The 7th Joint Session between JDDW-KDDW-TDDW1(JDDW)
Thu. November 2nd   9:00 - 12:00   Room 9: Portopia Hotel Main Building Kairaku 3
JKT1-2
 Long-term Outcomes of Endoscopic Resection in T1 Colorectal Cancer and Strategies for Determining Additional Surgery
Yunho Jung
Department of Internal Medicine, Soonchunhyang University College of Medicine
Introduction: Colorectal cancer (CRC) is the third or fourth commonest cancer worldwide. Some of the CRCs, which were treated only by surgery, are increasing in frequency of being treated with endoscopic procedures such as endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). However, since Lymph node metastasis (LNM) is observed in some T1 CRC cases, it is essential to consider the possibility of LNM before deciding on endoscopic and surgical treatment. In this chapter, I'd like to discuss the long-term outcome after endoscopic treatment in T1 CRC.
Histological classification and LNM: Depth of invasion into the submucosa and deeper colonic layers based on pathological assessment have been described according to different classification methods such as TNM staging, Haggitt, and Kikuchi systems. According to "TNM staging" of CRC, T1 means the malignant cells invade through the muscularis mucosae into the submucosa but do not breach the muscularis propria.1) The incidence of LNM was reported to be 6.8-17.8% in T1 CRC.2)
Recommendation by current guidelines: The indication criteria for surgical resection as an additional treatment after endoscopic resection of T1 CRC have been defined in the Korean,3) Japanese,4), and United States guidelines.5) Surgical resection with lymph node dissection is recommended if any of the following findings is observed: (1) positive vertical margin; (2) depth of submucosal invasion≥100µm; (3) positive lymphovascular invasion; (4) poorly differentiated adenocarcinoma, signet-ring cell carcinoma, or mucinous carcinoma; (5) Tumor budding (BD2/3).
Comparison of Outcomes of Endoscopic resection vs surgery: A population-based study of 13,157 patients reported no difference in the 5-year survival rate between endoscopic resection and surgical treatment for early-stage colon cancers located in the left colon regardless of size and right-sided lesions that were <2 cm; however, surgical resection had greater survival in comparison to endoscopic resection (20-39 mm: 91.8 vs 74.2%; ≥40 mm: 92.4 vs 60%).6) Similarly, Mounzer et al also reported no difference in 5-year colorectal cancer-specific recurrence-free survival rates (97.6% vs 97.5%; p=0.75) between endoscopic resection and surgical resection of T1 colorectal tumors.7)
Conclusions: When endoscopic removal was performed based on the current guidelines considering the possibility of L/N metastasis for T1 CRC, the long-term outcome does not appear to be inferior to surgical removal. After endoscopic removal of T1 CRC, it is considered important to establish additional surgery plans or appropriate follow-up plans based on histological results.
References
1. MB. A, SB. E. AJCC Cancer Staging Manual Springer 2017.
2. Saitoh Y, Inaba Y, Sasaki T, Sugiyama R, Sukegawa R, Fujiya M. Management of colorectal T1 carcinoma treated by endoscopic resection. Dig Endosc 2016;28:324-9.
3. Park CH, Yang DH, Kim JW, et al. Clinical Practice Guideline for Endoscopic Resection of Early Gastrointestinal Cancer. Clin Endosc 2020;53:142-66.
4. Hashiguchi Y, Muro K, Saito Y, et al. Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2019 for the treatment of colorectal cancer. Int J Clin Oncol 2020;25:1-42.
5. Kaltenbach T, Anderson JC, Burke CA, et al. Endoscopic Removal of Colorectal Lesions-Recommendations by the US Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc 2020;91:486-519.
6. Gangireddy VGR, Coleman T, Kanneganti P, et al. Polypectomy versus surgery in early colon cancer: size and location of colon cancer affect long-term survival. Int J Colorectal Dis 2018;33:1349-57.
7. Mounzer R, Das A, Yen RD, et al. Endoscopic and surgical treatment of malignant colorectal polyps: a population-based comparative study. Gastrointest Endosc 2015;81:733-40 e2.
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