Clinical outcome of non-curative endoscopic submucosal dissection for early colorectal cancer

Abstract

ObjectiveEndoscopic 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.DesignRetrospective 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.ResultsOf 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).ConclusionFollowing 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 numberNCT03987828.

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“…Endoscopic resection has emerged as an effective method to remove some early-stage CRCs before open surgery. 71 Unnecessary surgical resection may pose additional risks. However, 8% of patients with T1 and 18.5% of patients with T2 CRCs have lymph node metastases (LNM), which is a contraindication to endoscopic resection.…”

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“…ESD may, however, have a problem with the vertical resection margin in cases of deep submucosal invasion. Thus, a recent Western retrospective multicenter study with 207 colorectal ESDs reported a positive vertical margin in 57% of the cases, and a positive vertical margin was the most frequent reason for a 'noncurative' endoscopic resection [48]. A possible caveat regarding the vertical resection margin also comes from a small pilot study comparing colorectal specimens obtained by EMR (n = 6 benign lesions) versus ESD (n = 6, with one case of submucosal invasive cancer) and quite unexpectedly showed a better preserved and thicker submucosal layer in EMR specimens [49,50].…”

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“…However, such mere classification should not automatically result in the decision for surgery. For instance, an apparently noncurative resection due to a high-risk pathologic findings may be sufficient in a patient with a high risk of surgery-related mortality, 31,43 while a low-risk lesion may still not exclude surgery in a very young and fit patient. Thus, a multidisciplinary reassessment is required after the pathology assessment, and it may require the presence of other experts (eg oncologist, radiologist).…”