Low risk of local recurrence after a successful en bloc endoscopic submucosal dissection for noninvasive colorectal lesions with positive horizontal resection margins (R-ESD study)

Abstract

Background During endoscopic submucosal dissection (ESD), the normal mucosa is cut under constant optical control. We studied whether a positive horizontal resection margin after a complete en bloc ESD predicts local recurrence.

Methods In this European multicenter cohort study, patients with a complete en bloc colorectal ESD were selected from prospective registries. Cases were defined by a horizontal resection margin that was positive or indeterminate for dysplasia (HM1), whereas controls had a free resection margin (HM0). Low risk lesions with submucosal invasion (T1) and margins free of carcinoma were analyzed separately. The main outcome was local recurrence.

Results From 928 consecutive ESDs (2011–2020), 354 patients (40 % female; mean age 67 years, median follow-up 23.6 months), with 308 noninvasive lesions and 46 T1 lesions, were included. The recurrence rate for noninvasive lesions was 1/212 (0.5 %; 95 %CI 0.02 %–2.6 %) for HM0 vs. 2/96 (2.1 %; 95 %CI 0.57 %–7.3 %) for HM1. The recurrence rate for T1 lesions was 1/38 (2.6 %; 95 %CI 0.14 %–13.5 %) for HM0 vs. 2/8 (25 %; 95 %CI 7.2 %–59.1 %) for HM1.

Conclusion A positive horizontal resection margin after an en bloc ESD for noninvasive lesions is associated with a marginal nonsignificant increase in the local recurrence rate, equal to an ESD with clear horizontal margins. This could not be confirmed for T1 lesions.

• References

• 1 Belderbos TDG, Leenders M, Moons LMG. et al. Local recurrence after endoscopic mucosal resection of nonpedunculated colorectal lesions: Systematic review and meta-analysis. Endoscopy 2014; 46: 388-400
• 2 Dessain A, Snauwaert C, Baldin P. et al. Endoscopic submucosal dissection specimens in early colorectal cancer: lateral margins, macroscopic techniques, and possible pitfalls. Virchows Arch 2017; 470: 165-174
• 3 Reggiani Bonetti L, Manta R, Manno M. et al. Optimal processing of ESD specimens to avoid pathological artifacts. Tech Coloproctol 2018; 22: 857-866
• 4 Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T. et al. Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015; 47: 829-854
• 5 Park JH, Yoon JY, Hwang SW. et al. A surveillance endoscopy strategy based on local recurrence rates after colorectal endoscopic submucosal dissection. J Clin Med 2021; 10: 4591
• 6 Lee S, Kim J, Soh JS. et al. Recurrence rate of lateral margin-positive cases after en bloc endoscopic submucosal dissection of colorectal neoplasia. Int J Colorectal Dis 2018; 33: 735-743
• 7 Nagtegaal ID, Odze RD, Klimstra D. et al. The 2019 WHO classification of tumours of the digestive system. Histopathology 2020; 76: 182-188
• 8 Higaki S, Hashimoto S, Harada K. et al. Long-term follow-up of large flat colorectal tumors resected endoscopically. Endoscopy 2003; 35: 845-849
• 9 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.e1
• 10 Makazu M, Sakamoto T, So E. et al. Relationship between indeterminate or positive lateral margin and local recurrence after endoscopic resection of colorectal polyps. Endosc Int Open 2015; 3: E252-E257
• 11 Thorlacius H, Rönnow CF, Toth E. European experience of colorectal endoscopic submucosal dissection: a systematic review of clinical efficacy and safety. Acta Oncol (Madr) 2019; 58: S10-S14
• 12 Bordillon P, Pioche M, Wallenhorst T. et al. Double-clip traction for colonic endoscopic submucosal dissection: a multicenter study of 599 consecutive cases (with video). Gastrointest Endosc 2021; 94: 333-343
• 13 Pei Q, Qiao H, Zhang M. et al. Pocket-creation method versus conventional method of endoscopic submucosal dissection for superficial colorectal neoplasms: a meta-analysis. Gastrointest Endosc 2021; 93: 1038-1046.e4
• 14 Abe S, Wu SYS, Ego M. et al. Efficacy of current traction techniques for endoscopic submucosal dissection. Gut Liver 2020; 14: 673-684
• 15 Suchy C, Berger M, Steinbrück I. et al. Long-term follow-up after colorectal endoscopic submucosal dissection in 182 cases. Endosc Int Open 2021; 09: E258-E262
• 16 Shin J-W, Han KS, Hyun JH. et al. Risk of recurrence after endoscopic resection of early colorectal cancer with positive margins. Endoscopy 2018; 50: 241-247
• 17 Sato Y, Kudo SE, Ichimasa K. et al. Clinicopathological features of T1 colorectal carcinomas with skip lymphovascular invasion. Oncol Lett 2018; 16: 7264-7270
• 18 Okamoto Y, Mitomi H, Ichikawa K. et al. Effect of skip lymphovascular invasion on hepatic metastasis in colorectal carcinomas. Int J Clin Oncol 2015; 20: 761-766
• 19 Gijsbers KM, van der Schee L, van Veen T. et al. Impact of ≥ 0.1-mm free resection margins on local intramural residual cancer after local excision of T1 colorectal cancer. Endosc Int Open 2022; 10: E282-E290