Endoscopic mucosal resection: still a reliable therapeutic option for gastrointestinal neuroendocrine tumors

Abstract Background Neuroendocrine tumors (NETs), as a rare and heterogeneous category of solid tumors, feature various morphologies and behaviors. In recent years, the incidence of NETs has continued to increase. Endoscopic mucosal resection (EMR) is one of the therapeutic modalities for the treatment of gastric and rectal NETs. Methods We evaluated patients with well-differentiated NETs of the stomach, duodenum, or rectum between 2011 and 2018. In this study, all cases with tumors confined to the mucosal or submucosal layers and smaller than 20 mm were resected using the EMR technique. We used EUS, CT scan, or MRI to exclude patients with advanced disease. All patients were actively monitored for recurrence according to the recommended protocols. Results A total of 36 patients with NETs entered the study; 17 (47.2%) were female and the remaining 19 (52.8%) were male, with a total age range of 20–74 years (mean: 52.47 ± 13.47 years). Among the tumors, 31 cases (86.1%) were G1 and the remaining 5 (13.9%) were G2. Based on the pathology reports, 22 tumors (61.1%) were smaller than 1 cm, while the remaining 14 (38.9%) were between 1–2 cm. Twenty-two patients (61.1%) had a margin of specimen involved with the tumor. No recurrence was observed during the mean follow-up time of 63.5 ± 19.8 months (range: 39–103 months). All 36 cases survived during the study period. Conclusion Conventional EMR procedure provides low chance of R0 (complete resection) achievement in gastrointestinal NETs smaller than 20 mm and limited to the mucosa or sub mucosa. However, it could be an option if patients are closely followed. Postoperative marginal involvement is not a reliable predictor of disease recurrence, which may be explained by the deleterious effect of heat coagulation and cauterization applied during tumor removal.

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Measurement of circulating transcript levels (NETest) to detect disease recurrence and improve follow-up after curative surgical resection of well-differentiated pancreatic neuroendocrine tumors

Journal of Surgical Oncology ◽

10.1002/jso.25129 ◽

2018 ◽

Vol 118 (1) ◽

pp. 37-48 ◽

Cited By ~ 11

Author(s):

Cansu G. Genç ◽

Anneke P.J. Jilesen ◽

Els J.M. Nieveen van Dijkum ◽

Heinz-Josef Klümpen ◽

Casper H.J. van Eijck ◽

...

Keyword(s):

Surgical Resection ◽

Neuroendocrine Tumors ◽

Disease Recurrence ◽

Pancreatic Neuroendocrine Tumors ◽

Transcript Levels ◽

Well Differentiated

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Circumferential submucosal incision prior to endoscopic mucosal resection provides comparable clinical outcomes to submucosal dissection for well-differentiated neuroendocrine tumors of the rectum

Surgical Endoscopy ◽

10.1007/s00464-014-3831-0 ◽

2014 ◽

Vol 29 (6) ◽

pp. 1500-1505 ◽

Cited By ~ 8

Author(s):

Dae Young Cheung ◽

Soo Kyoung Choi ◽

Hyung-Keun Kim ◽

Sung Soo Kim ◽

Hiun-Suk Chae ◽

...

Keyword(s):

Clinical Outcomes ◽

Endoscopic Mucosal Resection ◽

Neuroendocrine Tumors ◽

Mucosal Resection ◽

Submucosal Dissection ◽

Well Differentiated

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Efficacy and safety of cap-assisted endoscopic mucosal resection for treatment of nonlifting colorectal polyps

Endoscopy ◽

10.1055/a-1559-2391 ◽

2021 ◽

Author(s):

Veronique R. H. Van der Voort ◽

Leon M. G. Moons ◽

Wilmar de Graaf ◽

Ruud W. M. Schrauwen ◽

Wouter L. Hazen ◽

...

Keyword(s):

Endoscopic Mucosal Resection ◽

Endoscopic Therapy ◽

Therapeutic Option ◽

Colorectal Polyps ◽

Efficacy And Safety ◽

Mucosal Resection ◽

Median Size ◽

Polyp Tissue ◽

Benign Histology

Background Suboptimal lifting increases complexity of endoscopic mucosal resection (EMR) for benign colorectal polyps. Cap-assisted EMR (EMR-C) may allow fibrotic polyp tissue to be captured in the snare. This study evaluated the efficacy and safety of EMR-C for benign nonlifting colorectal polyps. Methods This was a multicenter study, which prospectively registered all EMR-C procedures (2016–2018) for presumed benign nonlifting colorectal polyps. Results 70 nonlifting polyps with a median size of 25 mm (interquartile range [IQR] 15–40) were treated with EMR-C. Complete polyp removal was achieved in 68 (97.1 %), including 47 (67.1 %) with EMR-C alone. Overall, 66 polyps showed benign histology, and endoscopic follow-up after a median of 6 months (IQR 6–10) showed recurrence in 19.7 %. First (n = 10) and second (n = 2) benign recurrences were all treated endoscopically. Deep mural injury type III–V occurred in 7.4 % and was treated successfully with clips. Conclusion EMR-C may be an alternative therapeutic option for removal of benign nonlifting polyp tissue. Although recurrence still occurs, repeat endoscopic therapy usually leads to complete polyp clearance.

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UNDERWATER ENDOSCOPIC MUCOSAL RESECTION FOR SMALL RECTAL NEUROENDOCRINE TUMORS

10.1055/s-0039-1681667 ◽

2019 ◽

Author(s):

L Coutinho ◽

O Okazaki ◽

C Casamali ◽

L Lenz ◽

C Pennacchi ◽

...

Keyword(s):

Endoscopic Mucosal Resection ◽

Neuroendocrine Tumors ◽

Mucosal Resection

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Anchoring the snare tip is a feasible endoscopic mucosal resection method for small rectal neuroendocrine tumors

Scientific Reports ◽

10.1038/s41598-021-92462-y ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Jeongseok Kim ◽

Jisup Kim ◽

Eun Hye Oh ◽

Nam Seok Ham ◽

Sung Wook Hwang ◽

...

Keyword(s):

Endoscopic Mucosal Resection ◽

Neuroendocrine Tumors ◽

Similar Efficacy ◽

En Bloc Resection ◽

Lesion Size ◽

Bloc Resection ◽

En Bloc ◽

Delayed Bleeding ◽

Mucosal Resection ◽

The Mean

AbstractSmall rectal neuroendocrine tumors (NETs) can be treated using cap-assisted endoscopic mucosal resection (EMR-C), which requires additional effort to apply a dedicated cap and snare. We aimed to evaluate the feasibility of a simpler modified endoscopic mucosal resection (EMR) technique, so-called anchored snare-tip EMR (ASEMR), for the treatment of small rectal NETs, comparing it with EMR-C. We retrospectively evaluated 45 ASEMR and 41 EMR-C procedures attempted on small suspected or established rectal NETs between July 2015 and May 2020. The mean (SD) lesion size was 5.4 (2.2) mm and 5.2 (1.7) mm in the ASEMR and EMR-C groups, respectively (p = 0.558). The en bloc resection rates of suspected or established rectal NETs were 95.6% (43/45) and 100%, respectively (p = 0.271). The rates of histologic complete resection of rectal NETs were 94.1% (32/34) and 88.2% (30/34), respectively (p = 0.673). The mean procedure time was significantly shorter in the ASEMR group than in the EMR-C group (3.12 [1.97] vs. 4.13 [1.59] min, p = 0.024). Delayed bleeding occurred in 6.7% (3/45) and 2.4% (1/41) of patients, respectively (p = 0.618). In conclusion, ASEMR was less time-consuming than EMR-C, and showed similar efficacy and safety profiles. ASEMR is a feasible treatment option for small rectal NETs.

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FAS and Subsequent Therapies in Pancreatic Neuroendocrine Tumors

Neuroendocrinology ◽

10.1159/000514339 ◽

2021 ◽

Author(s):

Jane E. Rogers ◽

Michael Lam ◽

Daniel M. Halperin ◽

Cecile G. Dagohoy ◽

James C. Yao ◽

...

Keyword(s):

Neuroendocrine Tumors ◽

Cox Regression ◽

Progression Free Survival ◽

Pancreatic Neuroendocrine Tumors ◽

Free Survival ◽

Prior Therapy ◽

Well Differentiated ◽

Grade 3 ◽

Line Of Therapy

We evaluated outcomes of treatment with 5-fluorouracil (5-FU), doxorubicin, and streptozocin (FAS) in well-differentiated pancreatic neuroendocrine tumors (PanNETs) and its impact on subsequent therapy (everolimus or temozolomide). Advanced PanNET patients treated at our center from 1992 to 2013 were retrospectively reviewed. Patients received bolus 5-FU (400 mg/m2), streptozocin (400 mg/m2) (both IV, days 1-5) and doxorubicin (40 mg/m2 IV, day 1) every 28 days. Overall response rate (ORR) was assessed using RECIST version 1.1. Of 243 eligible patients, 220 were evaluable for ORR, progression-free survival (PFS), and toxicity. Most (90%) had metastatic, nonfunctional PanNETs; 14% had prior therapy. ORR to FAS was 41% (95% confidence interval [CI]: 36-48%). Median follow-up was 61 months. Median PFS was 20 (95% CI: 15-23) months; median overall survival (OS) was 63 (95% CI: 60-71) months. Cox regression analyses suggested improvement with first-line vs subsequent lines of FAS therapy. Main adverse events ≥ grade 3 were neutropenia (10%) and nausea/vomiting (5.5%). Dose reductions were required in 32% of patients. Post-FAS everolimus (n=108; 68% second line) had a median PFS of 10 (95% CI: 8-14) months. Post-FAS temozolomide (n=60; 53% > fourth line) had an ORR of 13% and median PFS of 5.2 (95% CI: 4-12) months. In this largest reported cohort of PanNETs treated with chemotherapy, FAS demonstrated activity without significant safety concerns. FAS did not appear to affect subsequent PFS with everolimus; this sequence is being evaluated prospectively. Responses were noted with subsequent temozolomide-based regimens although PFS was possibly limited by line of therapy.

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Risk factors for colon adenomas recurrence after endoscopic mucosal resection

Koloproktologia ◽

10.33878/2073-7556-2021-20-1-10-16 ◽

2021 ◽

Vol 20 (1) ◽

pp. 10-16

Author(s):

Yu. E. Vaganov ◽

V. V. Veselov ◽

A. A. Likutov ◽

E. A. Khomyakov ◽

S. V. Chernyshov ◽

...

Keyword(s):

Risk Factors ◽

Endoscopic Mucosal Resection ◽

Disease Recurrence ◽

Morbidity Rate ◽

Severe Dysplasia ◽

En Bloc ◽

Mucosal Resection ◽

Colon Adenomas ◽

Independent Risk Factors ◽

Mucosal Fold

Aim: to identify risk factors for neoplasms recurrence removed by endoscopic mucosal resection (EMR).Patients and methods: the single-center retrospective observational study included 207 patients with 260 benign colon neoplasms. There were 95 (45.9%) males and 112 (54.1%) females. The median age of the patients was 67 (27-80) years. The results obtained were assessed using following criteria: morbidity rate, complication type, hospital stay, tumor site, number of neoplasms in colon, lateral growth, fragmentation rate, technical difficulties (mucosal fold convergence)during surgery, grade of dysplasia, recurrence rate.Results: intraoperative fragmentation of the neoplasms during mucosectomy occurred in 48/260 (18.5%) cases. Postoperative complications within the period of up to 30 days occurred in 13/207 (6.3%) patients. The most frequent 9 (4.2%) postoperative complication arising after mucosectomy was post-polypectomy syndrome. Another 4 (2.0%) patients produced bleeding after the surgery, which required repeated endoscopic procedure. No mortality occurred. The tumor size exceeding 25 mm (Exp (B) = 0.179; 95% CI = 0.05-0.7; p = 0.014), severe dysplasia (Exp (B) = 0.113; 95% CI = 0.03-0.4; p = 0.001) and fold convergence (Exp (B) = 0.2; 95% CI = 0.07-0.7; p = 0.015) are independent risk factors for disease recurrence.Conclusion: mucosectomy is indicated for colon adenomas if its size does not exceed 25 mm and can be removed en bloc.

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Endoscopic Mucosal Resection: Early Experience in British Columbia

Canadian Journal of Gastroenterology ◽

10.1155/2010/897473 ◽

2010 ◽

Vol 24 (4) ◽

pp. 239-244 ◽

Cited By ~ 6

Author(s):

Mayur Brahmania ◽

Eric Lam ◽

Jennifer Telford ◽

Robert Enns

Keyword(s):

British Columbia ◽

Barrett’S Esophagus ◽

Endoscopic Mucosal Resection ◽

Barrett's Esophagus ◽

Low Grade ◽

Complication Rates ◽

The Third ◽

Mucosal Resection ◽

The Mean

BACKGROUND: Endoscopic mucosal resection (EMR) has been proposed as a primary method of managing patients with dysplasia- or mucosal-based cancers of the esophagus.OBJECTIVES: To evaluate the use of EMR for the treatment of Barrett’s esophagus with dysplasia or early adenocarcinoma, assessing efficacy, complication rates and long-term outcomes.METHODS: All patients who underwent EMR at St Paul’s Hospital (Vancouver, British Columbia) were reviewed. Eligible patients were assessed with aggressive biopsy protocols. Detected cancers were staged with both endoscopic ultrasound imaging and computed tomography. Appropriate patients were offered EMR using a commercially available mucosectomy device. EMR was repeated at six- to eight-week intervals until complete. Patients with less than one year of follow-up or who were undergoing other ablative methods were excluded.RESULTS: Twenty-two patients (all men) with a mean (± SD) age of 67±10.6 years were identified. The mean duration of gastroesophageal reflux disease was 17 years (range four to 40 years) and all were receiving proton pump inhibitor therapy. The mean length of Barrett’s esophagus was 5.5±3.5 cm. One patient had no dysplasia (isolated nodule), three had low-grade dysplasia, 15 had high-grade dysplasia (HGD) and three had adenocarcinoma. A mean of 1.7±0.83 endoscopic sessions were performed, with a mean of 6±5.4 sections removed. Following EMR, three patients developed strictures; two of these patients had pre-existing strictures and the third required two dilations, which resolved his symptoms. There were no other complications. Three patients underwent esophagectomy. Two had adenocarcinoma or HGD in a pre-existing stricture. The third patient had an adenocarcinoma not amenable to EMR. One patient with a long segment of Barrett’s esophagus underwent radiofrequency ablation. At a median follow-up of two years (range one to three years), the remaining 18 patients (82%) had no evidence of HGD or cancer.CONCLUSION: Most patients with esophageal dysplasia can be managed with EMR. Individuals with pre-existing strictures require other endoscopic and/or surgical methods to manage their dysplasia or adenocarcinoma.

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