Piecemeal resection of 20- to 25-mm colorectal polyps necessitates short-term surveillance colonoscopy to reduce local recurrence similar to en bloc removal

Abstract Background and study aims En bloc endoscopic mucosal resection (EMR) is preferred over piecemeal resection for polyps ≤ 20 mm. Data on colorectal EMR training are limited. We aimed to evaluate the en bloc EMR rate of polyps ≤ 20 mm among advanced endoscopy trainees and to identify predictors of failed en bloc EMR. Methods This was a multicenter prospective study evaluating trainee performance in EMR during advanced endoscopy fellowship. A logistic regression model was used to identify the number of procedures and lesion cut-off size associated with an en bloc EMR rate of ≥ 80 %. Multivariate analysis was performed to identify predictors of failed en bloc EMR. Results Six trainees from six centers performed 189 colorectal EMRs, of which 104 (55 %) were for polyps ≤ 20 mm. Of these, 57.7 % (60/104) were resected en bloc. Trainees with ≥ 30 EMRs (OR 6.80; 95 % CI: 2.80–16.50; P = 0.00001) and lesions ≤ 17 mm (OR 4.56;95 CI:1.23–16.88; P = 0.02) were more likely to be associated with an en bloc EMR rate of ≥ 80 %. Independent predictors of failed en bloc EMR on multivariate analysis included: larger polyp size (OR:6.83;95 % CI:2.55–18.4; P = 0.0001), right colon location (OR:7.15; 95 % CI:1.31–38.9; P = 0.02), increased procedural difficulty (OR 2.99; 95 % CI:1.13–7.91; P = 0.03), and having performed < 30 EMRs (OR: 4.87; 95 %CI: 1.05–22.61; P = 0.04). Conclusions In this pilot study, we demonstrated that a relatively low proportion of trainees achieved en bloc EMR for polyps ≤ 20 mm and identified procedure volume and lesion size thresholds for successful en bloc EMR and independent predictors for failed en bloc resection. These preliminary results support the need for future efforts to define EMR procedure competence thresholds during training.

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A Surveillance Endoscopy Strategy Based on Local Recurrence Rates after Colorectal Endoscopic Submucosal Dissection

Journal of Clinical Medicine ◽

10.3390/jcm10194591 ◽

2021 ◽

Vol 10 (19) ◽

pp. 4591

Author(s):

Jin Hwa Park ◽

Ji Young Yoon ◽

Sung Wook Hwang ◽

Sang Hyoung Park ◽

Dong-Hoon Yang ◽

...

Keyword(s):

Risk Factors ◽

Local Recurrence ◽

Endoscopic Submucosal Dissection ◽

Incomplete Resection ◽

Recurrence Rates ◽

En Bloc ◽

Submucosal Dissection ◽

Colorectal Endoscopic Submucosal Dissection ◽

Surveillance Endoscopy ◽

Piecemeal Resection

Backgrounds: It is not clear when and how frequently surveillance endoscopy should be performed after colorectal endoscopic submucosal dissection (ESD). We aimed to suggest a surveillance endoscopy strategy by investigating the cumulative local recurrence rates and identifying risk factors for local recurrence after colorectal ESD. Methods: We reviewed the medical records of 770 patients who underwent colorectal ESD for 778 lesions at our institution from 2005 to 2016. We investigated the cumulative local recurrence rates and risk factors for local recurrence. Results: Local recurrence developed in 12 (1.5%) of 778 lesions during the follow-up period of 37.4 ± 31.7 months. The one-, three-, and five-year cumulative local recurrence rates were 0.4%, 1.7%, and 2.2%, respectively. The risk factors for local recurrence were piecemeal resection (odds ratio (OR) 3.948, 95% confidence interval (CI) 1.164–13.385; p = 0.028) and histological incomplete resection (OR 8.713, 95% CI 2.588–29.334; p < 0.001). Local recurrence tended to develop frequently after ESD of early cancers. Conclusions: Short-term surveillance endoscopy should be recommended after piecemeal ESD, histological incomplete resection, and ESD of early colorectal cancers. Surveillance endoscopy with longer intervals can be suggested after en bloc ESD with the histological complete resection of benign colorectal tumors.

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Factors influencing the risk of local recurrence after resection of a single brain metastasis

Journal of Neurosurgery ◽

10.3171/2009.11.jns09659 ◽

2010 ◽

Vol 113 (2) ◽

pp. 181-189 ◽

Cited By ~ 76

Author(s):

Akash J. Patel ◽

Dima Suki ◽

Mustafa Aziz Hatiboglu ◽

Hiba Abouassi ◽

Weiming Shi ◽

...

Keyword(s):

Local Recurrence ◽

Brain Metastasis ◽

Proportional Hazards Model ◽

Cox Proportional Hazards ◽

Cox Proportional Hazards Model ◽

Cancer Center ◽

Karnofsky Performance Scale ◽

En Bloc ◽

Single Brain Metastasis ◽

Piecemeal Resection

Object Local recurrence (LR) of a resected brain metastasis occurs in up to 46% of patients. Postoperative whole-brain radiation therapy (WBRT) reduces that incidence. To isolate factors associated with the risk of LR after resection, the authors only studied patients who did not receive adjuvant radiotherapy. Methods The authors reviewed data from 570 cases involving patients who had undergone resection of a previously untreated single brain metastasis at The University of Texas M. D. Anderson Cancer Center between 1993 and 2006 without receiving postoperative WBRT. All tumors were measured preoperatively on MR images. The resection method (en bloc resection [EBR] or piecemeal resection [PMR]) was noted at the time of surgery. Predictors of LR were assessed using the Cox proportional hazards model. Results The median patient age was 58 years, 55% were male, and 88% had a Karnofsky Performance Scale Score ≥ 80. The most common primary cancers were those of the lung (28%), skin (melanoma, 21%), kidney (19%), and breast (11%). Piecemeal resection was performed in 201 patients (35%) and EBR in 369 (65%). Local recurrence developed in 84 patients (15%). The histological type of the primary cancer did not significantly predict LR; however, 7 of 22 patients with sarcoma developed LR (p = 0.16). The authors identified 2 variables that increased the risk of LR. Undergoing PMR carried a significantly higher LR risk than EBR (crude hazard ratio [HR] 1.7, 95% CI 1.1–2.6, p = 0.03). Tumors exceeding the median volume (9.7 cm3) had a significantly higher LR risk than those that were < 9.7 cm3 (crude HR 1.7; 95% CI 1.1–2.6; p = 0.02). In the multivariate analysis, small tumors removed by EBR had a significantly lower LR risk. Conclusions The LR risk of a single brain metastasis is influenced by biological factors (such as tumor volume) and treatments (such as the resection method). Early administration of postoperative WBRT may be particularly warranted when such negative tumor-related prognostic factors are noted or when treatment-related ones such as PMR are unavoidable.

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A121 UNDERWATER EMR FOR NON-LIFTING SESSILE COLORECTAL LESIONS

Journal of the Canadian Association of Gastroenterology ◽

10.1093/jcag/gwab002.119 ◽

2021 ◽

Vol 4 (Supplement_1) ◽

pp. 102-103

Author(s):

C Galts ◽

R Barclay ◽

D Percy

Keyword(s):

Surgical Resection ◽

De Novo ◽

Lesion Size ◽

Colorectal Polyps ◽

Invasive Cancer ◽

Previous Attempt ◽

Tubular Adenoma ◽

En Bloc ◽

Clinical Role ◽

Submucosal Injection

Abstract Background Sessile colorectal lesions which do not elevate with submucosal injection — “non-lifting” lesions — are considered poor candidates for EMR due to concerns of possible invasive cancer and increased procedural risk. However, a non-lifting sign is an unreliable predictor of malignancy, relegating many benign lesions to surgical resection. Underwater EMR (UEMR), which obviates submucosal injection, is effective for sessile colorectal polyps but has not been evaluated specifically for non-lifting lesions. Aims The aim of this study was to assess the efficacy of UEMR for “non-lifting” large sessile colorectal lesions with the hypothesis that UEMR may have a clinical role in managing complex lesions. Methods We reviewed our database from 2016 to 2019 for patients referred for large (≥ 20 mm) non-lifting colorectal lesions without overt signs of invasive cancer, who subsequently underwent UEMR. Results Thirty-two cases were successfully treated with single session UEMR. 18 (56%) were de novo lesions whereas the remainder had undergone previous attempt(s) at conventional EMR. The mean lesion size was 37 ± 17 mm. 4 cases (13%) were resected en bloc; the remainder piecemeal. Final pathology was T1 adenocarcinoma, N=3 (9%); tubulovillous adenoma, N=15 (47%); tubular adenoma, N=8 (25%); sessile serrated, N=6 (19%); high-grade dysplasia, N=2 (6%). One patient with cancer underwent surgical resection (T1N0); the remainder had endoscopic follow-up over 8 ± 3 months with benign recurrent/residual lesions in 8%, all amenable to UEMR. There were no procedural complications. Conclusions In this series of large sessile non-lifting colorectal lesions, UEMR was effective for both de novo and previously treated lesions, obviating surgery in the majority of cases. Funding Agencies None

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Discontinuities in a Transverse Velocity Profile of a Valley Glacier Measured by Photogrammetry

Annals of Glaciology ◽

10.1017/s0260305500007011 ◽

1989 ◽

Vol 12 ◽

pp. 89-91 ◽

Cited By ~ 3

Author(s):

W. Kick

Keyword(s):

Velocity Profile ◽

Single Unit ◽

Transverse Velocity ◽

Short Term ◽

En Bloc ◽

Block Motion ◽

Valley Glacier ◽

Unit Block ◽

Time Periods ◽

Shear Planes

The surface movement of part of a Nanga Parbat (Himalaya) glacier immediately below an ice fall has been investigated by terrestrial stereophotogrammetry. This method provides an opportunity of measuring many more points than by using other procedures. The shape of the transverse velocity profile indicated normal stream-like flow and not “blockschollen movement”, as might have been expected, because of its high velocity (45 cm/d). But, one feature of the ice fall above had been carried down-glacier to the location of the profile; namely, several discontinuities along the velocity diagram. The ice fall had transmitted a small part of its splitting into seracs to the flatter area below, but not its blockschollen movement. There seems to be a contradiction in that on one side there are discontinuities, i.e. the glacier is torn up into blocks by shear planes, but on the other side the glacier moves en bloc. In fact, a short-term investigation over hours or just a few days discloses cracks but, after time periods of a week or more, these irregularities compensate for one another so that they merge into a single unit block motion.

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Reduced local recurrence with en bloc radical cystectomy

European Urology ◽

10.1016/s0302-2838(21)01186-6 ◽

2021 ◽

Vol 79 ◽

pp. S1122-S1123

Author(s):

E. Kjøbli ◽

Ø. Salvesen ◽

C-J. Arum

Keyword(s):

Local Recurrence ◽

Radical Cystectomy ◽

En Bloc

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Mobile spine chordoma: results of 166 patients from the AOSpine Knowledge Forum Tumor database

Journal of Neurosurgery Spine ◽

10.3171/2015.7.spine15201 ◽

2016 ◽

Vol 24 (4) ◽

pp. 644-651 ◽

Cited By ~ 30

Author(s):

Ziya L. Gokaslan ◽

Patricia L. Zadnik ◽

Daniel M. Sciubba ◽

Niccole Germscheid ◽

C. Rory Goodwin ◽

...

Keyword(s):

Local Recurrence ◽

Survival Data ◽

Large Scale ◽

Surgical Techniques ◽

En Bloc Resection ◽

Bloc Resection ◽

En Bloc ◽

Increased Risk ◽

Significant Difference ◽

Mobile Spine

OBJECT A chordoma is an indolent primary spinal tumor that has devastating effects on the patient's life. These lesions are chemoresistant, resistant to conventional radiotherapy, and moderately sensitive to proton therapy; however, en bloc resection remains the preferred treatment for optimizing patient outcomes. While multiple small and largely retrospective studies have investigated the outcomes following en bloc resection of chordomas in the sacrum, there have been few large-scale studies on patients with chordomas of the mobile spine. The goal of this study was to review the outcomes of surgically treated patients with mobile spine chordomas at multiple international centers with respect to local recurrence and survival. This multiinstitutional retrospective study collected data between 1988 and 2012 about prognosis-predicting factors, including various clinical characteristics and surgical techniques for mobile spine chordoma. Tumors were classified according to the Enneking principles and analyzed in 2 treatment cohorts: Enneking-appropriate (EA) and Enneking-inappropriate (EI) cohorts. Patients were categorized as EA when the final pathological assessment of the margin matched the Enneking recommendation; otherwise, they were categorized as EI. METHODS Descriptive statistics were used to summarize the data (Student t-test, chi-square, and Fisher exact tests). Recurrence and survival data were analyzed using Kaplan-Meier survival curves, log-rank tests, and multivariate Cox proportional hazard modeling. RESULTS A total of 166 patients (55 female and 111 male patients) with mobile spine chordoma were included. The median patient follow-up was 2.6 years (range 1 day to 22.5 years). Fifty-eight (41%) patients were EA and 84 (59%) patients were EI. The type of biopsy (p < 0.001), spinal location (p = 0.018), and if the patient received adjuvant therapy (p < 0.001) were significantly different between the 2 cohorts. Overall, 58 (35%) patients developed local recurrence and 57 (34%) patients died. Median survival was 7.0 years postoperative: 8.4 years postoperative for EA patients and 6.4 years postoperative for EI patients (p = 0.023). The multivariate analysis showed that the EI cohort was significantly associated with an increased risk of local recurrence in comparison with the EA cohort (HR 7.02; 95% CI 2.96–16.6; p < 0.001), although no significant difference in survival was observed. CONCLUSIONS EA resection plays a major role in decreasing the risk for local recurrence in patients with chordoma of the mobile spine.

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