João Mafalda, Alves Susana, Areia Miguel, Elvas Luís, Brito Daniel, Saraiva Sandra, Martins Raquel, Cadime Ana Teresa
Gastroenterology Department, Portuguese Oncology Institute of Coimbra, Coimbra, Portugal.
Endocrinology Department and Head of the Multidisciplinary Neuroendocrine Tumors Group, Portuguese Oncology Institute of Coimbra, Coimbra, Portugal.
GE Port J Gastroenterol. 2022 Aug 26;30(2):107-114. doi: 10.1159/000525964. eCollection 2023 Mar.
The incidence of rectal neuroendocrine tumors (r-NETs) is increasing, and most small r-NETs can be treated endoscopically. The optimal endoscopic approach is still debatable. Conventional endoscopic mucosal resection (EMR) leads to frequent incomplete resection. Endoscopic submucosal dissection (ESD) allows higher complete resection rates but is also associated with higher complication rates. According to some studies, cap-assisted EMR (EMR-C) is an effective and safe alternative for endoscopic resection of r-NETs.
This study aimed to evaluate the efficacy and safety of EMR-C for r-NETs ≤10 mm without muscularis propria invasion or lymphovascular infiltration.
Single-center prospective study including consecutive patients with r-NETs ≤10 mm without muscularis propria invasion or lymphovascular invasion confirmed by endoscopic ultrasound (EUS), submitted to EMR-C between January 2017 and September 2021. Demographic, endoscopic, histopathologic, and follow-up data were retrieved from medical records.
A total of 13 patients (male: 54%; = 7) with a median age of 64 (interquartile range: 54-76) years were included. Most lesions were located at the lower rectum (69.2%, = 9), and median lesion size was 6 (interquartile range: 4.5-7.5) mm. On EUS evaluation, 69.2% ( = 9) of tumors were limited to muscularis mucosa. EUS accuracy for the depth of invasion was 84.6%. We found a strong correlation between size measurements by histology and EUS ( = 0.83, < 0.01). Overall, 15.4% ( = 2) were recurrent r-NETs and had been pretreated by conventional EMR. Resection was histologically complete in 92% (n = 12) of cases. Histologic analysis revealed grade 1 tumor in 76.9% ( = 10) of cases. Ki-67 index was inferior to 3% in 84.6% ( = 11) of cases. The median procedure time was 5 (interquartile range: 4-8) min. Only 1 case of intraprocedural bleeding was reported and was successfully controlled endoscopically. Follow-up was available in 92% ( = 12) of cases with a median follow-up of 6 (interquartile range: 12-24) months with no evidence of residual or recurrent lesion on endoscopic or EUS evaluation.
EMR-C is fast, safe, and effective for resection of small r-NETs without high-risk features. EUS accurately assesses risk factors. Prospective comparative trials are needed to define the best endoscopic approach.
直肠神经内分泌肿瘤（r-NETs）的发病率正在上升，大多数小的r-NETs可以通过内镜治疗。最佳的内镜治疗方法仍存在争议。传统的内镜黏膜切除术（EMR）常常导致切除不完全。内镜黏膜下剥离术（ESD）可实现更高的完整切除率，但也伴随着更高的并发症发生率。根据一些研究，帽辅助EMR（EMR-C）是内镜切除r-NETs的一种有效且安全的替代方法。
本研究旨在评估EMR-C治疗直径≤10 mm且无肌层浸润或脉管浸润的r-NETs的疗效和安全性。
一项单中心前瞻性研究，纳入2017年1月至2021年9月期间连续接受EMR-C治疗的直径≤10 mm、经内镜超声（EUS）证实无肌层浸润或脉管浸润的r-NETs患者。从病历中获取人口统计学、内镜、组织病理学和随访数据。
共纳入13例患者（男性占54%，n = 7），中位年龄为64岁（四分位间距：54 - 76岁）。大多数病变位于直肠下段（69.2%，n = 9），中位病变大小为6 mm（四分位间距：4.5 - 7.5 mm）。经EUS评估，69.2%（n = 9）的肿瘤局限于黏膜肌层。EUS对浸润深度的诊断准确率为84.6%。我们发现组织学测量大小与EUS测量大小之间存在强相关性（r = 0.83，P < 0.01）。总体而言，15.4%（n = 2）为复发性r-NETs，曾接受过传统EMR治疗。92%（n = 12）的病例切除在组织学上是完整的。组织学分析显示76.9%（n = 10）的病例为1级肿瘤。84.6%（n = 11）的病例Ki-67指数低于3%。中位手术时间为5分钟（四分位间距：4 - 8分钟）。仅报告1例术中出血，经内镜成功控制。92%（n = 12）的病例有随访，中位随访时间为6个月（四分位间距：12 - 24个月），内镜或EUS评估均无残留或复发病变的证据。
EMR-C对于切除无高危特征的小r-NETs快速、安全且有效。EUS能准确评估危险因素。需要进行前瞻性对比试验以确定最佳的内镜治疗方法。
