Why attempt en bloc resection of non-pedunculated colorectal adenomas? A systematic review of the prevalence of superficial submucosal invasive cancer after endoscopic submucosal dissection

Lorenzo Fuccio, Alessandro Repici, Cesare Hassan, Thierry Ponchon, Pradeep Bhandari, Rodrigo Jover, Konstantinos Triantafyllou, Daniele Mandolesi, Leonardo Frazzoni, Cristina Bellisario, Franco Bazzoli, Prateek Sharma, Thomas Rösch, Douglas Rex

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Abstract

Objective: Endoscopic submucosal dissection (ESD) aims to achieve en bloc resection of non-pedunculated colorectal adenomas which might be indicated in cases with superficial submucosal invasive cancers (SMIC), but the procedure is time consuming and complex. The prevalence of such cancers is not known but may determine the clinical necessity for ESD as opposed to the commonly used piecemeal mucosal resection (endoscopic mucosal resection) of colorectal adenomas. The main aim was to assess the prevalence of SMIC SM1 (ie, invasion ≤1000 μm or less than one-third of the submucosa) on colorectal lesions removed by ESD. Design: A literature review was conducted using electronic databases (up to March 2017) for colorectal ESD series reporting the histology of the dissected lesions. Results: 51 studies with data on 11 260 colorectal dissected lesions were included. Most resected lesions (82.2%; 95% CI 78.8% to 85.3%) were adenomas (low- and high-grade dysplasia, 26.8% and 55.4%, respectively). Overall, 15.7% were submucosal cancers, but only slightly more than half (8.0%; 95% CI 6.1% to 10.3%) had an infiltration depth of ≤1000 μm, providing a number needed to treat (NNT) to avoid one surgery of 12.5. Estimating an oncologically curative (R0; G1/2; L0/V0) resection rate of 75.3% (95% CI 52.2% to 89.4%) for malignant lesions, the prevalence of curative resection lowered to 6% (95% CI 4.2% to 7.2%) with an NNT of 16.7. Conclusion: The low prevalence of SMIC SM1 in lesions selected for ESD as well as the even lower rate of curative resection limits the clinical applicability of endoscopic en bloc resection. This calls for caution over an indiscriminate use of this technique in the resection of colorectal neoplasia.

Original languageEnglish (US)
JournalGut
DOIs
StateAccepted/In press - Dec 5 2017

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Adenoma
Numbers Needed To Treat
Neoplasms
Endoscopic Mucosal Resection
Histology
Databases

Keywords

  • colorectal cancer
  • endoscopic submucosal dissection
  • interventional endoscopy

ASJC Scopus subject areas

  • Gastroenterology

Cite this

Why attempt en bloc resection of non-pedunculated colorectal adenomas? A systematic review of the prevalence of superficial submucosal invasive cancer after endoscopic submucosal dissection. / Fuccio, Lorenzo; Repici, Alessandro; Hassan, Cesare; Ponchon, Thierry; Bhandari, Pradeep; Jover, Rodrigo; Triantafyllou, Konstantinos; Mandolesi, Daniele; Frazzoni, Leonardo; Bellisario, Cristina; Bazzoli, Franco; Sharma, Prateek; Rösch, Thomas; Rex, Douglas.

In: Gut, 05.12.2017.

Research output: Contribution to journalArticle

Fuccio, L, Repici, A, Hassan, C, Ponchon, T, Bhandari, P, Jover, R, Triantafyllou, K, Mandolesi, D, Frazzoni, L, Bellisario, C, Bazzoli, F, Sharma, P, Rösch, T & Rex, D 2017, 'Why attempt en bloc resection of non-pedunculated colorectal adenomas? A systematic review of the prevalence of superficial submucosal invasive cancer after endoscopic submucosal dissection', Gut. https://doi.org/10.1136/gutjnl-2017-315103
Fuccio, Lorenzo ; Repici, Alessandro ; Hassan, Cesare ; Ponchon, Thierry ; Bhandari, Pradeep ; Jover, Rodrigo ; Triantafyllou, Konstantinos ; Mandolesi, Daniele ; Frazzoni, Leonardo ; Bellisario, Cristina ; Bazzoli, Franco ; Sharma, Prateek ; Rösch, Thomas ; Rex, Douglas. / Why attempt en bloc resection of non-pedunculated colorectal adenomas? A systematic review of the prevalence of superficial submucosal invasive cancer after endoscopic submucosal dissection. In: Gut. 2017.
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abstract = "Objective: Endoscopic submucosal dissection (ESD) aims to achieve en bloc resection of non-pedunculated colorectal adenomas which might be indicated in cases with superficial submucosal invasive cancers (SMIC), but the procedure is time consuming and complex. The prevalence of such cancers is not known but may determine the clinical necessity for ESD as opposed to the commonly used piecemeal mucosal resection (endoscopic mucosal resection) of colorectal adenomas. The main aim was to assess the prevalence of SMIC SM1 (ie, invasion ≤1000 μm or less than one-third of the submucosa) on colorectal lesions removed by ESD. Design: A literature review was conducted using electronic databases (up to March 2017) for colorectal ESD series reporting the histology of the dissected lesions. Results: 51 studies with data on 11 260 colorectal dissected lesions were included. Most resected lesions (82.2{\%}; 95{\%} CI 78.8{\%} to 85.3{\%}) were adenomas (low- and high-grade dysplasia, 26.8{\%} and 55.4{\%}, respectively). Overall, 15.7{\%} were submucosal cancers, but only slightly more than half (8.0{\%}; 95{\%} CI 6.1{\%} to 10.3{\%}) had an infiltration depth of ≤1000 μm, providing a number needed to treat (NNT) to avoid one surgery of 12.5. Estimating an oncologically curative (R0; G1/2; L0/V0) resection rate of 75.3{\%} (95{\%} CI 52.2{\%} to 89.4{\%}) for malignant lesions, the prevalence of curative resection lowered to 6{\%} (95{\%} CI 4.2{\%} to 7.2{\%}) with an NNT of 16.7. Conclusion: The low prevalence of SMIC SM1 in lesions selected for ESD as well as the even lower rate of curative resection limits the clinical applicability of endoscopic en bloc resection. This calls for caution over an indiscriminate use of this technique in the resection of colorectal neoplasia.",
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T1 - Why attempt en bloc resection of non-pedunculated colorectal adenomas? A systematic review of the prevalence of superficial submucosal invasive cancer after endoscopic submucosal dissection

AU - Fuccio, Lorenzo

AU - Repici, Alessandro

AU - Hassan, Cesare

AU - Ponchon, Thierry

AU - Bhandari, Pradeep

AU - Jover, Rodrigo

AU - Triantafyllou, Konstantinos

AU - Mandolesi, Daniele

AU - Frazzoni, Leonardo

AU - Bellisario, Cristina

AU - Bazzoli, Franco

AU - Sharma, Prateek

AU - Rösch, Thomas

AU - Rex, Douglas

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N2 - Objective: Endoscopic submucosal dissection (ESD) aims to achieve en bloc resection of non-pedunculated colorectal adenomas which might be indicated in cases with superficial submucosal invasive cancers (SMIC), but the procedure is time consuming and complex. The prevalence of such cancers is not known but may determine the clinical necessity for ESD as opposed to the commonly used piecemeal mucosal resection (endoscopic mucosal resection) of colorectal adenomas. The main aim was to assess the prevalence of SMIC SM1 (ie, invasion ≤1000 μm or less than one-third of the submucosa) on colorectal lesions removed by ESD. Design: A literature review was conducted using electronic databases (up to March 2017) for colorectal ESD series reporting the histology of the dissected lesions. Results: 51 studies with data on 11 260 colorectal dissected lesions were included. Most resected lesions (82.2%; 95% CI 78.8% to 85.3%) were adenomas (low- and high-grade dysplasia, 26.8% and 55.4%, respectively). Overall, 15.7% were submucosal cancers, but only slightly more than half (8.0%; 95% CI 6.1% to 10.3%) had an infiltration depth of ≤1000 μm, providing a number needed to treat (NNT) to avoid one surgery of 12.5. Estimating an oncologically curative (R0; G1/2; L0/V0) resection rate of 75.3% (95% CI 52.2% to 89.4%) for malignant lesions, the prevalence of curative resection lowered to 6% (95% CI 4.2% to 7.2%) with an NNT of 16.7. Conclusion: The low prevalence of SMIC SM1 in lesions selected for ESD as well as the even lower rate of curative resection limits the clinical applicability of endoscopic en bloc resection. This calls for caution over an indiscriminate use of this technique in the resection of colorectal neoplasia.

AB - Objective: Endoscopic submucosal dissection (ESD) aims to achieve en bloc resection of non-pedunculated colorectal adenomas which might be indicated in cases with superficial submucosal invasive cancers (SMIC), but the procedure is time consuming and complex. The prevalence of such cancers is not known but may determine the clinical necessity for ESD as opposed to the commonly used piecemeal mucosal resection (endoscopic mucosal resection) of colorectal adenomas. The main aim was to assess the prevalence of SMIC SM1 (ie, invasion ≤1000 μm or less than one-third of the submucosa) on colorectal lesions removed by ESD. Design: A literature review was conducted using electronic databases (up to March 2017) for colorectal ESD series reporting the histology of the dissected lesions. Results: 51 studies with data on 11 260 colorectal dissected lesions were included. Most resected lesions (82.2%; 95% CI 78.8% to 85.3%) were adenomas (low- and high-grade dysplasia, 26.8% and 55.4%, respectively). Overall, 15.7% were submucosal cancers, but only slightly more than half (8.0%; 95% CI 6.1% to 10.3%) had an infiltration depth of ≤1000 μm, providing a number needed to treat (NNT) to avoid one surgery of 12.5. Estimating an oncologically curative (R0; G1/2; L0/V0) resection rate of 75.3% (95% CI 52.2% to 89.4%) for malignant lesions, the prevalence of curative resection lowered to 6% (95% CI 4.2% to 7.2%) with an NNT of 16.7. Conclusion: The low prevalence of SMIC SM1 in lesions selected for ESD as well as the even lower rate of curative resection limits the clinical applicability of endoscopic en bloc resection. This calls for caution over an indiscriminate use of this technique in the resection of colorectal neoplasia.

KW - colorectal cancer

KW - endoscopic submucosal dissection

KW - interventional endoscopy

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