Korean J Gastroenterol.  2024 Nov;84(5):230-234. 10.4166/kjg.2024.088.

Combining Endoscopic Submucosal Dissection and Adjuvant Chemoradiotherapy or Radiotherapy for Effective Management of Rectal Cancer with Deep Submucosal Invasion: A Case Series

• Park JH
• Kim JH
• Ko SH
• Park SJ

• KMID: 2561593
• DOI: http://doi.org/10.4166/kjg.2024.088

Abstract

Rectal cancer is one of the most prevalent malignancies worldwide, and the introduction of an endoscopic submucosal dissection (ESD) has offered minimally invasive management for early colorectal cancers. On the other hand, a post-ESD pathological examination showed that the risk of lymph node metastasis increases with deep submucosal (SM) invasion, positive lymphovascular invasion, grade 2/3 tumor budding, and certain histological types. An intestinal resection with a lymph node dissection is recommended in these cases, and chemoradiotherapy (CRT) is also effective adjuvant therapy. This paper reports a case series of patients who underwent ESD for rectal cancer and received concurrent CRT because of pathologically confirmed deep SM invasion.

Keyword

Rectal neoplasms; Endoscopic mucosal resection; Chemoradiotherapy

Figure

• 

  Fig. 1 (A) Colonoscopy examination revealed a nodular mixed-type lateral spreading tumor located 1–3 cm from the anal verge. (B) The tumor was removed by an endoscopic submucosal dissection. (C) The mucosal surface of the resected nodule displayed an amorphous surface pattern. (D) Follow-up colonoscopy showed no evidence of recurrence. (E) Follow-up abdominopelvic CT confirmed the absence of recurrence.

• 

  Fig. 2 (A) Colonoscopic examination identified a nodular mixed-type lateral spreading tumor situated 0–2 cm from the anal verge. (B) The tumor was excised using an endoscopic submucosal dissection. (C) Examination of the resected specimen’s nodule revealed an irregular mucosal surface. (D) Follow-up colonoscopy showed no evidence of recurrence. (E) Follow-up Abdominopelvic CT confirmed the absence of recurrence.

• 

  Fig. 3 (A) Colonoscopic examination detected an elevated lesion with a central depressed area located 1–3 cm from the anal verge. (B) The lesion was removed by an endoscopic submucosal dissection. (C) The central surface of the resected specimen exhibited an amorphous surface. (D) Follow-up colonoscopy revealed no evidence of recurrence. (E) Follow-up Abdominopelvic CT indicated no signs of recurrence.

Reference

1. Sung H, Ferlay J, Siegel RL, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2021; 71:209–249. DOI: 10.3322/caac.21660. PMID: 33538338.

2. Sakamoto T, Mori G, Yamada M, et al. 2014; Endoscopic submucosal dissection for colorectal neoplasms: a review. World J Gastroenterol. 20:16153–16158. DOI: 10.3748/wjg.v20.i43.16153. PMID: 25473168. PMCID: PMC4239502.

3. Sung HY, Kang WK, Kim SW, et al. 2010; Risk factors for lymph node metastasis in patients with submucosal invasive colorectal carcinoma. J Korean Surg Soc. 78:207–212. DOI: 10.4174/jkss.2010.78.4.207.

4. Kitajima K, Fujimori T, Fujii S, et al. 2004; Correlations between lymph node metastasis and depth of submucosal invasion in submucosal invasive colorectal carcinoma: a Japanese collaborative study. J Gastroenterol. 39:534–543. DOI: 10.1007/s00535-004-1339-4. PMID: 15235870.

5. Naito A, Iwamoto K, Ohtsuka M, et al. 2021; Risk factors for lymph node metastasis in pathological T1b colorectal cancer. In Vivo. 35:987–991. DOI: 10.21873/invivo.12341. PMID: 33622893. PMCID: PMC8045107.

6. Kawachi H, Eishi Y, Ueno H, et al. 2015; A three-tier classification system based on the depth of submucosal invasion and budding/sprouting can improve the treatment strategy for T1 colorectal cancer: a retrospective multicenter study. Mod Pathol. 28:872–879. DOI: 10.1038/modpathol.2015.36. PMID: 25720321.

7. Kikuchi R, Takano M, Takagi K, et al. 1995; Management of early invasive colorectal cancer. Risk of recurrence and clinical guidelines. Dis Colon Rectum. 38:1286–1295. DOI: 10.1007/BF02049154. PMID: 7497841.

8. Nascimbeni R, Burgart LJ, Nivatvongs S, Larson DR. 2002; Risk of lymph node metastasis in T1 carcinoma of the colon and rectum. Dis Colon Rectum. 45:200–206. DOI: 10.1007/s10350-004-6147-7. PMID: 11852333.

9. Gollins S, Sebag-Montefiore D. 2016; Neoadjuvant treatment strategies for locally advanced rectal cancer. Clin Oncol (R Coll Radiol). 28:146–151. DOI: 10.1016/j.clon.2015.11.003. PMID: 26645661.

10. Hashiguchi Y, Muro K, Saito Y, et al. 2020; Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2019 for the treatment of colorectal cancer. Int J Clin Oncol. 25:1–42. DOI: 10.1007/s10147-019-01485-z. PMID: 31203527. PMCID: PMC6946738.

11. Ueno H, Hase K, Hashiguchi Y, et al. 2014; Novel risk factors for lymph node metastasis in early invasive colorectal cancer: a multi-institution pathology review. J Gastroenterol. 49:1314–1323. DOI: 10.1007/s00535-013-0881-3. PMID: 24065123.

12. Zwager LW, Bastiaansen BAJ, Montazeri NSM, et al. 2022; Deep submucosal invasion is not an independent risk factor for lymph node metastasis in T1 colorectal cancer: A meta-analysis. Gastroenterology. 163:174–189. DOI: 10.1053/j.gastro.2022.04.010. PMID: 35436498.

13. den Dulk M, Marijnen CA, Collette L, et al. 2009; Multicentre analysis of oncological and survival outcomes following anastomotic leakage after rectal cancer surgery. Br J Surg. 96:1066–1075. DOI: 10.1002/bjs.6694. PMID: 19672927.

14. Juul T, Elfeki H, Christensen P, Laurberg S, Emmertsen KJ, Bager P. 2019; Normative data for the low anterior resection syndrome score (LARS Score). Ann Surg. 269:1124–1128. DOI: 10.1097/SLA.0000000000002750. PMID: 31082911.