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• W3161280031 abstract "With advances in endoscopic techniques over the past decade, including EMR and endoscopic submucosal dissection (ESD), endoscopic resection has become an alternative to surgery for selected malignant polyps.1Jayanna M. Burgess N.G. Singh R. et al.Cost analysis of laterally spreading colorectal lesions.Clin Gastroenterol Hepatol. 2016; 14: 271-278Abstract Full Text Full Text PDF PubMed Scopus (112) Google Scholar, 2Ma C. Teriaky A. Sheh S. et al.Morbidity and mortality after surgery for nonmalignant colorectal polyps: a 10-year national analysis.Am J Gastroenterol. 2019; 114: 1802-1810Crossref PubMed Scopus (16) Google Scholar, 3Dang H. de Vos Tot Nederveen Cappel W.H. van der Zwaan S.M.S. et al.Quality of life and fear of cancer recurrence in T1 colorectal cancer patients treated with endoscopic or surgical tumor resection.Gastrointest Endosc. 2019; 89: 533-544Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar The term malignant polyp is used to describe an early colorectal cancer (CRC) with invasion into, but not beyond, the submucosa and is categorized as T1 CRC according to the American Joint Committee on Cancer tumor node metastasis classification system.4Rex D.K. Shaukat A. Wallace M.B. Optimal management of malignant polyps, from endoscopic assessment and resection to decisions about surgery.Clin Gastroenterol Hepatol. 2019; 17: 1428-1437Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar,5Amin M.B. Edge S. Greene F. et al.AJCC cancer staging manual.8th ed. Springer, New York2017: 252-254Google Scholar Detailed endoscopic assessment of a lesion is the first critical step for the optimal management of these malignant polyps. Accurate identification followed by proper endoscopic resection of malignant polyps with low-risk features for lymph node metastasis (LNM) is considered curative.6National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology; Colon Cancer (v.3.2018).https://www.nccn.org/store/login/login.aspx?ReturnURL=https://www.nccn.org/professinals/physician_gls/pdf/colon.pdfGoogle Scholar Conversely, malignant polyps with deep submucosal invasion (SMI) and/or features for LNM should be considered for surgery. However, precise prediction of depth of invasion and lymph node involvement is a significant challenge.7Yang D, Draganov PV. Surgery referral of colorectal polyps based on real-time optical diagnosis alone: are we there yet? Gastroenterology. Epub 2021 Jan 13.Google Scholar,8Backes Y. Schwarts M.P. Borg F.T. et al.Multicentre prospective evaluation of real-time optical diagnosis of T1 colorectal cancer in large non-pedunculated colorectal polyps using narrow band imaging (the OPTICAL study).Gut. 2019; 68: 271-279Crossref PubMed Scopus (22) Google Scholar Although endoscopic resection may be curative in a subset of these patients, those with unfavorable histologic criteria will still require secondary surgery. Concerns have been raised about whether attempted endoscopic resection before surgery may have an impact on cancer recurrence.9Backes Y. Seerden T.C.J. van Gestel R. et al.Tumor seeding during colonoscopy as a possible cause for metachronous colorectal cancer.Gastroenterology. 2019; 157: 1222-1232.e4Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar However, data comparing long-term outcomes between patients after endoscopic resection of high-risk malignant polyps followed by secondary surgery versus a primary surgical approach remain limited.10Overwater A. Kessels K. Elias S.G. et al.Endoscopic resection of high-risk T1 colorectal carcinoma prior to surgical resection ahs no adverse effect on long-term outcomes.Gut. 2018; 67: 284-290Crossref PubMed Scopus (52) Google Scholar In this issue of Gastrointestinal Endoscopy, Oh et al11Oh E.H. Kim N. Hwang S.W. et al.Comparison of long-term recurrence-free survival between primary surgery and endoscopic resection followed by secondary surgery in T1 colorectal cancer.Gastrointest Endosc. 2021; 94: 394-404Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar retrospectively compared the long-term oncologic outcomes in 852 patients who underwent primary surgery or secondary surgery for malignant polyps (T1 CRC). The authors aimed to evaluate both locoregional and/or distant cancer recurrence between the 2 groups. Primary surgery was defined as surgery of T1 CRC without a prior attempt at endoscopic resection, whereas secondary surgery was defined as a preceding attempt at endoscopic resection (EMR, ESD, hybrid ESD) followed by surgery. Secondary surgery was performed in cases of failed endoscopic resection, in cases of incomplete resection due to deep margin involvement by cancer, and/or in the presence of high-risk features for LNM (poor differentiation, lymphovascular invasion [LVI], and/or SMI depth ≥1000 μm or Sm2 to Sm3). Patients with synchronous CRC, history of CRC, distant metastasis at diagnosis, hereditary polyposis syndrome, inflammatory bowel disease, <12 months of follow-up after surgery, and those who received preoperative neoadjuvant chemoradiotherapy were excluded. Out of the 852 patients, 388 and 464 underwent primary and secondary surgery, respectively, for T1 CRC. Notably, patients who underwent primary surgery had T1 CRC that was larger, had a higher frequency of deep SMI, had less LVI, and had more nodal stage 1-2 disease than did patients who underwent endoscopic resection before surgery. In the secondary surgery group, grossly complete endoscopic resection was achieved in 424 out of 464 (91.4%) patients by EMR (308/424; 72.6%), hybrid ESD (61/424; 14.4%), or ESD (55/424; 13%), with an overall en-bloc resection rate of 90.6% (384/424). Residual cancer was identified histologically on secondary surgery in 29 (6.8%) patients, all of whom had positive/indeterminate deep margins on the initial endoscopic resection specimen. At a median follow-up period after surgery of 57 months (range, 41-63 months), cancer recurred in 11 out of 388 (2.8%) patients in the primary surgery group versus 7 out of 464 (1.5%) patients in the secondary surgery group (P = .18). On Kaplan-Meier analysis, the estimated recurrence-free survival rates were similar and above 96% at 7 years in both groups (P = .194). Recurrence-free survival rates showed no difference between the 2 groups when stratified by nodal stage (stage 0 or 1 to 2), number of high-risk histologic features (1 or 2 to 3), or after propensity score analyses to control for confounders. On multiple logistic regression, which included cancer-related variables such as lesion location, size, morphology, differentiation, depth of SMI, nodal stage, and LVI), only baseline serum carcinoembryonic antigen level was identified as an independent risk factor for cancer recurrence (hazard ratio 1.45; 95% confidence interval, 1.23-1.71; P < .001). Advances in endoscopic technology and techniques have expanded the curative potential of endoscopic resection of selected malignant polyps and its application in clinical practice. The study by Oh et al11Oh E.H. Kim N. Hwang S.W. et al.Comparison of long-term recurrence-free survival between primary surgery and endoscopic resection followed by secondary surgery in T1 colorectal cancer.Gastrointest Endosc. 2021; 94: 394-404Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar demonstrates that attempts at endoscopic resection of T1 CRC did not negatively affect the risk of cancer recurrence after secondary surgery. The strengths of this study include the enrollment of a large number of patients with a long follow-up duration after surgery. Furthermore, the authors should be commended for their robust statistical analyses in an attempt to control for potential confounding variables. Not only did the authors demonstrate that the recurrence-free survival rate was similar between the 2 groups when stratified by nodal stage and number of high-risk histologic features, but also they included multiple endoscopic therapy–related parameters (ie, prior attempts for endoscopic resection, failed endoscopic resection, perforation, time interval from endoscopic resection to surgery, en-bloc vs piecemeal resection, and involvement of resection margins) in their analysis. Importantly, the results from this large study are consistent with those recently reported by other groups, further supporting the notion that endoscopic resection of T1 CRC does not affect cancer recurrence in cases where additional surgery was deemed appropriate.10Overwater A. Kessels K. Elias S.G. et al.Endoscopic resection of high-risk T1 colorectal carcinoma prior to surgical resection ahs no adverse effect on long-term outcomes.Gut. 2018; 67: 284-290Crossref PubMed Scopus (52) Google Scholar,12Tamaru Y. Oka S. Tanaka S. et al.Long-term outcomes after treatment for T1 colorectal carcinoma: a multicenter retrospective cohort study of Hiroshima GI Endoscopy Research Group.J Gastroenterol. 2017; 52: 1169-1179Crossref PubMed Scopus (37) Google Scholar, 13Yamashita K. Oka S. Tanaka S. et al.Preceding endoscopic submucosal dissection for T1 colorectal carcinoma does not affect the prognosis of patients who underwent additional surgery: a large multicenter propensity score-matched analysis.J Gastroenterol. 2019; 54: 897-906Crossref PubMed Scopus (18) Google Scholar, 14Yamaoka Y. Imai K. Shiomi A. et al.Endoscopic resection of T1 colorectal cancer prior to surgery does not affect surgical adverse events and recurrence.Surg Endosc. 2020; 34: 5006-5016Crossref PubMed Scopus (10) Google Scholar Nevertheless, this study is not without its limitations, including its retrospective design and risk for selection bias. Despite the large number of patients included in the study, it was a single-center experience, thereby limiting the generalizability of the results. Furthermore, there were significant differences in baseline tumor characteristics between the primary and secondary surgical groups, which could have influenced the estimates of cancer recurrence despite the adjusted analyses. Last, the total number of patients with T1 CRC who underwent endoscopic resection is not specified in the study, except for those who had additional surgery. Although these data might have been beyond the scope of this study, the data would have been clinically meaningful in the assessment of whether there was a difference in surgery requirements among the endoscopic resection modalities (EMR, hybrid ESD, ESD). The study by Oh et al11Oh E.H. Kim N. Hwang S.W. et al.Comparison of long-term recurrence-free survival between primary surgery and endoscopic resection followed by secondary surgery in T1 colorectal cancer.Gastrointest Endosc. 2021; 94: 394-404Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar contributes to the available literature and has direct clinical implications on how we may approach malignant polyps. In an ideal setting, malignant polyps with superficial SMI and low risk for LNM should undergo endoscopic resection, whereas those with deep SMI and/or high-risk features should be referred to surgery. However, as previously alluded, making this distinction on the basis of real-time optical diagnosis can be challenging. If endoscopic therapy does not adversely affect additional surgery or long-term oncologic outcomes, should an attempt at endoscopic resection be considered a preferred initial approach for malignant polyps devoid of overt signs of deep SMI? Theoretically, this may seem like a reasonable approach, given the lower cost, morbidity, and mortality of endoscopic resection in comparison with surgery.4Rex D.K. Shaukat A. Wallace M.B. Optimal management of malignant polyps, from endoscopic assessment and resection to decisions about surgery.Clin Gastroenterol Hepatol. 2019; 17: 1428-1437Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar In addition, this strategy may curtail the inappropriate surgical referral of nonmalignant polyps (neoplastic lesions confined to the mucosa) where the primary role of endoscopic resection is well established and supported by society guidelines.15Moon N. Aryan M. Khan W. et al.Effect of referral pattern and histopathology grade on surgery for nonmalignant colorectal polyps.Gastrointest Endosc. 2020; 92: 702-711.e2Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar,16Kaltenbach T. Anderson J.C. Burke C.A. et al.Endoscopic removal of colorectal lesions: recommendations by the US Multi-Society Task Force on colorectal cancer.Gastrointest Endosc. 2020; 91: 486-519Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Importantly, it should be emphasized that not all patients with endoscopic R1 resection of T1 CRC require secondary surgery. As shown in this study, most patients with positive/indeterminate endoscopic resection margins had no residual cancer on the surgical specimen. Hence, endoscopic resection followed by observation may be the best course of action among poor surgical candidates with unfavorable histologic criteria.4Rex D.K. Shaukat A. Wallace M.B. Optimal management of malignant polyps, from endoscopic assessment and resection to decisions about surgery.Clin Gastroenterol Hepatol. 2019; 17: 1428-1437Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar However, we should also caution that indiscriminate endoscopic resection is not without risks, including, but not limited to, additional costs, potential procedural adverse events, and possibly delaying definitive treatment. Furthermore, although in this study perforation at the time of endoscopic resection did not appear to compromise the oncologic outcomes, the finding was based on a small number of cases, and theoretic concerns remain. Hence, at this time, clinical decision making about malignant polyps, particularly those with equivocal features, should involve a multidisciplinary team of endoscopists, surgeons, and pathologists at a center with expertise. In conclusion, the study by Oh et al11Oh E.H. Kim N. Hwang S.W. et al.Comparison of long-term recurrence-free survival between primary surgery and endoscopic resection followed by secondary surgery in T1 colorectal cancer.Gastrointest Endosc. 2021; 94: 394-404Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar supports the primary role of endoscopic resection for malignant polyps (T1 CRC) with anticipated superficial SMI and low risk of lymph node metastasis. Importantly, oncologic outcomes were not compromised in cases where endoscopic resection did not provide curative therapy and secondary surgery was needed. Dr Yang is a consultant for Boston Scientific, Steris, and Lumendi. Dr Draganov is a consultant for Boston Scientific, Olympus, Cook Medical, Microtech, Steris, Merit Medical, Lumendi, and Fujifilm. Comparison of long-term recurrence-free survival between primary surgery and endoscopic resection followed by secondary surgery in T1 colorectal cancerGastrointestinal EndoscopyVol. 94Issue 2PreviewWe aimed to investigate whether endoscopic resection of T1 colorectal cancer (CRC) before surgery (secondary surgery) unfavorably affects long-term recurrence-free survival (RFS) compared with surgery without prior endoscopic resection (primary surgery). Full-Text PDF" @default.
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• W3161280031 title "Endoscopic resection of T1 colorectal cancer before surgery does not affect recurrence" @default.
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