Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
Department of Surgery, Odense University Hospital, Odense, Denmark.
Colorectal Dis. 2021 Apr;23(4):868-874. doi: 10.1111/codi.15480. Epub 2020 Dec 24.
The optimal management of a polyp cancer that has been removed endoscopically is unclear. Further local excision is often advocated to remove the polyp stalk or scar or to ensure clear margins, but the benefit of this is unclear. The aim of this paper is to determine whether the indications for further local excision can be better defined.
Data were collected from two institutions (in UK and Denmark) which maintain prospective databases to collect information on all patients undergoing transanal endoscopic microsurgery (TEM). The study group was all patients who had a TEM after macroscopically complete polypectomy for rectal cancer. Data covering an 11-year period were analysed.
Sixty three patients had TEM with no residual cancer after macroscopically complete polypectomy. Residual adenoma was found in 23 (37%). A postpolypectomy endoscopy had not detected the residual adenoma in three. Malignant local recurrence occurred in five patients (8%) and distant metastases in another two (3%). Recurrence occurred in 4/23 (17%) when there was residual adenoma in the TEM specimen and in 3/40 (7.5%) where there was scar only, although this did not reach significance. In two instances recurrence was around 10 years after TEM. Those with residual adenoma at TEM tended to have poorer survival.
Further local excision often reveals no residual cancer despite microscopically involved polypectomy margins. Careful endoscopy is required to assess the polypectomy site as residual tumour can be missed. In the absence of residual adenoma, TEM does not appear to be of benefit, although a small risk of recurrence exists.
对于内镜下切除的息肉样癌，其最佳处理方法尚不清楚。通常主张进一步局部切除以切除息肉蒂或疤痕，或确保切缘无肿瘤残留，但这种方法的益处尚不清楚。本文旨在确定是否可以更好地定义进一步局部切除的适应证。
从两个机构（英国和丹麦）收集数据，这些机构维护前瞻性数据库以收集所有接受经肛门内镜微创手术（TEM）的患者信息。研究组为所有经直肠镜下完整息肉切除后行 TEM 的患者。分析了为期 11 年的数据。
63 例患者在经直肠镜下完全息肉切除后行 TEM 治疗，未见肿瘤残留。23 例（37%）发现残留腺瘤。3 例残留腺瘤在术后结肠镜检查中未被发现。5 例（8%）发生恶性局部复发，2 例（3%）发生远处转移。在 TEM 标本中发现残留腺瘤的 4/23 例（17%）和仅发现疤痕的 3/40 例（7.5%）中发生复发，但无统计学意义。在 2 例中，复发发生在 TEM 后 10 年左右。TEM 中有残留腺瘤的患者生存情况较差。
尽管显微镜下有肿瘤累及的息肉切除边缘，但进一步局部切除通常不会发现残留肿瘤。需要仔细进行内镜检查以评估息肉切除部位，因为可能会遗漏残留肿瘤。在没有残留腺瘤的情况下，TEM 似乎没有益处，但存在复发的小风险。
