Introduction

Patients with T1 stage colorectal cancer (CRC) according to TNM classification can undergo endoscopic resection (ER) with curative intent. However, in the presence of high-risk recurrence characteristics, additional surgery may be proposed, which is associated with considerable morbidity, especially those involving rectum. Additionally, it is not yet established that surgery prevents the risk of distant recurrence of CRC.

Aims & Methods

We aim to compare the outcomes of high-risk T1 CRC patients who remained under surveillance versus those who underwent additional surgery. Unicentric, retrospective cohort study, including left colon high-risk T1 CRC patients who underwent to ER, between January 2015 and December 2020. After ER, the patients were included in one of the two groups: surveillance (clinical, laboratory, imaging, endoscopic) versus surgery with lymphadenectomy. The decision regarding follow-up (surveillance vs surgery) was based on the histological characteristics of the malignant polyp, the patient's age, surgical and anesthetic risk (patient's comorbidities), and the patient's willing. Minimum follow-up period was 3 years after the initial colonoscopy for ER (baseline). Primary outcome: recurrence or death at 36 months.

Results

Among the 109 included T1 CRC patients, 70 were deemed high-risk for recurrence and had a median follow-up of 73 months (IQR=55.93), either in the surveillance group (SvG, n=20) or the surgery+lymphadenectomy group (SG, n=50). Older age or history of cerebrovascular/cardiovascular disease was associated with a higher propensity for surveillance only (propensity score). The endoscopic resection technique used was mostly conventional mucosectomy (97%).The incidence of complications related to ER was 1.4% (1 patient, colonic perforation). In the SG, 51% of the patient were submitted to surgery involving rectum and colorectal anastomosis. The incidence of complications directed related to surgery with lymphadenectomy was 20% (10 patients; 3 Anastomotic dehiscence; 1 lower gastrointestinal haemorrhage related to colorectal anastomotic; 5 wound infection ; 1 colorectal anastomotic stenosis). In SG, 84% (n=42) showed no evidence of CRC in the specimen (pT0N0). From baseline to 36 months, no patient in SvG experienced recurrence, while 1 patient in SG did. During this period, 2 patients in SvG and 2 in SG died, all from causes unrelated to CRC. There was no significant difference in recurrence and mortality between the two groups (p-value >0.05). Additionally, within SG, there was no difference in recurrence and mortality between the subgroup of patients with pT0N0 versus non-pT0N0 disease (p-value > 0.05).

Conclusion

Our study suggests that high-risk T1 CRC patients undergoing ER may not benefit from additional surgery with lymphadenectomy, which, if confirmed in further studies, represents a paradigm shift in therapeutic decision-making based on current evidence.

References

1 - Corre F, Albouys J, Tran VT, et al. Impact of surgery after endoscopically resected high-risk T1 colorectal cancer: results of an emulated target trial. Gastrointest Endosc. 2024;99(3):408-416.e2. doi:10.1016/j.gie.2023.09.027
2 - Bartel MJ, Brahmbhatt BS, Wallace MB. Management of colorectal T1 carcinoma treated by endoscopic resection from the Western perspective. Dig Endosc. 2016;28(3):330-341. doi:10.1111/den.12598
3 - Chen Y, Jing W, Chen M, et al. Long-term outcomes of local resection versus surgical resection for high-risk T1 colorectal cancer: a systematic review and meta-analysis. Gastrointest Endosc. 2023;97(6):1016-1030.e14. doi:10.1016/j.gie.2023.02.027
4 - Zaffalon D, Daca-Alvarez M, Saez de Gordoa K, Pellisé M. Dilemmas in the Clinical Management of pT1 Colorectal Cancer. Cancers. 2023; 15(13):3511. https://doi.org/10.3390/cancers15133511

Disclosure

​Nothing to declare

Introduction

T1 colorectal cancer can be managed either by surgery or interventional endoscopy. High-risk features after endoscopic resection (G3, submucosal invasion >1000 µm, lympho-vascular invasion, tumour budding+, or R1 resection) increase the risk of lymphnode metastasis (10-15%), often requiring additional surgery. However, the benefits of surgery versus endoscopic resection alone remain unclear, particularly in elderly or frail patients.

Aims & Methods

The aim of the study is to assess recurrence rate and overall survival in patients underwent surgery, endoscopy or both. Secondary endpoints is to evaluate incidence of adverse events and length of hospital stay
All consecutive patients diagnosed with T1 colorectal cancer from 2018 to 2024 in our institution were enrolled in this retrospective study. We divided this cohort in 3 groups: endoscopic resection plus surgery (ER-S), upfront surgery (SR), or endoscopic resection alone (ER). Demographics data, mortality, cancer recurrence rate, disease free survival and AEs were recorded.

Results

One-hundred and thirty-three patients were enrolled in the study: 34 (72 years±10) in the SR group, 65 (65 years±11) in the ER-S group and 34 (77 years±11) in ER, respectively.
Lesions were similar (p-value 0.30) for dimension: 31±15 mm (ER) vs 23±12 mm (ER-S) vs 30±13 mm (ER) such as follow-up (23 vs 24 vs 21 months) for the three groups (p-value 0.428). Hospital stay after the procedure was significantly lower in the ER group (1 day median) vs SR (median 9 days;p-value 0.0001) and ER-S group (7 days median;p-value 0.003). Cumulative 30 days adverse events were higher in the SR group (62%; p-value 0.0001) and in the ER-S group (22%; p-value 0.001) compared to ER alone (12%). During the study period, no endoscopic/radiological recurrence occurred in the SR group whereas 1 patient in the ER-S group and 2 in the ER group showed recurrence non suitable for further treatments.
Five patients in SR group died after a median of 18 months (1 for early surgical complication); 2 died in the ER-S group after a median of 34 months and 3 died in the ER group after a median of 24 months (1 for rectal cancer progression) (p-value 0.365).
Overall survival was comparable among the three groups with no significant difference (p-value 0.718) with a median of 40 months (SR), 28 (ER-S) and 26 (ER) months.

Conclusion

Endoscopic resection alone appears to be a reasonable option for high-risk T1 CRC patients, especially those with increased surgical risk due to low rate of recurrence, low adverse events and a comparable overall survival in short-mid term.

References

1. Quénéhervé, L.; Pioche, M.; Jacques, J. Curative Criteria for Endoscopic Treatment of Colorectal Cancer. Best Pract. Res. Clin. Gastroenterol. 2024, 101883, doi:10.1016/j.bpg.2024.101883.
2. Chen, Y.; Jing, W.; Chen, M.; Wang, Z.; Wu, J.; Yang, J.; Yang, L.; Deng, K. Long-Term Outcomes of Local Resection versus Surgical Resection for High-Risk T1 Colorectal Cancer: A Systematic Review and Meta-Analysis. Gastrointest. Endosc. 2023, 97, 1016-1030.e14, doi:10.1016/j.gie.2023.02.027.
3. Spadaccini M, Bourke MJ, Maselli R, et al. Clinical outcome of non-curative endoscopic submucosal dissection for early colorectal cancer. Gut. Published online January 20, 2022. doi:10.1136/gutjnl-2020-323897
4. Corre, F.; Albouys, J.; Tran, V.-T.; Lepilliez, V.; Ratone, J.-P.; Coron, E.; Lambin, T.; Rahmi, G.; Karsenti, D.; Canard, J.-M.; et al. Impact of Surgery after Endoscopically Resected High-Risk T1 Colorectal Cancer: Results of an Emulated Target Trial. Gastrointest. Endosc. 2023, S0016-5107(23)02933-4, doi:10.1016/j.gie.2023.09.027.
5. UICC. TNM. Classification of malignant tumours. eighth ed. Wiley; 2016. p. 272

Disclosure

Giuseppe Grande is consultant for Olympus, Boston Scientific, ERBE, Fujifilm

Introduction

Early-stage colorectal cancer (T1CRC) patients are confronted with complex medical information and considerations throughout the course of their treatment. This study explored patients’ perspective on information provision and therapeutic decision-making.

Aims & Methods

Patients who underwent endoscopic or local surgical resection for T1CRC were eligible for participation in this cross-sectional multicenter study. Information provision was evaluated using the EORTC QLQ-INFO25 questionnaire (INFO25)(1). In patients with a high-risk T1CRC we additionally evaluated patients’ perception of involvement in decision-making regarding the choice to opt for or refrain from additional treatment after local resection, and the degree of decisional conflict using the decision conflict scale (DCS)(2).

Results

In the 98 responders (response rate: 71.5%), patients with high-risk T1CRC (n=45) reported to have received more information on multiple disease aspects compared to patients with low-risk T1CRC (n=53). However, the need for more information was not significantly different between both groups (p=0.31). Overall, 29 patients expressed a need for more information, with ‘prevention’ and ‘post-treatment care’ reported as the most common areas with unmet information needs. Of the 45 patients with high-risk T1CRC, 24 (53.3%) underwent additional treatment, whereas 21 (46.7%) opted for close monitoring. Twenty-seven patients (60%) reported that they were actively involved in this decision (i.e. ‘I made the decision myself’), while 18 patients (40%) reported to be passively involved (i.e. ‘I let my physician make the decision’ or ‘I didn't feel like there was a choice’). Satisfaction scores regarding information provision were similar between patients that underwent additional treatment or opted for close monitoring (range 0-100, 70.8 vs. 73.0, p=0.77). Higher educated patients were more likely to report active involvement in therapeutic decision-making compared to lower educated patients (92.9% vs. 43.3%, p=0.002) and to eventually undergo additional treatment (78.6% vs. 40%, p=0.02). The satisfaction scores regarding how the treatment decision was made did not differ significantly between patients with higher and lower levels of education (range 0-100, 83 vs. 85.1, p=0.78).

Conclusion

From the T1CRC patient’s perspective, this study found that higher educated patients were more likely to be actively involved in therapeutic decision-making than lower educated patients, although decisional satisfaction was irrespective of educational level. With respect to information needs, patients expressed a desire for more information on disease prevention and post-treatment care.

References

1. Arraras JI, Greimel E, Sezer O, Chie W-C, Bergenmar M, Costantini A, et al. An international validation study of the EORTC QLQ-INFO25 questionnaire: An instrument to assess the information given to cancer patients. European Journal of Cancer. 2010;46(15):2726-38.
2. O'Connor AM. Validation of a decisional conflict scale. Med Decis Making. 1995;15(1):25-30.

Introduction

Complete endoscopic resection and accurate histological evaluation for T1 colorectal cancer (CRC) is critical to determine subsequent treatment. Endoscopic full-thickness resection (EFTR) and endoscopic submucosal dissection (ESD) are potential curative methods for treatment of T1 CRC.

Aims & Methods

Primary aims were R0 resection rate, histopathological risk-assessment, and curative resections. Secondary aims were short-term outcomes of patients with T1 CRC after endoscopic and surgical resection.
​Consecutive EFTR and ESD procedures for T1 CRC at one tertiary endoscopic centre, prospectively recorded in National CRC Registry between 2015 and 2023, were retrospectively analysed. High risk factors included positive resection margin, low-grade differentiation (G3, G4), deep submucosal invasion (DSI) and lymphovascular invasion (LVI).

Results

We analysed 178 procedures: 114 (64 %) ESD and 64 (36 %) EFTR. From all resected lesions, 24 (13 %) were T1 carcinomas, 10 (6 %) subepithelial lesions (GIST/NET), 9 (5 %) T2 carcinomas, 2 (1%) T3 carcinomas, 58 (33 %) intramucosal carcinomas and 75 (42 %) low-grade adenomas. From 24 T1 CRC (54 % men, average diameter of lesion 25 mm) were 15 (63 %) lesions resected by EFTR, 7 (29 %) lesions resected by ESD, and 2 (8 %) lesions resected by hybrid technique ESD/EFTR. Overall R0 resection was achieved in 18 (75 %) lesions. Seven (29 %) T1 CRC had superficial submucosal invasion (≤ 1000µm), 17 (71 %) T1 CRC had deep submucosal invasion, including 1 lesion with lymphovascular invasion. Curative resection rate for resected T1 CRC was 29 % and 71 % after excluding deep submucosal invasion as a risk factor. Additional oncologic surgery was performed in 9 (38 %) patients, with residual cancer in 1 patient. Endoscopic follow-up was available in 22 (92 %) patients with a median of 3 years and no residual cancer were observed.

Conclusion

EFTR and ESD techniques are effective methods for treatment T1 CRC. Appropriate surveillance without additional surgery may be considered as another option in selected cases after endoscopic resection of T1 CRC.
Supported by programme projects of the Ministry of Health of the Czech Republic with Reg. No. NU22-08-00424, Reg. No. NV18-08-00246, DZVRO - MO1012 and Cooperatio.

Introduction

Endoscopic submucosal dissection (ESD) is widely recognized as the preferred technique for removing large benign colorectal lesions and those with a risk of submucosal invasive cancer (SMIC), with the goal of achieving en-bloc resection. R0 resection is crucial for enabling organ-preservation strategies, particularly in endoscopically resected T1-colorectal cancer (T1-CRC).

Aims & Methods

This study aims to evaluate R0 resection rates in a large cohort of colorectal ESDs by assessing vertical and lateral margins and identifying predictive factors for vertical margin involvement. Furthermore, the presence of other prognostic risk factors for lymph node metastasis (LNM) will be analyzed in this large cohort of T1-CRC. This is a multicenter prospective cohort study in 13 centers, including all colorectal ESDs between 09/2019 and 09/2024. Procedural and histological outcomes were analyzed using univariate and multivariate analysis.

Results

7495 large colorectal polyps were included, of which 781 were T1-CRCs with a median size of 45 [35-65] mm. En bloc resection occurred in 96.7% and R0 resection in 74.9%. Lateral resection margins were free in 92.5%, with positive margins for adenocarcinoma in only 0.8% (low grade dysplasia in 2.6%, high grade in 1.2%, missing data in 2.6%). Vertical margins were free in 80.3%, and decreased significantly when deep SMIC was present to 75.0%, compared to 95.7% for superficial SMIC. However deep SMIC with up to 2000 µm invasion depth, demonstrated free vertical resection margins in still 80.7%, after which it gradually decreased to 73.1% and 67.7% at an infiltration depth of 2000-3000 µm and >3000 µm respectively. Predictive factors for free vertical resection margins include lesion size >50mm (OR=1.66, [1.01;2.71], p=0.045) and rectal location (OR=1.86, [1.04;3.3], p=0.035). Significant difference was observed in the presence of prognostic risk factors for LNM between superficial and deep SMIC, with lympho-vascular invasion (LVI) being present in 9.6% and high-grade tumor budding (Bd) in 17.1% in superficial SMIC, compared to 25.0% and 30.0% respectively, in deep SMIC. However, absence of LVI, Bd or poor differentiation was noted in 75.9% of superficial and 61.7% of deep T1-CRC. Concerning deep SMIC, no relation was observed in the presence of these risk factors with respect to the depth of infiltration.

Conclusion

Following ESD for T1-CRC, the likelihood of achieving free vertical resection margins decreases significantly when invasion depth exceeds 2000 µm. Careful lesion selection through optical diagnosis is therefore critical. To push organ preservation, intermuscular dissection should be considered for T1-CRC with deeper invasion in the rectum. Achieving R0 resection remains paramount, as additional prognostic factors are present in approximately 38% of cases, irrespective of invasion depth.