Risk Stratification for Covert Invasive Cancer Among Patients Referred for Colonic Endoscopic Mucosal Resection: A Large Multicenter Cohort
Risk Stratification for Covert Invasive Cancer Among Patients Referred for Colonic Endoscopic Mucosal Resection: A Large Multicenter Cohort
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DOI：
10.1053/j.gastro.2017.05.047
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发表时间：
2017-09-01
期刊：
影响因子：
29.4
通讯作者：
Bourke, Michael J.
中科院分区：
文献类型：
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作者：
Burgess, Nicholas G.;Hourigan, Luke F.;Bourke, Michael J.
背景与目的：在患有大肠大的无蒂息肉或侧向扩散性病变的患者中，识别那些有粘膜下浸润性癌（SMIC）风险的患者是很重要的。具有明显SMIC内镜证据的病变被转诊进行手术，尽管那些没有这些特征的病变可能仍然包含在内镜检查中不可见的SMIC（隐性SMIC）。具有高隐性SMIC风险的病变可能更适合内镜粘膜下剥离术而不是内镜粘膜切除术（EMR）。我们分析了一组大结肠病变患者，以确定与SMIC相关的因素，并检查病变没有明显的内镜高风险体征，以确定与隐性SMIC相关的因素。方法：采用正交设计法我们对2008年9月至2016年9月在澳大利亚学术医院转诊进行EMR的大型无蒂或扁平结直肠息肉或侧向扩散病变（>= 20 mm）的连续患者进行了前瞻性队列研究。我们收集了患者和病变特征、手术结果和组织学结果的数据。由于锯齿状病变具有独特的表型和生物学特征，我们将其从隐性SMIC的分析中排除。结果：我们分析了2106例患者（平均年龄67.7岁; 53.2%为男性）的2277处病变（平均尺寸36.9 mm）。SMIC在171个病灶（7.6%）中明显。与SMIC相关的因素包括Kudo小凹模式V、凹陷成分（0-IIc）、直肠乙状结肠位置、0-Is或0-IIa+Is巴黎分类、非颗粒状表面形态和尺寸增加。排除明显SMIC或锯齿状病变后，与隐性SMIC相关的因素为直肠乙状结肠位置（比值比，1.87; P= 0.01）、联合巴黎分类、表面形态（比值比，3.96-22.5）和增大的大小（比值比，1.16/10 mm; P= 0.012）。结论：在一项对2106例因大的无蒂或扁平的结直肠息肉或侧向扩散性病变而接受EMR的患者的前瞻性研究中，我们将直肠乙状结肠位置、结合巴黎分类和表面形态以及大小增加与隐性恶性肿瘤风险增加相关联。直肠乙状结肠0-Is和0-IIa+Is非颗粒性病变恶性风险高，而近端0-Is或0-IIa颗粒性病变恶性风险低。这些发现可用于决定哪些患者应接受内镜粘膜下剥离术、EMR或手术。ClinicalTrials.gov，编号：NCT 02000141。
BACKGROUND & AIMS: Among patients with large colorectal sessile polyps or laterally spreading lesions, it is important to identify those at risk for submucosal invasive cancer (SMIC). Lesions with overt endoscopic evidence of SMIC are referred for surgery, although those without these features might still contain SMIC that is not visible on endoscopic inspection (covert SMIC). Lesions with a high covert SMIC risk might be better suited for endoscopic submucosal dissection than for endoscopic mucosal resection (EMR). We analyzed a group of patients with large colon lesions to identify factors associated with SMIC, and examined lesions without overt endoscopic high-risk signs to determine factors associated with covert SMIC. METHODS: We performed a prospective cohort study of consecutive patients referred for EMR of large sessile or flat colorectal polyps or laterally spreading lesions (>= 20 mm) at academic hospitals in Australia from September 2008 through September 2016. We collected data on patient and lesion characteristics, outcomes of procedures, and histology findings. We excluded serrated lesions from the analysis of covert SMIC due to their distinct phenotype and biologic features. RESULTS: We analyzed 2277 lesions (mean size, 36.9 mm) from 2106 patients (mean age, 67.7 years; 53.2% male). SMIC was evident in 171 lesions (7.6%). Factors associated with SMIC included Kudo pit pattern V, a depressed component (0-IIc), rectosigmoid location, 0-Is or 0-IIa+Is Paris classification, non-granular surface morphology, and increasing size. After exclusion of lesions that were obviously SMIC or serrated, factors associated with covert SMIC were rectosigmoid location (odds ratio, 1.87; P=similar to.01), combined Paris classification, surface morphology (odds ratios, 3.96-22.5), and increasing size (odds ratio, 1.16/10 mm; P=.012). CONCLUSIONS: In a prospective study of 2106 patients who underwent EMR for large sessile or flat colorectal polyps or laterally spreading lesions, we associated rectosigmoid location, combined Paris classification and surface morphology, and increasing size with increased risk for covert malignancy. Rectosigmoid 0-Is and 0-IIa+Is non-granular lesions have a high risk for malignancy, whereas proximally located 0-Is or 0-IIa granular lesions have a low risk. These findings can be used to inform decisions on which patients should undergo endoscopic submucosal dissection, EMR, or surgery. ClinicalTrials.gov, Number: NCT02000141.