- Email: [email protected]
Sa1561 Magnifying Chromoendoscopy Is Decisive to Define Management of Colorectal Neoplastic Lesions
Abstracts
differentiation of small and diminutive ADs, HPs and SSA/Ps. In a still image evaluation setting introduction of the WASP-classification showed a significant improvement of the accuracy of optical diagnosis overall as well as for SSA/Ps and neoplastic lesions in specific, which proved to be sustainable after 6 months. Future research is needed to validate the WASP-classification during real-time colonoscopy. Table 1. Comparison of the diagnostic accuracy of optical diagnosis in the first and the second validation phase
All lesions Total High confidence SSA/P vs non-SSA/P Total High confidence AD vs non-AD Total High confidence Neoplastic lesion vs HP Total High confidence
Accuracy (95% CI) First validation phase before training
Accuracy (95% CI) First validation phase after training
p-value
Accuracy (95% CI) Second validation phase
0.63 (0.54-0.71) 0.73 (0.64-0.82)
0.79 (0.72-0.86) 0.87 (0.80-0.95)
!0.001 !0.01
0.76 (0.72-0.80) 0.84 (0.81-0.88)
0.74 (0.66-0.82) 0.83 (0.75-0.91)
0.86 (0.80-0.91) 0.93 (0.87-0.98)
!0.001 0.02
0.87 (0.84-0.90) 0.91 (0.88-0.94)
0.76 (0.67-0.84) 0.82 (0.73-0.90)
0.87 (0.80-0.94) 0.92 (0.86-0.98)
!0.01 0.03
0.83 (0.80-0.87) 0.90 (0.87-0.93)
0.76 (0.69-0.83) 0.82 (0.74-0.89)
0.86 (0.80-0.91) 0.90 (0.84-0.96)
!0.001 !0.01
0.86 (0.79-0.86) 0.89 (0.85-0.92)
CI Z confidence interval; SSA/P Z sessile serrated adenoma/polyp; AD Z adenoma; HP Z hyperplastic polyp
Figure 1. The WASP-classification: method for optical diagnosis of hyperplastic polyps, sessile serrated adenomas/polyps and adenomas based on the NICE-criteria and the Hazewinkel criteria in a stepwise approach.
Sa1560 Clinical Validity of the Curative Criteria After Endoscopic Resection for Pedunculated-Type T1 Colorectal Carcinoma: a Multicenter Retrospective Cohort Study Naoki Asayama*1, Shinji Tanaka1, Shiro Oka1, Masaki Kunihiro2, Yuko Hiraga3, Shinji Nagata4, Akira Furudoi5, Hideharu Okanobu6, Seiji Onogawa7, Toshio Kuwai8, Tadamasa Tamura9, Shinichi Mukai10, Eizo Goto11, Hiroyuki Kanao12, Takayasu Kuwabara13, Fumio Shimamoto14, Kazuaki Chayama1 1 Hiroshima University Hospital, Hiroshima, Japan; 2Department of Internal medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan; 3Department of Endoscopy, Hiroshima Prefectural Hospital, Hiroshima, Japan; 4Department of Gastroenterology, Hiroshima City Asa Hospital, Hiroshima, Japan; 5Department of Gastroenterology, JA Hiroshima General Hospital, Hatsukaichi, Japan; 6 Department of Gastroenterology, Chugoku Rosai Hospital, Hiroshima, Japan; 7Department of Gastroenterology, Onomichi General Hospital, Onomichi, Japan; 8Department of Gastroenterology, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Kure, Japan; 9Department of Internal medicine, Hiroshimakinen Hospital, Hiroshima, Japan; 10Department of Gastroenterology, Miyoshi central Hospital, Miyoshi, Japan; 11Department of Gastroenterology, Higashihiroshima Medical center, Higashihiroshima, Japan; 12 Department of Gastroenterology, Hiroshima Red Cross Hoapital & Atomic-bomb Survivors Hospital, Hiroshima, Japan; 13Department of Gastroenterology, Shobara Red Cross Hospital, Shobara, Japan; 14 Department of the Faculty of Human Culture and Science, Prefectural University of Hiroshima, Hiroshima, Japan Background: The 2014 Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines for colorectal carcinoma (CRC) treatment list the criteria for curability of T1 CRC after endoscopic resection (ER) as well- or moderately differentiated or papillary histology, no vascular invasion, submucosal (SM) invasion depth of !1,000 mm, and budding grade 1; these factors indicate very low risk of lymph node (LN) metastasis. For pedunculated-type CRCs with tangled muscularis mucosae, depth of SM invasion is measured from the line of Haggitt’s level 2. Invasion within the head alone is defined as ‘‘head invasion.’’ Little is known of the risk of LN metastasis in pedunculated-type T1 CRCs and outcomes after ER. Objective: This study aimed to assess clinicopathological characteristics and clinical outcomes for pedunculated-type T1 CRCs after endoscopic or surgical resection. Patients and Methods: We examined 176 patients (138 [78%] men, mean age 64 years) resected endoscopically or surgically at Hiroshima University Hospital and 13 affiliated hospitals between January 1990 and December 2010. Patients who met the JSCCR curative criteria were defined as e-curable, and those who did not were defined as non-e-curable. We also evaluated the prognosis of the 116 patients (58 e-curable, 58 non-e-curable) who were followed up for more than 3 years after treatment. Results: Most tumors (172; 98%) were well-or moderately differentiated adenocarcinomas. Mean tumor size was 18 mm, with 147 (84%) located in the left colon, 21 (12%) in the right colon, and 8 (4%) in the rectum. SM invasion !1,000 mm was observed in 100 cases, with head invasion in 78 (78%) and stalk invasion in 19 (19%); invasion R1,000 mm (pT1b) was observed in 76 cases, with stalk invasion in 50 (66%). There were 38 cases of lymphatic invasion (22%), 14 of venous invasion (8%), and 24 of budding grade 2/3 (14%). The overall incidence of LN metastasis was 5% (4/81; 95% confidence interval 1.4-12%; 3 cases of pT1b [stalk invasion] and lymphatic invasion, 1 case of head invasion and budding grade 2/3). There was no local or metastatic recurrence in any of the e-curable patients, but 6 of them died of another cause (observation period 80 months). There was no local recurrence in the non-e-curable patients; however, distant metastasis was observed in 1 patient (2%; well-differentiated adenocarcinoma, pT1b [stalk invasion], budding grade 1, ly1, v0, HM0, VM0), with carcinoma recurring in the liver 7 months and in the lung 36 months after additional surgery. Death due to primary disease was not observed in non-e-curable patients until now, but 6 of them died of another cause (observation period 72 months). Conclusion: Our data support the validity of the JSCCR curative criteria after ER for pedunculated-type T1 CRCs. Head invasion alone in pedunculated type T1 CRC cannot be curative condition after ER.
Sa1561 Magnifying Chromoendoscopy Is Decisive to Define Management of Colorectal Neoplastic Lesions Fábio S. Kawaguti*1,2, Caterina Pennacchi1, Bruno C. Martins1, Felipe A. Retes1, Carlos Frederico S. Marques3, Caio Sergio R. Nahas3, Adriana V. Safatle-Ribeiro1, Ulysses Ribeiro3, Sergio C. Nahas3, Fauze Maluf-Filho1 1 Division of Endoscopy, Cancer Institute of São Paulo University Medical School, São Paulo, Brazil; 2Endoscopy Group, Fleury Medicina e Saúde, São Paulo, Brazil; 3Division of Surgery, Cancer Institute of São Paulo University Medical School, São Paulo, Brazil Introduction: Early colorectal cancer with submucosal deep invasion should not be treated by endoscopic resection due the high risk of lymph-nodes metastases. Magnifying chromoendoscopy and evaluation of pit pattern can predict the
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Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB261
Abstracts
malignant potential of colorectal lesions. Objective: Evaluate efficacy of magnifying chromoendoscopy in the definition of management of colorectal neoplastic lesions. Patientes and Methods: Between April 2009 and August 2014, patients with colorectal neoplastic lesions with high risk of submucosal invasion (sessile R 20 mm, depressed type and LST-type lesions) underwent magnifying chromoendoscopy. The therapeutic approach (endoscopic or surgical) was defined according to the endoscopic evaluation. Lesions with Vn pit pattern were referred to surgical resection. Lesions without Vn pit pattern were referred to endoscopic treatment and the decision of therapeutic approach was according to pit pattern, location and size. Final staging was possible with the histology of the surgical or endoscopic specimen. Lesions that were not resected or those where it was not possible to visualize the pit pattern due eroded surface were excluded. Results: A total of 104 lesions were found in 103 patients. Six lesions were excluded. The average size of lesions was 45.1 31.9 mm. The macroscopic classification was 15.3% sessile, 4.1% depressed and 80.6% LSTs. The endoscopic treatments were polypectomy in 2.0%, EMR in 15.3%, EPMR in 13.3%, ESD in 45.9% and TEM in 9.2%. Surgical resection was referred in 14.3% of the lesions. The correlation of pit pattern with pathology was:II: 100% adenomas with low-grade dysplasia (2/2)IIIL: 69.2% of low-grade adenoma (9/13)IIIS: 100% intramucosal adenocarcinoma (1/1)IV: 72.0% of adenoma with highgrade dysplasia or intramucosal adenocarcinoma (18/25)Vi: 86.9% of intramucosal adenocarcinoma or superficial submucosal invasion !1000 mm (40/46) / 6.5% adenocarcinoma with massive submucosal invasionO 1000 mm (3/46)- Vn: 54.5% of adenocarcinoma with massive submucosal invasion (6/11); 45.5% of adenocarcinoma with invasion to the muscularis propriaThe therapeutic indication was considered correct in 96.9% of cases (95/98). Three cases Vi pit pattern lesions were endoscopically resected and the histology demonstrated massive submucosal invasion. These patients were sent to surgical resection. Magnifying chromoendoscopy and pit pattern classification had a 78.6% sensitivity, a 100% specificity, a 100% positive predictive value, a 96.6% negative predictive value and a 96.9% accuracy to detect submucosal massive invasion, or deeper. Conclusion: Magnifying chromoendoscopy is accurate to detect submucosal massive invasion, or deeper, of colorectal neoplastic lesions which allows correct selection of patients to surgical or endoscopic resection. The Vn pit pattern contraindicates endoscopic resection.
Sa1562 Outcomes of Endoscopic Retreatment of Recurrent Lesions After Initial Salvage Endoscopic Treatment of Recurrent Large Nonpedunculated Colorectal Adenomas. Hyun Gun Kim*3, Saurabh Sethi1, Subhas Banerjee1, Shai Friedland1,2 1 Gastroenterology, Stanford University, Palo Alto, CA; 2Gastroenterology, VA Palo Alto HCS, Palo Alto, CA; 3Gastroenterology, Soonchunhyang University College of Medicine, Seoul, Korea (the Republic of) Background: Endoscopic mucosal resection (EMR) is now the standard treatment of large nonpedunculated colorectal adenomas. EMR is associated with significant recurrence rates ranging from 4% to 27%. Recurrent adenomas can be treated endoscopically with repeat EMR, underwater EMR (UEMR) and endoscopic submucosal dissection, with a reported success rate of 86%-100%. However, there is little data on outcomes after repeat treatment. Methods: Records of patients referred to an interventional endoscopy practice at 2 centers, a university hospital and a Veterans’ Administration hospital over a 4 year period were reviewed. Patients with recurrent colorectal lesions after initial endoscopic treatment of nonpedunculated colorectal adenomas R 2cm were identified. Results: 64 patients with 70 recurrent lesions after endoscopic treatment of nonpedunculated colorectal adenomas R 2cm were identified. Conventional EMR (39/70, 55.7%) and UEMR (31/70, 44.3%) were performed as the 1st salvage endoscopic treatment. After the 1st salvage procedure, follow up colonoscopy (mean interval 6.4 months) was performed on 62/70 lesions (89%) and a second recurrence was found in 21/62 (34%). One patient had an unresectable circumferential ileocecal valve adenoma and was referred for surgery. The other 20 second recurrences were treated by a 2nd salvage endoscopic resection. Follow up colonoscopy was performed on 15 of the 20 lesions (75%) after the 2nd salvage procedure. Twelve of the 15 (80%) had no recurrence after the 2nd salvage treatment. One patient was found to have a deep T1 cancer and underwent curative surgery. The two patients with recurrent adenoma had a third salvage endoscopic treatment; both patients had no recurrence on subsequent colonoscopy. There were 2 complications: postpolypectomy bleeding requiring hospitalization, both after the 1st salvage procedure. A mean of 1.3 salvage procedures was required to achieve a cure (range 1-3). Lesion size decreased from 34.5 8.6 mm initially to 22.2 11.7 mm on the first salvage and 10.2 4.8 mm on the second salvage procedure (p! 0.001). Conclusion: Endoscopic treatment of recurrent adenomas after EMR of large nonpedunculated colorectal adenomas is associated with a significant rate of second recurrences. However, second recurrences can be treated endoscopically with high cure rates, low complication rates and a low risk of progression to malignancy.
AB262 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
Sa1563 the Clinical Utility of a Universal or Selective Endoscopic Submucosal Dissection Strategy for Large Laterally Spreading and Sessile Colorectal Tumours in a Western Tertiary Referral Center Farzan F. Bahin*1,2, Dhruv Nayyar1, Khalid N. Rasouli1,2, Hema Mahajan3, Duncan J. Mcleod3, Stephen J. Williams1, Eric Y. Lee1, Michael J. Bourke1,2 1 Gastroenterology and Hepatology, Westmead Hospital, Westmead, NSW, Australia; 2Faculty of Medicine, University of Sydney, Sydney, NSW, Australia; 3Anatomical Pathology, Westmead Hospital, Westmead, NSW, Australia Backgound: Laterally spreading colorectal tumours (LST) have variable potential for submucosal invasion (SMI), the risk of which can be stratified by lesion morphology and surface pattern. En-bloc resection by endoscopic submucosal dissection (ESD) is being increasingly advocated as a superior treatment due to reduced recurrence, and most importantly, potential cure of submucosal invasive cancer (SMIC). However, ESD is technically challenging, more time and resource consuming, requires multi-day hospital admission and has greater frequency of significant complications compared to conventional treatment by wide-field endoscopic mucosal resection (WF-EMR). Residual disease occurs in 15% after WF-EMR. This can be treated, and the vast majority of patients are free of disease in long-term follow up. It is unknown whether a universal or selective ESD strategy delivers meaningful clinical gains. Aim: To evaluate the proportion of patients with large LST that could potentially be cured of SMIC by a selective or universal ESD strategy. Methods: A post-hoc analysis from a prospective observational study of WF-EMR for LSTs R 20mm at a single tertiary centre was performed (NCT01368289). LSTs were classed as suspicious or not suspicious for SMIC based on Paris 0-IIc morphology, Kudo pit pattern V and non-lifting. Surgery was offered in cases of strong suspicion of SMIC, or after unfavourable EMR histology. EMR and surgical specimens were reviewed by two expert histopathologists. Low risk SMIC (LR-SMIC) was defined as: well differentiated, vertical submucosal involvement !1000m and absence of lymphovascular invasion. ESD was assumed to achieve R0 resection in 100% of LR-SMIC. In cases of multiple lesions in a patient the lesion with the worst appearance or histology was selected to perform per patient analysis. Results: From September 2008 to September 2014, 1174 patients (mean age 67.8 years, 50.6% male) with 1236 lesions (mean size 37.1 mm, 52.4% right colon) were enrolled. The prevalence of SMIC and LR-SMIC in the entire cohort was 102/1174 (8.7%) (Table 1). The proportion of LR-SMIC that could potentially be cured by a universal ESD strategy was 43/1174 (3.7%). If a selective ESD strategy was applied to suspected SMIC, 82/1174 (7.0%) patients were eligible and cure of LR-SMIC could potentially be achieved in 20/82 (24.4%). This comprised 1.7% of the cohort. Conclusion: Given the substantially longer procedure time, greater resource consumption, technical difficulty, higher risk of significant adverse events, and the small potential for meaningful clinical benefit (! 4% of the cohort) compared to WF-EMR, a universal ESD strategy cannot be justified. A selective ESD strategy was applicable to 7.0% of the cohort but identified less than a quarter of eligible lesions. At present, it has limited utility and warrants further research.
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differentiation of small and diminutive ADs, HPs and SSA/Ps. In a still image evaluation setting introduction of the WASP-classification showed a significant improvement of the accuracy of optical diagnosis overall as well as for SSA/Ps and neoplastic lesions in specific, which proved to be sustainable after 6 months. Future research is needed to validate the WASP-classification during real-time colonoscopy. Table 1. Comparison of the diagnostic accuracy of optical diagnosis in the first and the second validation phase
All lesions Total High confidence SSA/P vs non-SSA/P Total High confidence AD vs non-AD Total High confidence Neoplastic lesion vs HP Total High confidence
Accuracy (95% CI) First validation phase before training
Accuracy (95% CI) First validation phase after training
p-value
Accuracy (95% CI) Second validation phase
0.63 (0.54-0.71) 0.73 (0.64-0.82)
0.79 (0.72-0.86) 0.87 (0.80-0.95)
!0.001 !0.01
0.76 (0.72-0.80) 0.84 (0.81-0.88)
0.74 (0.66-0.82) 0.83 (0.75-0.91)
0.86 (0.80-0.91) 0.93 (0.87-0.98)
!0.001 0.02
0.87 (0.84-0.90) 0.91 (0.88-0.94)
0.76 (0.67-0.84) 0.82 (0.73-0.90)
0.87 (0.80-0.94) 0.92 (0.86-0.98)
!0.01 0.03
0.83 (0.80-0.87) 0.90 (0.87-0.93)
0.76 (0.69-0.83) 0.82 (0.74-0.89)
0.86 (0.80-0.91) 0.90 (0.84-0.96)
!0.001 !0.01
0.86 (0.79-0.86) 0.89 (0.85-0.92)
CI Z confidence interval; SSA/P Z sessile serrated adenoma/polyp; AD Z adenoma; HP Z hyperplastic polyp
Figure 1. The WASP-classification: method for optical diagnosis of hyperplastic polyps, sessile serrated adenomas/polyps and adenomas based on the NICE-criteria and the Hazewinkel criteria in a stepwise approach.
Sa1560 Clinical Validity of the Curative Criteria After Endoscopic Resection for Pedunculated-Type T1 Colorectal Carcinoma: a Multicenter Retrospective Cohort Study Naoki Asayama*1, Shinji Tanaka1, Shiro Oka1, Masaki Kunihiro2, Yuko Hiraga3, Shinji Nagata4, Akira Furudoi5, Hideharu Okanobu6, Seiji Onogawa7, Toshio Kuwai8, Tadamasa Tamura9, Shinichi Mukai10, Eizo Goto11, Hiroyuki Kanao12, Takayasu Kuwabara13, Fumio Shimamoto14, Kazuaki Chayama1 1 Hiroshima University Hospital, Hiroshima, Japan; 2Department of Internal medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan; 3Department of Endoscopy, Hiroshima Prefectural Hospital, Hiroshima, Japan; 4Department of Gastroenterology, Hiroshima City Asa Hospital, Hiroshima, Japan; 5Department of Gastroenterology, JA Hiroshima General Hospital, Hatsukaichi, Japan; 6 Department of Gastroenterology, Chugoku Rosai Hospital, Hiroshima, Japan; 7Department of Gastroenterology, Onomichi General Hospital, Onomichi, Japan; 8Department of Gastroenterology, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Kure, Japan; 9Department of Internal medicine, Hiroshimakinen Hospital, Hiroshima, Japan; 10Department of Gastroenterology, Miyoshi central Hospital, Miyoshi, Japan; 11Department of Gastroenterology, Higashihiroshima Medical center, Higashihiroshima, Japan; 12 Department of Gastroenterology, Hiroshima Red Cross Hoapital & Atomic-bomb Survivors Hospital, Hiroshima, Japan; 13Department of Gastroenterology, Shobara Red Cross Hospital, Shobara, Japan; 14 Department of the Faculty of Human Culture and Science, Prefectural University of Hiroshima, Hiroshima, Japan Background: The 2014 Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines for colorectal carcinoma (CRC) treatment list the criteria for curability of T1 CRC after endoscopic resection (ER) as well- or moderately differentiated or papillary histology, no vascular invasion, submucosal (SM) invasion depth of !1,000 mm, and budding grade 1; these factors indicate very low risk of lymph node (LN) metastasis. For pedunculated-type CRCs with tangled muscularis mucosae, depth of SM invasion is measured from the line of Haggitt’s level 2. Invasion within the head alone is defined as ‘‘head invasion.’’ Little is known of the risk of LN metastasis in pedunculated-type T1 CRCs and outcomes after ER. Objective: This study aimed to assess clinicopathological characteristics and clinical outcomes for pedunculated-type T1 CRCs after endoscopic or surgical resection. Patients and Methods: We examined 176 patients (138 [78%] men, mean age 64 years) resected endoscopically or surgically at Hiroshima University Hospital and 13 affiliated hospitals between January 1990 and December 2010. Patients who met the JSCCR curative criteria were defined as e-curable, and those who did not were defined as non-e-curable. We also evaluated the prognosis of the 116 patients (58 e-curable, 58 non-e-curable) who were followed up for more than 3 years after treatment. Results: Most tumors (172; 98%) were well-or moderately differentiated adenocarcinomas. Mean tumor size was 18 mm, with 147 (84%) located in the left colon, 21 (12%) in the right colon, and 8 (4%) in the rectum. SM invasion !1,000 mm was observed in 100 cases, with head invasion in 78 (78%) and stalk invasion in 19 (19%); invasion R1,000 mm (pT1b) was observed in 76 cases, with stalk invasion in 50 (66%). There were 38 cases of lymphatic invasion (22%), 14 of venous invasion (8%), and 24 of budding grade 2/3 (14%). The overall incidence of LN metastasis was 5% (4/81; 95% confidence interval 1.4-12%; 3 cases of pT1b [stalk invasion] and lymphatic invasion, 1 case of head invasion and budding grade 2/3). There was no local or metastatic recurrence in any of the e-curable patients, but 6 of them died of another cause (observation period 80 months). There was no local recurrence in the non-e-curable patients; however, distant metastasis was observed in 1 patient (2%; well-differentiated adenocarcinoma, pT1b [stalk invasion], budding grade 1, ly1, v0, HM0, VM0), with carcinoma recurring in the liver 7 months and in the lung 36 months after additional surgery. Death due to primary disease was not observed in non-e-curable patients until now, but 6 of them died of another cause (observation period 72 months). Conclusion: Our data support the validity of the JSCCR curative criteria after ER for pedunculated-type T1 CRCs. Head invasion alone in pedunculated type T1 CRC cannot be curative condition after ER.
Sa1561 Magnifying Chromoendoscopy Is Decisive to Define Management of Colorectal Neoplastic Lesions Fábio S. Kawaguti*1,2, Caterina Pennacchi1, Bruno C. Martins1, Felipe A. Retes1, Carlos Frederico S. Marques3, Caio Sergio R. Nahas3, Adriana V. Safatle-Ribeiro1, Ulysses Ribeiro3, Sergio C. Nahas3, Fauze Maluf-Filho1 1 Division of Endoscopy, Cancer Institute of São Paulo University Medical School, São Paulo, Brazil; 2Endoscopy Group, Fleury Medicina e Saúde, São Paulo, Brazil; 3Division of Surgery, Cancer Institute of São Paulo University Medical School, São Paulo, Brazil Introduction: Early colorectal cancer with submucosal deep invasion should not be treated by endoscopic resection due the high risk of lymph-nodes metastases. Magnifying chromoendoscopy and evaluation of pit pattern can predict the
www.giejournal.org
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB261
Abstracts
malignant potential of colorectal lesions. Objective: Evaluate efficacy of magnifying chromoendoscopy in the definition of management of colorectal neoplastic lesions. Patientes and Methods: Between April 2009 and August 2014, patients with colorectal neoplastic lesions with high risk of submucosal invasion (sessile R 20 mm, depressed type and LST-type lesions) underwent magnifying chromoendoscopy. The therapeutic approach (endoscopic or surgical) was defined according to the endoscopic evaluation. Lesions with Vn pit pattern were referred to surgical resection. Lesions without Vn pit pattern were referred to endoscopic treatment and the decision of therapeutic approach was according to pit pattern, location and size. Final staging was possible with the histology of the surgical or endoscopic specimen. Lesions that were not resected or those where it was not possible to visualize the pit pattern due eroded surface were excluded. Results: A total of 104 lesions were found in 103 patients. Six lesions were excluded. The average size of lesions was 45.1 31.9 mm. The macroscopic classification was 15.3% sessile, 4.1% depressed and 80.6% LSTs. The endoscopic treatments were polypectomy in 2.0%, EMR in 15.3%, EPMR in 13.3%, ESD in 45.9% and TEM in 9.2%. Surgical resection was referred in 14.3% of the lesions. The correlation of pit pattern with pathology was:II: 100% adenomas with low-grade dysplasia (2/2)IIIL: 69.2% of low-grade adenoma (9/13)IIIS: 100% intramucosal adenocarcinoma (1/1)IV: 72.0% of adenoma with highgrade dysplasia or intramucosal adenocarcinoma (18/25)Vi: 86.9% of intramucosal adenocarcinoma or superficial submucosal invasion !1000 mm (40/46) / 6.5% adenocarcinoma with massive submucosal invasionO 1000 mm (3/46)- Vn: 54.5% of adenocarcinoma with massive submucosal invasion (6/11); 45.5% of adenocarcinoma with invasion to the muscularis propriaThe therapeutic indication was considered correct in 96.9% of cases (95/98). Three cases Vi pit pattern lesions were endoscopically resected and the histology demonstrated massive submucosal invasion. These patients were sent to surgical resection. Magnifying chromoendoscopy and pit pattern classification had a 78.6% sensitivity, a 100% specificity, a 100% positive predictive value, a 96.6% negative predictive value and a 96.9% accuracy to detect submucosal massive invasion, or deeper. Conclusion: Magnifying chromoendoscopy is accurate to detect submucosal massive invasion, or deeper, of colorectal neoplastic lesions which allows correct selection of patients to surgical or endoscopic resection. The Vn pit pattern contraindicates endoscopic resection.
Sa1562 Outcomes of Endoscopic Retreatment of Recurrent Lesions After Initial Salvage Endoscopic Treatment of Recurrent Large Nonpedunculated Colorectal Adenomas. Hyun Gun Kim*3, Saurabh Sethi1, Subhas Banerjee1, Shai Friedland1,2 1 Gastroenterology, Stanford University, Palo Alto, CA; 2Gastroenterology, VA Palo Alto HCS, Palo Alto, CA; 3Gastroenterology, Soonchunhyang University College of Medicine, Seoul, Korea (the Republic of) Background: Endoscopic mucosal resection (EMR) is now the standard treatment of large nonpedunculated colorectal adenomas. EMR is associated with significant recurrence rates ranging from 4% to 27%. Recurrent adenomas can be treated endoscopically with repeat EMR, underwater EMR (UEMR) and endoscopic submucosal dissection, with a reported success rate of 86%-100%. However, there is little data on outcomes after repeat treatment. Methods: Records of patients referred to an interventional endoscopy practice at 2 centers, a university hospital and a Veterans’ Administration hospital over a 4 year period were reviewed. Patients with recurrent colorectal lesions after initial endoscopic treatment of nonpedunculated colorectal adenomas R 2cm were identified. Results: 64 patients with 70 recurrent lesions after endoscopic treatment of nonpedunculated colorectal adenomas R 2cm were identified. Conventional EMR (39/70, 55.7%) and UEMR (31/70, 44.3%) were performed as the 1st salvage endoscopic treatment. After the 1st salvage procedure, follow up colonoscopy (mean interval 6.4 months) was performed on 62/70 lesions (89%) and a second recurrence was found in 21/62 (34%). One patient had an unresectable circumferential ileocecal valve adenoma and was referred for surgery. The other 20 second recurrences were treated by a 2nd salvage endoscopic resection. Follow up colonoscopy was performed on 15 of the 20 lesions (75%) after the 2nd salvage procedure. Twelve of the 15 (80%) had no recurrence after the 2nd salvage treatment. One patient was found to have a deep T1 cancer and underwent curative surgery. The two patients with recurrent adenoma had a third salvage endoscopic treatment; both patients had no recurrence on subsequent colonoscopy. There were 2 complications: postpolypectomy bleeding requiring hospitalization, both after the 1st salvage procedure. A mean of 1.3 salvage procedures was required to achieve a cure (range 1-3). Lesion size decreased from 34.5 8.6 mm initially to 22.2 11.7 mm on the first salvage and 10.2 4.8 mm on the second salvage procedure (p! 0.001). Conclusion: Endoscopic treatment of recurrent adenomas after EMR of large nonpedunculated colorectal adenomas is associated with a significant rate of second recurrences. However, second recurrences can be treated endoscopically with high cure rates, low complication rates and a low risk of progression to malignancy.
AB262 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
Sa1563 the Clinical Utility of a Universal or Selective Endoscopic Submucosal Dissection Strategy for Large Laterally Spreading and Sessile Colorectal Tumours in a Western Tertiary Referral Center Farzan F. Bahin*1,2, Dhruv Nayyar1, Khalid N. Rasouli1,2, Hema Mahajan3, Duncan J. Mcleod3, Stephen J. Williams1, Eric Y. Lee1, Michael J. Bourke1,2 1 Gastroenterology and Hepatology, Westmead Hospital, Westmead, NSW, Australia; 2Faculty of Medicine, University of Sydney, Sydney, NSW, Australia; 3Anatomical Pathology, Westmead Hospital, Westmead, NSW, Australia Backgound: Laterally spreading colorectal tumours (LST) have variable potential for submucosal invasion (SMI), the risk of which can be stratified by lesion morphology and surface pattern. En-bloc resection by endoscopic submucosal dissection (ESD) is being increasingly advocated as a superior treatment due to reduced recurrence, and most importantly, potential cure of submucosal invasive cancer (SMIC). However, ESD is technically challenging, more time and resource consuming, requires multi-day hospital admission and has greater frequency of significant complications compared to conventional treatment by wide-field endoscopic mucosal resection (WF-EMR). Residual disease occurs in 15% after WF-EMR. This can be treated, and the vast majority of patients are free of disease in long-term follow up. It is unknown whether a universal or selective ESD strategy delivers meaningful clinical gains. Aim: To evaluate the proportion of patients with large LST that could potentially be cured of SMIC by a selective or universal ESD strategy. Methods: A post-hoc analysis from a prospective observational study of WF-EMR for LSTs R 20mm at a single tertiary centre was performed (NCT01368289). LSTs were classed as suspicious or not suspicious for SMIC based on Paris 0-IIc morphology, Kudo pit pattern V and non-lifting. Surgery was offered in cases of strong suspicion of SMIC, or after unfavourable EMR histology. EMR and surgical specimens were reviewed by two expert histopathologists. Low risk SMIC (LR-SMIC) was defined as: well differentiated, vertical submucosal involvement !1000m and absence of lymphovascular invasion. ESD was assumed to achieve R0 resection in 100% of LR-SMIC. In cases of multiple lesions in a patient the lesion with the worst appearance or histology was selected to perform per patient analysis. Results: From September 2008 to September 2014, 1174 patients (mean age 67.8 years, 50.6% male) with 1236 lesions (mean size 37.1 mm, 52.4% right colon) were enrolled. The prevalence of SMIC and LR-SMIC in the entire cohort was 102/1174 (8.7%) (Table 1). The proportion of LR-SMIC that could potentially be cured by a universal ESD strategy was 43/1174 (3.7%). If a selective ESD strategy was applied to suspected SMIC, 82/1174 (7.0%) patients were eligible and cure of LR-SMIC could potentially be achieved in 20/82 (24.4%). This comprised 1.7% of the cohort. Conclusion: Given the substantially longer procedure time, greater resource consumption, technical difficulty, higher risk of significant adverse events, and the small potential for meaningful clinical benefit (! 4% of the cohort) compared to WF-EMR, a universal ESD strategy cannot be justified. A selective ESD strategy was applicable to 7.0% of the cohort but identified less than a quarter of eligible lesions. At present, it has limited utility and warrants further research.
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