Background and Aims
The standard treatment of locally advanced rectal cancer is chemoradiation (CRT) followed
by proctectomy and adjuvant chemotherapy. However, there is an emerging role for nonsurgical
management after CRT or total neoadjuvant therapy (TNT) consisting of CRT and neoadjuvant
chemotherapy. Endoscopic submucosal dissection (ESD) after CRT or TNT for rectal cancer,
termed “salvage ESD,” may be a viable nonsurgical option for carefully selected patients.
We aimed to evaluate the feasibility and safety of salvage ESD.
Methods
A retrospective chart review of cases of salvage ESD for locally advanced rectal cancer
and standard ESD for rectal tumors without prior CRT from July 2018 to August 2020
at our institution was performed. Clinical factors and imaging, procedural, and pathology
results were collected and compared.
Results
Twelve salvage ESD cases were compared with 27 standard ESD cases. Before CRT, 83.3%
of lesions in the salvage ESD group were initially clinically staged as T3. The en-bloc
resection rates were 92.7% and 91.7% (P = 1.00) and R0 resection rates 66.7% and 75.0% (P = .55) for the standard and salvage groups, respectively. In the salvage ESD group,
no adverse events were observed, and 75.0% of the adenocarcinomas in the salvage ESD
group had morphologically changed to hyperplasia or adenoma after CRT, with no identifiable
lesions greater than T1 tumor depth.
Conclusions
Salvage ESD for locally advanced rectal cancer is technically feasible with low adverse
event rates. There may be a diagnostic role in salvage ESD in assessing pathologic
response to CRT and a possible therapeutic role in resection of residual lesions with
the potential to avoid surgery.
Abbreviations:
CRT (chemoradiation), ESD (endoscopic submucosal dissection), JNET (Japan NBI Expert Team), PCM (pocket-creation method), pCR (pathologic complete response), TNT (total neoadjuvant therapy)To read this article in full you will need to make a payment
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References
Benson A, Venook A, Al-Hawary M, et al. NCCN guidelines version 6.2020 Rectal cancer. NCCN clinical practice guidelines in oncology. Available at: https://www.nccn.org/professionals/physician_gls/pdf/rectal.pdf. Accessed September 12, 2020.
- Preoperative versus postoperative chemoradiotherapy for locally advanced rectal cancer: results of the German CAO/ARO/AIO-94 randomized phase III trial after a median follow-up of 11 years.J Clin Oncol. 2012; 30: 1926-1933
- AGA Institute clinical update: endoscopic submucosal dissection in the United States.Clin Gastroenterol Hepatol. 2019; 17: 16-25
- Correlations between lymph node metastasis and depth of submucosal invasion in submucosal invasive colorectal carcinoma: a Japanese collaborative study.J Gastroenterol. 2004; 39: 534-543
- AGA clinical practice update on surveillance after pathologically curative endoscopic submucosal dissection of early gastrointestinal neoplasia in the United States: commentary.Gastroenterology. 2021; 161: 2030-2040
- Salvage endoscopic resection after definitive chemoradiotherapy for esophageal cancer: a Western experience.Gastrointest Endosc. 2021; 93: 888-898
- Clinicopathological examination of ESD as salvage therapy for esophageal cancer after definitive chemo-radiation therapy.Endosc Int Open. 2018; 6: E450-E461
- Salvage endoscopic submucosal dissection for the esophagus-localized recurrence of esophageal squamous cell cancer after definitive chemoradiotherapy.Gastrointest Endosc. 2014; 79: 348-353
- Technical feasibility of endoscopic submucosal dissection for local failure after chemoradiotherapy for esophageal squamous cell carcinoma.Gastrointest Endosc. 2018; 88: 637-646
- Narrow-band imaging (NBI) magnifying endoscopic classification of colorectal tumors proposed by the Japan NBI Expert Team.Dig Endosc. 2016; 28: 526-533
- Colon and rectum.in: AJCC cancer staging manual. 8th ed. American Joint Committee on Cancer. American College of Surgeons 2017. New York, Springer Cham2016: 1-8
- The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon.Gastrointest Endosc. 2003; 58: S3-S43
- Long-term outcomes of salvage endoscopic submucosal dissection for local failure after chemoradiotherapy for esophageal squamous cell carcinoma.Jpn J Clin Oncol. 2021; 51: 1036-1043
- Pocket-creation method facilitates endoscopic submucosal dissection of colorectal laterally spreading tumors, non-granular type.Endosc Int Open. 2017; 5: E123-E129
- Pocket-creation method versus conventional method of endoscopic submucosal dissection for superficial colorectal neoplasms: a meta-analysis.Gastrointest Endosc. 2021; 93: 1038-1046
- The efficacy of the pocket-creation method for cases with severe fibrosis in colorectal endoscopic submucosal dissection.Endosc Int Open. 2018; 6: E975-E983
- Successful en-bloc resection of large suuperficial tumors in the stomach and colon using sodium hyaluronate and small-caliber-tip transparent hood.Endoscopy. 2003; 35: 690-694
- Successful traction-assisted endoscopic submucosal dissection using dental floss and a clip for a huge superficial nonampullary duodenal epithelial tumor with severe fibrosis (with video).JGH Open. 2018; 3: 179-181
- Application of dental floss traction-assisted endoscopic submucosa dissection to rectal neuroendocrine neoplasm.Zhonghua Wei Chang Wai Ke Za Zhi. 2019; 22: 377-382
- Predicting outcomes in colorectal endoscopic submucosal dissection: a United States experience.Surg Endosc. 2019; 33: 4016-4025
- Successful endoscopic submucosal dissection of colon cancer with severe fibrosis after tattooing.Clin J Gastroenterol. 2017; 10: 426-430
- Endoscopic mucosal resection vs endoscopic submucosal dissection for Barrett’s esophagus and colorectal neoplasia.Clin Gastroenterol Hepatol. 2019; 17: 1019-1028
- Advances in the treatment of locally advanced rectal cancer.Ann Gastroenterol Surg. 2020; 5: 32-38
- Patterns of morphologic alteration in residual rectal carcinoma following preoperative chemoradiation and their association with long-term outcome.Am J Surg Pathol. 2004; 28: 215-223
- Long-term outcome in patients with a pathological complete response after chemoradiation for rectal cancer: a pooled analysis of individual patient data.Lancet Oncol. 2010; 11: 835-844
- Assessment of a watch-and-wait strategy for rectal cancer in patients with a complete response after neoadjuvant therapy.JAMA Oncol. 2019; 5e185896
- Nonoperative management of rectal cancer with complete clinical response after neoadjuvant therapy.Ann Surg. 2012; 256: 965-972
- A characterization of factors determining postoperative ileus after laparoscopic colectomy enables the generation of a novel predictive score.Ann Surg. 2011; 253: 78-81
- Wound infection after elective colorectal resection.Ann Surg. 2004; 239: 599-605
- Sexual function after treatment for rectal cancer: a review.Dis Colon Rectum. 2011; 54: 113-125
- Quality of life in rectal cancer patients after chemoradiation: watch-and-wait policy versus standard resection—a matched-controlled study.Dis Colon Rectum. 2017; 60: 1032-1040
- Management of adenomas within the area of rectal cancer that develop complete pathological response.Int J Colorectal Dis. 2015; 30: 1285-1287
Article Info
Publication History
Published online: February 17, 2022
Accepted:
February 9,
2022
Received:
December 1,
2021
Footnotes
DISCLOSURE: The following authors disclosed financial relationships: M. Nishimura: Consultant for Boston Scientific, Olympus America, and Lumendi. M. A. Schattner: Consultant for Boston Scientific; advisory board for Novo Nordisk. J. Garcia-Aguilar: Consultant for Ethicon, J&J, and Intuitive Surgical; equity in Intuitive Surgical. M. Weiser: Tumor board member for PreciCa; research funding from Clinical Genomics; section editor of UpToDate. All other authors disclosed no financial relationships.
DIVERSITY, EQUITY, AND INCLUSION: We worked to ensure gender balance in the recruitment of human subjects. One or more of the authors of this paper self-identifies as an under-represented gender minority in science. One or more of the authors of this paper self-identifies as an under-represented ethnic minority in science. The author list of this paper includes contributors from the location where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work.
If you would like to chat with an author of this article, you may contact Dr Leung at [email protected] .
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© 2022 by the American Society for Gastrointestinal Endoscopy
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- Is there a role for salvage endoscopic submucosal dissection after chemoradiation for locally advanced rectal cancer?Gastrointestinal EndoscopyVol. 96Issue 2
- PreviewFor decades, surgical resection has been the cornerstone for the treatment of locally advanced rectal adenocarcinoma (LARC). Recently, this paradigm has been questioned, with an organ-preserving watch-and-wait approach. After neoadjuvant chemoradiotherapy (nCRT), patients with complete clinical response are surveyed closely, and incomplete responders undergo total mesorectal excision. Given the operative morbidity and mortality associated with total mesorectal excision, this watch-and-wait approach is attractive for those who want to try to avoid surgery.
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