Colorectal tumors: ESD passes long-term test

 

Endoscopic submucosal dissection (ESD) of superficial colorectal tumors has a favorable long-term outcome, with 94.6% overall survival and 100% disease-specific survival at a median 79 months of follow-up, reported Kenjiro Shigita, MD, of the department of gastroenterology and metabolism, Hiroshima (Japan) University Hospital, and his associates.

The technique is more complicated than endoscopic mucosal resection, but continued advances in the technology and increasingly available training have made it safer than it was, Dr. Shigita and associates wrote (Gastrointest Endosc. 2017. doi: 10.1016/j.gie.2016.07.044).

“This is a provocative study that demonstrates the long-term effectiveness of endoscopic submucosal dissection of superficial colon cancers,” said John I. Allen, MD, professor of medicine at the University of Michigan, Ann Arbor, in an interview. He emphasized that the technique can only be used successfully by adequately trained, skilled endoscopists.

The study “shows what is possible with an aggressive endoscopic approach,” Dr. Allen added.

Dr. Shigita and associates analyzed data from 222 patients (224 tumors) at their institution for a minimum of 5 years, or until death (median 79 months). Overall survival was 94.6%, and disease-specific survival was 100%.

Patients received follow-up colonoscopy at 1 year if they had a histologic complete resection, defined as horizontal margin negative and vertical margin negative. Those with a histologic positive margin underwent additional colonoscopies at 6 months and 1 year following the ESD procedure.

The en bloc resection rate was 89.7% (201/224), the histologic complete resection rate was 85.7% (192/224), and the R0 resection rate was 83.0% (186/224). R0 was defined as histologic complete resection and no risk of lymph node metastasis as determined by histologic examination.

Delayed bleeding occurred in 6.3% of cases (14/224) and perforation in 5.4% (12/224). All of the adverse events were successfully managed during the procedure.

In 201 tumors, no further surgical resection was performed. In this sample, the local recurrence rate was 1.5%, and none were metastatic. Of these procedures, 179 were en bloc, while 22 were piecemeal. Only one of the en bloc procedures had a recurrence (0.6%), compared with two of the piecemeal procedures (9.1%, P = .038), the authors wrote.

Dr. Allen noted the importance of management and follow-up care of patients. “The authors were careful in deciding which patients needed traditional surgery in addition to endoscopic resection. Also there was careful follow-up with endoscopic surveillance to be sure resection was complete,” he said.

The study is limited by the fact that it is retrospective and was performed at a single center, and the authors stressed the importance of surveillance. “The possibility of local recurrence should be taken into account after piecemeal resection or histologic incomplete resection, and the likelihood of metachronous tumors should be considered,” the authors wrote.

The study is intriguing and warrants further investigation. “This approach should be carefully evaluated with U.S.-based studies and advanced endoscopic training offered,” Dr. Allen said.

 

Endoscopic submucosal dissection (ESD) of superficial colorectal tumors has a favorable long-term outcome, with 94.6% overall survival and 100% disease-specific survival at a median 79 months of follow-up, reported Kenjiro Shigita, MD, of the department of gastroenterology and metabolism, Hiroshima (Japan) University Hospital, and his associates.

The technique is more complicated than endoscopic mucosal resection, but continued advances in the technology and increasingly available training have made it safer than it was, Dr. Shigita and associates wrote (Gastrointest Endosc. 2017. doi: 10.1016/j.gie.2016.07.044).

“This is a provocative study that demonstrates the long-term effectiveness of endoscopic submucosal dissection of superficial colon cancers,” said John I. Allen, MD, professor of medicine at the University of Michigan, Ann Arbor, in an interview. He emphasized that the technique can only be used successfully by adequately trained, skilled endoscopists.

The study “shows what is possible with an aggressive endoscopic approach,” Dr. Allen added.

Dr. Shigita and associates analyzed data from 222 patients (224 tumors) at their institution for a minimum of 5 years, or until death (median 79 months). Overall survival was 94.6%, and disease-specific survival was 100%.

Patients received follow-up colonoscopy at 1 year if they had a histologic complete resection, defined as horizontal margin negative and vertical margin negative. Those with a histologic positive margin underwent additional colonoscopies at 6 months and 1 year following the ESD procedure.

The en bloc resection rate was 89.7% (201/224), the histologic complete resection rate was 85.7% (192/224), and the R0 resection rate was 83.0% (186/224). R0 was defined as histologic complete resection and no risk of lymph node metastasis as determined by histologic examination.

Delayed bleeding occurred in 6.3% of cases (14/224) and perforation in 5.4% (12/224). All of the adverse events were successfully managed during the procedure.

In 201 tumors, no further surgical resection was performed. In this sample, the local recurrence rate was 1.5%, and none were metastatic. Of these procedures, 179 were en bloc, while 22 were piecemeal. Only one of the en bloc procedures had a recurrence (0.6%), compared with two of the piecemeal procedures (9.1%, P = .038), the authors wrote.

Dr. Allen noted the importance of management and follow-up care of patients. “The authors were careful in deciding which patients needed traditional surgery in addition to endoscopic resection. Also there was careful follow-up with endoscopic surveillance to be sure resection was complete,” he said.

The study is limited by the fact that it is retrospective and was performed at a single center, and the authors stressed the importance of surveillance. “The possibility of local recurrence should be taken into account after piecemeal resection or histologic incomplete resection, and the likelihood of metachronous tumors should be considered,” the authors wrote.

The study is intriguing and warrants further investigation. “This approach should be carefully evaluated with U.S.-based studies and advanced endoscopic training offered,” Dr. Allen said.

 

Endoscopic submucosal dissection (ESD) of superficial colorectal tumors has a favorable long-term outcome, with 94.6% overall survival and 100% disease-specific survival at a median 79 months of follow-up, reported Kenjiro Shigita, MD, of the department of gastroenterology and metabolism, Hiroshima (Japan) University Hospital, and his associates.

The technique is more complicated than endoscopic mucosal resection, but continued advances in the technology and increasingly available training have made it safer than it was, Dr. Shigita and associates wrote (Gastrointest Endosc. 2017. doi: 10.1016/j.gie.2016.07.044).

“This is a provocative study that demonstrates the long-term effectiveness of endoscopic submucosal dissection of superficial colon cancers,” said John I. Allen, MD, professor of medicine at the University of Michigan, Ann Arbor, in an interview. He emphasized that the technique can only be used successfully by adequately trained, skilled endoscopists.

The study “shows what is possible with an aggressive endoscopic approach,” Dr. Allen added.

Dr. Shigita and associates analyzed data from 222 patients (224 tumors) at their institution for a minimum of 5 years, or until death (median 79 months). Overall survival was 94.6%, and disease-specific survival was 100%.

Patients received follow-up colonoscopy at 1 year if they had a histologic complete resection, defined as horizontal margin negative and vertical margin negative. Those with a histologic positive margin underwent additional colonoscopies at 6 months and 1 year following the ESD procedure.

The en bloc resection rate was 89.7% (201/224), the histologic complete resection rate was 85.7% (192/224), and the R0 resection rate was 83.0% (186/224). R0 was defined as histologic complete resection and no risk of lymph node metastasis as determined by histologic examination.

Delayed bleeding occurred in 6.3% of cases (14/224) and perforation in 5.4% (12/224). All of the adverse events were successfully managed during the procedure.

In 201 tumors, no further surgical resection was performed. In this sample, the local recurrence rate was 1.5%, and none were metastatic. Of these procedures, 179 were en bloc, while 22 were piecemeal. Only one of the en bloc procedures had a recurrence (0.6%), compared with two of the piecemeal procedures (9.1%, P = .038), the authors wrote.

Dr. Allen noted the importance of management and follow-up care of patients. “The authors were careful in deciding which patients needed traditional surgery in addition to endoscopic resection. Also there was careful follow-up with endoscopic surveillance to be sure resection was complete,” he said.

The study is limited by the fact that it is retrospective and was performed at a single center, and the authors stressed the importance of surveillance. “The possibility of local recurrence should be taken into account after piecemeal resection or histologic incomplete resection, and the likelihood of metachronous tumors should be considered,” the authors wrote.

The study is intriguing and warrants further investigation. “This approach should be carefully evaluated with U.S.-based studies and advanced endoscopic training offered,” Dr. Allen said.