Intest Res.  2019 Oct;17(4):516-526. 10.5217/ir.2018.00169.

Clinical outcomes of positive resection margin after endoscopic mucosal resection of early colon cancers

Affiliations
  • 1Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea. medgun@schmc.ac.kr
  • 2Department of Pathology, Soonchunhyang University College of Medicine, Seoul, Korea.

Abstract

BACKGROUND/AIMS
When determining the subsequent management after endoscopic resection of the early colon cancer (ECC), various factors including the margin status should be considered. This study assessed the subsequent management and outcomes of ECCs according to margin status.
METHODS
We examined the data of 223 ECCs treated by endoscopic mucosal resection (EMR) from 215 patients during 2004 to 2014, and all patients were followed-up at least for 2 years.
RESULTS
According to histological analyses, the margin statuses of all lesions after EMR were as follows: 138 cases (61.9%) were negative, 65 cases (29.1%) were positive for dysplastic cells on the resection margins, and 20 cases (8.9%) were uncertain. The decision regarding subsequent management was affected not only by pathologic outcomes but also by the endoscopist's opinion on whether complete resection was obtained. Surgery was preferred if the lesion extended to the submucosa (odds ratio [OR], 25.46; 95% confidence interval [CI], 7.09-91.42), the endoscopic resection was presumed incomplete (OR, 15.55; 95% CI, 4.28-56.56), or the lymph system was invaded (OR, 13.69; 95% CI, 1.76-106.57). Fourteen patients (6.2%) had residual or recurrent malignancies at the site of the previous ECC resection and were significantly associated with presumed incomplete endoscopic resection (OR, 4.59; 95% CI, 1.21-17.39) and submucosal invasion (OR, 5.14; 95% CI, 1.18-22.34).
CONCLUSIONS
Subsequent surgery was associated with submucosa invasion, lymphatic invasion, and cancer-positive margins. Presumed completeness of the resection may be helpful for guiding the subsequent management of patients who undergo endoscopic resection of ECC.

Keyword

Early colon cancer; Endosocpic mucosal resection; Margins of excision

MeSH Terms

Colon*
Colonic Neoplasms*
Humans

Figure

  • Fig. 1. Endoscopically presumed incomplete resection. (A) A nodular, mixed, laterally spreading tumor was identified after submucosal injection of a saline and indigo carmine solution. (B) Endoscopic piecemeal mucosal resection (EPMR) was performed using a conventional snare. (C) Additional injection of saline and indigo carmine during EPMR. (D) A section of the tumor removed using EPMR. The arrow indicates tissue that was torn during the procedure and was considered a possible remnant tumor island. It was difficult to determine whether or not the tumor had been completely removed even at the lateral resection margin.

  • Fig. 2. Study flowchart. Among the 191 lesions that were followed using surveillance colonoscopy with another systemic evaluation, 2 cases of cancer recurrence were identified. Among the 32 lesions that were treated using subsequent surgery, remnant cancers were identified in 12 cases and adenomas were identified in 2 cases. EMR, endoscopic mucosal resection; LGD, low-grade dysplasia; HGD, high-grade dysplasia; LST, lateral spreading tumor; EPMR, endoscopic piecemeal mucosal resection; PCR, presumed complete resection; PIR, presumed incomplete resection; SM, submucosa.

  • Fig. 3. Study flowchart of 65 cases with positive resection margins. Among the 56 lesions with a positive lateral margin, 50 with endoscopically presumed complete resection (PCR) were followed, and there was no recurrence during surveillance. Three remnant cancers were detected during subsequent surgery of 6 cases of positive lateral margin and 9 cases of positive vertical or both margins. Three residual cancer cases included lesions that underwent endoscopically presumed incomplete/uncertain resection. LGD, low-grade dysplasia; HGD, high-grade dysplasia; EPMR, endoscopic piecemeal mucosal resection; PIR, presumed incomplete resection; EMR, endoscopic mucosal resection; LST, lateral spreading tumor; SM, submucosa.


Cited by  1 articles

Clinical outcomes of submucosal colorectal cancer diagnosed after endoscopic resection: a focus on the need for surgery
Yun Sik Choi, Wan Soo Kim, Sung Wook Hwang, Sang Hyoung Park, Dong-Hoon Yang, Byong Duk Ye, Seung-Jae Myung, Suk-Kyun Yang, Jeong-Sik Byeon
Intest Res. 2020;18(1):96-106.    doi: 10.5217/ir.2019.00092.


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