Additional surgery after endoscopic submucosal dissection for colorectal cancer: a review of 53 cases

Completion Surgery after Non-Curative Local Resection of Early Rectal Cancer

Background

The expanding indications of local - endoscopic and transanal surgical - resection of early rectal cancer has led to their increased popularity and inclusion in the treatment guidelines. The accuracy of the current diagnostic tools in identifying the low-risk T1 tumors that can be curatively treated with a local resection is low, and thus several patients require additional oncologic surgery with total mesorectal excision (TME). An efficient clinical strategy which avoids overtreatment and obstacle surgical procedures is under debate between different disciplines.

Summary

Completion surgery has comparable outcomes to primary surgery regarding perioperative morbidity and mortality but also recurrence rates and overall survival. However, local scarring in the mesorectum can make mesorectal excision technically challenging, especially after full-thickness resections, and has been associated with increased rates of permanent ostomy and worse quality of the TME specimen. This risk seems to be lower after muscle-sparing procedures like endoscopic submucosal dissection, which seem to show a benefit in comparison to full-thickness resections.

Key Messages

Completion surgery after non-curative local resection of gastrointestinal malignancies is safe and feasible. Full-thickness resection techniques can cause scarring of the mesorectum; therefore, muscle-sparing procedures should be preferred.

Clinical outcomes of colorectal neoplasm with positive resection margin after endoscopic submucosal dissection

A positive resection margin after colorectal endoscopic submucosal dissection (ESD) is associated with an increased risk of recurrence. We aimed to identify the clinical significance of positive resection margins in colorectal neoplasms after ESD. We reviewed 632 patients who had en bloc colorectal ESD at two hospitals between 2015 and 2020. The recurrence rates and presence of residual tumor after surgery were evaluated. The rate of additional surgery after ESD and recurrence rate were significantly higher in patients with incomplete resection (n = 75) compared to patients with complete resection (n = 557). When focusing solely on non-invasive lesions, no significant differences in recurrence rates were observed between the groups with complete and incomplete resection (0.2% vs. 1.9%, p = 0.057). Among 84 patients with submucosal invasive carcinoma, 39 patients underwent additional surgery due to non-curative resection. Positive vertical margin and lymphovascular invasion were associated with residual tumor. Lymphovascular invasion was associated with lymph node metastasis. However, no residual tumor nor lymph node metastases were found in patients with only one unfavorable histological factor. In conclusion, a positive resection margin in non-invasive colorectal lesions, did not significantly impact the recurrence rate. Also, in T1 colorectal cancer with a positive vertical resection margin, salvage surgery can be considered in selected patients with additional risk factors.

Additional staining for lymphovascular invasion is associated with increased estimation of lymph node metastasis in patients with T1 colorectal cancer: Systematic review and meta-analysis

OBJECTIVES

Lymphovascular invasion (LVI) is a critical risk factor for lymph node metastasis (LNM), which requires additional surgery after endoscopic resection of T1 colorectal cancer (CRC). However, the impact of additional staining on estimating LNM is unclear. This systematic review aimed to evaluate the impact of additional staining on determining LNM in T1 CRC.

METHODS

We searched five electronic databases. Outcomes were diagnostic odds ratio (DOR), assessed using hierarchical summary receiver operating characteristic curves, and interobserver agreement among pathologists for positive LVI, assessed using Kappa coefficients (κ). We performed a subgroup analysis of studies that simultaneously included a multivariable analysis for other risk factors (deep submucosal invasion, poor differentiation, and tumor budding).

RESULTS

Among the 64 studies (18,097 patients) identified, hematoxylin-eosin (HE) and additional staining for LVI had pooled sensitivities of 0.45 (95% confidence interval [CI] 0.32-0.58) and 0.68 (95% CI 0.44-0.86), specificities of 0.88 (95% CI 0.78-0.94) and 0.76 (95% CI 0.62-0.86), and DORs of 6.26 (95% CI 3.73-10.53) and 6.47 (95% CI 3.40-12.32) for determining LNM, respectively. In multivariable analysis, the DOR of additional staining for LNM (DOR 5.95; 95% CI 2.87-12.33) was higher than that of HE staining (DOR 1.89; 95% CI 1.13-3.16) (P = 0.01). Pooled κ values were 0.37 (95% CI 0.22-0.52) and 0.62 (95% CI 0.04-0.99) for HE and additional staining for LVI, respectively.

CONCLUSION

Additional staining for LVI may increase the DOR for LNM and interobserver agreement for positive LVI among pathologists.

Diagnostic Accuracy of Highest-Grade or Predominant Histological Differentiation of T1 Colorectal Cancer in Predicting Lymph Node Metastasis: A Systematic Review and Meta-Analysis

INTRODUCTION

Treatment guidelines for colorectal cancer (CRC) suggest 2 classifications for histological differentiation-highest grade and predominant. However, the optimal predictor of lymph node metastasis (LNM) in T1 CRC remains unknown. This systematic review aimed to evaluate the impact of the use of highest-grade or predominant differentiation on LNM determination in T1 CRC.

METHODS

The study protocol is registered in the International Prospective Register of Systematic Reviews (PROSPERO, registration number: CRD42023416971) and was published in OSF ( https://osf.io/TMAUN/ ) on April 13, 2023. We searched 5 electronic databases for studies assessing the diagnostic accuracy of highest-grade or predominant differentiation to determine LNM in T1 CRC. The outcomes were sensitivity and specificity. We simulated 100 cases with T1 CRC, with an LNM incidence of 11.2%, to calculate the differences in false positives and negatives between the highest-grade and predominant differentiations using a bootstrap method.

RESULTS

In 42 studies involving 41,290 patients, the differentiation classification had a pooled sensitivity of 0.18 (95% confidence interval [CI] 0.13-0.24) and 0.06 (95% CI 0.04-0.09) ( P < 0.0001) and specificity of 0.95 (95% CI 0.93-0.96) and 0.98 (95% CI 0.97-0.99) ( P < 0.0001) for the highest-grade and predominant differentiations, respectively. In the simulation, the differences in false positives and negatives between the highest-grade and predominant differentiations were 3.0% (range 1.6-4.4) and -1.3% (range -2.0 to -0.7), respectively.

DISCUSSION

Highest-grade differentiation may reduce the risk of misclassifying cases with LNM as negative, whereas predominant differentiation may prevent unnecessary surgeries. Further studies should examine differentiation classification using other predictive factors.

Weighing the benefits of lymphadenectomy in early-stage colorectal cancer

Recent advancements in endoscopic procedures have resulted in a growing diagnosis of early colorectal cancer (CRC) cases, where classical en bloc lymph node (LN) dissection is not performed and treatment is terminated with the removal of the main cancer lesion by endoscopy without pathologic LN staging. Although many studies report noninferior outcomes of endoscopic resection in comparison to surgical resection, a cautious approach to completing treatment with endoscopic resection alone is recommended because LN metastases may be present even in early-stage CRC. In most countries, including the United States, Europe, and South Korea, the guidelines for additional surgery after endoscopic resection are very similar. If LN metastasis is suspected, even in T1 stage or lower lesions, further surgery is an essential treatment modality, but confirmation of the presence of LN metastasis is perhaps the most difficult part of this process. Another paradoxical recent trend is the expansion of more extensive and complete surgical lymphadenectomy for CRC. The success rate of surgery has improved dramatically over the past decade with the introduction of surgical devices and minimally invasive surgery, and the associated risks have been significantly reduced. While the burden of surgery on patients is understandable, the indications for surgery in early colon cancer need to be carefully reviewed to improve cure rates. In this process, we believe that an integrated decision-making process with surgeons, radiologists, and pathologists, in addition to the opinions of endoscopists, will be an important process to improve the cure rate.

Outcome of Completion Surgery after Endoscopic Submucosal Dissection in Early-Stage Colorectal Cancer Patients

T1 colorectal cancers (T1CRC) are increasingly being treated by endoscopic submucosal dissection (ESD). After ESD of a T1CRC, completion surgery is indicated in a subgroup of patients. Currently, the influence of ESD on surgical morbidity and mortality is unknown. The aim of this study was to compare 90-day morbidity and mortality of completion surgery after ESD to primary surgery. The completion surgery group consisted of suspected T1CRC patients from a multicenter prospective ESD database (2014-2020). The primary surgery group consisted of pT1CRC patients from a nationwide surgical registry (2017-2019). Patients with rectal or sigmoidal cancers were selected. Patients receiving neoadjuvant therapy were excluded. Propensity score adjustment was used to correct for confounders. In total, 411 patients were included: 54 in the completion surgery group (39 pT1, 15 pT2) and 357 in the primary surgery group with pT1CRC. Adverse event rate was 24.1% after completion surgery and 21.3% after primary surgery. After completion surgery 90-day mortality did not occur, though one patient died in the primary surgery group. After propensity score adjustment, lymph node yield did not differ significantly between the groups. Among other morbidity-related outcomes, stoma rate (OR 1.298 95%-CI 0.587-2.872, p = 0.519) and adverse event rate (OR 1.162; 95%-CI 0.570-2.370, p = 0.679) also did not differ significantly. A subgroup analysis was performed in patients undergoing rectal surgery. In this subgroup (37 completion and 136 primary surgery), these morbidity outcomes also did not differ significantly. In conclusion, this study suggests that ESD does not compromise morbidity or 90-day mortality of completion surgery.

Risk of residual neoplasia after a noncurative colorectal endoscopic submucosal dissection for malignant lesions: a multinational study

BACKGROUND : Endoscopic submucosal dissection (ESD) in colorectal lesions is technically demanding and a significant rate of noncurative procedures is expected. We aimed to assess the rate of residual lesions after a noncurative ESD for colorectal cancer (CRC) and to establish predictive scores to be applied in the clinical setting. METHODS : Retrospective multicenter analysis of consecutive colorectal ESDs. Patients with noncurative ESDs performed for the treatment of CRC lesions submitted to complementary surgery or with at least one follow-up endoscopy were included. RESULTS : From 2255 colorectal ESDs, 381 (17 %) were noncurative, and 135 of these were performed in CRC lesions. A residual lesion was observed in 24 patients (18 %). Surgery was performed in 96 patients and 76 (79 %) had no residual lesion in the colorectal wall or in the lymph nodes. The residual lesion rate for sm1 cancers was 0 %, and for > sm1 cancers was also 0 % if no other risk factors were present. Independent risk factors for lymph node metastasis were poor differentiation and lymphatic permeation (NC-Lymph score). Risk factors for the presence of a residual lesion in the wall were piecemeal resection, poor differentiation, and positive/indeterminate vertical margin (NC-Wall score). CONCLUSIONS : Lymphatic permeation or poor differentiation warrant surgery owing to their high risk of lymph node metastasis, mainly in > sm1 cancers. In the remaining cases, en bloc and R0 resections resulted in a low risk of residual lesions in the wall. Our scores can be a useful tool for the management of patients who undergo noncurative colorectal ESDs.

Composite scoring system and optimal tumor budding cut-off number for estimating lymph node metastasis in submucosal colorectal cancer

BACKGROUND

Tumor budding is associated with lymph node (LN) metastasis in submucosal colorectal cancer (CRC). However, the rate of LN metastasis associated with the number of tumor buds is unknown. Here, we determined the optimal tumor budding cut-off number and developed a composite scoring system (CSS) for estimating LN metastasis of submucosal CRC.

METHODS

In total, 395 patients with histologically confirmed T1N0-2M0 CRC were evaluated. The clinicopathological characteristics were subjected to univariate and multivariate analyses. The Akaike information criterion (AIC) values of the multivariate models were evaluated to identify the optimal cut-off number. A CSS for LN metastasis was developed using independent risk factors.

RESULTS

The prevalence of LN metastasis was 13.2%. Histological differentiation, lymphatic or venous invasion, and tumor budding were associated with LN metastasis in univariate analyses. In multivariate models adjusted for histological differentiation and lymphatic or venous invasion, the AIC value was lowest for five tumor buds. Unfavorable differentiation (odds ratio [OR], 8.16; 95% confidence interval [CI], 1.80-36.89), lymphatic or venous invasion (OR, 5.91; 95% CI, 2.91-11.97), and five or more tumor buds (OR, 3.01; 95% CI, 1.21-7.69) were independent risk factors. In a CSS using these three risk factors, the rates of LN metastasis were 5.6%, 15.5%, 31.0%, and 52.4% for total composite scores of 0, 1, 2, and ≥ 3, respectively.

CONCLUSIONS

For the estimation of LN metastasis in submucosal CRC, the optimal tumor budding cut-off number was five. Our CSS can be utilized to estimate LN metastasis.

Patient outcomes after non-curative endoscopic submucosal dissection for early colorectal cancer: a single-center, retrospective cohort study

Background

The treatment patterns and outcomes for patients after non-curative endoscopic submucosal dissection (ESD) remain controversial, particularly among those requiring preservation of the anal sphincter or advanced age. This retrospective study aimed to investigate the treatment patterns and outcomes in patients after non-curative ESD for early colorectal cancer (CRC).

Methods

This was a retrospective review in Chinese patients who received non-curative ESD for early CRC, and who were treated in the Cancer Hospital at the Chinese Academy of Medical Sciences from 2010 to 2019. Demographic parameters, clinicopathologic features, treatment patterns, and clinical outcomes were analyzed.

Results

Of the 180 patients who received non-curative ESD, 85 received additional surgery; the remaining 95 patients were kept under surveillance only. Patients in the surveillance-only group tended to be older than those in the additional surgery group. Furthermore, tumors in the surveillance-only group were located in the rectum significantly more often, were better differentiated with a shallower depth of invasion and less perineuronal invasion than in the additional surgery group; there were fewer high-risk factors for residual cancer or lymph node (LN) metastasis in the surveillance-only group compared with the additional surgery group. There was no significant difference in 5-year overall survival (OS) (92.6% versus 92.7%, P=0.355), 5-year disease-free survival (DFS) (94.7% versus 91.9%, P=0.340), 5-year cancer-specific survival (CSS) (93.8% versus 92.7%, P=0.791), or total recurrence rates (4.7% versus 9.5%, P=0.217) between the additional surgery and surveillance-only groups, respectively.

Conclusions

ESD results in favorable outcomes for patients with early CRC. Surveillance in patients who receive non-curative ESD may be an alternative option for those with advanced age and fewer high-risk factors for residual cancer or LN metastasis.

Does Additional Laparoscopic-Assisted Surgery after Endoscopic Submucosal Dissection Affect Short Outcomes in Patients with Stage T1 Colorectal Cancer? A Propensity Score-Based Analysis

BACKGROUND

Additional surgery is necessary in cases with non-curative endoscopic submucosal dissection. It is still unknown whether preceding endoscopic submucosal dissection (ESD) for T1 colorectal carcinoma affects the short outcomes of patients who underwent additional surgery or not as compared with surgery alone without ESD.

METHODS

Patients (101 pairs) with T1 colorectal cancer who underwent additional laparoscopic-assisted surgery after endoscopic submucosal dissection (additional surgery group, n = 101) or laparoscopic-assisted surgery alone (surgery alone group, n = 101) were matched (1:1). Short-term morbidity, operation outcomes, and lymph node metastasis of the resected specimen were compared.

RESULTS

There were no significant differences between the additional laparoscopic-assisted surgery and laparoscopic-assisted surgery alone groups in lymph node metastasis (9.9 vs. 5.9%, respectively, p = 0.297), operative time (147.76 ± 52.00 min vs. 156.50 ± 54.28 min, p = 0.205), first flatus time (3.56 ± 1.10 days vs. 3.63 ± 1.05 days, p = 0.282), first stool time (4.30 ± 1.04 days vs. 4.39 ± 1.22 days, p = 0.293), time to intake (5.00 ± 1.18 days vs. 5.25 ± 1.39 days, p = 0.079), blood loss (44.75 ± 45.40 mL vs. 60.40 ± 78.98 mL, p = 0.603), harvest lymph nodes (18.74 ± 7.22 vs. 20.32 ± 9.69, p = 0.438), postoperative surgical complications (p = 0.733), and postoperative length of hospital stay (8.68 ± 4.00 days vs. 8.39 ± 1.94 days, p = 0.401).

CONCLUSION

ESD did not increase the difficulty of additional laparoscopic-assisted surgery, hospital stay, or the incidence of postoperative complications. Additional laparoscopic-assisted surgery is safe and recommended for patients with T1 cancer at high risk of lymph node metastasis and residual cancer after non-curative ESD.

Bioinformatic analysis reveals an exosomal miRNA-mRNA network in colorectal cancer

BACKGROUND

Exosomes play important roles in angiogenesis, drug resistance, and metastasis of colorectal cancer (CRC), but the underlying mechanism has seldom been reported. Herein, our study aimed to reveal an exosomal miRNA-mRNA network involved in CRC by performing bioinformatical analysis.

METHODS

The mRNA and miRNA data of colon adenocarcinoma and rectal adenocarcinoma were downloaded from The Cancer Genome Atlas (TCGA) database, and exosomal miRNAs data were downloaded from the GEO dataset GSE39833. The differential expression analysis was performed using "limma" and "edgeR". Target mRNAs of miRNAs were predicted using FunRich 3.1.3, miRNAtap and multiMiR. The candidate mRNAs and exosomal miRNAs were obtained by intersecting two groups of differentially expressed miRNAs and intersection of the differential expressed mRNAs and the target mRNAs, respectively. Key mRNAs and exosomal miRNAs were identified by the least absolute shrinkage and selection operator regression analysis, and used to construct the exosomal miRNA-mRNA network. The network verified was by receiver operating characteristic curve, GEPIA and LinkedOmics. Functional enrichment analysis was also performed for studied miRNAs and mRNAs.

RESULTS

A total of 6568 differentially expressed mRNAs and 531 differentially expressed miRNAs from TCGA data, and 166 differentially expressed exosomal miRNAs in GSE39833 dataset were identified. Next, 16 key mRNAs and five key exosomal miRNAs were identified from the 5284 candidate mRNAs and 61 candidate exosomal miRNAs, respectively. The exosomal miRNA-mRNA network with high connectivity contained 13 hub mRNAs (CBFB, CDH3, ETV4, FOXQ1, FUT1, GCNT2, GRIN2D, KIAA1549, KRT80, LZTS1, SLC39A10, SPTBN2, and ZSWIM4) and five hub exosomal miRNAs (hsa-miR-126, hsa-miR-139, hsa-miR-141, hsa-miR-29c, and hsa-miR-423). The functional annotation revealed that these hub mRNAs were mainly involved in the regulation of B cell receptor signaling pathway and glycosphingolipid biosynthesis related pathways. All hub mRNAs and hub exosomal miRNAs exhibited high diagnosis value for CRC. Furthermore, the association of the hub mRNAs with overall survival, stages, and MSI phenotype of CRC revealed their important roles in CRC progression.

CONCLUSION

This study constructed an exosomal miRNA-mRNA network which may play crucial roles in the carcinogenesis and progression of CRC, thus providing potential diagnostic biomarkers and therapeutic targets for CRC.