Long-term Oncological Outcome of Segmental Versus Extended Colectomy for Colorectal Cancer in Crohn’s Disease: Results from an International Multicentre Study

Abstract

Background and Aims Crohn’s Disease increases colorectal cancer risk, with high prevalence of synchronous and metachronous cancers. Current guidelines for colorectal cancer in Crohn’s Disease recommend pan-proctocolectomy. Aim of this study was to evaluate oncologic outcomes of a less invasive surgical approach. Methods Retrospective database analysis of Crohn’s disease patients with colorectal cancer undergoing surgery at selected European and U.S. tertiary centres. Outcomes of segmental colectomy were compared with those of extended colectomy: total colectomy and pan-proctocolectomy. Primary outcome was progression-free survival. Secondary outcomes included overall survival, synchronous and metachronous colorectal cancer and major postoperative complications. Results Ninety-nine patients were included: 66 patients underwent segmental colectomy and 33 extended colectomy. Segmental colectomy patients were older (p= 0.0429), had less extensive colitis (p = 0.0002) and no pre-operatively identified synchronous lesions (p = 0.0109). Median follow up was 43 (31-62) months. There was no difference in unadjusted progression-free survival (p = 0.2570) nor in overall survival (p = 0.4191) between segmental and extended colectomy. Multivariate analysis adjusting for age, sex, ASA score and AJCC staging, confirmed no difference for progression-free survival (HR 1.00 p = 0.9993) or overall survival (HR 0.77 p = 0.6654). Synchronous and metachronous cancers incidence was 9% and 1.5% respectively. Perioperative mortality was nil and major complications were comparable (7.58% vs 6.06% p = 0.9998). Conclusions Segmental colectomy seems to offer similar long-term outcomes to more extensive surgery. Incidence of synchronous and metachronous cancers appears much lower than previously described. Further prospective studies are warranted to confirm these results.

Endoscopic and surgical treatment outcomes of colitis-associated advanced colorectal neoplasia: a multicenter cohort study

“…We found synchronous advanced neoplasia in 3.4% of CD patients and 6.6% of UC patients treated with (sub)total or proctocolectomy. A recent Italian study in CD patients reported a higher advanced neoplasia rate of 9% after (sub)total or proctocolectomy 10 . Another observational UC study observed a higher synchronous advanced neoplasia rate of 14% 18 .…”

“…As such, one study in CD patients ( n =64) reported a cumulative metachronous CRC incidence of 40% following partial colectomy and 35% after (sub)total colectomy after median 7 years 19 . Another CD study ( n =99) reported 1.3% and 0.0% CRC rates after median 3.5 years, respectively 10 . A UC study ( n =59) did not detect any metachronous CRC after (sub)total or partial colectomy for CRC with a median follow-up of 7 years 11 .…”

“…However, advances in surveillance techniques such as high-definition and chromo-endoscopy have improved lesion detection, limiting the risk of missed synchronous neoplasia 8 , 9 . A recent study in Crohn’s disease (CD) patients with CRC reported no increased metachronous CRC risk after partial colectomy compared with (sub)total or proctocolectomy, suggesting that a more restrictive surgical approach may be feasible in patients with limited disease 10 . Another study in ulcerative colitis (UC) patients with CRC showed no metachronous CRC after 7 years of follow-up, suggesting that partial colectomy might be feasible in elderly patients 11 .…”

Colitis-Associated Colorectal Cancer in Patients with Inflammatory Bowel Diseases in a Tertiary Referral Center: A Propensity Score Matching Analysis

“…For this reason, IPAA is today the gold standard for UC patients with CAC. In Crohn's disease current guidelines recommend pan-proctocolectomy in CAC patients [41,42]. Recent studies presented that less extended resections, involving segmental colonic resections, offer similar long-term outcomes to more extensive surgery in patients with Crohn's disease and ulcerative colitis with endoscopic remission of intestinal lesions.…”

DECIDE: Delphi Expert Consensus Statement on Inflammatory Bowel Disease Dysplasia Shared Management Decision-Making

“…(iii) Colorectal cancer after segmental colectomy: Reported rates of metachronous neoplasia if segmental colectomy has been performed for cancer, have varied from 0 -40% over a 7-year surveillance follow-up period with the highest incidences occurring in patients who pre-operatively had cancer rather than dysplasia 86,166,[170][171][172] . Recent studies reflecting modern surveillance and high definition endoscopic imaging practices suggest that the true synchronous rates are much lower than previously reported 4,173 .…”