Adenoma recurrence after piecemeal colonic EMR is predictable: the Sydney EMR recurrence tool

Published:November 28, 2016DOI:https://doi.org/10.1016/j.gie.2016.11.027

      Background and Aims

      EMR is the primary treatment of large laterally spreading lesions (LSLs) in the colon. Residual or recurrent adenoma (RRA) is a major limitation. We aimed to identify a robust method to stratify the risk of RRA.

      Methods

      Prospective multicenter data on consecutive LSLs ≥20 mm removed by piecemeal EMR from 8 Australian tertiary-care centers were included (September 2008 until May 2016). A logistic regression model for endoscopically determined recurrence (EDR) was created on a randomly selected half of the cohort to yield the Sydney EMR recurrence tool (SERT), a 4-point score to stratify the incidence of RRA based on characteristics of the index EMR. SERT was validated on the remainder of the cohort.

      Results

      Analysis was performed on 1178 lesions that underwent first surveillance colonoscopy (SC1) (median 4.9 months, interquartile range [IQR] 4.9-6.2). EDR was detected in 228 of 1178 (19.4%) patients. LSL size ≥40 mm (odds ratio [OR] 2.47; P < .001), bleeding during the procedure (OR 1.78; P = .024), and high-grade dysplasia (OR 1.72; P = .029) were identified as independent predictors of EDR and allocated scores of 2, 1, and 1, respectively to create SERT. Lesions with SERT scores of 0 (SERT = 0) had a negative predictive value of 91.3% for RRA at SC1, and SERT was shown to stratify RRA to specific follow-up intervals by using Kaplan Meier curves (log-rank P < .001).

      Conclusions

      Guidelines recommend SC1 within 6 months of EMR. SERT accurately stratifies the incidence of RRA after EMR. SERT = 0 lesions could safely undergo first surveillance at 18 months, whereas lesions with SERT scores between 1 and 4 (SERT 1-4) require surveillance at 6 and 18 months. (Clinical trial registration number: NCT01368289.)

      Abbreviations:

      EDR (endoscopically determined recurrence), HDR (histologically determined recurrence), LSL (laterally spreading lesion), RRA (residual or recurrent adenoma), SC1 (first surveillance colonoscopy after EMR), SERT (Sydney EMR recurrence tool)
      To read this article in full you will need to make a payment

      Subscribe:

      Subscribe to Gastrointestinal Endoscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Jayanna M.
        • Burgess N.G.
        • Singh R.
        • et al.
        Cost analysis of endoscopic mucosal resection vs surgery for large laterally spreading colorectal lesions.
        Clin Gastroenterol Hepatol. 2016; 14: 271-272
        • Ahlenstiel G.
        • Hourigan L.F.
        • Brown G.
        • et al.
        Actual endoscopic versus predicted surgical mortality for treatment of advanced mucosal neoplasia of the colon.
        Gastrointest Endosc. 2014; 80: 668-676
        • Khashab M.
        • Eid E.
        • Rusche M.
        • et al.
        Incidence and predictors of “late” recurrences after endoscopic piecemeal resection of large sessile adenomas.
        Gastrointest Endosc. 2009; 70: 344-349
        • Moss A.
        • Williams S.J.
        • Hourigan L.F.
        • et al.
        Long-term adenoma recurrence following wide-field endoscopic mucosal resection (WF-EMR) for advanced colonic mucosal neoplasia is infrequent: results and risk factors in 1000 cases from the Australian Colonic EMR (ACE) study.
        Gut. 2014; 64: 57-65
        • Belderbos T.
        • Belderbos T.D.G.
        • Leenders M.
        • et al.
        Local recurrence after endoscopic mucosal resection of nonpedunculated colorectal lesions: systematic review and meta-analysis.
        Endoscopy. 2014; 46: 388-402
        • Hassan C.
        • Quintero E.
        • Dumonceau J.-M.
        • et al.
        Post-polypectomy colonoscopy surveillance: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.
        Endoscopy. 2013; 45: 842-864
        • Lieberman D.A.
        • Rex D.K.
        • Winawer S.J.
        • et al.
        Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer.
        Gastroenterology. 2012; 143: 844-857
        • Hassan C.
        • Repici A.
        • Sharma P.
        • et al.
        Efficacy and safety of endoscopic resection of large colorectal polyps: a systematic review and meta-analysis.
        Gut. 2015; 65: 806-820
        • Moss A.
        • Bourke M.J.
        • Williams S.J.
        • et al.
        Endoscopic mucosal resection outcomes and prediction of submucosal cancer from advanced colonic mucosal neoplasia.
        Gastroenterology. 2011; 140: 1909-1918
        • Bassan M.S.
        • Holt B.
        • Moss A.
        • et al.
        Carbon dioxide insufflation reduces number of postprocedure admissions after endoscopic resection of large colonic lesions: a prospective cohort study.
        Gastrointest Endosc. 2013; 77: 90-95
        • Holt B.A.
        • Bourke M.J.
        Wide field endoscopic resection for advanced colonic mucosal neoplasia: current status and future directions.
        Clin Gastroenterol Hepatol. 2012; 10: 969-979
      1. ERBE VIO 300 D, Product Information Guide. http://www.erbe-med.com/de/medical-technology/public/Products/Electrosurgery/Units-and-modules/VIO---300-D.707. Accessed September 7, 2016.

        • Moss A.
        • Field A.
        • Bourke M.J.
        • et al.
        A randomized, double-blind trial of succinylated gelatin submucosal injection for endoscopic resection of large sessile polyps of the colon.
        Am J Gastroenterol. 2010; 105: 2375-2382
      2. Burgess NG, Bassan MS, McLeod D, et al. Deep mural injury and perforation after colonic endoscopic mucosal resection: a new classification and analysis of risk factors. Gut. Epub 2016 Jul 27.

      3. Bick BL, Ponugoti PL, Rex DK. High yield of synchronous lesions in referred patients with large lateral spreading colorectal tumors. Gastrointest Endosc. Epub 2016 Jun 23.

        • Fujiya M.
        • Tanaka K.
        • Dokoshi T.
        • et al.
        Efficacy and adverse events of EMR and endoscopic submucosal dissection for the treatment of colon neoplasms: a meta-analysis of studies comparing EMR and endoscopic submucosal dissection.
        Gastrointest Endosc. 2015; 81: 583-595
        • Gotoda T.
        • Yang H.K.
        The desired balance between treatment and curability in treatment planning for early gastric cancer.
        Gastrointest Endosc. 2015; 82: 308-310
      4. Desomer L, Tutticci N, Tate DJ, et al. A standardized imaging protocol is accurate in detecting recurrence after endoscopic mucosal resection. Gastrointest Endosc. Epub 2016 Jun 22.

        • Brooker J.C.
        • Saunders B.P.
        • Shah S.G.
        • et al.
        Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps: a randomized trial and recommendations.
        Gastrointest Endosc. 2002; 55: 371-375