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Recurrence with malignancy after endoscopic resection of large colon polyps with high-grade dysplasia: incidence and risk factors

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Abstract

Background

In the West, piecemeal endoscopic resection remains the primary treatment for large colon polyps (LCP), as most recurrences are believed to be benign and resectable with follow-up endoscopy. However, invasive malignancy at the site of prior piecemeal endoscopic mucosal resection has been reported in the Asian literature. This study aims to identify the incidence of and the risk factors for local recurrence with malignancy after endoscopic resection of LCP with high-grade dysplasia (HGD).

Methods

In this retrospective cohort study, we identified patients undergoing complete endoscopic resection of LCPs (≥ 20 mm) with HGD at the Cleveland Clinic between January 2000 and December 2016. Demographic, endoscopic, and pathologic data were collected. All subsequent endoscopic and pathology reports were reviewed to identify recurrence. The cumulative incidence of malignancy at the polypectomy site was determined and univariate analysis was performed to assess risk factors.

Results

A total of 254 LCPs with HGD were resected in 229 patients. Mean polyp size was 29.2 mm. There were 138 lesions resected in piecemeal fashion and 116 en-bloc. After a median follow-up of 28.7 months for the entire cohort, local recurrence with malignancy was diagnosed in six cases. Median time to malignancy diagnosis was 28.5 months. All malignant cases occurred after piecemeal resection and none after en-bloc resection (HR 11.4; 95% CI 0.48–273).

Conclusion

Malignancy after endoscopic resection of LCPs with HGD is uncommon and may be associated with piecemeal resection. When possible, en-bloc resection should be the goal for the management of LCPs.

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Abbreviations

ESD:

Endoscopic submucosal dissection

HGD:

High-grade dysplasia

LCP:

Large colon polyp

LGD:

Low-grade dysplasia

P-EMR:

Piecemeal endoscopic mucosal resection

References

  1. Siegel RL, Miller KD, Jemal A (2019) Cancer statistics, 2019. CA: Cancer J Clin 69(1):7–34

    Google Scholar 

  2. Heitman SJ, Ronksley PE, Hilsden RJ et al (2009) Prevalence of adenomas and colorectal cancer in average risk individuals: a systematic review and meta-analysis. Clin Gastroenterol Hepatol 7(12):1272–1278

    PubMed  Google Scholar 

  3. Ahlawat SK, Gupta N, Benjamin SB et al (2011) Large colorectal polyps: endoscopic management and rate of malignancy: does size matter? J Clin Gastroenterol 45(4):347–354

    PubMed  Google Scholar 

  4. Church JM (2003) Experience in the endoscopic management of large colonic polyps. ANZ J Surg 73(12):988–995

    PubMed  Google Scholar 

  5. Binmoeller KF, Bohnacker S, Seifert H et al (1996) Endoscopic snare excision of “giant” colorectal polyps. Gastrointest Endosc 43(3):183–188

    CAS  PubMed  Google Scholar 

  6. Waye JD (2005) Advanced polypectomy. Gastrointest Endosc Clin N Am 15(4):733–756

    PubMed  Google Scholar 

  7. Kaltenbach T, Soetikno R (2013) Endoscopic resection of large colon polyps. Gastrointest Endosc Clin N Am 23(1):137–152

    PubMed  Google Scholar 

  8. Hurlstone DP, Sanders DS, Cross SS et al (2004) Colonoscopic resection of lateral spreading tumours: a prospective analysis of endoscopic mucosal resection. Gut 53(9):1334–1339

    CAS  PubMed  PubMed Central  Google Scholar 

  9. Swan MP, Bourke MJ, Alexander S et al (2009) Large refractory colonic polyps: is it time to change our practice? A prospective study of the clinical and economic impact of a tertiary referral colonic mucosal resection and polypectomy service (with videos). Gastrointest Endosc 70(6):1128–1136

    PubMed  Google Scholar 

  10. Moss A, Williams SJ, Hourigan LF et al (2015) 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 64(1):57–65

    PubMed  Google Scholar 

  11. Belderbos TDG, Leenders M, Moons LMG et al (2014) Local recurrence after endoscopic mucosal resection of nonpedunculated colorectal lesions: systematic review and meta-analysis. Endoscopy 46(5):388–402

    PubMed  Google Scholar 

  12. Knabe M, Pohl J, Gerges C et al (2014) Standardized long-term follow-up after endoscopic resection of large, nonpedunculated colorectal lesions: a prospective two-center study. Am J Gastroenterol 109(2):183–189

    PubMed  Google Scholar 

  13. Oka S, Tanaka S, Saito Y et al (2015) Local recurrence after endoscopic resection for large colorectal neoplasia: a multicenter prospective study in Japan. Am J Gastroenterol 110(5):697–707

    PubMed  Google Scholar 

  14. Saito Y, Fukuzawa M, Matsuda T et al (2010) Clinical outcome of endoscopic submucosal dissection versus endoscopic mucosal resection of large colorectal tumors as determined by curative resection. Surg Endosc 24(2):343–352

    PubMed  Google Scholar 

  15. Tajika M, Niwa Y, Bhatia V et al (2011) Comparison of endoscopic submucosal dissection and endoscopic mucosal resection for large colorectal tumors. Eur J Gastroenterol Hepatol 23(11):1042–1049

    PubMed  Google Scholar 

  16. Lee EJ, Lee JB, Lee SH et al (2012) Endoscopic treatment of large colorectal tumors: comparison of endoscopic mucosal resection, endoscopic mucosal resection-precutting, and endoscopic submucosal dissection. Surg Endosc 26(8):2220–2230

    PubMed  Google Scholar 

  17. Makazu M, Sakamoto T, So E et al (2015) Relationship between indeterminate or positive lateral margin and local recurrence after endoscopic resection of colorectal polyps. Endosc Int Open 3(3):E252–E257

    PubMed  PubMed Central  Google Scholar 

  18. Kobayashi N, Saito Y, Uraoka T et al (2009) Treatment strategy for laterally spreading tumors in japan: before and after the introduction of endoscopic submucosal dissection. J Gastroenterol Hepatol 24(8):1387–1392

    PubMed  Google Scholar 

  19. Tanaka S, Kashida H, Saito Y et al (2015) JGES guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection. Dig Endosc 27(4):417–434

    PubMed  Google Scholar 

  20. Seo GJ, Sohn DK, Han KS et al (2010) Recurrence after endoscopic piecemeal mucosal resection for large sessile colorectal polyps. World J Gastroenterol 16(22):2806–2811

    PubMed  PubMed Central  Google Scholar 

  21. Saito Y, Yamada M, So E et al (2014) Colorectal endoscopic submucosal dissection: technical advantages compared to endoscopic mucosal resection and minimally invasive surgery. Dig Endosc 26(Suppl1):52–61

    PubMed  Google Scholar 

  22. Bartel MJ, Brahmbhatt BS, Wallace MB (2016) Management of colorectal T1 carcinoma treated by endoscopic resection from the western perspective. Dig Endosc 28(3):330–341

    PubMed  Google Scholar 

  23. Friedel D, Stavropoulos SN (2018) Introduction of endoscopic submucosal dissection in the west. World J Gastroint Endosc 10(10):225–238

    Google Scholar 

  24. Arezzo A, Passera R, Marchese N et al (2016) Systematic review and meta-analysis of endoscopic submucosal dissection vs endoscopic mucosal resection for colorectal lesions. United Eur Gastroenterol J 4(1):18–29

    CAS  Google Scholar 

  25. Bourke M (2009) Current status of colonic endoscopic mucosal resection in the west and the interface with endoscopic submucosal dissection. Dig Endosc 21(Suppl1):S22–27

    PubMed  Google Scholar 

  26. Bond JH (2000) Polyp guideline: diagnosis, treatment, and surveillance for patients with colorectal polyps. Practice Parameters Committee of The American College of Gastroenterology. Am J Gastroenterol 95(11):3053–3063

    CAS  PubMed  Google Scholar 

  27. Moss A, Bourke MJ, Williams SJ et al (2011) Endoscopic mucosal resection outcomes and prediction of submucosal cancer from advanced colonic mucosal neoplasia. Gastroenterology 140(7):1909–1918

    PubMed  Google Scholar 

  28. Puli SR, Kakugawa Y, Gotoda T et al (2009) Meta-analysis and systematic review of colorectal endoscopic mucosal resection. World J Gastroenterol 15(34):4273–4277

    PubMed  PubMed Central  Google Scholar 

  29. Ikematsu H, Yoda Y, Matsuda T et al (2013) Long-term outcomes after resection for submucosal invasive colorectal cancers. Gastroenterology 144(3):551–559

    PubMed  Google Scholar 

  30. Pohl H, Srivastava A, Bensen SP et al (2013) Incomplete polyp resection during colonoscopy-results of the Complete Adenoma Resection (CARE)Study. Gastroenterology 144(1):74–80.e1

    PubMed  Google Scholar 

  31. Saito Y, Bhatt A, Matsuda T (2017) Colorectal endoscopic submucosal dissection and its journey to the west. Gastrointest Endosc 86(1):90–92

    PubMed  Google Scholar 

  32. Kim HG, Thosani N, Banerjee S et al (2015) Effect of prior biopsy sampling, tattoo placement, and snare sampling on endoscopic resection of large nonpedunculated colorectal lesions. Gastrointest Endosc 81(1):204–213

    PubMed  Google Scholar 

  33. Kim HG, Thosani N, Banerjee S et al (2014) Underwater endoscopic mucosal resection for recurrences after previous piecemeal resection of colorectal polyps (with video). Gastrointest Endosc 80(6):1094–1102

    PubMed  Google Scholar 

  34. Nakajima T, Saito Y, Tanaka S et al (2013) Current status of endoscopic resection strategy for large, early colorectal neoplasia in Japan. Surg Endosc 27(9):3262–3270

    PubMed  Google Scholar 

  35. Fuccio L, Hassan C, Ponchon T et al (2017) Clinical outcomes after endoscopic submucosal dissection for colorectal neoplasia: a systematic review and meta-analysis. Gastrointest Endosc 86(1):74–86.e17

    PubMed  Google Scholar 

  36. Saito Y, Uraoka T, Yamaguchi Y et al (2010) A prospective, multicenter study of 1111 colorectal endoscopic submucosal dissections (with video). Gastrointest Endosc 72(6):1217–1225

    PubMed  Google Scholar 

  37. Kobayashi N, Yoshitake N, Hirahara Y et al (2012) Matched case-control study comparing endoscopic submucosal dissection and endoscopic mucosal resection for colorectal tumors. J Gastroenterol Hepatol 27(4):728–733

    PubMed  Google Scholar 

  38. Facciorusso A, Di Maso M, Serviddio G et al (2016) Factors associated with recurrence of advanced colorectal adenoma after endoscopic resection. Clin Gastroenterol Hepatol 14(8):1148–1154.e4

    PubMed  Google Scholar 

  39. Lieberman DA, Rex DK, Winawer SJ, Giardiello FM, Johnson DA, Levin TR (2012) Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 143(3):844–857

    PubMed  Google Scholar 

  40. Lakoff J, Paszat LF, Saskin R, Rabeneck L (2008) Risk of developing proximal versus distal colorectal cancer after a negative colonoscopy: a population-based study. Clin Gastroenterol Hepatol 6(10):1117–1121

    PubMed  Google Scholar 

  41. Baxter NN, Goldwasser MA, Paszat LF et al (2009) Association of colonoscopy and death from colorectal cancer. Ann Intern Med 150(1):1–8

    PubMed  Google Scholar 

  42. Brenner H, Chang-Claude J, Seiler CM et al (2011) Protection from colorectal cancer after colonoscopy: a population-based, case-control study. Ann Intern Med 154(1):22–30

    PubMed  Google Scholar 

  43. Yood MU, Oliveria S, Boyer JG et al (2003) Colon polyp recurrence in a managed care population. Arch Intern Med 163(4):422–426

    PubMed  Google Scholar 

  44. Cottet V, Jooste V, Fournel I et al (2012) Long-term risk of colorectal cancer after adenoma removal: a population-based cohort study. Gut 61(8):1180–1186

    PubMed  Google Scholar 

  45. Brueckl WM, Fritsche B, Seifert B et al (2006) Non-compliance in surveillance for patients with previous resection of large (≥ 1cm) colorectal adenomas. World J Gastroenterol 12(45):7313–7318

    PubMed  PubMed Central  Google Scholar 

  46. Lund J, Scholefield J, Grainge M et al (2001) Risks, costs, and compliance limit colorectal adenoma surveillance: lessons from a randomised trial. Gut 49(1):91–96

    CAS  PubMed  PubMed Central  Google Scholar 

  47. Yoda Y, Ikematsu H, Matsuda T et al (2013) A Large-scale multicenter study of long-term outcomes after endoscopic resection for submucosal invasive colorectal cancer. Endoscopy 45(9):718–724

    PubMed  Google Scholar 

  48. Kishino T, Matsuda T, Sakamoto T et al (2010) Recurrent advanced colonic cancer occurring 11 years after initial endoscopic piecemeal resection: a case report. BMC Gastroenterol 10:87

    PubMed  PubMed Central  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Desk A30, 9500 Euclid Avenue, Cleveland, OH, 44195, USA

    Neal Mehta

  2. Department of Internal Medicine, Medicine Institute, Cleveland Clinic Foundation, Cleveland, OH, USA

    Ashraf Abushahin & Mohammad Alomari

  3. Department of Hematology and Oncology, Cleveland Clinic, Cleveland, OH, USA

    Meena Sadaps

  4. Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA

    John Vargo, Carol A. Burke & Amit Bhatt

  5. Department of Pathology, Cleveland Clinic, Cleveland, OH, USA

    Deepa Patil

  6. Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA

    Rocio Lopez

  7. Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA

    Matthew Kalady, Conor P. Delaney, Emre Gorgun & James Church

  8. Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan

    Yutaka Saito

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  1. Neal Mehta
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Contributions

NM, AA, MS, MA, JV, DP, MK, CPD, EG, JC, YS, CAB, AB: Role in manuscript preparation: concept and design; acquisition of data; analysis and/or interpretation of data; drafting of the manuscript and critical revision of the manuscript for important intellectual content. RL: Role in manuscript preparation: statistical analysis and critical revision of the manuscript for important intellectual content.

Corresponding author

Correspondence to Neal Mehta.

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Disclosures

Dr. Gorgun is a consultant for Lumendi. Neither are related to the content of this submission. Dr. Bhatt is a consultant for Medtronic and Lumendi. Neither are related to the content of this submission. Neal Mehta, Ashraf Abushahin, Meena Sadaps, Mohammad Alomari, John Vargo, Deepa Patil, Rocio Lopez, Matthew Kalady, Conor P. Delaney, Emre Gorgun, James Church, Yutaka Saito, Carol A. Burke have no conflicts of interest or financial ties to disclose.

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Mehta, N., Abushahin, A., Sadaps, M. et al. Recurrence with malignancy after endoscopic resection of large colon polyps with high-grade dysplasia: incidence and risk factors. Surg Endosc 35, 2500–2508 (2021). https://doi.org/10.1007/s00464-020-07660-y

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