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

Sexually transmitted infections (STIs) are increasingly recognized as causes of proctitis, particularly among men who have sex with men (MSM). These infections frequently mimic inflammatory bowel diseases (IBD) in clinical, endoscopic, and histological presentations, leading to potential misdiagnosis and inappropriate treatments. Accurate recognition requires detailed sexual history and targeted diagnostic tests.

Aims & Methods

Patients were identified from IBD outpatient visits (2021–2023) and retrospectively selected for suspected infectious proctitis mimicking IBD. Diagnosis was confirmed via clinical evaluation, targeted tests (rectal swabs, PCR, serology), and histology. Follow-up continued for six months post-treatment.

Results

1. A 42-year-old MSM with secondary syphilis treated with benzathine penicillin presented with bloody diarrhea, tenesmus, anorectal pain, and 10-kg weight loss. Mild anemia (Hb 12 g/dL) and elevated CRP were noted. Rectosigmoidoscopy (RSCS) revealed fibrinous ulcers causing luminal narrowing. Rectal swabs confirmed Chlamydia trachomatis. Treatment with doxycycline led to clinical and endoscopic resolution at six months.
2. A 33-year-old MSM with unprotected intercourse reported mucorrhea and tenesmus for one month. Calprotectin levels were elevated (861 µg/g). Colonoscopy revealed mild proctitis with mucosal hyperemia, and histology showed mild-to-moderate inflammation with crypt abscesses. Swabs confirmed Neisseria gonorrhoeae. Ceftriaxone resolved symptoms and normalized calprotectin (40 µg/g).
3. A 34-year-old male with primary sclerosing cholangitis (PSC) presented with two weeks of tenesmus, anal bleeding, and pruritus. Colonoscopy appeared macroscopically normal, but histology revealed human papillomavirus (HPV) infection. Anal canal condylomas were identified and successfully treated with cryotherapy, resulting in significant relief.

Conclusion

The rising prevalence of STI-related proctitis highlights the need for awareness among clinicians, as these infections often mimic IBD. Misdiagnosis can lead to inappropriate treatments, including steroids or biologics, causing adverse effects and delays in proper management. Detailed sexual history and targeted diagnostics, such as PCR and rectal swabs, are critical for accurate identification and effective treatment. These cases emphasize the critical role of integrating sexual history into clinical evaluation for proctitis. Awareness and timely recognition of STI-related proctitis are crucial to avoid misdiagnosis as IBD, ensure effective and targeted treatment, improve patient outcomes, and prevent inappropriate and prolonged follow-up.

References

-Infectious Proctitis: When to Suspect It Is Not InflammatoryBowel DiseaseFrank Hoentjen • David T. Rubin (Dig Dis Sci (2012) 57:269–273) -Proctitis: a glance beyond inflammatory bowel diseasesStefano Rizza et all Minerva Gastroenterol Dietol. 2020 Sep;66(3):252-266
-Proctitis in Men Who Have Sex with Men. Julia M. Steed et all