Reply to Santos-Antunes et al.

Thank you for your thoughtful reply.

I agree with the main messages of Santos-Antunes et al. that clinical algorithms combining and weighing the different risk factors with each other are the way to better select patients with a noncurative endoscopic submucosal dissection for complementary treatment, especially in high risk surgical candidates. However, as pointed out by Santos-Antunes et al., the lymph node metastasis and recurrence rates of T1 colorectal cancer are still controversial owing to the numbers of cases, regional differences, and pathologic diagnostic criteria such as measuring invasive distance and determining lymphovascular invasion.

A new nomogram predicting metastatic rates, based on data from 4673 multicenter colorectal T1 cancer cases in a recent Japanese Society of Colorectal Cancer of the Colon and Rectum project, has been published [1]. According to the nomogram, new predictors of metastasis were identified, including submucosal invasion depth > 2000 μm, moderately differentiated tubular adenocarcinoma, tumor location, and female sex. If salvage surgery is possible, a watch-and-wait strategy is feasible, but unfortunately more than half of patients with invasive cancer or metastatic recurrence die of cancer [2], so we must be cautious. Of course, we agree that this is not the case for patients at high surgical risk. We hope that colorectal cancer screening and colonoscopy will prevent colorectal cancer deaths in as many patients as possible.

Publication History

Article published online:
29 August 2023

• References

• 1 Kajiwara Y, Oka S, Tanaka S. et al. Nomogram as a novel predictive tool for lymph node metastasis in T1 colorectal cancer treated with endoscopic resection: A nationwide, multicenter study. Gastrointest Endosc 2023; DOI: 10.1016/j.gie.2023.01.022.
• 2 Saito Y. 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. Endoscopy 2023; 55: 252-254