Long-term Recurrence-free Survival After Standard Endoscopic Resection Versus Surgical Resection of Submucosal Invasive Colorectal Cancer: A Population-based Study.
There is controversy over the optimal management for T1 colorectal cancer (T1 CRC). This study compared initial endoscopic resection with or without additional surgery, or initial surgery for T1 CRC, and assessed risk factors for lymph node metastases (LNMs) and long-term recurrence.



We performed a registration study that included all patients diagnosed with T1 CRC from 1995 through 2011 in the southeast area of The Netherlands (n = 1315). High-risk histology (with regard to LNM) was defined as the presence of poor differentiation, lymphangio-invasion, and/or deep submucosal invasion. The primary outcome measure was the combined rate of local and distant CRC recurrence during a mean follow-up period of 6.6 years. Logistic regression and Cox proportional hazards regression analyses were performed to evaluate independent risk factors for LNM and CRC recurrence, respectively.



Endoscopic resection was performed in 590 patients (44.9%); of these, 220 (16.7%) underwent additional surgery. Initial surgery was performed in 725 patients (55.1%). The risk of LNM was higher in T1 CRC with histologic risk factors (15.5% vs 7.1% without histologic risk factors; odds ratio, 2.21; 95% confidence interval, 1.33-3.70). Thirty-day mortality did not differ between patients who received additional surgery (0.9%) and those who underwent only endoscopic resection (1.4%; P = .631). Rates of CRC recurrence were 6.2% (9.8/1000 patient-years) after only endoscopic resection vs 6.4% (9.4/1000 patient-years) after additional surgery (P = .912), and 3.4% (5.2/1000 patient-years) after initial surgery (P = .031). In multivariate analysis, this difference was not significant. The only independent risk factor for long-term recurrence was a positive resection margin (hazard ratio, 6.88; 95% confidence interval, 2.27-20.87).



Based on a population analysis of patients diagnosed with T1 CRC, additional surgery after endoscopic resection should be considered only for patients with high-risk histology or a positive resection margin.
Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands. Electronic address: t.d.g.belderbos@umcutrecht.nl.
Tim D G
TD
Belderbos
Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands; Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands.
Felice N
FN
van Erning
Department of Surgery, Catharina Hospital Eindhoven, The Netherlands.
Ignace H J T
IH
de Hingh
Department of Medical Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
Martijn G H
MG
van Oijen
Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands; Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands.
Valery E P P
VE
Lemmens
Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands; Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands.
Peter D
PD
Siersema
D000368:Aged; D000369:Aged, 80 and over; D015179:Colorectal Neoplasms / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009362:Neoplasm Metastasis; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology*; D009426:Netherlands / Q000453:epidemiology; D012189:Retrospective Studies; D013514:Surgical Procedures, Operative / Q000379:methods*; D016019:Survival Analysis
Colon Cancer; Early Stage CRC; Lymph Node Metastasis; Polypectomy