title: 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.
abstract: OBJECTIVE
  Wide-field endoscopic mucosal resection (WF-EMR) is an alternative to surgery for treatment of advanced colonic mucosal neoplasia up to 120 mm in size, but has been criticised for its potentially high recurrence rates. We aimed to quantify recurrence at 4 months (early) and 16 months (late) following successful WF-EMR and identify its risk factors and clinical significance.
  
  
  METHODS
  Ongoing multicentre, prospective, intention-to-treat analysis of sessile or laterally spreading colonic lesions ≥20 mm in size referred for WF-EMR to seven academic endoscopy units. Surveillance colonoscopy (SC) was performed 4 months (SC1) and 16 months (SC2) after WF-EMR, with photographic documentation and biopsy of the scar.
  
  
  RESULTS
  1134 consecutive patients were enrolled when 1000 successful EMRs were achieved, of whom 799 have undergone SC1. 670 were normal. Early recurrent/residual adenoma was present in 128 (16.0%, 95% CI 13.6% to 18.7%). One case was unknown. The recurrent/residual adenoma was diminutive in 71.7% of cases. On multivariable analysis, risk factors were lesion size >40 mm, use of argon plasma coagulation and intraprocedural bleeding. Of 670 with normal SC1, 426 have undergone SC2, with late recurrence present in 17 cases (4.0%, 95% CI 2.4% to 6.2%). Overall, recurrent/residual adenoma was successfully treated endoscopically in 135 of 145 cases (93.1%, 95% CI 88.1% to 96.4%). If the initial EMR was deemed successful and did not contain submucosal invasion requiring surgery, 98.1% (95% CI 96.6% to 99.0%) were adenoma-free and had avoided surgery at 16 months following EMR.
  
  
  CONCLUSIONS
  Following colonic WF-EMR, early recurrent/residual adenoma occurs in 16%, and is usually unifocal and diminutive. Risk factors were identified. Late recurrence occurs in 4%. Overall, recurrence was managed endoscopically in 93% of cases. Recurrence is not a significant clinical problem following WF-EMR, as with strict colonoscopic surveillance, it can be managed endoscopically with high success rates.
  
  
  BACKGROUND
  NCT01368289.
authors.affiliation: Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia Department of Endoscopy, Western Health and The University of Melbourne, Melbourne, Australia.
authors.forename: Alan
authors.initials: A
authors.lastname: Moss
authors.affiliation: Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia.
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: Williams
authors.affiliation: Department of Gastroenterology, Princess Alexandra Hospital, Brisbane, Australia.
authors.forename: Luke F
authors.initials: LF
authors.lastname: Hourigan
authors.affiliation: Department of Gastroenterology, The Epworth Hospital, Melbourne, Australia Department of Gastroenterology, The Alfred Hospital, Melbourne, Australia.
authors.forename: Gregor
authors.initials: G
authors.lastname: Brown
authors.affiliation: Department of Gastroenterology, Lyell McEwin Hospital, Adelaide, Australia.
authors.forename: William
authors.initials: W
authors.lastname: Tam
authors.affiliation: Department of Gastroenterology, Lyell McEwin Hospital, Adelaide, Australia.
authors.forename: Rajvinder
authors.initials: R
authors.lastname: Singh
authors.affiliation: Department of Endoscopy, Western Health and The University of Melbourne, Melbourne, Australia Department of Gastroenterology, The Alfred Hospital, Melbourne, Australia.
authors.forename: Simon
authors.initials: S
authors.lastname: Zanati
authors.affiliation: Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia.
authors.forename: Nicholas G
authors.initials: NG
authors.lastname: Burgess
authors.affiliation: Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Sonson
authors.affiliation: Medical Statistician, Research and Education Network, Westmead Hospital and Sydney University, Sydney, New South Wales, Australia.
authors.forename: Karen
authors.initials: K
authors.lastname: Byth
authors.affiliation: Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Bourke
mesh_terms: D000236:Adenoma / Q000453:epidemiology* / Q000473:pathology / Q000601:surgery*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001315:Australia / Q000453:epidemiology; D003082:Colectomy / Q000379:methods*; D003110:Colonic Neoplasms / Q000453:epidemiology* / Q000473:pathology / Q000601:surgery*; D003113:Colonoscopy; D005260:Female; D006801:Humans; D057194:Intention to Treat Analysis; D007413:Intestinal Mucosa / Q000601:surgery; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology*; D009367:Neoplasm Staging; D011446:Prospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
keywords: Adenoma; Colonic Polyps; Colonoscopy; Colorectal Cancer; Endoscopic Polypectomy