ABSTRACT
BACKGROUND AND AIMS: We aimed to compare the long-term outcomes of patients with high-risk T1 colorectal cancer (CRC) resected endoscopically who received either additional surgery or surveillance. METHODS: We used data from routine care to emulate a target trial aimed at comparing 2 strategies after endoscopic resection of high-risk T1 CRC: surgery with lymph node dissection (treatment group) versus surveillance alone (control group). All patients from 14 tertiary centers who underwent an endoscopic resection for high-risk T1 CRC between March 2012 and August 2019 were included. The primary outcome was a composite outcome of cancer recurrence or death at 48 months. RESULTS: Of 197 patients included in the analysis, 107 were categorized in the treatment group and 90 were categorized in the control group. From baseline to 48 months, 4 of 107 patients (3.7%) died in the treatment group and 6 of 90 patients (6.7%) died in the control group. Four of 107 patients (3.7%) in the treatment group experienced a cancer recurrence and 4 of 90 patients (4.4%) in the control group experienced a cancer recurrence. After balancing the baseline covariates by inverse probability of treatment weighting, we found no significant difference in the rate of death and cancer recurrence between patients in the 2 groups (weighted hazard ratio, .95; 95% confidence interval, .52-1.75). CONCLUSIONS: Our study suggests that patients with high-risk T1 CRC initially treated with endoscopic resection may not benefit from additional surgery.
Subject(s)
Colorectal Neoplasms , Neoplasm Recurrence, Local , Humans , Retrospective Studies , Neoplasm Recurrence, Local/pathology , Colorectal Neoplasms/surgery , Colorectal Neoplasms/pathology , Endoscopy/methods , Lymph Node Excision , Risk Factors , Treatment OutcomeABSTRACT
BACKGROUND: Endoscopic submucosal dissection (ESD) is potentially a curative treatment for T1 colorectal cancer under certain conditions. The aim of this study was to evaluate the feasibility and effectiveness of ESD for lesions with a suspicion of focal deep invasion. METHODS: In this retrospective multicenter study, consecutive patients with colorectal neoplasia displaying a focal (< 15âmm) deep invasive pattern (FDIP) that were treated by ESD were included. We excluded ulcerated lesions (Paris III), lesions with distant metastasis, and clearly advanced tumors (tumoral strictures). RESULTS: 124 patients benefited from 126 diagnostic dissection attempts for FDIP lesions. Dissection was feasible in 120/126 attempts (95.2â%) and, where possible, the en bloc and R0 resection rates were 95.8â% (115/120) and 76.7â% (92/120), respectively. Thirty-three resections (26.2â%) were for very low risk tumors, so considered curative, and 38 (30.2â%) were for low risk lesions. Noncurative R0 resections were for lesions with lymphatic or vascular invasion (LVI; nâ=â8), or significant budding (nâ=â9), and LVIâ+âbudding combination (nâ=â4). CONCLUSION: ESD is feasible and safe for colorectal lesions with an FDIPâ≤â15âmm. It was curative in 26.6â% of patients and could be a valid option for a further 30.6â% of patients with low risk T1 cancers, especially for frail patients with co-morbidities.
Subject(s)
Colorectal Neoplasms , Endoscopic Mucosal Resection , Humans , Colorectal Neoplasms/surgery , Colorectal Neoplasms/pathology , Endoscopic Mucosal Resection/adverse effects , Retrospective Studies , Treatment Outcome , Feasibility StudiesSubject(s)
Colonic Diseases , Endoscopic Mucosal Resection , Humans , Traction , Surgical Instruments , Treatment OutcomeSubject(s)
Endoscopic Mucosal Resection , Ileocecal Valve , Neoplasms , Humans , Ileocecal Valve/surgery , Dissection , Magnetic Phenomena , Treatment Outcome , TractionABSTRACT
Pancreatic ductal adenocarcinoma (PDAC) diagnosis accompanies a somber prognosis for the patient, with dismal survival odds: 5% at 5 years. Despite extensive research, PDAC is expected to become the second leading cause of mortality by cancer by 2030. Ultrasound (US) has been used successfully in treating other types of cancer and evidence is flourishing that it could benefit PDAC patients. High-intensity focused US (HIFU) is currently used for pain management in palliative care. In addition, clinical work is being performed to use US to downstage borderline resectable tumors and increase the proportion of patients eligible for surgical ablation. Focused US (FUS) can also induce mechanical effects, which may elicit an anti-tumor response through disruption of the stroma and can be used for targeted drug delivery. More recently, sonodynamic therapy (akin to photodynamic therapy) and immunomodulation have brought new perspectives in treating PDAC. The aim of this review is to summarize the current state of those techniques and share our opinion on their future and challenges.
ABSTRACT
Pancreatic ductal adenocarcinoma (PDAC) is expected to become the second leading cause of death from cancer by 2030. Despite intensive research in the field of therapeutics, the 5-year overall survival is approximately 8%, with only 20% of patients eligible for surgery at the time of diagnosis. The tumoral microenvironment (TME) of the PDAC is one of the main causes for resistance to antitumoral treatments due to the presence of tumor vasculature, stroma, and a modified immune response. The TME of PDAC is characterized by high stiffness due to fibrosis, with hypo microvascular perfusion, along with an immunosuppressive environment that constitutes a barrier to effective antitumoral treatment. While systemic therapies often produce severe side effects that can alter patients' quality of life, locoregional therapies have gained attention since their action is localized to the pancreas and can thus alleviate some of the barriers to effective antitumoral treatment due to their physical effects. Local hyperthermia using radiofrequency ablation and radiation therapy - most commonly using a local high single dose - are the two main modalities holding promise for clinical efficacy. Recently, irreversible electroporation and focused ultrasound-derived cavitation have gained increasing attention. To date, most of the data are limited to preclinical studies, but ongoing clinical trials may help better define the role of these locoregional therapies in the management of PDAC patients.
Subject(s)
Carcinoma, Pancreatic Ductal , Pancreatic Neoplasms , Carcinoma, Pancreatic Ductal/pathology , Humans , Pancreatic Neoplasms/pathology , Quality of Life , Tumor Microenvironment , Pancreatic NeoplasmsSubject(s)
CREST Syndrome , Esophageal and Gastric Varices , Esophagitis , Hemostasis, Endoscopic , Peptic Ulcer , Humans , Esophageal and Gastric Varices/complications , Esophageal and Gastric Varices/therapy , Cyanoacrylates/therapeutic use , CREST Syndrome/therapy , Ultrasonography, Interventional , Gastrointestinal Hemorrhage/etiology , Gastrointestinal Hemorrhage/therapy , Treatment Outcome , RecurrenceABSTRACT
Background and study aims The aim of this study was to validate the COlorectal NEoplasia Classification to Choose the Treatment (CONECCT) classification that groups all published criteria (including covert signs of carcinoma) in a single table. Patients and methods For this multicenter comparative study an expert endoscopist created an image library (nâ=â206 lesions; from hyperplastic to deep invasive cancers) with at least white light Imaging and chromoendoscopy images (virtual ± dye based). Lesions were resected/biopsied to assess histology. Participants characterized lesions using the Paris, Laterally Spreading Tumours, Kudo, Sano, NBI International Colorectal Endoscopic Classification (NICE), Workgroup serrAted polypS and Polyposis (WASP), and CONECCT classifications, and assessed the quality of images on a web-based platform. Krippendorff alpha and Cohen's Kappa were used to assess interobserver and intra-observer agreement, respectively. Answers were cross-referenced with histology. Results Eleven experts, 19 non-experts, and 10 gastroenterology fellows participated. The CONECCT classification had a higher interobserver agreement (Krippendorff alphaâ=â0.738) than for all the other classifications and increased with expertise and with quality of pictures. CONECCT classification had a higher intra-observer agreement than all other existing classifications except WASP (only describing Sessile Serrated Adenoma Polyp). Specificity of CONECCT IIA (89.2, 95â% CI [80.4;94.9]) to diagnose adenomas was higher than the NICE2 category (71.1, 95â% CI [60.1;80.5]). The sensitivity of Kudo Vi, Sano IIIa, NICE 2 and CONECCT IIC to detect adenocarcinoma were statistically different ( P â<â0.001): the highest sensitivities were for NICE 2 (84.2â%) and CONECCT IIC (78.9â%), and the lowest for Kudo Vi (31.6â%). Conclusions The CONECCT classification currently offers the best interobserver and intra-observer agreement, including between experts and non-experts. CONECCT IIA is the best classification for excluding presence of adenocarcinoma in a colorectal lesion and CONECCT IIC offers the better compromise for diagnosing superficial adenocarcinoma.
Subject(s)
Endoscopic Mucosal Resection , Spiders , Animals , Gastric Mucosa/pathology , Gastroscopy , Traction , Treatment OutcomeSubject(s)
Endoscopic Mucosal Resection , Traction , Dissection , Gastroscopy , Humans , Treatment OutcomeABSTRACT
BACKGROUND: In France, it is mandatory that gastroenterology fellows have mastered the basic level of endoscopy by the end of training. The aim of this study was to assess improvement in the quality of fellows' endoscopy training in France during the last four years. METHODS: All fellows in France in training were eligible for participation. A 21-item questionnaire was sent out. The primary outcome was the completion by fourth year fellows of all the number of procedures recommended. Results were compared with those of a 2016 survey. RESULTS: Two-hundred-and-sixty-five fellows responded to the survey. The participation rate was 47.0%. The mean age was 27.3 ± 1.0 years and 56.4% were female. Access to theoretical courses (63.7% vs. 30.6%, p < 0.001) and simulation-based training (virtual reality simulator: 58.4% vs. 28.2%, p < 0.001, animal models: 29.4% vs. 17.2%, p < 0.001) was significantly higher in 2020. Although the number of procedures did not increase, significantly higher perception of skill acquisition in colonoscopy as well as diminished pressure to advance procedures were noted. CONCLUSION: Access to theoretical courses and simulation-based training and perceived acquisition of numerous skills has gotten better. However, the quality of training in endoscopy still needs improvement.