Endoscopic full-thickness resection of T1 colorectal cancers: a retrospective analysis from a multicenter Dutch eFTR registry

Abstract

Background and study aims: Complete endoscopic resection and accurate histological evaluation for T1 colorectal cancer (CRC) is critical to determine subsequent treatment. Endoscopic Full-Thickness Resection (eFTR) is a new treatment option for T1 CRC <2cm. We aim to report clinical outcomes and short-term results. Patients and methods: Consecutive eFTR procedures for T1 CRC, prospectively recorded in our national registry between November 2015 and April 2020, were retrospectively analysed. Primary outcomes were technical success and R0 resection. Secondary outcomes were histological risk-assessment, curative resections, adverse events and short-term outcomes. Results: We included 330 procedures: 132 primary resections and 198 secondary scar resections after incomplete T1 CRC resection. Overall technical success, R0 resection and curative resection rates were 87.0% (95% CI [82.7 – 90.3%]), 85.6% (95% CI [81.2 – 89.2%]) and 60.3% (95% CI [54.7 – 65.7%]). Curative resection rate for primary resected T1 CRC was 23.7% (95% CI [15.9 – 33.6%]) and 60.8% (95% CI [50.4 – 70.4%]) after excluding deep submucosal invasion as risk-factor. Risk-stratification was possible in 99.3%. Severe adverse event rates was 2.2%. Additional oncologic surgery was performed in 49/320 (15.3%), with residual cancer in 11/49 (22.4%). Endoscopic follow-up was available in 200/242 (82.6%), with a median of 4 months and residual cancer in 1 (0.5%) following an incomplete resection. Conclusions: eFTR is a relatively safe and effective method to resect small T1 CRC, both as primary and secondary treatment. eFTR can expand endoscopic treatment options for T1 CRC and could help to reduce surgical overtreatment. Future studies should focus on long-term outcomes.

Deep Submucosal Invasion Is Not an Independent Risk Factor for Lymph Node Metastasis in T1 Colorectal Cancer: A Meta-Analysis

“…Novel advanced local resection techniques, such as ESD, eFTR, and transanal minimal invasive surgery, have expanded the therapeutic armamentarium available for T1 CRC. 19,93,94 These minimal invasive techniques have been shown to allow a high rate of R0 resections, even when deeper invasion is present. For ESD, R0 resection rates of 62%-65% for deep submucosal invasive T1 CRC have been reported.…”

“…Recent prospective eFTR registry data demonstrated R0 rates of 82% in a large number of T1 CRCs, of which 60% showed DSI. 19 For nonexposed eFTR, current size restriction of the resection device allow lesions up to approximately 2 cm amenable for radical resection, which is a serious constraint, as opposed to ESD. However, as the maximum diameter of the invasive front in T1 CRC rarely exceeds 15 mm, logic would suggest eFTR might have therapeutic potential in a proper subset of T1 CRC.…”

“…10,11,18 Availability and technical improvements of local excision techniques like endoscopic submucosal dissection (ESD), endoscopic full-thickness resection (eFTR), and transanal minimal invasive surgery are evolving and enable complete local excision as first-line treatment, also when deeper submucosal invasion is present. 19 A total excisional biopsy can be a viable option to allow for histopathologic risk assessment and guide further treatment. Moreover, high-quality evidence shows that a local excision does not affect surgical or oncologic outcomes in patients who need completion surgery.…”

Endoscopic Full Thickness Resection: A Systematic Review

“…Retrospective analyses of Dutch EFTR registry have shown a curative resection rate of 23.7% in T1 CRC and 60.8% excluding high risk features (deep SMIC). Full thickness histological assessment after EFTR with FTRD can help in avoiding oncologic resection in low risk patients 56.…”

Endoscopic full-thickness resection for T1 colorectal cancer: here to stay!

“…In this issue of Endoscopy, Zwager et al present a detailed retrospective analysis of 330 cases undergoing endoscopic full-thickness resection (EFTR) for T1 carcinomas [1]. These cases had been recorded in the nationwide Dutch EFTR registry; results of the total cohort, including other indications for EFTR, have been reported previously [2].…”