Endoscopic submucosal dissection for early rectal neoplasia: experience from a European center

Abstract

Background and study aims Endoscopic resection is a curative treatment option for large nonpedunculated colorectal polyps (LNPCPs). Endoscopic submucosal dissection (ESD) allows en bloc resection but ESD experience is still limited outside Asia. The aim of our study was to evaluate the role of ESD in the treatment of early rectal neoplasia in a European center.

Patients and methods 330 patients referred for endoscopic resection of rectal LNPCPs were included prospectively.

Results ESD was performed for 302 LNPCPs (median diameter 40 mm). Submucosal invasive cancer (SMIC) was present in 17.2 % (n = 52). SMIC was associated with Paris type (54.5 % among type 0-Is lesions, 100 % of 0-Is-IIc type, 0 % of 0-IIa, 14.9 % of 0-IIa-Is, and 59.3 % of 0-IIa-IIc type; P < 0.001) and with surface pattern (71.4 % among nongranular plus mixed surface lesions, 17.9 % of lesions with granular surface and nodule ≥ 10 mm). For SMICs, resection rates were en bloc 81.4 %, R0 65.1 %, and curative 30.2 %. Curative resection rate improved from 13.6 % to 47.6 % over the study period (P = 0.036). The reason for 83.3 % (25/30) of noncurative resections was submucosal invasion exceeding 1000 µm. For benign lesions (n = 250, 82.8 %), the R0 resection increased from 55.2 % to 84.8 % over the study period (P < 0.001). Recurrence rate was 4.8 %, bleeding rate 5.2 %, and perforation rate 0.8 % (all complications managed conservatively). Median follow-up was 35 months.

Conclusions The majority of rectal LNPCPs are benign lesions. ESD offers high R0 resection and low recurrence rates but EMR may be appropriate. In lesions with a risk for SMIC, ESD should be offered to achieve R0 resection. Despite high rates of R0 resection the curative resection rate of ESD for rectal SMIC is < 50 %. Pretherapeutic lesion selection needs improvement.

• References

• 1 Zauber AG. Winawer SJ. O’Brien MJ. et al. Colonoscopy polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med 2012; 366: 687-696
• 2 Moss A. Williams SJ. Hourigan LF. et al. Long-term adenoma recurrence following wide-field endoscopic mucosal resection (WF-EMR) for advanced colonic mucosal neoplasia is infrequent: results and risk factors in 1000 cases from the Australian Colonic EMR (ACE) study. Gut 2015; 64: 57-65
• 3 Oka S. Tanaka S. Saito Y. et al. Local recurrence after endoscopic resection for large colorectal neoplasia: a multicenter prospective study in Japan. Am J Gastroenterol 2015; 110: 697-707
• 4 Saito Y. Uraoka T. Yamaguchi Y. et al. A prospective, multicenter study of 1111 colorectal endoscopic submucosal dissections (with video). Gastrointest Endosc 2010; 72: 1217-1225
• 5 Saito Y. Fukuzawa M. Matsuda T. et al. Clinical outcome of endoscopic submucosal dissection versus endoscopic mucosal resection of large colorectal tumors determined by curative resection. Surg Endosc 2010; 24: 343-352
• 6 Probst A. Golger D. Arnholdt H. et al. Endoscopic submucosal dissection of early cancers, flat adenomas and submucosal tumors in the gastrointestinal tract. Clin Gastroenterol Hepatol 2009; 7: 149-155
• 7 Probst A. Golger D. Anthuber M. et al. Endoscopic submucosal dissection of large sessile lesions of the rectosigmoid: learning curve in a European center. Endoscopy 2012; 44: 660-667
• 8 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
• 9 Repici A. Hassan C. Pagano N. et al. High efficacy of endoscopic submucosal dissection for rectal laterally spreading tumors larger than 3cm. Gastrointest Endosc 2013; 77: 96-101
• 10 Endoscopic Classification Review Group. Update on the Paris Classification of Superficial Neoplastic Lesions in the Digestive Tract. Endoscopy 2005; 37: 570-578
• 11 Kudo S. Lambert R. Allen JI. et al. Nonpolypoid neoplastic lesions of the colorectal mucosa. Gastrointest Endosc 2008; 68: S3-S47
• 12 Kudo S. Tamura S. Nakajima T. et al. Diagnosis of colorectal tumorous lesions by magnifying endoscopy. Gastrointest Endosc 1996; 44: 8-14
• 13 Ikematsu H. Matsuda T. Emura F. et al. Efficacy of capillary pattern IIIA/IIIB by magnifying narrow band imaging for estimating depth of invasion of early colorectal neoplasms. BMC Gastroenterol
• 14 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
• 15 Pox CP. Altenhofen L. Brenner H. et al. Efficacy of a nationwide screening colonoscopy program for colorectal cancer. Gastroenterology 2012; 142: 1460-1467
• 16 Mou S. Soetikno R. Shimoda T. et al. Pathologic predictive factors for lymph node metastasis in submucosal invasive (T1) colorectal cancer: a systematic review and meta-analysis. Surg Endosc 2013; 27: 2692-2703
• 17 Yoda Y. Ikematsu H. Matsuda T. et al. A large-scale multicenter study of long-term outcomes after endoscopic resection for submucosal invasive cancer. Endoscopy 2013; 45: 718-724
• 18 Ikematsu H. Yoda Y. Matsuda T. et al. Long-term outcomes after resection for submucosal invasive colorectal cancers. Gastroenterology 2013; 144: 551-559
• 19 Rutter MD. Chattree A. Barbour JA. et al. 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: 1847-1873
• 20 Morino M. Risio M. Bach S. et al. Early rectal cancer: the European Association for Endoscopic Surgery (EAES) clinical consensus conference. Surg Endosc 2015; 29: 755-773
• 21 Matsuda T. Fujii T. Saito Y. et al. Efficacy of the invasive/non-invasive pattern by magnifying chromoendoscopy to estimate the depth of invasion of early colorectal neoplasms. Am J Gastroenterol 2008; 103: 2700-2706
• 22 Moss A. Bourke MJ. Williams SJ. et al. Endoscopic mucosal resection outcomes and prediction of submucosal cancer from advanced colonic mucosal neoplasia. Gastroenterology 2011; 140: 1909-1918
• 23 Yamada M. Saito Y. Sakamoto T. et al. Endoscopic predictors of deep submucosal invasion in colorectal laterally spreading tumors. Endoscopy 2016; 48: 456-464
• 24 Sakamoto T. Matsuda T. Nakajima T. et al. Impact of clinical experience on type V pit pattern analysis using magnifying chromoendoscopy in early colorectal cancer: a cross-sectional interpretation test. BMC Gastroenterology 2014; 14: 100-106
• 25 Niimi K. Fujishiro M. Kodashima S. et al. Long-term outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms. Endoscopy 2010; 42: 723-729
• 26 Nakajima T. Saito Y. Tanaka S. et al. Current status of endoscopic resection strategy for large, early colorectal neoplasia in Japan. Surg Endosc 2013; 27: 3262-3270
• 27 Ricker A. Aliyev R. Belle S. et al. Oncologic colorectal resection after endoscopic treatment of malignant polyps: Does endoscopy have an adverse effect on oncologic and surgical outcomes?. Gastrointest Endosc 2014; 79: 951-960