Improving Assessment and Management of Large Non-pedunculated Colorectal Lesions in a Western Center over 10 Years: Lessons Learned and Clinical Impact

Overview

Journal Endosc Int Open

Specialty Gastroenterology

Date 2020 Oct 5

PMID 33015326

Authors

Giuseppe Vanella

Chiara Coluccio

Giulio Antonelli

Stefano Angeletti

Federica Micheli

Antonio Barbato

Gaia De Rossi

Alessandro Marchetti

Elena Mereu

Paola Pepe

Vito Domenico Corleto

Giancarlo DAmbra

Maurizio Ruggeri

Emilio Di Giulio

Affiliations

Soon will be listed here.

Abstract

Outcomes of endoscopic assessment and management of large colorectal (CR) non-pedunculated lesions (LNPLs) are still under evaluation, especially in Western settings. We analyzed the clinical impact of changes in LNPL management over the last decade in a European center. All consecutive LNPLs ≥ 20 mm endoscopically assessed (2008-2019) were retrospectively included. Lesion, patient, and resection characteristics were compared among clinically relevant subgroups. Multivariate logistic regression (for predictors of submucosal invasion [SMI] and recurrence), Kaplan-Meier curves and ROC curves (for temporal cut-offs in trends analyses) were used. A total of 395 LNPLs were included (30 mm [range 20-40]; SMI = 9.6 %; primary endoscopic resection [ER] = 88.4 %). Pseudo-depression and JNET classification independently predicted SMI beyond single morphologies/location. After complete ER, involvement of ileocecal valve/dentate line, piece-meal resection and high-grade dysplasia independently predicted recurrence. Rates of 5-year recurrence-free, surgery-free and cancer-free survival were 77.5 %, 98.6 % and 100 %, respectively, with 93.8 % recurrences endoscopically managed and no death attributable to ER or CR cancer (versus 3.4 % primary surgery mortality). ROC curves identified the period ≥ 2015 (following Endoscopic Submucosal Dissection [ESD] introduction and education on pre-resective lesion assessment) as associated with improved lesions' characterization, increased en-bloc resection of SMI lesions (87.5 % vs 37.5 %; p = 0.0455), reduced primary surgery (7.5 % vs 16.7 %; p = 0.0072), surgical referral of benign lesions (5.1 % vs 14.8 %; p = 0.0019), and recurrences. ESD introduction and educational interventions allowed ER of more complex lesions, offset by increased complementary surgery for complications or intrinsic histological risk. Nevertheless, overall, they have reduced surgery demand and increased appropriateness and safety of LNPL management in our center.

References

Ronnow C, Uedo N, Toth E, Thorlacius H . Endoscopic submucosal dissection of 301 large colorectal neoplasias: outcome and learning curve from a specialized center in Europe. Endosc Int Open. 2018; 6(11):E1340-E1348. PMC: 6221812. DOI: 10.1055/a-0733-3668. View

Bahin F, Heitman S, Rasouli K, Mahajan H, McLeod D, Lee E . Wide-field endoscopic mucosal resection versus endoscopic submucosal dissection for laterally spreading colorectal lesions: a cost-effectiveness analysis. Gut. 2017; 67(11):1965-1973. DOI: 10.1136/gutjnl-2017-313823. View

Sumimoto K, Tanaka S, Shigita K, Hayashi N, Hirano D, Tamaru Y . Diagnostic performance of Japan NBI Expert Team classification for differentiation among noninvasive, superficially invasive, and deeply invasive colorectal neoplasia. Gastrointest Endosc. 2017; 86(4):700-709. DOI: 10.1016/j.gie.2017.02.018. View

Maple J, Abu Dayyeh B, Chauhan S, Hwang J, Komanduri S, Manfredi M . Endoscopic submucosal dissection. Gastrointest Endosc. 2015; 81(6):1311-25. DOI: 10.1016/j.gie.2014.12.010. View

Miyamoto H, Ikematsu H, Fujii S, Osera S, Odagaki T, Oono Y . Clinicopathological differences of laterally spreading tumors arising in the colon and rectum. Int J Colorectal Dis. 2014; 29(9):1069-75. DOI: 10.1007/s00384-014-1931-x. View

Soliman H, Brieau B, Guillaumot M, Leblanc S, Barret M, Camus M . Invasive pit pattern, macronodule and depression are predictive factors of submucosal invasion in colorectal laterally spreading tumours from a Western population. United European Gastroenterol J. 2018; 6(10):1569-1577. PMC: 6297923. DOI: 10.1177/2050640618804713. View

Sano Y, Tanaka S, Kudo S, Saito S, Matsuda T, Wada Y . Narrow-band imaging (NBI) magnifying endoscopic classification of colorectal tumors proposed by the Japan NBI Expert Team. Dig Endosc. 2016; 28(5):526-33. DOI: 10.1111/den.12644. View

Saito Y, Fukuzawa M, Matsuda T, Fukunaga S, Sakamoto T, Uraoka T . Clinical outcome of endoscopic submucosal dissection versus endoscopic mucosal resection of large colorectal tumors as determined by curative resection. Surg Endosc. 2009; 24(2):343-52. DOI: 10.1007/s00464-009-0562-8. View

Repici A, Hassan C, Pagano N, Rando G, Romeo F, Spaggiari P . High efficacy of endoscopic submucosal dissection for rectal laterally spreading tumors larger than 3 cm. Gastrointest Endosc. 2012; 77(1):96-101. DOI: 10.1016/j.gie.2012.08.036. View

10.

Margagnoni G, Angeletti S, DAmbra G, Pagnini C, Ruggeri M, Corleto V . Outcome and risk of recurrence for endoscopic resection of colonic superficial neoplastic lesions over 2 cm in diameter. Dig Liver Dis. 2016; 48(4):399-403. DOI: 10.1016/j.dld.2015.10.006. View

11.

Milano R, Viale E, Bartel M, Notaristefano C, Testoni P . Resection outcomes and recurrence rates of endoscopic submucosal dissection (ESD) and hybrid ESD for colorectal tumors in a single Italian center. Surg Endosc. 2017; 32(5):2328-2339. DOI: 10.1007/s00464-017-5928-8. View

12.

Bae J, Yang D, Lee S, Soh J, Lee S, Lee H . Optimized hybrid endoscopic submucosal dissection for colorectal tumors: a randomized controlled trial. Gastrointest Endosc. 2015; 83(3):584-92. DOI: 10.1016/j.gie.2015.06.057. View

13.

Minoda Y, Ogino H, Chinen T, Ihara E, Haraguchi K, Akiho H . Objective validity of the Japan Narrow-Band Imaging Expert Team classification system for the differential diagnosis of colorectal polyps. Dig Endosc. 2019; 31(5):544-551. DOI: 10.1111/den.13393. View

14.

Kiriyama S, Saito Y, Yamamoto S, Soetikno R, Matsuda T, Nakajima T . Comparison of endoscopic submucosal dissection with laparoscopic-assisted colorectal surgery for early-stage colorectal cancer: a retrospective analysis. Endoscopy. 2012; 44(11):1024-30. DOI: 10.1055/s-0032-1310259. View

15.

Geramizadeh B, Owen D . Handling and Pathology Reporting of Gastrointestinal Endoscopic Mucosal Resection. Middle East J Dig Dis. 2017; 9(1):5-11. PMC: 5308135. DOI: 10.15171/mejdd.2016.45. View

16.

Probst A, Ebigbo A, Markl B, Schaller T, Anthuber M, Fleischmann C . Endoscopic submucosal dissection for early rectal neoplasia: experience from a European center. Endoscopy. 2016; 49(3):222-232. DOI: 10.1055/s-0042-118449. View

17.

Bogie R, Veldman M, Snijders L, Winkens B, Kaltenbach T, Masclee A . Endoscopic subtypes of colorectal laterally spreading tumors (LSTs) and the risk of submucosal invasion: a meta-analysis. Endoscopy. 2017; 50(3):263-282. DOI: 10.1055/s-0043-121144. View

18.

Rutter M, Chattree A, Barbour J, Thomas-Gibson S, Bhandari P, Saunders B . British Society of Gastroenterology/Association of Coloproctologists of Great Britain and Ireland guidelines for the management of large non-pedunculated colorectal polyps. Gut. 2015; 64(12):1847-73. PMC: 4680188. DOI: 10.1136/gutjnl-2015-309576. View

19.

Burgess N, Hourigan L, Zanati S, Brown G, Singh R, Williams S . Risk Stratification for Covert Invasive Cancer Among Patients Referred for Colonic Endoscopic Mucosal Resection: A Large Multicenter Cohort. Gastroenterology. 2017; 153(3):732-742.e1. DOI: 10.1053/j.gastro.2017.05.047. View

20.

Hwang J, Konda V, Abu Dayyeh B, Chauhan S, Enestvedt B, Fujii-Lau L . Endoscopic mucosal resection. Gastrointest Endosc. 2015; 82(2):215-26. DOI: 10.1016/j.gie.2015.05.001. View