Endoscopic full-thickness resection of T1 colorectal cancers: a retrospective analysis from a multicenter Dutch eFTR registry

Abstract

Background Complete endoscopic resection and accurate histological evaluation for T1 colorectal cancer (CRC) are critical in determining subsequent treatment. Endoscopic full-thickness resection (eFTR) is a new treatment option for T1 CRC < 2 cm. We aimed to report clinical outcomes and short-term results.

Methods Consecutive eFTR procedures for T1 CRC, prospectively recorded in our national registry between November 2015 and April 2020, were retrospectively analyzed. Primary outcomes were technical success and R0 resection. Secondary outcomes were histological risk assessment, curative resection, adverse events, and short-term outcomes.

Results We included 330 procedures: 132 primary resections and 198 secondary scar resections after incomplete T1 CRC resection. Overall technical success, R0 resection, and curative resection rates were 87.0 % (95 % confidence interval [CI] 82.7 %–90.3 %), 85.6 % (95 %CI 81.2 %–89.2 %), and 60.3 % (95 %CI 54.7 %–65.7 %). Curative resection rate was 23.7 % (95 %CI 15.9 %–33.6 %) for primary resection of T1 CRC and 60.8 % (95 %CI 50.4 %–70.4 %) after excluding deep submucosal invasion as a risk factor. Risk stratification was possible in 99.3 %. The severe adverse event rate was 2.2 %. Additional oncological surgery was performed in 49/320 (15.3 %), with residual cancer in 11/49 (22.4 %). Endoscopic follow-up was available in 200/242 (82.6 %), with a median of 4 months and residual cancer in 1 (0.5 %) following an incomplete resection.

Conclusions eFTR is relatively safe and effective for resection of small T1 CRC, both as primary and secondary treatment. eFTR can expand endoscopic treatment options for T1 CRC and could help to reduce surgical overtreatment. Future studies should focus on long-term outcomes.

^* Both authors contributed equally to this article

Publikationsverlauf

Eingereicht: 02. April 2021

Angenommen: 06. September 2021

Accepted Manuscript online:
06. September 2021

Artikel online veröffentlicht:
11. Januar 2022

• References

• 1 Reggiani-Bonetti L, Di Gregorio C, Pedroni M. et al. Incidence trend of malignant polyps through the data of a specialized colorectal cancer registry: clinical features and effect of screening. Scand J Gastroenterol 2013; 48: 1294-1301
• 2 Toes-Zoutendijk E, Kooyker AI, Elferink MA. et al. Stage distribution of screen-detected colorectal cancers in the Netherlands. Gut 2018; 67: 1745-1746
• 3 Kim JB, Lee HS, Lee HJ. et al. Long-term outcomes of endoscopic versus surgical resection of superficial submucosal colorectal cancer. Dig Dis Sci 2015; 60: 2785-2792
• 4 Vermeer NCA, Backes Y, Snijders HS. et al. National cohort study on postoperative risks after surgery for submucosal invasive colorectal cancer. BJS Open 2019; 3: 210-217
• 5 Ferlitsch M, Moss A, Hassan C. et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2017; 49: 270-297
• 6 Shaukat A, Kaltenbach T, Dominitz JA. et al. Endoscopic recognition and management strategies for malignant colorectal polyps: recommendations of the US Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2020; 115: 1751-1767
• 7 Beaton C, Twine CP, Williams GL. et al. Systematic review and meta-analysis of histopathological factors influencing the risk of lymph node metastasis in early colorectal cancer. Colorectal Dis 2013; 15: 788-797
• 8 Ikematsu H, Yoda Y, Matsuda T. et al. Long-term outcomes after resection for submucosal invasive colorectal cancers. Gastroenterology 2013; 144: 551-559
• 9 Arezzo A, Passera R, Marchese N. et al. Systematic review and meta-analysis of endoscopic submucosal dissection vs endoscopic mucosal resection for colorectal lesions. United European Gastroenterol J 2016; 4: 18-29
• 10 Vleugels JLA, Koens L, Dijkgraaf MGW. et al. Suboptimal endoscopic cancer recognition in colorectal lesions in a national bowel screening programme. Gut 2020; 69: 977-980
• 11 Butte JM, Tang P, Gonen M. et al. Rate of residual disease after complete endoscopic resection of malignant colonic polyp. Dis Colon Rectum 2012; 55: 122-127
• 12 Schmidt A, Beyna T, Schumacher B. et al. Colonoscopic full-thickness resection using an over-the-scope device: a prospective multicentre study in various indications. Gut 2018; 67: 1280-1289
• 13 Velegraki M, Trikola A, Vasiliadis K. et al. Endoscopic full-thickness resection of colorectal lesions with the full-thickness resection device: clinical experience from two referral centers in Greece. Ann Gastroenterol 2019; 32: 482-488
• 14 Aepli P, Criblez D, Baumeler S. et al. Endoscopic full thickness resection (EFTR) of colorectal neoplasms with the Full Thickness Resection Device (FTRD): Clinical experience from two tertiary referral centers in Switzerland. United European Gastroenterol J 2018; 6: 463-470
• 15 Valli PV, Mertens J, Bauerfeind P. Safe and successful resection of difficult GI lesions using a novel single-step full-thickness resection device (FTRD(). Surg Endosc 2018; 32: 289-299
• 16 Andrisani G, Pizzicannella M, Martino M. et al. Endoscopic full-thickness resection of superficial colorectal neoplasms using a new over-the-scope clip system: a single-centre study. Dig Liver Dis 2017; 49: 1009-1013
• 17 Vitali F, Naegel A, Siebler J. et al. Endoscopic full-thickness resection with an over-the-scope clip device (FTRD) in the colorectum: results from a university tertiary referral center. Endosc Int Open 2018; 6: E98-E103
• 18 Meier B, Stritzke B, Kuellmer A. et al. Efficacy and safety of endoscopic full-thickness resection in the colorectum: results from the German Colonic FTRD Registry. Am J Gastroenterol 2020; 115: 1998-2006
• 19 Castor Electronic Data Capture. Amsterdam: 2019 https://www.castoredc.com Accessed: 2 April 2021
• 20 Zwager LW, Bastiaansen BAJ, Bronzwaer MES. et al. Endoscopic full-thickness resection (eFTR) of colorectal lesions: results from the Dutch colorectal eFTR registry. Endoscopy 2020;
• 21 Dutch Colorectal Cancer Guideline [In Dutch]. 2014 https://richtlijnendatabase.nl/richtlijn/colorectaal_carcinoom_crc/startpagina_-_crc.html Accessed: 2 April 2021
• 22 Yasue C, Chino A, Takamatsu M. et al. Pathological risk factors and predictive endoscopic factors for lymph node metastasis of T1 colorectal cancer: a single-center study of 846 lesions. J Gastroenterol 2019; 54: 708-717
• 23 Nakadoi K, Tanaka S, Kanao H. et al. Management of T1 colorectal carcinoma with special reference to criteria for curative endoscopic resection. J Gastroenterol Hepatol 2012; 27: 1057-1062
• 24 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454
• 25 Kuellmer A, Mueller J, Caca K. et al. Endoscopic full-thickness resection for early colorectal cancer. Gastrointest Endosc 2019; 89: 1180-1189
• 26 Hassan C, Repici A, Sharma P. et al. Efficacy and safety of endoscopic resection of large colorectal polyps: a systematic review and meta-analysis. Gut 2016; 65: 806-820
• 27 Fuccio L, Repici A, Hassan C. et al. Why attempt en bloc resection of non-pedunculated colorectal adenomas? A systematic review of the prevalence of superficial submucosal invasive cancer after endoscopic submucosal dissection. Gut 2018; 67: 1464-1474
• 28 Watanabe D, Toyonaga T, Ooi M. et al. Clinical outcomes of deep invasive submucosal colorectal cancer after ESD. Surg Endosc 2018; 32: 2123-2130
• 29 Tanaka S, Asayama N, Shigita K. et al. Towards safer and appropriate application of endoscopic submucosal dissection for T1 colorectal carcinoma as total excisional biopsy: future perspectives. Dig Endosc 2015; 27: 216-222
• 30 Park EY, Baek DH, Lee MW. et al. Long-term outcomes of T1 colorectal cancer after endoscopic resection. J Clin Med 2020; 9: 2451
• 31 Nishimura T, Oka S, Tanaka S. et al. Clinical significance of immunohistochemical lymphovascular evaluation to determine additional surgery after endoscopic submucosal dissection for colorectal T1 carcinoma. Int J Colorectal Dis 2020;
• 32 Sumimoto K, Tanaka S, Shigita K. et al. Diagnostic performance of Japan NBI Expert Team classification for differentiation among noninvasive, superficially invasive, and deeply invasive colorectal neoplasia. Gastrointest Endosc 2017; 86: 700-709
• 33 Richards CH, Ventham NT, Mansouri D. et al. An evidence-based treatment algorithm for colorectal polyp cancers: results from the Scottish Screen-detected Polyp Cancer Study (SSPoCS). Gut 2018; 67: 299-306
• 34 Fuccio L, Hassan C, Ponchon T. et al. Clinical outcomes after endoscopic submucosal dissection for colorectal neoplasia: a systematic review and meta-analysis. Gastrointest Endosc 2017; 86: 74-86
• 35 Ohtsuki K, Koyama F, Tamura T. et al. Prognostic value of immunohistochemical analysis of tumor budding in colorectal carcinoma. Anticancer Res 2008; 28: 1831-1836