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Sa1600 Endoscopic Submucosal Dissection of Cecal Lesions in Proximity to the Appendiceal Orifice
Abstracts with R2 SSA/Ps R10mm at initial colonoscopy had 91% chances of being high-risk patients after SLC. Conclusions: SPS is frequently under diagnosed with a single colonoscopy. A SLC in patients with SP increases the yield of SPS diagnosis by 200%. Presence of R5 SP or R2 SSA/P at initial colonoscopy could be consider an optimal threshold for indicating a SLC after a screening colonoscopy.
Table 1. Demographic variables and main differences between
patients scheduled to second look colonoscopy vs patients without second look colonoscopy (surveillance according to current protocols)
Age Gender (male) At least one HPR10mm At least one proximal HP R10mm At least one SSA/P At least one SSA/P R5mm At least one SSA/P R10mm At least one proximal SSA/P At least one proximal SSA/P R5mm At least one proximal SSA/P R10mm
Second Look Colonoscopy YES N [ 82
Second Look Colonoscopy NO N [ 114
p
58 1.1 52.4% 30.5% 20.7%
59.1 1.1 60.5% 29.8% 7.9%
0.957 0.259 0.920 0.009
63.4% 62.2% 32.9% 56.1% 56.1%
27.2% 28.1% 15.8% 20.2% 19.3%
!0.001 !0.001 !0.001 !0.001 0.005
23.2%
7.9%
0.003
HP: Hyperplastic polyp; proximal Z proximal to splenic flexure; SSA/P: sessile serrated adenoma/polyp.
Table 2. Main findings in Second Look Colonoscopy in relation to
initial findings
Findings at initial colonoscopy* 1-2 SP ! 10mm 3-4 SP ! 10mm 1-2 SP R 10mm 3-4 SP R 10mm R5 SP 1 SSA/P R2 SSA/P R2 SSA/P R10mm R2 proximal SSA/P R2 proximal SSA/P R10mm
Total patients N [ 71
SLC diagnosis High-risk (SPS + SPS-like) N [ 35 (20 + 15)
SLC diagnosis High-risk (SPS + SPS-like) %
Sporadic SP N [ 36
Sporadic SP %
13 9 11 34 29 18 25 11 24 8
2 (0 + 2) 3 (1 + 2) 4 (2 + 2) 20 (12 + 8) 20 (13 + 7) 6 (6 + 0) 18 (12 + 6) 10 (7 + 3) 18 (12 + 6) 7 (5 + 2)
15% 33% 36% 59% 69% 33% 72% 91% 75% 88%
11 6 7 14 9 12 7 1 6 1
85% 67% 64% 41% 31% 67% 28% 9% 25% 13%
SP: serrated polyps (including hyperplastic polyps, SSA/Ps and TSA), SSA/P: sessile serrated adenoma/polyp, proximal Z proximal to splenic flexure, SLC: Second Look Colonoscopy. *Taking into account the selection criteria: at least one R5mm proximal to the splenic flexure or R10mm in any location.
Sa1600 Endoscopic Submucosal Dissection of Cecal Lesions in Proximity to the Appendiceal Orifice Harold Jacob*1, Takashi Toyonaga2, Shinwa Tanaka2, Takeshi Azuma3 1 Gastroenterology, Hadassah University Hospital, Jerusalem, Israel; 2 Department of Endoscopy, Kobe University Hospital, Kobe, Japan; 3 Gastroenterology, Kobe University Hospital, Kobe, Japan Introduction: ESD in proximity to the appendiceal orifice is now feasible. We report our experience with cecal ESD in proximity to the appendiceal orifice. Methods: We reviewed all patients who underwent ESD for a Cecal Lesion over the past 10 years at Kobe University Hospital and Kishiwada Tokushukai Hospital,Osaka,Japan. We classified the lesions as follows:TYPE 0-Target lesion in proximity to appendiceal orifice but leaves appendiceal orifice with rim of normal mucosa. Type 1-Target lesion reaches border of the appendix, but does not enter appendiceal orifice. TYPE 2-Target lesion reaches border of the appendix and enters the appendiceal orifice. The transition from the target lesion to the normal appendiceal mucosa is discernible on inspection of the appendiceal lumen. TYPE 3-Target lesion involves the appendiceal orifice and enters the orifice such that no normal appendiceal mucosa is seen when looking into appendiceal lumen. ESD was not undertaken in Type 3 lesions unless there was a prior appendectomy. Results: 49 cases were found to satisfy the inclusion criteria of this review. There were 27 female and 23 male patients. The age range was from 50 to 91 years old with an average age of 68 years old. The spectrum of
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macroscopic classification of the lesions included 38 lateral spreading tumors granular type of which there were 17 mixed type,13 homogenous type and 8 characterized as other. There were 9 lateral spreading tumors non-granular type (LST-NG) of which 8 were characterized as flat type and 1 characterized as other.2 lesions were described as lateral spreading tumors (LST) only. Histological examination revealed 28 cases of well differentiated carcinoma in a tubular adenoma,13 cases of tubular adenoma one of which had high grade dysplasia, three cases of serrated adenoma, 2 cases of tubulovillous adenoma, 2 adenomas and one papillary lesion. Depth of invasion was mucosal only in 42 patients,4 were PHMO,1pSM and 1SM2. Specimen size ranged from 16mm to 114mm and tumor size between 14mm to 110mm. Aside from 2 specimens resected piecemeal, all specimens were resected en-bloc. In all specimens, the lateral and vertical margins were clean. 47 lesions could be classified using our classification system, 30 type 0 lesions,11 type 1 lesions, 3 type 2 lesions and 2 type 3 lesions.6 patients had undergone appendectomy including the 2 type 3 lesions that underwent ESD. 2 patients experienced complications. One delayed bleeding treated endoscopically and one with transient pain that improved with antibiotics. Procedure time ranged between 39 and 240 minutes, average of 102 minutes. Conclusion: ESD in proximity to the appendiceal orifice is safe and effective in Type 0,1and 2 lesions. Type 3 lesions can undergo ESD if the patient has a prior appendectomy. Type 3 lesions with an intact appendix are at risk for incomplete resection and should not undergo ESD.
Sa1601 Lower Risk of Metastatic Disease in Pedunculated Polyps Containing T1 Colorectal Carcinoma Compared to Lateral Spreading Tumors Aneya Van Den Blink*1, Anouk Overwater1, Martijn G. Van Oijen1, Tom Seerden2, Marcel Spanier3, Hendrikus J. Pullens4, Wouter H. De Vos Tot Nederveen Cappel5, Johan Offerhaus6, Dirkjan Bac7, Marjon Kerkhof8, Koen Kessels9, Peter D. Siersema1, Miangela M. Laclé6, Leon M. Moons1 1 Gastroenterology & Hepatology, University Medical Center Utrecht, Utrecht, Netherlands; 2Gastroenterology & Hepatology, Amphia Hospital, Breda, Netherlands; 3Gastroenterology & Hepatology, Rijnstate Hospital, Arnhem, Netherlands; 4Gastroenterology & Hepatology, Meander Medical Center, Amersfoort, Netherlands; 5Gastroenterology & Hepatology, Isala Clinics, Zwolle, Netherlands; 6Pathology, University Medical Center, Utrecht, Netherlands; 7Gastroenterology & Hepatology, Gelderse Vallei Hospital, Ede, Netherlands; 8Gastroenterology & Hepatology, Groene Hart Hospital, Gouda, Netherlands; 9 Gastroenterology & Hepatology, Flevo Hospital, Almere, Netherlands Background: Although a lower incidence of lymph node metastasis of T1 colorectal cancer (CRC) is suggested in pedunculated polyps compared to lateral spreading tumors (LSTs), no large cohort study has been performed comparing number of lymph node metastasis, recurrence and complications of treatment. AIM: To determine outcomes of T1 CRC in pedunculated polyps and LSTs. Method: Patients diagnosed with a T1 CRC in 8 hospitals between January 2000 and July 2014 were extracted from the national database of the Netherlands Cancer Registry. Patient characteristics, endoscopic and histopathological findings, treatment, and follow-up were collected of all patients. Recurrence was defined as the detection of metastasis or local recurrence during follow-up. Survival was estimated by Kaplan-Meier analysis and Cox proportional hazard regression analyses were used to adjust for gender, age, location in colon, polyp size, type of therapy and adequate follow-up by radiologic imaging. A Chi-square test was used to compare rates of lymph node metastasis, mortality and major complications. Results: A total of 821 patients with T1 CRC (332 pedunculated and 489 LSTs) were included. Polyps were treated with endoscopy only (pedunculated nZ174 (52%) vs. LST nZ121 (25%)), endoscopy followed by surgery (nZ98 (30%) vs. nZ106 (22%)) or primary surgery (nZ60 (18%) vs. nZ262 (54%)). Median follow-up was 3.4 years (IQR 1.5-6.0) in both groups. Pedunculated T1 CRCs had a more favorable 5-year disease free survival rate than LSTs (98% vs. 93%; adjusted HR 3.4 95%CI 1.3-8.7; p!0.01). After stratification to treatment, most survival benefit was observed for T1 CRCs treated with endoscopy only (98.8% vs. 88.2%). However, after adjustment for follow-up with imaging and location in rectum this was no longer significant (HR 4.6 95%CI 0.8-25.9, pZ0.084). In the primary surgery group, the rate of lymph node metastasis was lower for pedunculated polyps (3.3% vs. 9.6%, pZ0.116). Recurrence was detected in 3/174 (1.7%) pedunculated polyps treated with endoscopy only. In patients treated with endoscopy followed by surgery, lymph node metastasis were found in 9/98 (9.2%), and 2/98 (2%) patients developed a recurrence during follow-up. Cumulative risk of local recurrence and/or metastatic disease for pedunculated polyps was 14/272 (5.1%), which was significantly lower compared to LSTs (30/227 (13.2%), p!0.01). Major complications and mortality rates of surgery vs. endoscopy were 20.7% vs. 8.8% (p!0.01) and 2.7% vs. 0.55% (pZ0.18) respectively. Conclusion: Compared to LSTs, pedunculated T1 CRCs have a lower risk of developing lymph node metastasis and recurrence and are more often curatively treated with endoscopic resection. This low risk closely approaches the risk of mortality from surgery, and benefits from surgery may easily disappear in the presence of risk factors for surgery.
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB277
Table 1. Demographic variables and main differences between
patients scheduled to second look colonoscopy vs patients without second look colonoscopy (surveillance according to current protocols)
Age Gender (male) At least one HPR10mm At least one proximal HP R10mm At least one SSA/P At least one SSA/P R5mm At least one SSA/P R10mm At least one proximal SSA/P At least one proximal SSA/P R5mm At least one proximal SSA/P R10mm
Second Look Colonoscopy YES N [ 82
Second Look Colonoscopy NO N [ 114
p
58 1.1 52.4% 30.5% 20.7%
59.1 1.1 60.5% 29.8% 7.9%
0.957 0.259 0.920 0.009
63.4% 62.2% 32.9% 56.1% 56.1%
27.2% 28.1% 15.8% 20.2% 19.3%
!0.001 !0.001 !0.001 !0.001 0.005
23.2%
7.9%
0.003
HP: Hyperplastic polyp; proximal Z proximal to splenic flexure; SSA/P: sessile serrated adenoma/polyp.
Table 2. Main findings in Second Look Colonoscopy in relation to
initial findings
Findings at initial colonoscopy* 1-2 SP ! 10mm 3-4 SP ! 10mm 1-2 SP R 10mm 3-4 SP R 10mm R5 SP 1 SSA/P R2 SSA/P R2 SSA/P R10mm R2 proximal SSA/P R2 proximal SSA/P R10mm
Total patients N [ 71
SLC diagnosis High-risk (SPS + SPS-like) N [ 35 (20 + 15)
SLC diagnosis High-risk (SPS + SPS-like) %
Sporadic SP N [ 36
Sporadic SP %
13 9 11 34 29 18 25 11 24 8
2 (0 + 2) 3 (1 + 2) 4 (2 + 2) 20 (12 + 8) 20 (13 + 7) 6 (6 + 0) 18 (12 + 6) 10 (7 + 3) 18 (12 + 6) 7 (5 + 2)
15% 33% 36% 59% 69% 33% 72% 91% 75% 88%
11 6 7 14 9 12 7 1 6 1
85% 67% 64% 41% 31% 67% 28% 9% 25% 13%
SP: serrated polyps (including hyperplastic polyps, SSA/Ps and TSA), SSA/P: sessile serrated adenoma/polyp, proximal Z proximal to splenic flexure, SLC: Second Look Colonoscopy. *Taking into account the selection criteria: at least one R5mm proximal to the splenic flexure or R10mm in any location.
Sa1600 Endoscopic Submucosal Dissection of Cecal Lesions in Proximity to the Appendiceal Orifice Harold Jacob*1, Takashi Toyonaga2, Shinwa Tanaka2, Takeshi Azuma3 1 Gastroenterology, Hadassah University Hospital, Jerusalem, Israel; 2 Department of Endoscopy, Kobe University Hospital, Kobe, Japan; 3 Gastroenterology, Kobe University Hospital, Kobe, Japan Introduction: ESD in proximity to the appendiceal orifice is now feasible. We report our experience with cecal ESD in proximity to the appendiceal orifice. Methods: We reviewed all patients who underwent ESD for a Cecal Lesion over the past 10 years at Kobe University Hospital and Kishiwada Tokushukai Hospital,Osaka,Japan. We classified the lesions as follows:TYPE 0-Target lesion in proximity to appendiceal orifice but leaves appendiceal orifice with rim of normal mucosa. Type 1-Target lesion reaches border of the appendix, but does not enter appendiceal orifice. TYPE 2-Target lesion reaches border of the appendix and enters the appendiceal orifice. The transition from the target lesion to the normal appendiceal mucosa is discernible on inspection of the appendiceal lumen. TYPE 3-Target lesion involves the appendiceal orifice and enters the orifice such that no normal appendiceal mucosa is seen when looking into appendiceal lumen. ESD was not undertaken in Type 3 lesions unless there was a prior appendectomy. Results: 49 cases were found to satisfy the inclusion criteria of this review. There were 27 female and 23 male patients. The age range was from 50 to 91 years old with an average age of 68 years old. The spectrum of
www.giejournal.org
macroscopic classification of the lesions included 38 lateral spreading tumors granular type of which there were 17 mixed type,13 homogenous type and 8 characterized as other. There were 9 lateral spreading tumors non-granular type (LST-NG) of which 8 were characterized as flat type and 1 characterized as other.2 lesions were described as lateral spreading tumors (LST) only. Histological examination revealed 28 cases of well differentiated carcinoma in a tubular adenoma,13 cases of tubular adenoma one of which had high grade dysplasia, three cases of serrated adenoma, 2 cases of tubulovillous adenoma, 2 adenomas and one papillary lesion. Depth of invasion was mucosal only in 42 patients,4 were PHMO,1pSM and 1SM2. Specimen size ranged from 16mm to 114mm and tumor size between 14mm to 110mm. Aside from 2 specimens resected piecemeal, all specimens were resected en-bloc. In all specimens, the lateral and vertical margins were clean. 47 lesions could be classified using our classification system, 30 type 0 lesions,11 type 1 lesions, 3 type 2 lesions and 2 type 3 lesions.6 patients had undergone appendectomy including the 2 type 3 lesions that underwent ESD. 2 patients experienced complications. One delayed bleeding treated endoscopically and one with transient pain that improved with antibiotics. Procedure time ranged between 39 and 240 minutes, average of 102 minutes. Conclusion: ESD in proximity to the appendiceal orifice is safe and effective in Type 0,1and 2 lesions. Type 3 lesions can undergo ESD if the patient has a prior appendectomy. Type 3 lesions with an intact appendix are at risk for incomplete resection and should not undergo ESD.
Sa1601 Lower Risk of Metastatic Disease in Pedunculated Polyps Containing T1 Colorectal Carcinoma Compared to Lateral Spreading Tumors Aneya Van Den Blink*1, Anouk Overwater1, Martijn G. Van Oijen1, Tom Seerden2, Marcel Spanier3, Hendrikus J. Pullens4, Wouter H. De Vos Tot Nederveen Cappel5, Johan Offerhaus6, Dirkjan Bac7, Marjon Kerkhof8, Koen Kessels9, Peter D. Siersema1, Miangela M. Laclé6, Leon M. Moons1 1 Gastroenterology & Hepatology, University Medical Center Utrecht, Utrecht, Netherlands; 2Gastroenterology & Hepatology, Amphia Hospital, Breda, Netherlands; 3Gastroenterology & Hepatology, Rijnstate Hospital, Arnhem, Netherlands; 4Gastroenterology & Hepatology, Meander Medical Center, Amersfoort, Netherlands; 5Gastroenterology & Hepatology, Isala Clinics, Zwolle, Netherlands; 6Pathology, University Medical Center, Utrecht, Netherlands; 7Gastroenterology & Hepatology, Gelderse Vallei Hospital, Ede, Netherlands; 8Gastroenterology & Hepatology, Groene Hart Hospital, Gouda, Netherlands; 9 Gastroenterology & Hepatology, Flevo Hospital, Almere, Netherlands Background: Although a lower incidence of lymph node metastasis of T1 colorectal cancer (CRC) is suggested in pedunculated polyps compared to lateral spreading tumors (LSTs), no large cohort study has been performed comparing number of lymph node metastasis, recurrence and complications of treatment. AIM: To determine outcomes of T1 CRC in pedunculated polyps and LSTs. Method: Patients diagnosed with a T1 CRC in 8 hospitals between January 2000 and July 2014 were extracted from the national database of the Netherlands Cancer Registry. Patient characteristics, endoscopic and histopathological findings, treatment, and follow-up were collected of all patients. Recurrence was defined as the detection of metastasis or local recurrence during follow-up. Survival was estimated by Kaplan-Meier analysis and Cox proportional hazard regression analyses were used to adjust for gender, age, location in colon, polyp size, type of therapy and adequate follow-up by radiologic imaging. A Chi-square test was used to compare rates of lymph node metastasis, mortality and major complications. Results: A total of 821 patients with T1 CRC (332 pedunculated and 489 LSTs) were included. Polyps were treated with endoscopy only (pedunculated nZ174 (52%) vs. LST nZ121 (25%)), endoscopy followed by surgery (nZ98 (30%) vs. nZ106 (22%)) or primary surgery (nZ60 (18%) vs. nZ262 (54%)). Median follow-up was 3.4 years (IQR 1.5-6.0) in both groups. Pedunculated T1 CRCs had a more favorable 5-year disease free survival rate than LSTs (98% vs. 93%; adjusted HR 3.4 95%CI 1.3-8.7; p!0.01). After stratification to treatment, most survival benefit was observed for T1 CRCs treated with endoscopy only (98.8% vs. 88.2%). However, after adjustment for follow-up with imaging and location in rectum this was no longer significant (HR 4.6 95%CI 0.8-25.9, pZ0.084). In the primary surgery group, the rate of lymph node metastasis was lower for pedunculated polyps (3.3% vs. 9.6%, pZ0.116). Recurrence was detected in 3/174 (1.7%) pedunculated polyps treated with endoscopy only. In patients treated with endoscopy followed by surgery, lymph node metastasis were found in 9/98 (9.2%), and 2/98 (2%) patients developed a recurrence during follow-up. Cumulative risk of local recurrence and/or metastatic disease for pedunculated polyps was 14/272 (5.1%), which was significantly lower compared to LSTs (30/227 (13.2%), p!0.01). Major complications and mortality rates of surgery vs. endoscopy were 20.7% vs. 8.8% (p!0.01) and 2.7% vs. 0.55% (pZ0.18) respectively. Conclusion: Compared to LSTs, pedunculated T1 CRCs have a lower risk of developing lymph node metastasis and recurrence and are more often curatively treated with endoscopic resection. This low risk closely approaches the risk of mortality from surgery, and benefits from surgery may easily disappear in the presence of risk factors for surgery.
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB277