Blink, A. van den (Aneya) (2014) Clinical outcome of T1 colorectal carcinoma in pedunculated tumors, as compared to lateral spreading tumors: a retrospective multicenter study. thesis, Medicine.
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Abstract
Introduction: Although a lower incidence of lymph node metastasis (LNM) 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 LNM, recurrence, and residual tissue. This study aimed to determine clinical outcomes of T1 CRC in pedunculated polyps and LSTs, and assess the risk-benefit balance of additional surgery in pedunculated T1 CRCs. Method: Patients diagnosed with a T1 CRC in 8 hospitals between January 2000 and July 2014 were extracted from the database of the Netherlands Cancer Registry. Patient characteristics, endoscopic and histological findings, treatment, and follow-up were collected of all patients. Recurrence was defined as the detection of metastasis or local recurrence during follow-up. Pedunculated T1 CRCs were at high risk if one or more of the following criteria were present: tumor at resection margin, poor differentiation, submucosal invasion into the stalk, lymphovascular invasion. Results: A total of 1026 patients with T1 CRC (410 pedunculated and 616 LSTs) were included. Polyps were treated with endoscopy only (pedunculated n=213 (52%) vs. LST n=156 (25%)), endoscopy followed by surgery (n=130 (32%) vs. n=123 (20%)) or primary surgery (n=67 (16%) vs. n=337 (55%)). Median follow-up was 41 months (IQR 18-74) in both groups. Pedunculated T1 CRCs had a more favorable 5-year disease free survival rate than LSTs (98% vs. 94%). Stratified to treatment, most survival benefit was observed for pedunculated T1 CRCs treated with endoscopy only (98% vs. 89%). However, after adjustment for follow-up with imaging and location in rectum this was no longer significant (adjusted HR 3.0 95%CI 0.9-10, p=0.08). In the primary surgery group, the rate of LNM was lower in pedunculated polyps (3% vs. 10%, p=0.06). Residual tissue was detected in 11.5% of pedunculated tumors versus 23.6% of LSTs. Piece-meal resection method was independently associated with residual tissue (OR 5.09; 95%CI 2.25-11.53; p<0.01). In high risk pedunculated T1 CRCs no difference in 5-year disease free survival was observed between endoscopic and surgical resection. Tumor at resection margin and lymphovascular invasion in the endoscopic resected tumor was associated with referral to surgeon, resulting in a higher rate of detected LNM as compared to the general population. Invasion into Haggitt level 4 was directly associated with LNM or/and recurrence. Cumulative risk of recurrence or/and LNM in pedunculated T1 CRCs was 7.0%. Morbidity and mortality after surgery was 20% and 2.5%, respectively. In a high risk population of patients with a higher age (>68) or with high comorbidity the mortality rate increased to 5.6%. Conclusion: Compared to LSTs, pedunculated T1 CRCs have a more favorable 5-year disease free survival and a lower risk of LNM. Effectiveness of surgical resection is comparable to endoscopic resection in pedunculated T1 CRCs with high risk features, suggesting the current risk factors are no efficient criteria for surgery in pedunculated T1 CRCs. In pedunculated T1 CRCs with tumor invasion deeply into the stalk, lymphovascular invasion or tumor at resection margin additional surgery seems of benefit in the current study. Further research with histological reevaluation of the resected specimens is needed to support these conclusions. Piece-meal resection method is an important risk factor for residual tissue and should be avoided. In patients of older age or with high comorbidity, the risk of mortality after surgery closely approaches the oncologic benefit, and surgery should therefore be carefully considered in these patients.
| Item Type: | Thesis (Thesis) |
|---|---|
| Supervisor name: | Dullemen, Dr. H.M. van |
| Supervisor name: | Moons, Dr. L.M.G. and UMC Utrecht |
| Faculty: | Medical Sciences |
| Date Deposited: | 25 Jun 2020 11:03 |
| Last Modified: | 25 Jun 2020 11:03 |
| URI: | https://umcg.studenttheses.ub.rug.nl/id/eprint/2319 |
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