title: Adenoma recurrence after piecemeal colonic EMR is predictable: the Sydney EMR recurrence tool.
abstract: OBJECTIVE
  EMR is the primary treatment of large laterally spreading lesions (LSLs) in the colon. Residual or recurrent adenoma (RRA) is a major limitation. We aimed to identify a robust method to stratify the risk of RRA.
  
  
  METHODS
  Prospective multicenter data on consecutive LSLs ≥20 mm removed by piecemeal EMR from 8 Australian tertiary-care centers were included (September 2008 until May 2016). A logistic regression model for endoscopically determined recurrence (EDR) was created on a randomly selected half of the cohort to yield the Sydney EMR recurrence tool (SERT), a 4-point score to stratify the incidence of RRA based on characteristics of the index EMR. SERT was validated on the remainder of the cohort.
  
  
  RESULTS
  Analysis was performed on 1178 lesions that underwent first surveillance colonoscopy (SC1) (median 4.9 months, interquartile range [IQR] 4.9-6.2). EDR was detected in 228 of 1178 (19.4%) patients. LSL size ≥40 mm (odds ratio [OR] 2.47; P < .001), bleeding during the procedure (OR 1.78; P = .024), and high-grade dysplasia (OR 1.72; P = .029) were identified as independent predictors of EDR and allocated scores of 2, 1, and 1, respectively to create SERT. Lesions with SERT scores of 0 (SERT = 0) had a negative predictive value of 91.3% for RRA at SC1, and SERT was shown to stratify RRA to specific follow-up intervals by using Kaplan Meier curves (log-rank P < .001).
  
  
  CONCLUSIONS
  Guidelines recommend SC1 within 6 months of EMR. SERT accurately stratifies the incidence of RRA after EMR. SERT = 0 lesions could safely undergo first surveillance at 18 months, whereas lesions with SERT scores between 1 and 4 (SERT 1-4) require surveillance at 6 and 18 months. (Clinical trial registration number: NCT01368289.).
authors.affiliation: Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, The University of Sydney Medical School, Sydney, New South Wales, Australia.
authors.forename: David J
authors.initials: DJ
authors.lastname: Tate
authors.affiliation: Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.
authors.forename: Lobke
authors.initials: L
authors.lastname: Desomer
authors.affiliation: Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.
authors.forename: Amir
authors.initials: A
authors.lastname: Klein
authors.affiliation: Department of Gastroenterology and Hepatology, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Gastroenterology and Hepatology, Epworth Hospital, Melbourne, Victoria, Australia.
authors.forename: Gregor
authors.initials: G
authors.lastname: Brown
authors.affiliation: Department of Gastroenterology and Hepatology, Greenslopes Private Hospital, Brisbane, Queensland, Australia; Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.
authors.forename: Luke F
authors.initials: LF
authors.lastname: Hourigan
authors.affiliation: Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.
authors.forename: Eric Y T
authors.initials: EY
authors.lastname: Lee
authors.affiliation: Department of Gastroenterology and Hepatology, The Western Hospital, Melbourne, Victoria, Australia; Department of Medicine, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia.
authors.forename: Alan
authors.initials: A
authors.lastname: Moss
authors.affiliation: Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.
authors.forename: Donald
authors.initials: D
authors.lastname: Ormonde
authors.affiliation: Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.
authors.forename: Spiro
authors.initials: S
authors.lastname: Raftopoulos
authors.affiliation: Department of Gastroenterology and Hepatology, Lyell McEwan Hospital, Adelaide, South Australia, Australia.
authors.forename: Rajvinder
authors.initials: R
authors.lastname: Singh
authors.affiliation: Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: Williams
authors.affiliation: Department of Gastroenterology and Hepatology, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Gastroenterology and Hepatology, The Western Hospital, Melbourne, Victoria, Australia.
authors.forename: Simon
authors.initials: S
authors.lastname: Zanati
authors.affiliation: Research and Education Network, Westmead Hospital and The University of Sydney, New South Wales, Australia.
authors.forename: Karen
authors.initials: K
authors.lastname: Byth
authors.affiliation: Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, The University of Sydney Medical School, Sydney, New South Wales, Australia.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Bourke
mesh_terms: D000236:Adenoma / Q000473:pathology / Q000601:surgery*; D000368:Aged; D016063:Blood Loss, Surgical / Q000706:statistics & numerical data; D003110:Colonic Neoplasms / Q000473:pathology / Q000601:surgery*; D003113:Colonoscopy / Q000379:methods*; D000069916:Endoscopic Mucosal Resection / Q000379:methods*; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology*; D018365:Neoplasm, Residual; D011230:Precancerous Conditions / Q000453:epidemiology; D011446:Prospective Studies; D018570:Risk Assessment; D047368:Tumor Burden