Retrospective Cohort Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Jul 16, 2020; 12(7): 198-211
Published online Jul 16, 2020. doi: 10.4253/wjge.v12.i7.198
Colon mucosal neoplasia referred for endoscopic mucosal resection: Recurrence of adenomas and prediction of submucosal invasion
Mamoon Ur Rashid, Neelam Khetpal, Hammad Zafar, Saeed Ali, Evgeny Idrisov, Yuan Du, Assaf Stein, Deepanshu Jain, Muhammad Khalid Hasan
Mamoon Ur Rashid, Neelam Khetpal, Hammad Zafar, Yuan Du, Department of Internal Medicine, Advent Health Graduate Medical Education, Orlando, FL 32804, United States
Saeed Ali, Department of Internal Medicine, Univerity of Iowa hospital, Iowa City, IA 52242, United States
Evgeny Idrisov, Department of Gastroenterology, University of Oklahoma Health Sciences, Oklahoma, OK 73104, United States
Assaf Stein, Deepanshu Jain, Muhammad Khalid Hasan, Center for Interventional Endoscopy, AdventHealth, Orlando, FL 32803, United States
Author contributions: Rashid MU, Khetpal N, Zafar H, Ali S, Idrisov E and Du Y was involved in conceptualization, writing-original draft, software and visualization; Ali S, Idrisov E and Du Y was involved in data curation, formal analysis, investigation, methodology; Stein A, Jain D and Hasan MK performed writing review and editing; all authors have read and approve the final manuscript.
Institutional review board statement: The study was reviewed and approved for publication by our institutional reviewer.
Informed consent statement: As it is a retrospective study and data was reviewed retrospectively from chart review so patient’s consents are not needed.
Conflict-of-interest statement: All the Authors except Dr. Hasan have no conflict of interest related to the manuscript Dr. Hasan is consultant for Olympus America and Boston Scientific Corporation.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Mamoon Ur Rashid, MBBS, MD, Doctor, Medical Resident, Department of Internal Medicine, Advent Health Graduate Medical Education, 2501 North Orange Avenue, Orlando, FL 32804, United States. mamoon.rashid.md@adventhealth.com
Received: March 10, 2020
Peer-review started: March 10, 2020
First decision: April 2, 2020
Revised: May 28, 2020
Accepted: June 10, 2020
Article in press: June 10, 2020
Published online: July 16, 2020
Processing time: 119 Days and 8.1 Hours
Abstract
BACKGROUND

Endoscopic mucosal resection (EMR) is an effective and minimally invasive alternative to surgery for large polyps and laterally spreading lesions. Gross morphology and surface characteristics may help predict submucosal invasion of the lesion (SMIL) during endoscopic evaluation. This is one of the largest single-center studies reporting endoscopic mucosal resection for larger (≥ 20 mm) colorectal lesions in the United States.

AIM

To determine the recurrence rate of adenomas and endoscopic features that may predict submucosal invasion of colonic mucosal neoplasia.

METHODS

This is a retrospective cohort study of all the patients referred for endoscopic mucosal resection for lesions ≥ 20 mm, spanning a period from January 2013 to February 2017. The main outcome measure was identifying features that may predict submucosal invasion of mucosal lesions and predict recurrence of adenomas on follow-up surveillance colonoscopy performed at 4-6 mo.

RESULTS

A total of 480 patients with 500 lesions were included in the study. The median age was 68 (Inter quantile range: 14) with 52% males. The most common lesion location was ascending colon (161; 32%). Paris classification 0-IIa (Flat elevation of mucosa - 316; 63.2%); Kudo Pit Pattern IIIs (192; 38%) and Granular surface morphology (260; 52%) were most prevalent. Submucosal invasion was present in 23 (4.6%) out of 500 lesions. The independent risk factors for SMIL were Kudo Pit Pattern IIIL + IV and V (Odds ratio: 4.5; P value < 0.004) and Paris classification 0-IIc (Odds ratio: 18.2; P value < 0.01). Out of 500, 354 post-endoscopic mucosal resection scars were examined at surveillance colonoscopy. Recurrence was noted in 21.8% (77 cases).

CONCLUSION

There was overall low prevalence of SMIL in our study. Kudo pit pattern (IIIL + IV and V) and Paris classification 0-IIc were the only factors identified as an independent risk factor for submucosal invasion. The independent risk factor for recurrence was adenoma size (> 40 mm). Almost all recurrences (98.8%) were treated endoscopically.

Keywords: Endoscopy; Polyp; Endoscopic mucosal resection; Recurrence; Submucosal invasion

Core tip: Endoscopic mucosal resection is an effective and minimally invasive alternative to surgery for large polyps and laterally spreading lesions. Endoscopic features can also help identify the high-risk features for submucosal invasion and recurrence of adenomas. Our study conducted review of 480 patients with 500 lesions. We found endoscopic mucosal resection to be an effective treatment for large colon lesions. We were also able to identify independent risk factors for submucosal invasion (Kudo Pit Pattern IIIL + IV and V and Paris classification 0-IIc) and recurrence.