Clin Endosc.  2022 Jul;55(4):496-506. 10.5946/ce.2022.115.

Endoscopic treatment for rectal neuroendocrine tumor: which method is better?

• Hong SM
• Baek DH

• KMID: 2531941
• DOI: http://doi.org/10.5946/ce.2022.115

Abstract

Recently, research on rectal neuroendocrine tumors (NETs) has increased during the last few decades. Rectal NETs measuring <10 mm without atypical features and confined to the submucosal layer have only 1% risk of metastasis, and the long-term survival probability of patients without metastasis at the time of diagnosis is approximately 100%. Therefore, the current guidelines suggest endoscopic resection of rectal NETs of <10 mm is regarded as a safe therapeutic option. However, there are currently no clear recommendations for technique selection for endoscopic resection. The choice of treatment modality for rectal NETs should be based on the lesion size, endoscopic characteristics, grade of differentiation, depth of vertical involvement, lymphovascular invasion, and risk of metastasis. Moreover, the complete resection rate, complications, and experience at the center should be considered. Modified endoscopic mucosal resection is the most suitable resection method for rectal NETs of <10 mm, because it is an effective and safe technique that is relatively simple and less time-consuming compared with endoscopic submucosal dissection. Endoscopic submucosal dissection should be considered when the tumor size is >10 mm, suctioning is not possible due to fibrosis in the lesion, or when the snaring for modified endoscopic mucosal resection does not work well.

Keyword

Endoscopic mucosal resection; Endoscopic resection; Endoscopic submucosal dissection; Rectal neuroendocrine tumor

Figure

• 

  Fig. 1. Each endoscopic resection procedure for rectal neuroendocrine tumor. (A) Conventional endoscopic mucosal resection (EMR). (B) EMR with a cap. (C) EMR with band ligation. (D) EMR after circumferential incision/precutting. (E) anchored snare-tip EMR. (F) Endoscopic submucosal dissection.

Reference

1. Gastrointestinal Pathology Study Group of Korean Society of Pathologists, Cho MY, Kim JM, et al. Current trends of the incidence and pathological diagnosis of gastroenteropancreatic neuroendocrine tumors (GEP-NETs) in Korea 2000-2009: multicenter study. Cancer Res Treat. 2012; 44:157–165.

2. Lim CH, Lee IS, Jun BY, et al. Incidence and clinical characteristics of gastroenteropancreatic neuroendocrine tumor in Korea: a single-center experience. Korean J Intern Med. 2017; 32:452–458.

3. Ito T, Sasano H, Tanaka M, et al. Epidemiological study of gastroenteropancreatic neuroendocrine tumors in Japan. J Gastroenterol. 2010; 45:234–243.

4. Yao JC, Hassan M, Phan A, et al. One hundred years after “carcinoid”: epidemiology of and prognostic factors for neuroendocrine tumors in 35,825 cases in the United States. J Clin Oncol. 2008; 26:3063–3072.

5. Dasari A, Shen C, Halperin D, et al. Trends in the incidence, prevalence, and survival outcomes in patients with neuroendocrine tumors in the United States. JAMA Oncol. 2017; 3:1335–1342.

6. Ito T, Igarashi H, Nakamura K, et al. Epidemiological trends of pancreatic and gastrointestinal neuroendocrine tumors in Japan: a nationwide survey analysis. J Gastroenterol. 2015; 50:58–64.

7. Lee J, Park YE, Choi JH, et al. Comparison between cap-assisted and ligation-assisted endoscopic mucosal resection for rectal neuroendocrine tumors. Ann Gastroenterol. 2020; 33:385–390.

8. Basuroy R, Haji A, Ramage JK, et al. Review article: the investigation and management of rectal neuroendocrine tumours. Aliment Pharmacol Ther. 2016; 44:332–345.

9. Delle Fave G, O’Toole D, Sundin A, et al. ENETS consensus guidelines update for gastroduodenal neuroendocrine neoplasms. Neuroendocrinology. 2016; 103:119–124.

10. Anthony LB, Strosberg JR, Klimstra DS, et al. The NANETS consensus guidelines for the diagnosis and management of gastrointestinal neuroendocrine tumors (NETs): well-differentiated nets of the distal colon and rectum. Pancreas. 2010; 39:767–774.

11. Ngamruengphong S, Kamal A, Akshintala V, et al. Prevalence of metastasis and survival of 788 patients with T1 rectal carcinoid tumors. Gastrointest Endosc. 2019; 89:602–606.

12. Caplin M, Sundin A, Nillson O, et al. ENETS consensus guidelines for the management of patients with digestive neuroendocrine neoplasms: colorectal neuroendocrine neoplasms. Neuroendocrinology. 2012; 95:88–97.

13. Kim GU, Kim KJ, Hong SM, et al. Clinical outcomes of rectal neuroendocrine tumors ≤ 10 mm following endoscopic resection. Endoscopy. 2013; 45:1018–1023.

14. Maione F, Chini A, Milone M, et al. Diagnosis and management of rectal neuroendocrine tumors (NETs). Diagnostics (Basel). 2021; 11:771.

15. de Mestier L, Brixi H, Gincul R, et al. Updating the management of patients with rectal neuroendocrine tumors. Endoscopy. 2013; 45:1039–1046.

16. He L, Deng T, Luo H. Efficacy and safety of endoscopic resection therapies for rectal carcinoid tumors: a meta-analysis. Yonsei Med J. 2015; 56:72–81.

17. Ramage JK, De Herder WW, Delle Fave G, et al. ENETS consensus guidelines update for colorectal neuroendocrine neoplasms. Neuroendocrinology. 2016; 103:139–143.

18. Wang AY, Ahmad NA. Rectal carcinoids. Curr Opin Gastroenterol. 2006; 22:529–535.

19. Lee SP, Sung IK, Kim JH, et al. The effect of preceding biopsy on complete endoscopic resection in rectal carcinoid tumor. J Korean Med Sci. 2014; 29:512–518.

20. Judd S, Nangia S, Levi E, et al. Rectal carcinoid tumor: a delayed localized recurrence 23 years after endoscopic resection. Endoscopy. 2014; 46 Suppl 1 UCTN:E555–E556.

21. Onozato Y, Kakizaki S, Iizuka H, et al. Endoscopic treatment of rectal carcinoid tumors. Dis Colon Rectum. 2010; 53:169–176.

22. Son HJ, Sohn DK, Hong CW, et al. Factors associated with complete local excision of small rectal carcinoid tumor. Int J Colorectal Dis. 2013; 28:57–61.

23. Zhang HP, Wu W, Yang S, et al. Endoscopic treatments for rectal neuroendocrine tumors smaller than 16 mm: a meta-analysis. Scand J Gastroenterol. 2016; 51:1345–1353.

24. Ono A, Fujii T, Saito Y, et al. Endoscopic submucosal resection of rectal carcinoid tumors with a ligation device. Gastrointest Endosc. 2003; 57:583–587.

25. Soga J. Carcinoids of the rectum: an evaluation of 1271 reported cases. Surg Today. 1997; 27:112–119.

26. Matsui K, Iwase T, Kitagawa M. Small, polypoid-appearing carcinoid tumors of the rectum: clinicopathologic study of 16 cases and effectiveness of endoscopic treatment. Am J Gastroenterol. 1993; 88:1949–1953.

27. Lee HS, Moon HS, Kwon IS, et al. Comparison of conventional and modified endoscopic mucosal resection methods for the treatment of rectal neuroendocrine tumors. Surg Endosc. 2021; 35:6055–6065.

28. Im YC, Jung SW, Cha HJ, et al. The effectiveness of endoscopic submucosal resection with a ligation device for small rectal carcinoid tumors: focused on previously biopsied tumors. Surg Laparosc Endosc Percutan Tech. 2014; 24:264–269.

29. Kim KM, Eo SJ, Shim SG, et al. Treatment outcomes according to endoscopic treatment modalities for rectal carcinoid tumors. Clin Res Hepatol Gastroenterol. 2013; 37:275–282.

30. Yang DH, Park Y, Park SH, et al. Cap-assisted EMR for rectal neuroendocrine tumors: comparisons with conventional EMR and endoscopic submucosal dissection (with videos). Gastrointest Endosc. 2016; 83:1015–1022.

31. Zhao ZF, Zhang N, Ma SR, et al. A comparative study on endoscopy treatment in rectal carcinoid tumors. Surg Laparosc Endosc Percutan Tech. 2012; 22:260–263.

32. Oshitani N, Hamasaki N, Sawa Y, et al. Endoscopic resection of small rectal carcinoid tumours using an aspiration method with a transparent overcap. J Int Med Res. 2000; 28:241–246.

33. Park SB, Kim HW, Kang DH, et al. Advantage of endoscopic mucosal resection with a cap for rectal neuroendocrine tumors. World J Gastroenterol. 2015; 21:9387–9393.

34. Berkelhammer C, Jasper I, Kirvaitis E, et al. “Band-snare” resection of small rectal carcinoid tumors. Gastrointest Endosc. 1999; 50:582–585.

35. Lim HK, Lee SJ, Baek DH, et al. Resectability of rectal neuroendocrine tumors using endoscopic mucosal resection with a ligation band device and endoscopic submucosal dissection. Gastroenterol Res Pract. 2019; 2019:8425157.

36. Li D, Xie J, Hong D, et al. Efficacy and safety of ligation-assisted endoscopic submucosal resection combined with endoscopic ultrasonography for treatment of rectal neuroendocrine tumors. Scand J Gastroenterol. 2022; Feb. 2. [Epub]. https://doi.org/10.1080/00365521.2022.2033828.

37. So H, Yoo SH, Han S, et al. Efficacy of precut endoscopic mucosal resection for treatment of rectal neuroendocrine tumors. Clin Endosc. 2017; 50:585–591.

38. Chen R, Liu X, Sun S, et al. Comparison of endoscopic mucosal resection with circumferential incision and endoscopic submucosal dissection for rectal carcinoid tumor. Surg Laparosc Endosc Percutan Tech. 2016; 26:e56–e61.

39. Kim J, Kim J, Oh EH, et al. Anchoring the snare tip is a feasible endoscopic mucosal resection method for small rectal neuroendocrine tumors. Sci Rep. 2021; 11:12918.

40. Sung HY, Kim SW, Kang WK, et al. Long-term prognosis of an endoscopically treated rectal neuroendocrine tumor: 10-year experience in a single institution. Eur J Gastroenterol Hepatol. 2012; 24:978–983.

41. Yong JN, Lim XC, Nistala KR, et al. Endoscopic submucosal dissection versus endoscopic mucosal resection for rectal carcinoid tumor: a meta-analysis and meta-regression with single-arm analysis. J Dig Dis. 2021; 22:562–571.

42. Zheng Y, Guo K, Zeng R, et al. Prognosis of rectal neuroendocrine tumors after endoscopic resection: a single-center retrospective study. J Gastrointest Oncol. 2021; 12:2763–2774.

43. Wang XY, Chai NL, Linghu EQ, et al. The outcomes of modified endoscopic mucosal resection and endoscopic submucosal dissection for the treatment of rectal neuroendocrine tumors and the value of endoscopic morphology classification in endoscopic resection. BMC Gastroenterol. 2020; 20:200.

44. Wang XY, Chai NL, Linghu EQ, et al. Efficacy and safety of hybrid endoscopic submucosal dissection compared with endoscopic submucosal dissection for rectal neuroendocrine tumors and risk factors associated with incomplete endoscopic resection. Ann Transl Med. 2020; 8:368.

45. Zheng JC, Zheng K, Zhao S, et al. Efficacy and safety of modified endoscopic mucosal resection for rectal neuroendocrine tumors: a meta-analysis. Z Gastroenterol. 2020; 58:137–145.

46. Zhou X, Xie H, Xie L, et al. Endoscopic resection therapies for rectal neuroendocrine tumors: a systematic review and meta-analysis. J Gastroenterol Hepatol. 2014; 29:259–268.

47. Pan J, Zhang X, Shi Y, et al. Endoscopic mucosal resection with suction vs. endoscopic submucosal dissection for small rectal neuroendocrine tumors: a meta-analysis. Scand J Gastroenterol. 2018; 53:1139–1145.

48. Kamigaichi Y, Yamashita K, Oka S, et al. Clinical outcomes of endoscopic resection for rectal neuroendocrine tumors: advantages of endoscopic submucosal resection with a ligation device compared to conventional EMR and ESD. DEN Open. 2021; 2:e35.

49. Noh SM, Kim JY, Park JC, et al. Tip-in versus conventional endoscopic mucosal resection for flat colorectal neoplasia 10 mm or larger in size. Int J Colorectal Dis. 2020; 35:1283–1290.

50. Pioche M, Wallenhorst T, Lepetit H, et al. Endoscopic mucosal resection with anchoring of the snare tip: multicenter retrospective evaluation of effectiveness and safety. Endosc Int Open. 2019; 7:E1496–E1502.

51. Jacques J, Legros R, Charissoux A, et al. Anchoring the snare tip by means of a small incision facilitates en bloc endoscopic mucosal resection and increases the specimen size. Endoscopy. 2017; 49(S 01):E39–E41.