Patient outcomes after non-curative endoscopic submucosal dissection for early colorectal cancer: a single-center, retrospective cohort study

Abstract

Background: The treatment patterns and outcomes for patients after non-curative endoscopic submucosal dissection (ESD) remain controversial, particularly among those requiring preservation of the anal sphincter or advanced age. This retrospective study aimed to investigate the treatment patterns and outcomes in patients after non-curative ESD for early colorectal cancer (CRC). Methods: This was a retrospective review in Chinese patients who received non-curative ESD for early CRC, and who were treated in the Cancer Hospital at the Chinese Academy of Medical Sciences from 2010 to 2019. Demographic parameters, clinicopathologic features, treatment patterns, and clinical outcomes were analyzed.Results: Of the 180 patients who received non-curative ESD, 85 received additional surgery; the remaining 95 patients were kept under surveillance only. Patients in the surveillance-only group tended to be older than those in the additional surgery group. Furthermore, tumors in the surveillance-only group were located in the rectum significantly more often, were better differentiated with a shallower depth of invasion and less perineuronal invasion than in the additional surgery group; there were fewer high-risk factors for residual cancer or lymph node (LN) metastasis in the surveillance-only group compared with the additional surgery group. There was no significant difference in 5-year overall survival (OS) (92.6% versus 92.7%, P=0.355), 5-year disease-free survival (DFS) (94.7% versus 91.9%, P=0.340), 5-year cancer-specific survival (CSS) (93.8% versus 92.7%, P=0.791), or total recurrence rates (4.7% versus 9.5%, P=0.217) between the additional surgery and surveillance-only groups, respectively.Conclusions: ESD results in favorable outcomes for patients with early CRC. Surveillance in patients who receive non-curative ESD may be an alternative option for those with advanced age and fewer high-risk factors for residual cancer or LN metastasis.

How Does Omitting Additional Surgery after Local Excision Affect the Prognostic Outcome of Patients with High-risk T1 Colorectal Cancer?

“…Moreover, the survival impact of additional surgical intervention has been reported to be limited even in patients with high-risk T1 tumors in several studies, although those studies were retrospective in design and had relatively small numbers of patients. 14,21,22 Thus, the true impact of additional surgery, especially in patients at high surgical risk, still remains a topic of debate.…”

“…Incidence rates of lymph node metastasis, however, are reported to be around 10.3% to 14.0% based on this background, 14,22,25 suggesting that many patients end up undergoing unnecessary invasive procedures. Moreover, the survival impact of additional surgical intervention has been reported to be limited even in patients with high-risk T1 tumors in several studies, although those studies were retrospective in design and had relatively small numbers of patients 14,21,22 . Thus, the true impact of additional surgery, especially in patients at high surgical risk, still remains a topic of debate.…”

“…Indeed, the rate of lymph node metastasis among patients with high-risk T1 CRC according to those guidelines is not necessarily higher than that among patients without high-risk features, and this fact discourages some surgeons from performing invasive treatment in frail patients. Moreover, several studies reported limited improvement in survival among high-risk patients with T1 CRC with additional surgical resection 14,21,22 . Thus, there is a need to verify the impact of omitting additional invasive treatment in these patients.…”

“…Moreover, several studies reported limited improvement in survival among high-risk patients with T1 CRC with additional surgical resection. 14,21,22 Thus, there is a need to verify the impact of omitting additional invasive treatment in these patients.…”

Clinical outcomes of colorectal neoplasm with positive resection margin after endoscopic submucosal dissection

“…Although recent studies reported that salvage ESD for local/recurrent colorectal tumors is effective and safe, most of the tumors included in this study were resected using the endoscopic mucosal resection (EMR) method, and most of the procedure was performed by experts in large volume centers 7 . For patients with non-curative resected T1 CRC, there is still controversy whether additional surgery is necessary or if surveillance alone is sufficient 8 . Although current guidelines recommend surgery, residual tumor was found in less than 7–18% of patients in previous studies 9 , 10 .…”