Recurrence and cancer-specific mortality after endoscopic resection of low- and high-risk pT1 colorectal cancers: a meta-analysis

      Background and Aims

      Clinical management after complete endoscopic resection of pT1 colorectal cancers (CRCs) is still under debate. Follow-up data are heterogeneous and poorly reported, resulting in variable clinical management. Our aim was to meta-analyze recurrence and cancer-specific mortality (CSM) occurring after endoscopic resection of low- and high-risk pT1 CRCs undergoing conservative (nonsurgical) management.

      Methods

      Literature was systematically searched until February 2019 for studies describing patients with pT1 CRCs, histologically classifiable as low or high risk, endoscopically resected without complementary surgery and with ≥12 months of follow-up. Pooled cumulative incidence (and incidence rate when specific follow-up intervals were available) of recurrence and CSM were calculated separately for low- and high-risk pT1 CRCs. Quality, publication bias, and heterogeneity were explored.

      Results

      Pooled cumulative incidences of recurrence and CSM among high-risk lesions (5 studies, 571 patients) were, respectively, 9.5% (95% confidence interval [CI], 6.7%-13.3%; I2 = 38.4%) and 3.8% (95% CI, 2.4%-5.8%; I2 = 0%), whereas among low-risk lesions (7 studies, 650 patients) they were, respectively, 1.2% (95% CI, .6%-2.5%; I2 = 0%) and .6% (95% CI, .2%-1.7%; I2 = 0%). Pooled incidence rates of recurrence and CSM among high-risk lesions (3 cohorts, 237 patients) were, respectively, 11 (95% CI, 2-20; I2 = 43.3%) and 4 (95% CI, 1-7; I2 = 0%) per 1000 patient-years, whereas among low-risk lesions (3 cohorts, 229 patients) they were 3 (95% CI, 0-6; I2 = 0%) and 2 (95% CI, 0-4; I2 = 0%) per 1000 patient-years, respectively. No publication bias or significant heterogeneity was found.

      Conclusions

      Pooled estimates of adverse events after endoscopic resection of pT1 CRCs suggest a conservative approach for low-risk lesions. In high-risk lesions, increased surgical risk might justify a conservative management, whereas fitness for surgery makes surgical completion appropriate.

      Graphical abstract

      Abbreviations:

      CRC (colorectal cancer), CSM (cancer-specific mortality)
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      References

        • Edge S.B.
        • Compton C.C.
        The American Joint Committee on Cancer: the 7th edition of the AJCC cancer staging manual and the future of TNM.
        Ann Surg Oncol. 2010; 17: 1471-1474
        • Lopez A.
        • Bouvier A.M.
        • Jooste V.
        • et al.
        Outcomes following polypectomy for malignant colorectal polyps are similar to those following surgery in the general population.
        Gut. 2019; 68: 111-117
        • Bianco F.
        • Arezzo A.
        • Agresta F.
        • et al.
        Practice parameters for early colon cancer management: Italian Society of Colorectal Surgery (Societa Italiana di Chirurgia Colo-Rettale; SICCR) guidelines.
        Tech Coloproctol. 2015; 19: 577-585
        • Kim J.B.
        • Lee H.S.
        • Lee H.J.
        • et al.
        Long-term outcomes of endoscopic versus surgical resection of superficial submucosal colorectal cancer.
        Dig Dis Sci. 2015; 60: 2785-2792
        • Bosch S.L.
        • Teerenstra S.
        • de Wilt J.H.
        • et al.
        Predicting lymph node metastasis in pT1 colorectal cancer: a systematic review of risk factors providing rationale for therapy decisions.
        Endoscopy. 2013; 45: 827-834
        • Ueno H.
        • Mochizuki H.
        • Hashiguchi Y.
        • et al.
        Risk factors for an adverse outcome in early invasive colorectal carcinoma.
        Gastroenterology. 2004; 127: 385-394
        • Hassan C.
        • Zullo A.
        • Risio M.
        • et al.
        Histologic risk factors and clinical outcome in colorectal malignant polyp: a pooled-data analysis.
        Dis Colon Rectum. 2005; 48: 1588-1596
        • Choi D.H.
        • Sohn D.K.
        • Chang H.J.
        • et al.
        Indications for subsequent surgery after endoscopic resection of submucosally invasive colorectal carcinomas: a prospective cohort study.
        Dis Colon Rectum. 2009; 52: 438-445
        • Watanabe T.
        • Muro K.
        • Ajioka Y.
        • et al.
        Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2016 for the treatment of colorectal cancer.
        Int J Clin Oncol. 2018; 23: 1-34
        • Williams J.G.
        • Pullan R.D.
        • Hill J.
        • et al.
        Management of the malignant colorectal polyp: ACPGBI position statement.
        Colorectal Dis. 2013; 15: 1-38
        • Tamaru Y.
        • Oka S.
        • Tanaka S.
        • et al.
        Long-term outcomes after treatment for T1 colorectal carcinoma: a multicenter retrospective cohort study of Hiroshima GI Endoscopy Research Group.
        J Gastroenterol. 2017; 52: 1169-1179
        • Antonelli G.B.G.
        • Rampioni Vinciguerra G.L.
        • Brescia A.
        • et al.
        Clinical management of endoscopically resected pT1 colorectal cancer.
        Endosc Int Open. 2018; 6: E1462-E1469
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • et al.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        J Clin Epidemiol. 2009; 62: 1006-1012
        • von Karsa L.
        • Patnick J.
        • Segnan N.
        • et al.
        • European Colorectal Cancer Screening Guidelines Working Group
        European guidelines for quality assurance in colorectal cancer screening and diagnosis: overview and introduction to the full supplement publication.
        Endoscopy. 2013; 45: 51-59
        • Labianca R.
        • Nordlinger B.
        • Beretta G.D.
        • et al.
        Early colon cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up.
        Ann Oncol. 2013; 24: vi64-vi72
        • Cappellesso R.
        • Luchini C.
        • Veronese N.
        • et al.
        Tumor budding as a risk factor for nodal metastasis in pT1 colorectal cancers: a meta-analysis.
        Hum Pathol. 2017; 65: 62-70
        • Slim K.
        • Nini E.
        • Forestier D.
        • et al.
        Methodological index for non-randomized studies (MINORS): development and validation of a new instrument.
        Aust N Z J Surg. 2003; 73: 712-716
        • Ata-Ali J.
        • Diago-Vilalta J.V.
        • Melo M.
        • et al.
        What is the frequency of anatomical variations and pathological findings in maxillary sinuses among patients subjected to maxillofacial cone beam computed tomography? A systematic review.
        Med Oral Patol Oral Cirug Bucal. 2017; 22: e400-e409
        • Elkhadem A.
        • Mickan S.
        • Richards D.
        Adverse events of surgical extrusion in treatment for crown-root and cervical root fractures: a systematic review of case series/reports.
        Dental Traumatol. 2014; 30: 1-14
        • Vanella G.
        • Crippa S.
        • Archibugi L.
        • et al.
        Meta-analysis of mortality in patients with high-risk intraductal papillary mucinous neoplasms under observation.
        British J Surg. 2018; 105: 328-338
        • Begg C.B.
        • Mazumdar M.
        Operating characteristics of a rank correlation test for publication bias.
        Biometrics. 1994; 50: 1088-1101
        • Backes Y.
        • de Vos Tot Nederveen Cappel W.H.
        • van Bergeijk J.
        • et al.
        Risk for incomplete resection after macroscopic radical endoscopic resection of T1 colorectal cancer: a multicenter cohort study.
        Am J Gastroenterol. 2017; 112: 785-796
        • Ikematsu H.
        • Yoda Y.
        • Matsuda T.
        • et al.
        Long-term outcomes after resection for submucosal invasive colorectal cancers.
        Gastroenterology. 2013; 144 (quiz e14): 551-559
        • Kim B.
        • Kim E.H.
        • Park S.J.
        • et al.
        The risk of lymph node metastasis makes it unsafe to expand the conventional indications for endoscopic treatment of T1 colorectal cancer: a retrospective study of 428 patients.
        Medicine. 2016; 95: e4373
        • Suh J.H.
        • Han K.S.
        • Kim B.C.
        • et al.
        Predictors for lymph node metastasis in T1 colorectal cancer.
        Endoscopy. 2012; 44: 590-595
        • Yoshii S.
        • Nojima M.
        • Nosho K.
        • et al.
        Factors associated with risk for colorectal cancer recurrence after endoscopic resection of T1 tumors.
        Clin Gastroenterol Hepatol. 2014; 12: 292-302
        • de Neree Tot Babberich M.P.M.
        • Vermeer N.C.A.
        • Wouters M.
        • et al.
        Postoperative outcomes of screen-detected vs non-screen-detected colorectal cancer in the Netherlands.
        JAMA Surg. 2018; : e183567
        • Komuta K.
        • Batts K.
        • Jessurun J.
        • et al.
        Interobserver variability in the pathological assessment of malignant colorectal polyps.
        Br J Surg. 2004; 91: 1479-1484
        • Beaton C.
        • Twine C.P.
        • Williams G.L.
        • et al.
        Systematic review and meta-analysis of histopathological factors influencing the risk of lymph node metastasis in early colorectal cancer.
        Colorectal Dis. 2013; 15: 788-797
        • Backes Y.
        • Moss A.
        • Reitsma J.B.
        • et al.
        Narrow band imaging, magnifying chromoendoscopy, and gross morphological features for the optical diagnosis of T1 colorectal cancer and deep submucosal invasion: a systematic review and meta-analysis.
        Am J Gastroenterol. 2017; 112: 54-64
        • Kuellmer A.
        • Mueller J.
        • Caca K.
        • et al.
        Endoscopic full-thickness resection for early colorectal cancer.
        Gastrointest Endosc. 2019; 89: 1180-1189.e1