Gastroenterology

Gastroenterology

Volume 127, Issue 2, August 2004, Pages 385-394
Gastroenterology

Clinical-alimentary tract
Risk factors for an adverse outcome in early invasive colorectal carcinoma

https://doi.org/10.1053/j.gastro.2004.04.022Get rights and content

Abstract

Background & Aims:: Various histologic findings exist for managing patients with malignant polyps. Our goal was to determine the criteria for a conservative approach to patients with locally excised early invasive carcinoma. Methods: In 292 early invasive tumors (local resection followed by laparotomy [80 tumors, group A], local resection only [41 tumors, group B], and primarily laparotomy [171 tumors, group C], potential parameters for nodal involvement were analyzed. The status of the endoscopic resection margin also was examined for the risk for intramural residual tumor. Results: Unfavorable tumor grade, definite vascular invasion, and tumor budding were the combination of qualitative factors that most effectively discriminated the risk for nodal involvement in patients in groups A-C. The nodal involvement rate was 0.7%, 20.7%, and 36.4% in the no-risk, single-risk, and multiple-risks group, respectively. Thirty-two and 9 patients from group B were assigned to the no-risk and one-risk group, respectively; extramural recurrence occurred in 2 patients with risk factors. Considering quantitative risk parameters for submucosal invasion (i.e., width ≥4000 μm or depth ≥2000 μm), nodal involvement (including micrometastases) was not observed in the redefined no-risk group that accounted for about 25% of the patients from groups A and C. An insufficiency of endoscopic resection could be evaluated most precisely based on the coagulation-involving tumor, rather than the 1-mm rule for the resection margin. Conclusions: Provided that the criterion of sufficient excision is satisfied, the absence of an unfavorable tumor grade, vascular invasion, tumor budding, and extensive submucosal invasion would be the strict criteria for a wait-and-see policy.

Section snippets

Early invasive colorectal cancers examined

Data on 292 early invasive colorectal adenocarcinomas from 285 consecutive patients treated between 1980 and 2002 were gathered from the National Defense Medical College Hospital (251 cancers, including 33 cancers treated first with local excision at other hospitals and National Defense Medical College Hospital provided the second opinions about their additional laparotomy) and the Self-Defense Forces Central Hospital (41 cancers). These tumors were confirmed pathologically to invade through

Qualitative parameters as risk factors for lymph node metastases

Neither the type of growth pattern, the presence of a depression zone on the tumor surface, the presence of an adenoma component, or mucin production was found to have a significant impact on lymph node metastases. The incidence of nodal involvement was, however, significantly affected by the following histologic parameters: cribriform formation, tumor grade, vascular invasion, and tumor budding (Table 3). Multivariate logistic analysis showed that these 4 parameters have an independent impact

Discussion

In specimens of early invasive colorectal cancer, there are more than a few potential indicators of adverse outcomes after minor excision (Table 1). Qualitative parameters such as the tumor grade, vascular invasion, tumor budding, and cribriform formation, and quantitative parameters such as Haggitt’s system and the width and depth of submucosal invasion, are the parameters significantly related to nodal involvement. Obviously, what is practically important is to determine the ultimate

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