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Endoscopy 2023; 55(10): 976
DOI: 10.1055/a-2085-5872
Letter to the editor

Reply to Kilincalp and Mottacki

Michael X. Ma 
1   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
2   Department of Gastroenterology and Hepatology, Fiona Stanley Hospital, Perth, Western Australia, Australia
3   Department of Medicine, Midland St John of God Hospital, Perth, Western Australia, Australia
,
Michael J. Bourke
1   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
4   University of Sydney, Sydney, New South Wales, Australia
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Comments on: “Effect of pre-resection biopsy on detection of advanced dysplasia in large nonpedunculated colorectal polyps undergoing endoscopic mucosal resection”Endoscopy 2023; 55(10): 975-975
DOI: 10.1055/a-2085-5532

We thank Kilincalp and Mottacki for their interest and comments on our recently published article [1]. The authors have raised concerns with respect to possible referral bias in our cohort and seek clarification regarding proportion of pre-resection biopsy (PRB) cases upstaged to high grade dysplasia (HGD) versus cancer following endoscopic mucosal resection (EMR).

We acknowledge that a limitation of this study is the unknown number of lesions assessed by PRB that actually had cancer and thus were not referred for EMR. Referrals for EMR in this study came from many peripheral centers, and therefore we only had data on these cases. We agree that knowing the proportion of cancer diagnoses following PRB can provide useful information regarding its clinical utility. However, from a practical perspective, ascertaining this requires data collection from the referring sites themselves. Given that large nonpedunculated colorectal polyps (LNPCPs) comprise only about 5 % of all polyps, and of these, covert malignancy occurs in a small proportion [2], a multicenter study is likely needed to determine whether PRB meaningfully detects cancer in these lesions prior to endoscopic resection.

As reported in our article, 12.6 % and 5.8 % of PRB cases were upstaged to HGD and cancer, respectively, after EMR [1]. Overall, the EMR histology differed from PRB histology in over one in three cases, with the degree of dysplasia being upstaged in the majority of discordant cases. Taken together, this indicates PRB is an unreliable detector of advanced dysplastic change and probably did not change management any more than the endoscopist’s initial endoscopic assessment of an LNPCP as being not overtly malignant, and hence suitable for EMR. Nonetheless, unresolved questions regarding utility of PRB remain, including whether targeted versus nontargeted biopsy, location of biopsy (flat versus sessile areas), and number of biopsies may also affect outcomes after endoscopic resection.



Publication History

Article published online:
27 September 2023

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  • References

  • 1 Ma MX, Tate DJ, Sidhu M. et al. Effect of pre-resection biopsy on detection of advanced dysplasia in large nonpedunculated colorectal polyps undergoing endoscopic mucosal resection. Endoscopy 2023; 55: 267-273
    Article in Thieme ConnectPubMedGoogle Scholar
  • 2 Burgess NG, Hourigan LF, Zanati SA. et al. Risk stratification for covert invasive cancer among patients referred for colonic endoscopic mucosal resection: a large multicenter cohort. Gastroenterology 2017; 153: 732-742
    CrossrefPubMedGoogle Scholar