Salvage colectomy for endoscopically removed malignant colon polyps: is it possible to determine the optimal number of lymph nodes that need to be harvested?

Ileocecal Valve Sparing Resection for the Treatment of Benign Cecal Polyps Unsuitable for Polypectomy

Background:

Not all benign-appearance polyps are amenable to endoscopic removal and colectomy is required in some cases. This study aims to compare the early outcomes of cecal wedge resection with ileocecal valve sparring versus standard right colectomy in patients with endoscopically unresectable cecal polyps referred for surgery.

Methods:

From Apr 2010 to Aug 2019, all consecutive patients who underwent cecal wedge resection or right colectomy in ten European centers for a presumed endoscopically benign polyp unsuitable for endoscopic resection were retrospectively analyzed. The primary endpoint was morbidity. Secondary endpoints were operative time and length of hospital stay.

Results:

One hundred and ten patients were included: 25 patients underwent cecal wedge resection and 85 a right colectomy. There were 56 men (51%) and 90% of the procedures were performed laparoscopically. 29 lesions were located at the appendix orifice (26.4%). Mortality was nil. There were no significant differences between both procedures for morbidity rate (20% versus 24.7%) or reoperation (4% versus 4.7%). Cecal wedge was related to shorter operative time (63 min versus 150 min, P = .008) and shorter hospital stay (5 days versus 6 days, P = .049). Only 1 patient had a salvage right colectomy after cecal wedge for a pTis adenoma.

Conclusions:

For benign-appearance cecal polyps unsuitable for endoscopic ablation, cecal wedge resection is safe and should be considered as an attractive alternative to right colectomy.

Effects of preceding endoscopic treatment on laparoscopic surgery for early rectal cancer

AIM

Endoscopic treatment for rectal cancer, such as endoscopic mucosal resection and endoscopic submucosal dissection, causes inflammation, oedema and fibrosis in the surrounding tissue. However, little is known about the effect of these endoscopic therapies on salvage laparoscopic rectal surgery. The objective of this retrospective cohort study was to analyse the effect of preceding endoscopic treatment on the outcomes of laparoscopic surgery for rectal cancer.

METHOD

We analysed 53 patients who underwent laparoscopic surgery for rectal cancer with clinical Tis or T1 at our department between May 2011 and June 2019. Data from 30 patients who underwent laparoscopic surgery after preceding endoscopic treatment (Group E + S) were compared with those of 23 patients who underwent laparoscopic surgery alone (Group S).

RESULTS

There was no significant difference between the groups with respect to preoperative details. The mean operative time tended to be longer in Group E + S, and the volume of intra-operative blood loss was greater in Group E + S than in Group S (median 63 ml vs 10 ml, P = 0.049). There were no significant differences between the groups in other surgical parameters or oncological outcomes.

CONCLUSION

Laparoscopic surgery after endoscopic treatment for rectal cancer may be difficult due to an increased risk of intra-operative bleeding. Long-term prognosis after surgery was not affected by preceding endoscopic treatment in rectal cancer.

Surgical or endoscopic management of malignant colon polyps

BACKGROUND

To evaluate indications for colectomy in T1 polyps and possible risk factors for lymph node metastasis.

METHODS

Between 2004 and 2017, 40 patients underwent colectomy after endoscopic removal of malignant polyps with T1 carcinoma. Resection was done based on at least one of the unfavourable histopathological criteria. We collected and prospectively studied histopathologic features, short-term results and the benefit-risk balance. Complications were assessed by Clavien-Dindo classification.

RESULTS

Twenty-five patients (62.5%) underwent laparoscopic bowel resection. Twenty-nine patients (63.0%) had more than two unfavourable criteria in the polyp that justified colorectal resection. Thirty-five patients (76%) had G2 (moderately differentiated) cancer, 11 (24%) had G1 (well-differentiated). Five patients (12.5%) had lymph node metastases and one (2.5%) had residual adenocarcinoma. All five patients with lymph node metastasis had G2 cancer. Nine patients (22.5%) had residual adenoma. Overall complications were identified in six (15.0%) patients. Oncologic benefit (or risk factors for lymph node metastasis) was significantly associated with polyp size ≥18 mm (P = 0.006), lymphovascular invasion (P = 0.05) and budding (P = 0.02).

CONCLUSIONS

Female gender, lymphovascular invasion, desmoplastic reaction, criteria for surgery ≥2 and polyp size ≥18 mm were all in complex significant risk factors for lymph node metastasis in T1 colorectal cancer. Acting as a single factor, these variables had no effect to increased risk of metastasis.

Endoscopic resection of high-risk T1 colorectal carcinoma prior to surgical resection has no adverse effect on long-term outcomes

OBJECTIVE

It is difficult to predict the presence of histological risk factors for lymph node metastasis (LNM) before endoscopic treatment of T1 colorectal cancer (CRC). Therefore, endoscopic therapy is propagated to obtain adequate histological staging. We examined whether secondary surgery following endoscopic resection of high-risk T1 CRC does not have a negative effect on patients' outcomes compared with primary surgery.

DESIGN

Patients with T1 CRC with one or more histological risk factors for LNM (high risk) and treated with primary or secondary surgery between 2000 and 2014 in 13 hospitals were identified in the Netherlands Cancer Registry. Additional data were collected from hospital records, endoscopy, radiology and pathology reports. A propensity score analysis was performed using inverse probability weighting (IPW) to correct for confounding by indication.

RESULTS

602 patients were eligible for analysis (263 primary; 339 secondary surgery). Overall, 34 recurrences were observed (5.6%). After adjusting with IPW, no differences were observed between primary and secondary surgery for the presence of LNM (OR 0.97; 95% CI 0.49 to 1.93; p=0.940) and recurrence during follow-up (HR 0.97; 95% CI 0.41 to 2.34; p=0.954). Further adjusting for lymphovascular invasion, depth of invasion and number of retrieved lymph nodes did not alter this outcome.

CONCLUSIONS

Our data do not support an increased risk of LNM or recurrence after secondary surgery compared with primary surgery. Therefore, an attempt for an en-bloc resection of a possible T1 CRC without evident signs of deep invasion seems justified in order to prevent surgery of low-risk T1 CRC in a significant proportion of patients.

The prognostic value of lymph node yield in the earliest stage of colorectal cancer: a multicenter cohort study

BACKGROUND

In patients with stage II colorectal cancer (CRC) the number of surgically retrieved lymph nodes (LNs) is associated with prognosis, resulting in a minimum of 10-12 retrieved LNs being recommended for this stage. Current guidelines do not provide a recommendation regarding LN yield in T1 CRC. Studies evaluating LN yield in T1 CRC suggest that such high LN yields are not feasible in this early stage, and a lower LN yield might be appropriate. We aimed to validate the cut-off of 10 retrieved LNs on risk for recurrent cancer and detection of LN metastasis (LNM) in T1 CRC, and explored whether this number is feasible in clinical practice.

METHODS

Patients diagnosed with T1 CRC and treated with surgical resection between 2000 and 2014 in thirteen participating hospitals were selected from the Netherlands Cancer Registry. Medical records were reviewed to collect additional information. The association between LN yield and recurrence and LNM respectively were analyzed using 10 LNs as cut-off. Propensity score analysis using inverse probability weighting (IPW) was performed to adjust for clinical and histological confounding factors (i.e., age, sex, tumor location, size and morphology, presence of LNM, lymphovascular invasion, depth of submucosal invasion, and grade of differentiation).

RESULTS

In total, 1017 patients with a median follow-up time of 49.0 months (IQR 19.6-81.5) were included. Four-hundred five patients (39.8%) had a LN yield ≥ 10. Forty-one patients (4.0%) developed recurrence. LN yield ≥ 10 was independently associated with a decreased risk for recurrence (IPW-adjusted HR 0.20; 95% CI 0.06-0.67; P = 0.009). LNM were detected in 84 patients (8.3%). LN yield ≥ 10 was independently associated with increased detection of LNM (IPW-adjusted OR 2.27; 95% CI 1.39-3.69; P = 0.001).

CONCLUSIONS

In this retrospective observational study, retrieving < 10 LNs was associated with an increased risk of CRC recurrence, advocating the importance to perform an appropriate oncologic resection of the draining LNs and diligent LN search when patients with T1 CRC at high-risk for LNM are referred for surgical resection. Given that both gastroenterologists, surgeons and pathologists will encounter T1 CRCs with increasing frequency due to the introduction of national screening programs, awareness on the consequences of an inadequate LN retrieval is of utmost importance.

Surgery has a key role for quality assurance of colorectal cancer screening programs: impact of the third level multidisciplinary team on lymph nodal staging

PURPOSE

From 2011 to 2013 in the area of the Naples 3 public health district (ASL-NA3), a colorectal cancer screening program (CCSP) was developed. In order to stress the need of quality assurance procedures for surgery and pathology, a third level oncologic pathway was added and set up at a referral colorectal cancer center (RC). Lymph nodal (LN) harvesting, as a process indicator, and nodal positivity were adopted for an interim analysis.

METHODS

The program was implemented by a series of audit meetings and a double type of multidisciplinary team (MDT): "horizontal" and "vertical." Three hundred and forty colorectal cancer (CRC) patients underwent surgery: 119 chose to be operated at the RC (Gr In), 65 were operated at 22 district hospitals (DH) (Gr Out), and 156 symptomatic not screened patients were operated at the RC (Gr Sym).

RESULTS

Statistical analysis revealed differences between Gr In and Gr Out colon groups both for LN harvesting (median of 26 and 11, respectively, P = 0.0001), and for nodal positivity after the first screening round (34.78 and 19.45%, respectively, P = 0.0169). Results were all the more significant in a subset analysis on early T stage colon subgroups (In vs Out) both for LN harvesting (P < 0.0001) and nodal positivity (P < 0.0001).

CONCLUSION

xSignificant differences between RC and DHs were found, particularly for early-stage CRC patients. LN harvesting should be considered as a surrogate marker of quality assurance for at least screening hospitals for "minimum best" standard of care. This should lead to set up a third level in any CCSP.

Practice parameters for early colon cancer management: Italian Society of Colorectal Surgery (Società Italiana di Chirurgia Colo-Rettale; SICCR) guidelines

Early colon cancer (ECC) has been defined as a carcinoma with invasion limited to the submucosa regardless of lymph node status and according to the Royal College of Pathologists as TNM stage T1 NX M0. As the potential risk of lymph node metastasis ranges from 6 to 17% and the preoperative assessment of lymph node metastasis is not reliable, the management of ECC is still controversial, varying from endoscopic to radical resection. A meeting on recent advances on the management of colorectal polyps endorsed by the Italian Society of Colorectal Surgery (SICCR) took place in April 2014, in Genoa (Italy). Based on this material the SICCR decided to issue guidelines updating the evidence and to write a position statement paper in order to define the diagnostic and therapeutic strategy for ECC treatment in context of the Italian healthcare system.

The management of malignant polyps in colorectal cancer screening programmes: A retrospective Italian multi-centre study

BACKGROUND

Although recognition of colorectal malignant polyps is increasing, treatment plans lack the evidence of randomised trials.

AIM

To retrospectively evaluate presentation, management and outcomes of screen-detected colorectal malignant polyps, with special focus on the role of histological factors in therapeutic decision-making.

METHODS

We retrospectively analysed data regarding malignant polyps detected during faecal immuno-chemical test-based screening programmes in five centres in North-Eastern Italy between April 2008 and April 2013.

RESULTS

306 malignant polyps in 306 patients were included; 72 patients underwent surgery directly (23.6%). Of 234 patients treated endoscopically, 133 subsequently underwent radicalisation surgery (56.8%) and in 17 there was evidence of residual disease (12.8%). Involved, unsafe (<1mm) or invaluable resection margins and sessile morphology represented the most frequent determinants of subsequent surgery. The mean number of nodes harvested during radicalisation surgery was 7.1±6.4 (range 0-29). Histological diagnosis was re-evaluated according to new guidelines in 125 cases (41%); in 18 this led to modification of the risk class (14.4%).

CONCLUSIONS

Although the rate of surgical treatment following endoscopic resection is similar to other studies, residual disease at surgery was lower than most international series. Adhering to the new histological reporting system and respecting guidelines on node harvesting may favourably influence prognosis.

Colorectal cancer and lymph nodes: The obsession with the number 12

Lymphadenectomy of colorectal cancer is a decisive factor for the prognostic and therapeutic staging of the patient. For over 15 years, we have asked ourselves if the minimum number of 12 examined lymph nodes (LNs) was sufficient for the prevention of understaging. The debate is certainly still open if we consider that a limit of 12 LNs is still not the gold standard mainly because the research methodology of the first studies has been criticized. Moreover many authors report that to date both in the United States and Europe the number “12” target is uncommon, not adequate, or accessible only in highly specialised centres. It should however be noted that both the pressing nature of the debate and the dissemination of guidelines have been responsible for a trend that has allowed for a general increase in the number of LNs examined. There are different variables that can affect the retrieval of LNs. Some, like the surgeon, the surgery, and the pathology exam, are without question modifiable; however, other both patient and disease-related variables are non-modifiable and pose the question of whether the minimum number of examined LNs must be individually assigned. The lymph nodal ratio, the sentinel LNs and the study of the biological aspects of the tumor could find valid application in this field in the near future.