T1 colonic carcinoma – Is endoscopic resection sufficient?

HC Yip

JHGR 21/7/2012

Colonoscopy – sigmoid colon:

Questions

1. Can we remove this lesion completely with endoscope?

2. If pathology confirms invasive carcinoma, is endoscopic resection sufficient? Do we need formal surgical resection?

Further endoscopic assessment of lesion Morphological assessment

Paris classification 2002

Pedunculated

Sessile

Polypoid

Elevated, 0-IIa

Flat, 0-IIb

Depressed, 0-IIc

Ulcer

Non-polypoid

Excavated

SM invasive carcinoma

Lateral spreading tumor

Lateral growth of lesions at least 10mm diameter

Subtypes: Granular (Homogenous / nodular mixed) Non-granular (Flat elevated / pseudo-

depressed) Deeper SM invasion

LST-G: low (6.6%) LST-NG: high (30%)

Uraoka et al, Gut 2006

Chromoendoscopy – pit pattern analysis

Kudo classification

Endoscopic resection

Surgery

Kudo S. et al. Gastrointest Endosc 1996; 44: 8-14

NBI endoscopy – vascular pattern analysis

Sano Y. Clin. Gastroenterol. 2009

Decision of treatment

Endoscopic assessment

•Benign

•Intramucosal carcinoma

Endoscopic resection:

ESD / EMR

Superficial SM invasive CA

Endoscopic resection +/- additional surgery

Deep SM invasive CA

Surgery

Endoscopic assessment – not 100% accurate

Endoscopic resection

Endoscopic mucosal resection (EMR)

Endoscopic submucosal dissection (ESD)

Endoscopic Mucosal Resection Injection assisted EMR

“Inject and cut” (A) “Inject, lift and cut” (B)

Ligation assisted EMR (D)

Limitation of EMR

Difficult for en-bloc resection for lesions > 20mm in size

Piecemeal resection of large lesions Possible local recurrence due to residual lesion

Published rate of recurrence up to 27.2% Inability to obtain complete specimen for detail

pathological assessment

Endoscopic Submucosal Dissection First developed by

Japanese endoscopists Dr. Ono, Dr. Gotoda since 2001 on gastric lesion

Indication of ESD

Tanaka et al, GIE 2007

Indications for colorectal ESD recommended by the Colorectal ESD Standardization Implementation Working Group

Short term outcomes of ESD – Systemic review 2841 ESD treated lesions R0 resection rate: 88% Bleeding rate: 2% Perforation rate: 4%

ESD is safe and effective, at least in expert hands

Repici A et al. Endoscopy 2012

Long term outcomes of ESD for colorectal neoplasms 146 adenomas, 164 carcinomas Local recurrence rate: 2.0% Median FU 38.7 months 3 year overall survival: 97.1% 5 year overall survival: 95.3%

Niimi K, Fujishiro M, Endoscopy 2010

Potential pitfalls for ESD

Technically demanding Tortuous structures – difficulty in maintaining

scope position Narrow lumen – difficulty in controlling the knife Thin colonic wall – Increase risk of perforation

Overall risk of perforation higher than EMR or EPMR

Questions

1. Can we remove this lesion completely with endoscope?

2. If pathology confirms invasive carcinoma, is endoscopic resection adequate? Do we need formal surgical resection?

Risk of recurrence after endoscopic resection alone Adequacy of local tumor control

Margin positivity

Adequacy of regional tumor control Lymphatic involvement Need for further lymphatic clearance, i.e. formal

colonic resection?

Adequacy of local tumor control Resection margin involved or less than 1mm Relapse rate 21–33%

Most authors believe a resection margin of ≥ 2 mm is safe and the probability of residual disease or recurrent carcinoma is low

Cooper HS et al, Gastroenterology 1995

L Bujanda et al, W. J. Gastroenterology 2010

Predictive factor of recurrence after endoscopic resection

Multiple studies addressing the issue since 1980s

Haggitt classification

Haggitt el al, Gastroenterology 1985

Main focus on pedunculated polyp

Risk of LN metastases Level 1-3: <1% Level 4: 12-25%

No subdivision of level 4 lesion

Nivatvongs S et al, Dis Colon Rectum 1991

Japanese classification

SM1

SM2

SM3

Kudo et al, Endoscopy 1993

Sakatani A et al, Stomach and Intestine 1991

Risk of LNM in SM1-3 carcinomaLevel of invasion

LNM positive or LR positive

Neither LNM or LR

SM1 0 93 P<0.0001

SM2 8 92

SM3 9 26

Kikuchi et al, Dis Colon Rectum 1995

Journal of Gastrointestinal Surgery 2012

Meta-analysis 2012

76 papers selected 42 different histopathological features

identified

Sean C et al, J Gastrointestinal Surg 2012

Lymphatic invasion Vascular invasion Tumor Budding Differentiation at

invasive front

Sean C et al, J Gastrointestinal Surg 2012

Depth of SM invasion

Kitajima et al, J Gastroenterology 2004

Haggitt 2

Kitajima et al, J Gastroenterology 2004

Conclusion

Endoscopic resection adequate if SM invasion <1000μm for non-pedunculated

polyp SM invasion <3000μm for pedunculated polyp in

the absence of lymphatic invasion

Kitajima et al, J Gastroenterology 2004

K Nakadoi et al, J Gastroenterology and Hepatology 2011

Well / mod. differentiated/papillary, absence of vascular invasion, grade 1 tumor budding

Japanese guidelines

Submucosal carcinomas can be followed up: Tumor-negative horizontal margin Differentiated adenocarcinoma Submucosal invasion of < 1000 μm Absence of vascular invasion Grade 1 (low grade) tumor budding

Otherwise additional surgery with lymph node dissection recommended

Japanese Society for Cancer of the Colon and Rectum. 2010

NCCN guidelines 2012

Favorable histological features: Grade 1 or 2, no angiolymphatic invasion, negative margin

of resection Controversy regarding endoscopic management of

sessile malignant polyp

T1 colonic carcinoma – Is endoscopic resection sufficient? No direct comparison between endoscopic resection alone

with formal surgical resection in prospective manner Practically difficult to conduct

Endoscopic resection alone should be safe in selected subgroup of patients with favorable histology and limited SM invasion

Endoscopic resection also useful in accurate staging to predict need for additional surgery in marginal cases

Need good liaison with dedicated pathologist to accurately identify the histological features that predict risk of lymph node metastases

Questions?

Thank you

Acknowledgement:

Dr. SF Hon, PWH