Intest Res.  2019 Oct;17(4):516-526. 10.5217/ir.2018.00169.

Clinical outcomes of positive resection margin after endoscopic mucosal resection of early colon cancers

• Park J
• Kim HG
• Jeong SO
• Jo HG
• Song HY
• Kim J
• Ryu S
• Cho Y
• Youn HJ
• Jeon SR
• Kim JO
• Ko BM
• Jeen YM
• Jin SY

• KMID: 2465817
• DOI: http://doi.org/10.5217/ir.2018.00169

Abstract

BACKGROUND/AIMS
When determining the subsequent management after endoscopic resection of the early colon cancer (ECC), various factors including the margin status should be considered. This study assessed the subsequent management and outcomes of ECCs according to margin status.
METHODS
We examined the data of 223 ECCs treated by endoscopic mucosal resection (EMR) from 215 patients during 2004 to 2014, and all patients were followed-up at least for 2 years.
RESULTS
According to histological analyses, the margin statuses of all lesions after EMR were as follows: 138 cases (61.9%) were negative, 65 cases (29.1%) were positive for dysplastic cells on the resection margins, and 20 cases (8.9%) were uncertain. The decision regarding subsequent management was affected not only by pathologic outcomes but also by the endoscopist's opinion on whether complete resection was obtained. Surgery was preferred if the lesion extended to the submucosa (odds ratio [OR], 25.46; 95% confidence interval [CI], 7.09-91.42), the endoscopic resection was presumed incomplete (OR, 15.55; 95% CI, 4.28-56.56), or the lymph system was invaded (OR, 13.69; 95% CI, 1.76-106.57). Fourteen patients (6.2%) had residual or recurrent malignancies at the site of the previous ECC resection and were significantly associated with presumed incomplete endoscopic resection (OR, 4.59; 95% CI, 1.21-17.39) and submucosal invasion (OR, 5.14; 95% CI, 1.18-22.34).
CONCLUSIONS
Subsequent surgery was associated with submucosa invasion, lymphatic invasion, and cancer-positive margins. Presumed completeness of the resection may be helpful for guiding the subsequent management of patients who undergo endoscopic resection of ECC.

Keyword

Early colon cancer; Endosocpic mucosal resection; Margins of excision

MeSH Terms

Colon*
Colonic Neoplasms*
Humans

Figure

• 

  Fig. 1. Endoscopically presumed incomplete resection. (A) A nodular, mixed, laterally spreading tumor was identified after submucosal injection of a saline and indigo carmine solution. (B) Endoscopic piecemeal mucosal resection (EPMR) was performed using a conventional snare. (C) Additional injection of saline and indigo carmine during EPMR. (D) A section of the tumor removed using EPMR. The arrow indicates tissue that was torn during the procedure and was considered a possible remnant tumor island. It was difficult to determine whether or not the tumor had been completely removed even at the lateral resection margin.

• 

  Fig. 2. Study flowchart. Among the 191 lesions that were followed using surveillance colonoscopy with another systemic evaluation, 2 cases of cancer recurrence were identified. Among the 32 lesions that were treated using subsequent surgery, remnant cancers were identified in 12 cases and adenomas were identified in 2 cases. EMR, endoscopic mucosal resection; LGD, low-grade dysplasia; HGD, high-grade dysplasia; LST, lateral spreading tumor; EPMR, endoscopic piecemeal mucosal resection; PCR, presumed complete resection; PIR, presumed incomplete resection; SM, submucosa.

• 

  Fig. 3. Study flowchart of 65 cases with positive resection margins. Among the 56 lesions with a positive lateral margin, 50 with endoscopically presumed complete resection (PCR) were followed, and there was no recurrence during surveillance. Three remnant cancers were detected during subsequent surgery of 6 cases of positive lateral margin and 9 cases of positive vertical or both margins. Three residual cancer cases included lesions that underwent endoscopically presumed incomplete/uncertain resection. LGD, low-grade dysplasia; HGD, high-grade dysplasia; EPMR, endoscopic piecemeal mucosal resection; PIR, presumed incomplete resection; EMR, endoscopic mucosal resection; LST, lateral spreading tumor; SM, submucosa.

Reference

1. Okuyama T, Oya M, Ishikawa H. Budding as a risk factor for lymph node metastasis in pT1 or pT2 well-differentiated colorectal adenocarcinoma. Dis Colon Rectum. 2002; 45:628–634.

2. Yim K, Won DD, Lee IK, Oh ST, Jung ES, Lee SH. Novel predictors for lymph node metastasis in submucosal invasive colorectal carcinoma. World J Gastroenterol. 2017; 23:5936–5944.

3. Ueno H, Hase K, Hashiguchi Y, et al. Novel risk factors for lymph node metastasis in early invasive colorectal cancer: a multiinstitution pathology review. J Gastroenterol. 2014; 49:1314–1323.

4. Bosch SL, Teerenstra S, de Wilt JH, Cunningham C, Nagtegaal ID. Predicting lymph node metastasis in pT1 colorectal cancer: a systematic review of risk factors providing rationale for therapy decisions. Endoscopy. 2013; 45:827–834.

5. Suh JH, Han KS, Kim BC, et al. Predictors for lymph node metastasis in T1 colorectal cancer. Endoscopy. 2012; 44:590–595.

6. Beaton C, Twine CP, Williams GL, Radcliffe AG. Systematic review and meta-analysis of histopathological factors influencing the risk of lymph node metastasis in early colorectal cancer. Colorectal Dis. 2013; 15:788–797.

7. Kitajima K, Fujimori T, Fujii S, et al. Correlations between lymph node metastasis and depth of submucosal invasion in submucosal invasive colorectal carcinoma: a Japanese collaborative study. J Gastroenterol. 2004; 39:534–543.

8. Cooper HS, Deppisch LM, Gourley WK, et al. Endoscopically removed malignant colorectal polyps: clinicopathologic correlations. Gastroenterology. 1995; 108:1657–1665.

9. Doornebosch PG, Tollenaar RA, De Graaf EJ. Is the increasing role of Transanal Endoscopic Microsurgery in curation for T1 rectal cancer justified? A systematic review. Acta Oncol. 2009; 48:343–353.

10. Cunningham KN, Mills LR, Schuman BM, Mwakyusa DH. Long-term prognosis of well-differentiated adenocarcinoma in endoscopically removed colorectal adenomas. Dig Dis Sci. 1994; 39:2034–2037.

11. Volk EE, Goldblum JR, Petras RE, Carey WD, Fazio VW. Management and outcome of patients with invasive carcinoma arising in colorectal polyps. Gastroenterology. 1995; 109:1801–1807.

12. Gill MD, Rutter MD, Holtham SJ. Management and short-term outcome of malignant colorectal polyps in the north of England(1). Colorectal Dis. 2013; 15:169–176.

13. Borschitz T, Gockel I, Kiesslich R, Junginger T. Oncological outcome after local excision of rectal carcinomas. Ann Surg Oncol. 2008; 15:3101–3108.

14. Bach SP, Hill J, Monson JR, et al. A predictive model for local recurrence after transanal endoscopic microsurgery for rectal cancer. Br J Surg. 2009; 96:280–290.

15. Shin JW, Han KS, Hyun JH, et al. Risk of recurrence after endoscopic resection of early colorectal cancer with positive margins. Endoscopy. 2018; 50:241–247.

16. Kim KM, Eo SJ, Shim SG, et al. Risk factors for residual cancer and lymph node metastasis after noncurative endoscopic resection of early colorectal cancer. Dis Colon Rectum. 2013; 56:35–42.

17. Schlemper RJ, Hirata I, Dixon MF. The macroscopic classification of early neoplasia of the digestive tract. Endoscopy. 2002; 34:163–168.

18. Zauber AG, Winawer SJ, O’Brien MJ, et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med. 2012; 366:687–696.

19. Lambert R, Kudo SE, Vieth M, et al. Pragmatic classification of superficial neoplastic colorectal lesions. Gastrointest Endosc. 2009; 70:1182–1199.

20. ASGE Technology Committee, Kantsevoy SV, Adler DG, et al. Endoscopic mucosal resection and endoscopic submucosal dissection. Gastrointest Endosc. 2008; 68:11–18.

21. Watanabe T, Itabashi M, Shimada Y, et al. Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2014 for treatment of colorectal cancer. Int J Clin Oncol. 2015; 20:207–239.

22. Bujanda L, Cosme A, Gil I, Arenas-Mirave JI. Malignant colorectal polyps. World J Gastroenterol. 2010; 16:3103–3111.

23. Butte JM, Tang P, Gonen M, et al. Rate of residual disease after complete endoscopic resection of malignant colonic polyp. Dis Colon Rectum. 2012; 55:122–127.

24. ASGE Standards of Practice Committee, Fisher DA, Shergill AK, et al. Role of endoscopy in the staging and management of colorectal cancer. Gastrointest Endosc. 2013; 78:8–12.

25. Goldstein NS, Watts JC, Neill JS, et al. The effect of electrothermal cautery-assisted resection of diminutive colonic polyps on histopathologic diagnosis. Am J Clin Pathol. 2001; 115:356–361.

26. Groisman GM, Amar M, Meir A. Utility of MIB-1 (Ki-67) in evaluating diminutive colorectal polyps with cautery artifact. Arch Pathol Lab Med. 2007; 131:1089–1093.