Endoscopic resection is more effective than biopsy or EUS to detect residual rectal neuroendocrine tumor^[*]

Abstract

Background and study aims Rectal neuroendocrine tumors (NETs) are often discovered incidentally and may be misidentified as adenomatous polyps. This can result in a partial resection at the index procedure, and lesions are often referred for staging or evaluation for residual disease at the resection site. The aim of this study was to identify the ideal method to confirm complete excision of small rectal NETs.

Patients and methods Data from patients with a previously resected rectal NET referred for follow-up endoscopy or endoscopic ultrasound (EUS) were retrospectively reviewed. Univariate analysis was performed on categorical data using the Chi-squared test.

Results Forty-nine patients with rectal NETs were identified by pathology specimens. Of those, 39 underwent follow-up endoscopy or EUS and were included. Baseline characteristics included gender (71 % F, 29 % M), age (57.2 ± 13.4 yrs) lesion size (7.3 ± 4.2 mm) and location. The prior resection site was identified in 37/39 patients who underwent tissue sampling. Residual NET was found histologically in 14/37 lesions. All residual disease was found during salvage endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) and 43 % had a normal-appearing scar. Every patient undergoing EUS had an unremarkable exam. Initial cold biopsy polypectomy (P = 0.006), visible lesions (P = 0.001) and EMR/ESD of the prior resection site (P = 0.01) correlated with residual NET.

Conclusions Localized rectal NETs may be incompletely removed with standard polypectomy. If an advanced resection is not performed initially, repeat endoscopy with salvage EMR or ESD of the scar should be considered. For small rectal NETs, biopsy may miss residual disease when there is no visible lesion and EUS appears to have no benefit.

^* Meeting presentations: Digestive Disease Week 2018

Publication History

Received: 01 April 2020

Accepted: 05 October 2020

Article published online:
01 January 2021

• References

• 1 Anthony LB, Strosberg JR, Klimstra DS. et al. The NANETS Consensus Guidelines for the Diagnosis and Management of Gastrointestinal Neuroendocrine Tumors (NETs): Well-Differentiated NETs of the Distal Colon and Rectum. Pancreas 2010; 39: 767-774
• 2 Caplin M, Sundin A, Nillson O. et al. ENETS Consensus Guidelines for the management of patients with digestive neuroendocrine neoplasms: colorectal neuroendocrine neoplasms. Neuroendocrinology 2012; 95: 88-97
• 3 Chablaney S, Zator ZA, Kumta NA. Diagnosis and management of rectal neuroendocrine tumors. Clin Endosc 2017; 50: 530-536
• 4 Dasari A, Shen C, Halperin D. et al. Trends in the incidence, prevalence, and survival outcomes in patients with neuroendocrine tumors in the United States. JAMA Oncol 2017; 3: 1335-1342
• 5 Yao JC, Hassan M, Phan A. et al. One hundred years after "carcinoid": epidemiology of and prognostic factors for neuroendocrine tumors in 35,825 cases in the United States. J Clin Oncol 2008; 26: 3063-3072
• 6 Tsikitis VL, Wertheim BC, Guerrero MA. Trends of incidence and survival of gastrointestinal neuroendocrine tumors in the United States: a seer analysis. J Cancer 2012; 3: 292-302
• 7 Modlin IM, Lye KD, Kidd M. A 5-decade analysis of 13,715 carcinoid tumors. Cancer 2003; 97: 934-959
• 8 de Mestier L, Brixi H, Gincul R. et al. Updating the management of patients with rectal neuroendocrine tumors. Endoscopy 2013; 45: 1039-1046
• 9 Ramage JK, De Herder WW, Delle Fave G. et al. ENETS Consensus Guidelines Update for Colorectal Neuroendocrine Neoplasms. Neuroendocrinology 2016; 103: 139-143
• 10 Chung TP, Hunt SR. Carcinoid and neuroendocrine tumors of the colon and rectum. Clin Colon Rectal Surg 2006; 19: 45-48
• 11 Ishii N, Horiki N, Itoh T. et al. Endoscopic submucosal dissection and preoperative assessment with endoscopic ultrasonography for the treatment of rectal carcinoid tumors. Surg Endosc 2010; 24: 1413-1419
• 12 Kobayashi K, Katsumata T, Yoshizawa S. et al. Indications of Endoscopic polypectomy for rectal carcinoid tumors and clinical usefulness of endoscopic ultrasonography. Dis Colon Rectum 2005; 48: 285
• 13 Matsumoto T, Iida M, Suekane H. et al. Endoscopic ultrasonography in rectal carcinoid tumors: contribution to selection of therapy. Gastrointest Endosc 1991; 37: 539-542
• 14 Park SB, Kim DJ, Kim HW. et al. Is endoscopic ultrasonography essential for endoscopic resection of small rectal neuroendocrine tumors?. World J Gastroenterol 2017; 23: 2037-2043
• 15 Fraenkel M, Kim M, Faggiano A. et al. Incidence of gastroenteropancreatic neuroendocrine tumours: a systematic review of the literature. Endocr Relat Cancer 2014; 21: R153-163
• 16 Jung YS, Yun KE, Chang Y. et al. Risk factors associated with rectal neuroendocrine tumors: a cross-sectional study. Cancer Epidemiol Biomarkers Prev 2014; 23: 1406-1413
• 17 Son HJ, Sohn DK, Hong CW. et al. Factors associated with complete local excision of small rectal carcinoid tumor. Int J Colorectal Dis 2013; 28: 57-61
• 18 Onozato Y, Kakizaki S, Iizuka H. et al. Endoscopic treatment of rectal carcinoid tumors. Dis Colon Rectum 2010; 53: 169-176
• 19 Kim J, Kim JH, Lee JY. et al. Clinical outcomes of endoscopic mucosal resection for rectal neuroendocrine tumor. BMC Gastroenterol 2018; 18: 77
• 20 Park CH, Cheon JH, Kim JO. et al. Criteria for decision making after endoscopic resection of well-differentiated rectal carcinoids with regard to potential lymphatic spread. Endoscopy 2011; 43: 790-795
• 21 Yang DH, Park Y, Park SH. et al. Cap-assisted EMR for rectal neuroendocrine tumors: comparisons with conventional EMR and endoscopic submucosal dissection (with videos). Gastrointest Endosc 2016; 83: 1015-1022; quiz 1023- e1016
• 22 Zhou X, Xie H. et al. Endoscopic resection therapies for rectal neuroendocrine tumors: a systematic review and meta-analysis. J Gastroenterol Hepatol 2014; 29: 259-268
• 23 Sekiguchi M, Sekine S, Sakamoto T. et al. Excellent prognosis following endoscopic resection of patients with rectal neuroendocrine tumors despite the frequent presence of lymphovascular invasion. J Gastroenterol 2015; 50: 1184-1189
• 24 Jeon SM, Lee JH, Hong SP. et al. Feasibility of salvage endoscopic mucosal resection by using a cap for remnant rectal carcinoids after primary EMR. Gastrointest Endosc 2011; 73: 1009-1014
• 25 Chen T, Yao LQ, Xu MD. et al. Efficacy and Safety of endoscopic submucosal dissection for colorectal carcinoids. Clin Gastroenterol Hepatol 2016; 14: 575-581
• 26 Park HW, Byeon JS, Park YS. et al. Endoscopic submucosal dissection for treatment of rectal carcinoid tumors. Gastrointest Endosc 2010; 72: 143-149
• 27 Matsushita M, Takakuwa H, Nishio A. Management of rectal carcinoid tumors. Gastrointest Endosc 2003; 58: 641; author reply 641-642
• 28 Lee DS, Jeon SW, Park SY. et al. The feasibility of endoscopic submucosal dissection for rectal carcinoid tumors: comparison with endoscopic mucosal resection. Endoscopy 2010; 42: 647-651
• 29 Fine C, Roquin G, Terrebonne E. et al. Endoscopic management of 345 small neuroendocrine tumors: A national study from the French group of endocrine tumors (GTE). United Eur Gastroenterol J 2019; 7: 1102-1112
• 30 Efthymiou M, Taylor AC, Desmond PV. et al. Biopsy forceps is inadequate for the resection of diminutive polyps. Endoscopy 2011; 43: 312-316
• 31 Anderloni A, Jovani M, Hassan C. et al. Advances, problems, and complications of polypectomy. Clin Exp Gastroenterol 2014; 7: 285-296
• 32 Zhang Q, Gao P, Han B. et al. Polypectomy for complete endoscopic resection of small colorectal polyps. Gastrointest Endosc 2018; 87: 733-740
• 33 Monkemuller KE, Fry LC, Jones BH. et al. Histological quality of polyps resected using the cold versus hot biopsy technique. Endoscopy 2004; 36: 432-436
• 34 Goldstein NS, Watts JC, Neill JS. et al. The effect of electrothermal cautery-assisted resection of diminutive colonic polyps on histopathologic diagnosis. Am J Clin Pathol 2001; 115: 356-361