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504 Endoscopic Piecemeal Resection of Large Colorectal Adenomas: a Systematic Two-Step Approach to Optimize Outcomes
Abstracts
504 Endoscopic Piecemeal Resection of Large Colorectal Adenomas: a Systematic Two-Step Approach to Optimize Outcomes Livio Cipolletta, Maria Antonia Bianco, Fabio Cipolletta, Claudia Cesaro, Gianluca Rotondano* Gastroenterology, Hospital Maresca, Torre del Greco, Italy Endoscopic piecemeal resection (EPMR) of colorectal lesions larger than 30 mm may occasionally require multiple steps and not infrequently end up with standard surgery. Two-step EPMR, i.e. the completion of the procedure within 4 to 6 weeks, would allow avoidance of excessive manipulation of the severed area thus reducing the risk of complications and, at the same time, facilitate early identification and treatment of adenoma remnants thus reducing the neoplastic recurrence rate. Aim of the study is to evaluate the impact of systematic two-step EPMR on early morbidity and 12-mo outcomes. Patients with sessile polyps or laterally spreading tumours (LST) larger than 30 mm were recruited in a prospective single-center study. EPMR was systematically performed in two scheduled sequential steps. At 1st step as much of the lesion as possible was removed, with obvious intent to complete resection; in the 2nd step, carried out 4 to 6 wks later, the procedure was completed. At this stage, magnified inspection of the resection area provided clues to simple biopsy (scar tissue devoid of any pattern) or further resection ⫾ APC (adenoma remnants). Endoscopic follow-up was scheduled at 6 and 12 months after this second step (time zero). Over a period of 19 months, a total of 54 patients were included (35 males, mean age 66.8 years, age range 27-82). There were 23 sessile polyps mean size 42 (range 30-55) mm and 31 LSTs - mean size 49 (range 30-75) mm. Sessile lesions were located in the rectosigmoid (17) and proximal colon (6), whereas LSTs were located in the proximal colon (13), left colon (5) and rectum (13). The standard ER technique by submucosal injection and snare resection was always employed. Intra-procedural bleeding was recorded in 7 instances, all successfully controlled by thermal therapy or clips. No delayed bleeding or perforation occurred. There was no procedure-related mortality. Final histology of the resected lesions was low-grade adenoma (4 sessile and 17 LST), high grade adenoma or mucosal cancer (19 sessile and 13 LST) and submucosal carcinoma (1 G-mixed LST). Retreatment was deemed necessary in 19/54 pts during the second step. See table for 12-months outcomes.Two-step EPMR of colorectal lesions ⱖ 30 mm is safe and allows completion of the procedure at a later stage without jeopardizing positive long-term outcomes. This approach may potentially reduce the rate of “recurrent” adenoma by early inspection and retreatment of any residual tissue.
Follow-up
Scheduled retreatment
4-6 weeks (2° step) 19/54 6 months* — 12 months* — *from the end of the procedure (time zero after second step)
Residual or recurrent adenoma — 8/54 (14.8%) 4/53 (7.5%)
505 Comparison of Large Sessile Serrated Adenoma Characteristics With Conventional Advanced Mucosal Neoplasia Resected by Wide Field Endoscopic Mucosal Resection in a Multicenter Prospective Cohort Nicholas G. Burgess*1, Kavinderjit S. Nanda1, Stephen J. Williams1, Rajvinder Singh2, Luke F. Hourigan3,4, Simon a. Zanati5,6, Gregor J. Brown5,7, Duncan J. Mcleod8, Michael J. Bourke1 1 Gastroenterology, Westmead Hospital, Sydney, NSW, Australia; 2 Gastroenterology, Lyell McEwin Hospital, Adelaide, SA, Australia; 3 Gastroenterology, Princess Alexandra Hospital, Brisbane, QLD, Australia; 4Gastroenterology, Greenslopes Private Hospital, Brisbane, QLD, Australia; 5Gastroenterology, The Alfred Hospital, Melbourne, VIC, Australia; 6Gastroenterology, Western Hospital, Melbourne, VIC, Australia; 7Gastroenterology, Epworth Hospital, Melbourne, VIC, Australia; 8Tissue Pathology, ICPMR Westmead Hospital, Sydney, NSW, Australia Introduction: Serrated lesions (SL) are thought to account for up to 30% of all sporadic colorectal cancers. Most data is derived from the study of conventional (ⱕ10mm) SL. Larger SL may be at greater risk. The clinical and endoscopic characteristics of large SL are unknown and predictors and risk of invasive neoplasia have not been described. We present data on a large multicenter cohort of patients with SL ⱖ20mm, in comparison to patients with conventional adenomatous advanced mucosal neoplasia (AMN-C)Aim To examine the characteristics of SL ⱖ20mm compared to AMN-C. Methods: Prospective multicenter data of large sessile colorectal polyps or LSTs ⱖ20 mm referred for resection by wide field endoscopic mucosal resection (EMR) (June 2008-Nov 2012) was analysed. Data collection included patient and lesion characteristics,
procedural outcomes, complications and scheduled follow up at 14 days, 4 and 12 months. Conventional EMR technique was used. Peri procedural care was standardised. Where multiple lesions were resected, one was selected at random for analysis. Results: 1245 lesions were analysed in 1151 patients: 173 (15%) sessile serrated adenoma (SSA), 14 (1.2%) traditional serrated adenoma (TSA). 964 (83.8%) were AMN-C (31.6% tubular histology, 62.6% tubulovillous, 3.2% villous, 2.6% other)Patients with SSA differed from AMN-C by median age, female sex, lesion size, location, submucosal fibrosis and en-bloc excision rates. (Table 1) SSAs were more likely to be Paris type IIa and less likely to contain any Paris Is component. Cancer diagnosis was lower in SSAs (3.5% vs 9.4% p 0.01)119 SSAs had cytological dysplasia (SSA-CD) (65 Low Grade Dysplasia (LGD), 47 high grade dysplasia (HGD), 7 cancer). SSA-CD were larger, more distal, had granular or mixed morphology and were more likely to exhibit a Paris Is component. Recurrence rates were higher. Patients with higher levels of dysplasia were more likely to have comorbidities and there was a trend to increasing age. (Median age (years): No dysplasia 64, LGD 64.9, HGD 68, cancer 73, p 0.07)15 TSAs were resected. (mean size 45.0mm, 80% distal colon). 6 lesions had CD and 3 cancers were diagnosed in these lesions. HGD/Cancer rates were similar to AMN-CIn SSAs, multiple logistic regression analysis showed HGD/cancer was predicted by Paris Is component (OR 7.1 p ⬍0.001). Conclusion: Compared to AMN-C, large SSAs are associated with younger age, female sex, smaller lesion size, proximal location and higher en-bloc excision rates. Cancer is present in 3.5% and HGD/cancer in 13.3%. SSA-CD are at greater risk of recurrence. SSAs with a Paris type Is component are more likely to contain cancer or HGD. TSAs were larger and more distally located than AMN-C. Morphology is a dominant feature guiding cancer risk in large SSAs and endoscopists should carefully examine these lesions for a Paris Is component. Table 1. Comparison of Sessile Serrated Adenoma (SSA) characteristics to Conventional Advanced Mucosal Neoplasia (AMN-C). AMN-C nⴝ964
SSA nⴝ173
p
70 430 (44.7%) 36.6 623 (64.6%)
65 98 (56.6%) 28.8 134 (77.5%)
<0.001 0.004 <0.001 0.001
476 (49.4%) 104 (11.2%) 181 (19.0%) 847 (91.9%) 0 661 (68.6%) 202 (21.0%) 90 (9.4%)
46 (26.6%) 4 (2.4%) 54 (31.2%) 161 (94.2%) 62 (35.8%) 88 (50.9%) 17 (9.8%) 6 (3.5%)
<0.001 <0.001 <0.001 0.31 <0.001
n⫽587 130 (22.1%)
n⫽107 15 (14.0%)
Variable Median Age (years) Female Sex Lesion Size, mm (mean) Location Proximal to Splenic Flexure Paris Is component Non Lifting En Bloc Excision Procedural Success rate No Dysplasia Low Grade Dysplasia High Grade Dysplasia Cancer Recurrence Lesions with follow up data Recurrence rate
0.010
0.087
Table 2. Characteristics of Sessile Serrated Adenomas according to Cytological Dysplasia.
Variable Median Age, years (SD) Female Sex Lesion Size, mm (mean, 95%CI) Location Proximal to Splenic Flexure Paris Is Component Morphology Granular Non Granular Mixed Not classified En Bloc Excision Procedural Success rate Recurrence Lesions with follow up data Recurrence rate
SSA No Dysplasia (SSA-ND)
SSA with Dysplasia (SSA-CD)
p
n⫽62 64 (12.7) 39 (62.9%) 26.5 (24.7-28.2) 55 (88.7%) 8 (12.9%)
n⫽111 66 (11.7) 59 (53.2%) 34.3 (31.0-37.6) 79 (71.2%) 38 (34.2%)
0.2 0.2 0.024 0.008 0.002
25 (41.0%) 26 (42.6%) 1 (1.6%) 9 (14.8%) 21 (33.9%) 60 (98.4%)
63 (56.8%) 16 (14.4%) 7 (6.3%) 25 (22.5%) 33 (29.7%) 101 (91.8%)
n⫽29 1 (3.4%)
n⫽78 14 (17.9%)
<0.001
0.58 0.1
0.048
(Sessile Serrated Adenoma - No Dysplasia (SSA-ND), Sessile Serrated Adenoma Cytological Dysplasia (SSA-CD)
AB157 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013
www.giejournal.org
504 Endoscopic Piecemeal Resection of Large Colorectal Adenomas: a Systematic Two-Step Approach to Optimize Outcomes Livio Cipolletta, Maria Antonia Bianco, Fabio Cipolletta, Claudia Cesaro, Gianluca Rotondano* Gastroenterology, Hospital Maresca, Torre del Greco, Italy Endoscopic piecemeal resection (EPMR) of colorectal lesions larger than 30 mm may occasionally require multiple steps and not infrequently end up with standard surgery. Two-step EPMR, i.e. the completion of the procedure within 4 to 6 weeks, would allow avoidance of excessive manipulation of the severed area thus reducing the risk of complications and, at the same time, facilitate early identification and treatment of adenoma remnants thus reducing the neoplastic recurrence rate. Aim of the study is to evaluate the impact of systematic two-step EPMR on early morbidity and 12-mo outcomes. Patients with sessile polyps or laterally spreading tumours (LST) larger than 30 mm were recruited in a prospective single-center study. EPMR was systematically performed in two scheduled sequential steps. At 1st step as much of the lesion as possible was removed, with obvious intent to complete resection; in the 2nd step, carried out 4 to 6 wks later, the procedure was completed. At this stage, magnified inspection of the resection area provided clues to simple biopsy (scar tissue devoid of any pattern) or further resection ⫾ APC (adenoma remnants). Endoscopic follow-up was scheduled at 6 and 12 months after this second step (time zero). Over a period of 19 months, a total of 54 patients were included (35 males, mean age 66.8 years, age range 27-82). There were 23 sessile polyps mean size 42 (range 30-55) mm and 31 LSTs - mean size 49 (range 30-75) mm. Sessile lesions were located in the rectosigmoid (17) and proximal colon (6), whereas LSTs were located in the proximal colon (13), left colon (5) and rectum (13). The standard ER technique by submucosal injection and snare resection was always employed. Intra-procedural bleeding was recorded in 7 instances, all successfully controlled by thermal therapy or clips. No delayed bleeding or perforation occurred. There was no procedure-related mortality. Final histology of the resected lesions was low-grade adenoma (4 sessile and 17 LST), high grade adenoma or mucosal cancer (19 sessile and 13 LST) and submucosal carcinoma (1 G-mixed LST). Retreatment was deemed necessary in 19/54 pts during the second step. See table for 12-months outcomes.Two-step EPMR of colorectal lesions ⱖ 30 mm is safe and allows completion of the procedure at a later stage without jeopardizing positive long-term outcomes. This approach may potentially reduce the rate of “recurrent” adenoma by early inspection and retreatment of any residual tissue.
Follow-up
Scheduled retreatment
4-6 weeks (2° step) 19/54 6 months* — 12 months* — *from the end of the procedure (time zero after second step)
Residual or recurrent adenoma — 8/54 (14.8%) 4/53 (7.5%)
505 Comparison of Large Sessile Serrated Adenoma Characteristics With Conventional Advanced Mucosal Neoplasia Resected by Wide Field Endoscopic Mucosal Resection in a Multicenter Prospective Cohort Nicholas G. Burgess*1, Kavinderjit S. Nanda1, Stephen J. Williams1, Rajvinder Singh2, Luke F. Hourigan3,4, Simon a. Zanati5,6, Gregor J. Brown5,7, Duncan J. Mcleod8, Michael J. Bourke1 1 Gastroenterology, Westmead Hospital, Sydney, NSW, Australia; 2 Gastroenterology, Lyell McEwin Hospital, Adelaide, SA, Australia; 3 Gastroenterology, Princess Alexandra Hospital, Brisbane, QLD, Australia; 4Gastroenterology, Greenslopes Private Hospital, Brisbane, QLD, Australia; 5Gastroenterology, The Alfred Hospital, Melbourne, VIC, Australia; 6Gastroenterology, Western Hospital, Melbourne, VIC, Australia; 7Gastroenterology, Epworth Hospital, Melbourne, VIC, Australia; 8Tissue Pathology, ICPMR Westmead Hospital, Sydney, NSW, Australia Introduction: Serrated lesions (SL) are thought to account for up to 30% of all sporadic colorectal cancers. Most data is derived from the study of conventional (ⱕ10mm) SL. Larger SL may be at greater risk. The clinical and endoscopic characteristics of large SL are unknown and predictors and risk of invasive neoplasia have not been described. We present data on a large multicenter cohort of patients with SL ⱖ20mm, in comparison to patients with conventional adenomatous advanced mucosal neoplasia (AMN-C)Aim To examine the characteristics of SL ⱖ20mm compared to AMN-C. Methods: Prospective multicenter data of large sessile colorectal polyps or LSTs ⱖ20 mm referred for resection by wide field endoscopic mucosal resection (EMR) (June 2008-Nov 2012) was analysed. Data collection included patient and lesion characteristics,
procedural outcomes, complications and scheduled follow up at 14 days, 4 and 12 months. Conventional EMR technique was used. Peri procedural care was standardised. Where multiple lesions were resected, one was selected at random for analysis. Results: 1245 lesions were analysed in 1151 patients: 173 (15%) sessile serrated adenoma (SSA), 14 (1.2%) traditional serrated adenoma (TSA). 964 (83.8%) were AMN-C (31.6% tubular histology, 62.6% tubulovillous, 3.2% villous, 2.6% other)Patients with SSA differed from AMN-C by median age, female sex, lesion size, location, submucosal fibrosis and en-bloc excision rates. (Table 1) SSAs were more likely to be Paris type IIa and less likely to contain any Paris Is component. Cancer diagnosis was lower in SSAs (3.5% vs 9.4% p 0.01)119 SSAs had cytological dysplasia (SSA-CD) (65 Low Grade Dysplasia (LGD), 47 high grade dysplasia (HGD), 7 cancer). SSA-CD were larger, more distal, had granular or mixed morphology and were more likely to exhibit a Paris Is component. Recurrence rates were higher. Patients with higher levels of dysplasia were more likely to have comorbidities and there was a trend to increasing age. (Median age (years): No dysplasia 64, LGD 64.9, HGD 68, cancer 73, p 0.07)15 TSAs were resected. (mean size 45.0mm, 80% distal colon). 6 lesions had CD and 3 cancers were diagnosed in these lesions. HGD/Cancer rates were similar to AMN-CIn SSAs, multiple logistic regression analysis showed HGD/cancer was predicted by Paris Is component (OR 7.1 p ⬍0.001). Conclusion: Compared to AMN-C, large SSAs are associated with younger age, female sex, smaller lesion size, proximal location and higher en-bloc excision rates. Cancer is present in 3.5% and HGD/cancer in 13.3%. SSA-CD are at greater risk of recurrence. SSAs with a Paris type Is component are more likely to contain cancer or HGD. TSAs were larger and more distally located than AMN-C. Morphology is a dominant feature guiding cancer risk in large SSAs and endoscopists should carefully examine these lesions for a Paris Is component. Table 1. Comparison of Sessile Serrated Adenoma (SSA) characteristics to Conventional Advanced Mucosal Neoplasia (AMN-C). AMN-C nⴝ964
SSA nⴝ173
p
70 430 (44.7%) 36.6 623 (64.6%)
65 98 (56.6%) 28.8 134 (77.5%)
<0.001 0.004 <0.001 0.001
476 (49.4%) 104 (11.2%) 181 (19.0%) 847 (91.9%) 0 661 (68.6%) 202 (21.0%) 90 (9.4%)
46 (26.6%) 4 (2.4%) 54 (31.2%) 161 (94.2%) 62 (35.8%) 88 (50.9%) 17 (9.8%) 6 (3.5%)
<0.001 <0.001 <0.001 0.31 <0.001
n⫽587 130 (22.1%)
n⫽107 15 (14.0%)
Variable Median Age (years) Female Sex Lesion Size, mm (mean) Location Proximal to Splenic Flexure Paris Is component Non Lifting En Bloc Excision Procedural Success rate No Dysplasia Low Grade Dysplasia High Grade Dysplasia Cancer Recurrence Lesions with follow up data Recurrence rate
0.010
0.087
Table 2. Characteristics of Sessile Serrated Adenomas according to Cytological Dysplasia.
Variable Median Age, years (SD) Female Sex Lesion Size, mm (mean, 95%CI) Location Proximal to Splenic Flexure Paris Is Component Morphology Granular Non Granular Mixed Not classified En Bloc Excision Procedural Success rate Recurrence Lesions with follow up data Recurrence rate
SSA No Dysplasia (SSA-ND)
SSA with Dysplasia (SSA-CD)
p
n⫽62 64 (12.7) 39 (62.9%) 26.5 (24.7-28.2) 55 (88.7%) 8 (12.9%)
n⫽111 66 (11.7) 59 (53.2%) 34.3 (31.0-37.6) 79 (71.2%) 38 (34.2%)
0.2 0.2 0.024 0.008 0.002
25 (41.0%) 26 (42.6%) 1 (1.6%) 9 (14.8%) 21 (33.9%) 60 (98.4%)
63 (56.8%) 16 (14.4%) 7 (6.3%) 25 (22.5%) 33 (29.7%) 101 (91.8%)
n⫽29 1 (3.4%)
n⫽78 14 (17.9%)
<0.001
0.58 0.1
0.048
(Sessile Serrated Adenoma - No Dysplasia (SSA-ND), Sessile Serrated Adenoma Cytological Dysplasia (SSA-CD)
AB157 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013
www.giejournal.org