Long-term outcomes after endoscopic versus surgical resection of T1 colorectal carcinoma

Long-term outcomes of additional surgery versus surveillance-only clinical decision for early colorectal cancer patients after non-curative endoscopic resection: a meta-analysis

OBJECTIVES

The clinical decision-making regarding post hoc management of early colorectal cancer (CRC) patients who have undergone non-curative endoscopic resection (ER) remains a subject of debate. This systematic review and meta-analysis aims to compare the clinical outcomes between patients undergoing additional surgery and those receiving surveillance only.

METHODS

A comprehensive literature search was conducted across three major medical databases: PubMed, Embase, and the Cochrane Library. STATA software was utilized for pooling analysis. The methodological quality of the included studies was assessed using the Newcastle-Ottawa Quality Scale.

RESULTS

A total of 15 eligible studies encompassing 3,508 early CRC patients were included in this meta-analysis (additional surgery group: 1,974 cases; surveillance-only group: 1,533 cases). All included studies demonstrated good methodological quality, with Newcastle-Ottawa scores no less than 6. The results of the meta-analysis indicated that compared to the surveillance-only group, patients in the additional surgery group exhibited significantly improved overall survival (OR = 2.95, 95% CI: 2.05-4.24, P < 0.05), enhanced recurrence-free survival (OR = 2.53, 95% CI = 1.38-4.62, P < 0.05), a reduced recurrence rate (OR = 1.96, 95% CI = 1.22-3.13, P < 0.05), and a lower local recurrence rate (OR = 2.35, 95% CI = 1.12-4.95, P < 0.05). No significant sources of heterogeneity were identified among the studies analyzed; publication bias was also deemed acceptable across these investigations. Furthermore, we performed subgroup analyses based on inclusion criteria and age stratification which revealed notable differences in effect sizes between groups (JSCCR subgroup: OR = 2.09; 95% CI = 1.32-3.30 versus Non-JSCCR subgroup: OR = 1 .54; 95% CI = 0.89 -2.65, indicating negative results). Pooling analysis showed no significant difference between subgroups when stratified by age using a cutoff value of 65 years old.

CONCLUSIONS

Compared to patients who underwent surveillance only, those receiving additional surgical treatment demonstrated superior outcomes in terms of overall survival, recurrence-free survival, recurrence rates, and control of local recurrences. This suggests that such an approach may represent a more optimal clinical decision for early-stage colorectal cancer (CRC) patients who have received non-curative endoscopic resection (ER). Furthermore, this study indicates that the inclusion criteria significantly influence the reported outcomes. Notably, age did not affect the recurrence rate. Overall, this is the first meta-analysis aimed at exploring and clarifying this ongoing controversy.

Comparative prediction of lymph node metastasis in pT1 colorectal cancer among Western and Japanese guidelines

Background

Additional surgery with lymph node (LN) dissection is recommended for pT1 colorectal carcinoma (CRC) resected by endoscopy, based on pathological risk factors for LN metastasis (LNM), according to guidelines by the Japanese Society for Cancer of the Colon and Rectum (JSCCR), National Comprehensive Cancer Network (NCCN), and European Society for Medical Oncology (ESMO).

Methods

We retrospectively analyzed 560 consecutive patients with T1 CRC who underwent endoscopic resection alone (n=190) or initial or additional surgery with LN dissection (n=370) between 1992 and 2017 at Hiroshima University Hospital. Patients were classified into LNM low- and high-risk groups according to guidelines by the JSCCR, NCCN, and ESMO as follows. Patients without any specified pathological LNM risk factor were included in the LNM low-risk group, while the high-risk group comprised all other patients. We analyzed the LNM predictive ability of each guideline.

Results

The LNM high-risk rate, sensitivity, specificity, positive and negative predictive values, accuracy of LNM risk, and AUC for LNM predictive ability were 82%, 100%, 19%, 9%, 100%, 26% and 0.596 in the JSCCR guidelines; 52%, 98%, 52%, 15%, 99%, 56%, and 0.749 in the NCCN; and 54%, 98%, 50%, 15%, 99%, 54%, and 0.743 in the ESMO, respectively.

Conclusions

The JSCCR guidelines could diagnose LNM in all cases but had the highest false-positive rate. It is important to reduce unnecessary additional surgeries for pT1 CRCs after ER.

Bowel function, quality of life, and mental health of patients with high-grade intraepithelial neoplasia or T1 colorectal cancer after organ-preserving versus organ-resection surgeries: a cross-sectional study at a Chinese tertiary care center

BACKGROUND

This study aimed to determine the postoperative intestinal functioning, quality of life (QoL), and psychological well-being of patients treated either with organ-preserving surgery (OPS) or organ-resection surgery (ORS) for high-grade intraepithelial neoplasia (HIN) or T1 colorectal cancer (CRC).

METHODS

This cross-sectional study was conducted at a single tertiary care center. In total, 175 eligible individuals with T1 CRC or HIN were divided into the OPS (n = 103) or ORS (n = 72) group based on whether the relevant segment of the intestine was preserved or resected. Intestinal function was evaluated using low anterior resection syndrome (LARS) scores. QoL was evaluated using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ)-C30 and EORTC-QLQ-CR29. Psychological status was evaluated using the Fear of Progression Questionnaire-Short Form and the Self-rating Anxiety and Depression scales. Propensity score matching (PSM) was used to minimize the influence of potential confounders.

RESULTS

Overall, 130 of 175 patients (74.29%) responded to the questionnaires; 56 and 74 were in the ORS and OPS groups, respectively. Thirty-five patient pairs were successfully matched through PSM. The mild and severe LARS rates were significantly higher in the ORS group than in the OPS group (P < 0.001). The EORTC-QLQ-C30 and EORTC-QLQ-CR29 scores revealed significantly better physical, role, and emotional functioning and an overall improved state of health (with multiple reduced symptom scores) in the OPS group than in the ORS group (P < 0.05). Significantly more patients were depressed in the ORS group than in the OPS group (P = 0.034), whereas anxiety or fear of disease progression did not differ significantly between the groups.

CONCLUSIONS

OPS for the treatment of HIN or T1 CRC was found to be more advantageous for patients in terms of improved intestinal function, QoL, and psychological status than was ORS.

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.

Colon cancer: the 2023 Korean clinical practice guidelines for diagnosis and treatment

Colorectal cancer is the third most common cancer in Korea and the third leading cause of death from cancer. Treatment outcomes for colon cancer are steadily improving due to national health screening programs with advances in diagnostic methods, surgical techniques, and therapeutic agents.. The Korea Colon Cancer Multidisciplinary (KCCM) Committee intends to provide professionals who treat colon cancer with the most up-to-date, evidence-based practice guidelines to improve outcomes and help them make decisions that reflect their patients' values and preferences. These guidelines have been established by consensus reached by the KCCM Guideline Committee based on a systematic literature review and evidence synthesis and by considering the national health insurance system in real clinical practice settings. Each recommendation is presented with a recommendation strength and level of evidence based on the consensus of the committee.

Long-term outcomes of endoscopic or surgical resection in T1 colorectal cancer patients: a retrospective cohort study

BACKGROUND

The personalized treatments of T1 colorectal cancer (CRC) remains controversial. We compared the long-term outcomes of T1 CRC patients after endoscopic resection (ER) and surgery, and evaluated the risk factors for the long-term prognosis.

METHODS

T1 CRCs after resection at the Cancer Hospital, Chines Academy of Medical Sciences from June 2011 to November 2021 were reviewed. High-risk factors included positive resection margin, poor differentiation, deep submucosal invasion (DSI ≥ 1000 μm), lymphovascular invasion and intermediate/high tumor budding. Comparative analyses were conducted based on three treatment methods: follow-up after ER (Group A), additional surgery after ER (Group B) and initial surgery (Group C). The primary endpoints included recurrence-free survival (RFS) and overall survival (OS). Cox proportional hazard regression models were constructed to identify risk factors for RFS and OS.

RESULTS

A total of 528 patients were enrolled (173 patients in Group A, 102 patients in Group B, 253 patients in Group C). The 3-year RFS, 5-year RFS, 3-year OS, and 5-year OS rates were 96.7%, 94.7%, 99.1%, and 97.8%, respectively. In the absence of other high-risk factors, RFS (P = 0.321) and OS (P = 0.155) of patients with DSI after ER were not inferior to those after surgery. Multivariate analyses identified sex (HR 0.379; 95% CI 0.160-0.894), Charlson comorbidities index (CCI) (HR 3.330; 95% CI 1.571-7.062), margin (HR 8.212; 95% CI 2.325-29.006), and budding (HR 3.794; 95% CI 1.686-8.541) as independent predictive factors of RFS, and identified CCI (HR 10.266; 95% CI 2.856-36.899) as an independent predictive factor of OS.

CONCLUSION

The long-term outcomes of ER are comparable to those of surgery in T1 CRC patients with DSI when other high-risk factors are negative. Resection margin, tumor budding, sex, and CCI may be the most important long-term prognostic factors for T1 CRC patients.

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.