Risk of residual neoplasia after a noncurative colorectal endoscopic submucosal dissection for malignant lesions: a multinational study

Abstract

Background and study aims: Endoscopic submucosal dissection (ESD) in colorectal lesions is technically demanding, and a significant rate of non-curative procedures is expected. We aimed to assess the rate of residual lesion after a non-curative ESD for colorectal cancer (CRC), and to establish predictive scores to be applied in the clinical setting. Patients and Methods: Retrospective multicenter analysis of consecutive colorectal ESDs. Patients with non-curative ESDs performed for the treatment of CRC lesions submitted to complementary surgery or with at least one follow-up endoscopy were included. Results: From 2255 colorectal ESDs, 381 (17%) were non-curative, and 135 of them were performed in CRC lesions. Residual lesion was observed in 24 (18%) patients. Surgery was performed in 96 patients, and 76 (79%) had no residual lesion in the colorectal wall or in the lymph nodes. Residual lesion rate for SM1 cancers was 0%, and for >SM1 cancers was also 0% if no other risk factors were present. Independent risk factors for lymph node metastasis were poor differentiation and lymphatic permeation (NC-Lymph score). Risk factors for the presence of residual lesion in the wall was piecemeal resection, poor differentiation and positive or indeterminate vertical margin (NC-Wall score). Conclusions: Lymphatic permeation or poor differentiation warrants surgery due to the high risk of lymph node metastasis, mainly in >SM1 cancers. In the remaining cases, en-bloc and R0 resections determine low risk of residual lesion in the wall. Our scores can be a useful tool for the management of patients submitted to non-curative colorectal ESDs.

Outcomes of endoscopic submucosal dissection in cirrhotic patients: First American cohort

“…Lesion recurrence (or residual neoplasia) after ESD can occur and is influenced by several factors. Primarily, piecemeal resection, poor differentiation, and positive/indeterminate vertical margin have been identified as the strongest risk factors in a recent large multicenter analysis[ 24 ]. While overall follow up rates were low, we found no significant association between cirrhosis and disease recurrence after multivariate analysis.…”

Pathologic sm2 carries a moderate risk of metastases even without other unfavorable factors, but positive horizontal margins have low local recurrence risk after en bloc resection

“…In summary, the results of the study by Santos-Antunes et al [1] on the risk of lymph node metastasis should be interpreted with great caution. In our experience, in a large cohort of patients with long-term follow-up data, pT1b (sm2) still results in an elevated risk of LNM even without other poor prognostic factors, and complementary surgical resection should be recommended in patients who are good candidates for surgery.…”

“…The multicenter study of colorectal endoscopic submucosal dissection (ESD) in the West, reported by Santos-Antunes et al 1 , showed that the risk factors for the presence of residual lesions in the wall were piecemeal resection, poor differentiation, and positive or indeterminate vertical margin. pT1b cancers (invasion deeper than 1000 μm from the muscularis mucosae) without any other risk factors did not present with residual lesions during the follow-up period.…”

Risk of lymph node metastasis and local or distant recurrence after endoscopic resection of T1 colorectal adenocarcinoma with submucosal invasion>1000 mm and no other histological pejorative factors

“…However, these different risk criteria do not have the same impact on the lymph node prognosis of these lesions. Some recent data show that the histological criterion of submucosal invasion depth<1000µm may not be an independent risk criterion for lymph node metastasis 3 , and the risk associated with it seems low 4 . The aim of this study was to evaluate the risk of lymph node metastasis or recurrence in cases of endoscopic resection with or without complementary surgery of T1 colorectal cancer with submucosal invasion of more than 1000 µm and without any other pejorative histological factors.…”