  24. Asma Alkandari18,19,
  25. Cesare Hassan1,2,
  26. Alessandro Repici1,2
  27. on behalf of the ESD Western Alliance (EWA)
  1. 1Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
  2. 2Endoscopy Unit, Humanitas Clinical and Research Center -IRCCS-, Rozzano, Italy
  3. 3Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
  4. 4Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
  5. 5Endoscopy unit, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
  6. 6Endoscopy unit, Portsmouth Hospitals NHS Trust, Portsmouth, UK
  7. 7Gastroenterology, Hospital Dupuytren, Limoges, France
  8. 8Endoscopy unit, King's College Hospital NHS Foundation Trust, London, UK
  9. 9Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA
  10. 10Gastroenterology Department, Complejo Hospitalario de Navarra, Pamplona, Navarra, Spain
  11. 11Department of Gastroenterology, Hepatology and Oncology, Medical Centre fo Postgraduate Education, Warsaw, Poland
  12. 12Department of Gastroenterological Oncology, The Maria Sklodowska-Curie Memorial Cancer Centre, Institute of Oncology, Warsaw, Poland
  13. 13Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Bayern, Germany
  14. 14Endoscopy unit, Hospital Universitario de Madrid, Madrid, Spain
  15. 15Endoscopy unit, Ospedale di Trento, Trento, Trentino-Alto Adige, Italy
  16. 16University Hospital Bratislava, Bratislava, Slovakia
  17. 17U.O. Gastroenterologia Universitaria, Policlinico di Bari, Bari, Italy
  18. 18Gastroenterology, Amiri Hospital, Kuwait City, Kuwait
  19. 19Gastroenterology, Queen Alexandra Hospital, Portsmouth, Hampshire, UK
  1. Correspondence to Dr Marco Spadaccini, Humanitas University, Rozzano, Italy; marcospadaccini9{at}gmail.com

Abstract

Objective Endoscopic submucosal dissection (ESD) in a curative intent for submucosa-invasive early (T1) colorectal cancers (T1-CRCs) often leads to subsequent surgical resection in case of histologic parameters indicating higher risk of nodal involvement. In some cases, however, the expected benefit may be offset by the surgical risks, suggesting a more conservative approach.

Design Retrospective analysis of consecutive patients with T1-CRC who underwent ESD at 13 centres ending inclusion in 2019 (n=3373). Cases with high risk of nodal involvement (non-curative ESD: G3, submucosal invasion>1000 µm, lymphovascular involvement, budding or incomplete resection/R1) were analysed if follow-up data (endoscopy/imaging) were available, regardless of the postendoscopic management (follow-up vs surgery) selected by the multidisciplinary teams in these institutions. Comorbidities were classified according to Charlson Comorbidity Index (CCI). Outcomes were disease recurrence, death and disease-related death rates in the two groups. Rate of residual disease (RD) at both the previous resection site and regional lymph nodes was assessed in the surgical cases as well as from follow-up in the follow-up group.

Results Of 604 patients treated by colorectal ESD for submucosally invasive cancer, 207 non-curative resections (34.3%) were included (138 male; mean age 67.6±10.9 years); in 65.2% of cases, no complete resection was achieved (R1). Of the 207 cases, 60.9% (n=126; median CCI: 3; IQR: 2–4) underwent surgical treatment with RD in 19.8% (25/126), while 39.1% (n=81, median CCI: 5; IQR: 4–6) were followed up by endoscopy in all cases. Patients in the follow-up group had a higher overall mortality (HR=3.95) due to non-CRC causes (n=9, mean survival after ESD 23.7±13.7 months). During this follow-up time, tumour recurrence and disease-specific survival rates were not different between the groups (median follow-up 30 months; range: 6–105).

Conclusion Following ESD for a lesion at high risk of RD, follow-up only may be a reasonable choice in patients at high risk for surgery. Also, endoscopic resection quality should be improved.

Trial registration number NCT03987828.

  • colonoscopy
  • adenocarcinoma

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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Footnotes

  • Twitter @edalbeniz, @shraddha_gulati

  • MS and MJB contributed equally.

  • Contributors MS: study concept and design, data collection, analysis and interpretation of data and drafting of the manuscript. MJB: data collection, analysis and interpretation of data and drafting of the manuscript. RM and AR: study concept and design and analysis and interpretation of data. MP, PB, JJ, AH, PD, EA, MFK, HM, AHdT, SS, BP, JR, SGeyl, SGulati, DY, NS, EH, CF and EV: data collection and critical revision of the manuscript for important intellectual content. AI: data collection and analysis and interpretation of data. AA and CH: critical revision of the manuscript for important intellectual content. The final manuscript was reviewed and approved by all authors. MS is responsible for the overall content as the 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.

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