**5. "The high risk polyp"**

The utility of including lymphatic invasion, vascular invasion or tumour budding is unclear at this time. Further work should be done to examine the risk from polyps of the lower third of the rectum, especially as these can often require a permanent stoma if oncological resec‐

Bernard et al. 1988 19 3 0 Christie 1988 88 6 0 Conte et al. 1987 30 4 0 Cooper et al. 1995 140 16 0 Cranley et al. 1986 39 10 0 Cunningham et al. 1994 36 2 0 Eckardt et al. 1988 61 11 0 Fried et al. 1984 22 0 0 Geraghty et al. 1991 80 5 0 Hackelsberger et al. 1995 86 8 0 Kikuchi et al. 1995 78 9 0 Kyzer et al. 1992 42 1 0 Morson et al. 1984 60 2 0 Netzer et al. 1998 70 16 0 Rossini et al. 1988 66 4 0 Shatney et al. 1975 28 1 0 Speroni et al. 1988 30 2 0 Sugihara et al. 1989 25 3 0 Volk et al. 1995 47 10 0 Whitlow et al. 1997 59 4 0 Seitz et al. 2004 114 16 0 Total 1,227 135 0

**Table 4.** Incidence of Adverse Outcome in Low Risk Polyps. Low risk = Low risk = excision complete with resection

margins of at least 2 mm, no Grade 3 carcinoma, and no vascular invasion. (From Sitz et al. 2004)

**Unfavourable Outcome**

**Unfavourable outcome in low risk group**

tion is performed.

**Study No. Of Polyps**

148 Colonoscopy and Colorectal Cancer Screening - Future Directions

Polyps that do not meet the low risk criteria should be considered for surgical removal even if there has been total excision of the primary lesion. Indeed, it is unusual to find residual tumour in the surgical specimen, especially if the lesion had clear histological margins.[6] The justification for surgery is the desire for regional control as the risk of nodal disease is much higher in these patients and oncological resection is required to obtain regional con‐ trol in a similar manner to other colorectal malignancies. The dilemma is that only a minori‐ ty of these patients have nodal disease requiring control and these patients are only reliably identified after resection. Especially in elderly, the decision to resect has the possibility to cause considerable harm without producing a benefit to the patient.

#### **5.1. "First do no harm..."**

It is an old surgical adage that surgery is only indicated if the natural history of the cure is better than the natural history of the disease. In situations of uncertainly like this it is useful to examine the possible outcomes of proposed courses of action in order to see were the sur‐ vival advantage lies.

The outcomes of the decision to operate will be a function of the risk of nodal disease and the risk of operative mortality and morbidity. We feel it is useful to consider these decisions with reference to a 2x2 table of results


**Table 5.** 2x2 Table of outcomes from the decision regarding further resection of high risk malignant polyps.

#### **5.2. Nodal disease and oncological resection**

We see no reason to regard these patients as any different from patients who had proceded straight to oncological resection and post operatively were staged either IIIa to IIIc (TNM v5). In the SEER data from 1998 to 2000 there is a huge difference between those with regard to five year survival (73% vs. 28% respectively). Clearly this stage differentiation has huge implications for the advisability of surgery. It has been suggested that T1-2N2 tumours have a better survival that T3-4N2 tumours and the TNMv6 classification has been changed to re‐ flect this. Newer SEER data shows five year survival of 87.7% for T1-2N1 disease and 75% for T1-2N2 disease. [30]

To our knowledge there is no current method of estimating the extent of nodal disease from polypectomy histology.

**5.6. The risk of further resection**

results in permanent stoma formation.

in the UK.[34]

have a beneficial effect.[33]

ic procedures. [35,36]

**5.7. The special case of rectal tumours**

tures described earlier.[40]

Oncological resection of colorectal lesions is performed via segmental resection of the affect‐ ed potion of the bowel and its draining lymph node basin. Harvesting these nodes gains lo‐ cal control and definatively stages the disease. It is a major undertaking with considerable risks. In the case of very low rectal tumours an abdomino-perinal excision of rectum (APER)

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151

In the UK at least, operative mortality has fallen in recent years. 30 day mortality was 6.8% in 1999, falling to 3.7% in 2009/10.[33,34] Rates from Scandinavia (4.8%)[26] and the US (3.1%)[27] are broadly similar. This remains considerably higher than the rate of no‐ dal disease in the low risk malignant polyps. The 90 day mortality rate, considered by some authors to be a more accurate measure of operative mortality is higher still, is 5.6%

This baseline rate is affected by both tumour and patient factors. Patients over the age of 80 are over ten times more likely to die than those under 50 (15% vs 1.2% 30 day mortality). [28,33] Comparing ASA1 and ASA4 patients, the odds ratio for death at 30 days is 14.06. Pa‐ tients with rectal tumours do better than those with colonic tumours, though this seems to be due to high mortality for patients undergoing subtotal or total colectomy. Female sex, af‐ fluence, high volume surgical centres and elective rather than emergency surgery all also

On top of mortality, anastomotic leaks, wound complications, cardiovascular complica‐ tions, defecatory disorders and the psychological impact of stoma formation must also be considered when deciding whether or not to resect. Morbidity rates of up to 35% have been reported in the past.[15] These seem to affect laparoscopic surgery as much as open resections, but hospital discharge and return to work occurs sooner following laparoscop‐

A more accurate individualised operative risk can be estimated from risk scoring systems. CR-POSSUM uses patient and operative parameters to estimate operative risk on an indi‐ vidual basis and has been well validated.[37,38] Cardiopulmonary exercise testing is also useful in predicting complications and the length of hospital stay. Both these tools can be of great use to the surgeon and patient when used thoughtfully during surgical planning. [39]

There has been considerable interest in recent years in local resection of early rectal tumours to avoid stoma formation. This is relevant as malignant polyps in the rectum are a variety of early rectal tumour. Transanal Endoscopic Microsurgery (TEMS) allows full thickness exci‐ sion of rectal lesions below the peritoneal fold, with excellent rates of local recurrence.[15] Its ability to harvest local lymph nodes is limited, and as such it is not generally a suitable second procedure for high risk lesions. It may have a role as secondary procedure for incom‐ pletely removed polyps which otherwise show favourable features. In its guidance the ACPGBI recommended full classical resection of rectal tumours that show the high risk fea‐

#### **5.3. Nodal disease and no further resection**

For those patients with nodal disease who do not have it resected the prognosis is likely to be compromised. Intensive surveillance is likely to detect continued disease progression.

The role of chemotherapy and or radiotherapy has not been clearly defined in this group but is likely to be palliative in nature.

#### **5.4. Absence of Nodal disease**

The survival of patients after endoscopic removal of T1 lesions and no nodal disease is ex‐ cellent. The mortality in these groups will be limited to the operative mortality from further resection.

#### **5.5. Risk of Nodal disease**

Various figures have been quoted in the text for the risk of nodal disease in high risk pa‐ tients. This can partly be explained by the differing criteria used to define risk by various authors. Further stratification within the "high risk group" may become apparent with fur‐ ther study.

The St Mark's Lymph Node Positivity Model[31] can be used to predict the individual risk of nodal metastasis after local resection of rectal tumours. However it makes no distinction within T1 tumours. Such assessment of individual risk factors to produce a personalised risk is not possible based on the current evidence. Further studies using multivariate analysis will be required to tease out the importance of individual risk factors.

For our analysis we have chosen to present data based on Sm depth as this has shown to be a reproducible predictor of nodal disease. Both Kikuchi and Nascimbeni reported rates of roughly 5, 10 and 25% for Sm 1, 2 and 3 respectively.[23,32]


**Table 6.** Incidence of nodal disease by risk factor

#### **5.6. The risk of further resection**

To our knowledge there is no current method of estimating the extent of nodal disease from

For those patients with nodal disease who do not have it resected the prognosis is likely to be compromised. Intensive surveillance is likely to detect continued disease progression.

The role of chemotherapy and or radiotherapy has not been clearly defined in this group but

The survival of patients after endoscopic removal of T1 lesions and no nodal disease is ex‐ cellent. The mortality in these groups will be limited to the operative mortality from further

Various figures have been quoted in the text for the risk of nodal disease in high risk pa‐ tients. This can partly be explained by the differing criteria used to define risk by various authors. Further stratification within the "high risk group" may become apparent with fur‐

The St Mark's Lymph Node Positivity Model[31] can be used to predict the individual risk of nodal metastasis after local resection of rectal tumours. However it makes no distinction within T1 tumours. Such assessment of individual risk factors to produce a personalised risk is not possible based on the current evidence. Further studies using multivariate analysis

For our analysis we have chosen to present data based on Sm depth as this has shown to be a reproducible predictor of nodal disease. Both Kikuchi and Nascimbeni reported rates of

Poorly differentiated 25-100%. *Not found to be important in multivariate*

Kikuchi SM1 = 5% Kikuchi Sm2 = 10% Kicuchi Sm3 = 25%[23, 32]

*analysis.*[14, 17]

will be required to tease out the importance of individual risk factors.

**Risk Factor Incidence of nodal disease** Depth of invasion Haggit 1.2.3 = <1%[9]

Lympho-vascular Invasion 41% *Poor reproducibility.*[18]

Incomplete resection 75%[20]

**Table 6.** Incidence of nodal disease by risk factor

roughly 5, 10 and 25% for Sm 1, 2 and 3 respectively.[23,32]

polypectomy histology.

**5.3. Nodal disease and no further resection**

150 Colonoscopy and Colorectal Cancer Screening - Future Directions

is likely to be palliative in nature.

**5.4. Absence of Nodal disease**

**5.5. Risk of Nodal disease**

resection.

ther study.

Oncological resection of colorectal lesions is performed via segmental resection of the affect‐ ed potion of the bowel and its draining lymph node basin. Harvesting these nodes gains lo‐ cal control and definatively stages the disease. It is a major undertaking with considerable risks. In the case of very low rectal tumours an abdomino-perinal excision of rectum (APER) results in permanent stoma formation.

In the UK at least, operative mortality has fallen in recent years. 30 day mortality was 6.8% in 1999, falling to 3.7% in 2009/10.[33,34] Rates from Scandinavia (4.8%)[26] and the US (3.1%)[27] are broadly similar. This remains considerably higher than the rate of no‐ dal disease in the low risk malignant polyps. The 90 day mortality rate, considered by some authors to be a more accurate measure of operative mortality is higher still, is 5.6% in the UK.[34]

This baseline rate is affected by both tumour and patient factors. Patients over the age of 80 are over ten times more likely to die than those under 50 (15% vs 1.2% 30 day mortality). [28,33] Comparing ASA1 and ASA4 patients, the odds ratio for death at 30 days is 14.06. Pa‐ tients with rectal tumours do better than those with colonic tumours, though this seems to be due to high mortality for patients undergoing subtotal or total colectomy. Female sex, af‐ fluence, high volume surgical centres and elective rather than emergency surgery all also have a beneficial effect.[33]

On top of mortality, anastomotic leaks, wound complications, cardiovascular complica‐ tions, defecatory disorders and the psychological impact of stoma formation must also be considered when deciding whether or not to resect. Morbidity rates of up to 35% have been reported in the past.[15] These seem to affect laparoscopic surgery as much as open resections, but hospital discharge and return to work occurs sooner following laparoscop‐ ic procedures. [35,36]

A more accurate individualised operative risk can be estimated from risk scoring systems. CR-POSSUM uses patient and operative parameters to estimate operative risk on an indi‐ vidual basis and has been well validated.[37,38] Cardiopulmonary exercise testing is also useful in predicting complications and the length of hospital stay. Both these tools can be of great use to the surgeon and patient when used thoughtfully during surgical planning. [39]

#### **5.7. The special case of rectal tumours**

There has been considerable interest in recent years in local resection of early rectal tumours to avoid stoma formation. This is relevant as malignant polyps in the rectum are a variety of early rectal tumour. Transanal Endoscopic Microsurgery (TEMS) allows full thickness exci‐ sion of rectal lesions below the peritoneal fold, with excellent rates of local recurrence.[15] Its ability to harvest local lymph nodes is limited, and as such it is not generally a suitable second procedure for high risk lesions. It may have a role as secondary procedure for incom‐ pletely removed polyps which otherwise show favourable features. In its guidance the ACPGBI recommended full classical resection of rectal tumours that show the high risk fea‐ tures described earlier.[40]

The anatomical location of the draining nodes in rectal lesions has also encouraged more ex‐ tensive use of imaging to predict local nodal metastases. Endoanal Ultrasound and MRI both have the ability to detect enlarged local nodes; however distinguishing between the commonly found reactive nodes and metastases can be difficult. Micrometastases have also been detected in radiologically normal nodes. The use of new contrast agents may improve accuracy but currently histological examination remains the gold standard for detecting no‐ dal disease. [15]

**Patient A Patient B Patient C Patient D**

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153

81.00 "/>99% 90.50 95.25

Age 55 55 80 60

Risk of nodal disease 25% <1% 10% 5%

Operative Mortality 1% 1% 10% 5%

Compsite survival with resection 94.20 99% 88.50 94.00

Survival advantage 13.20 - - -

**Table 7.** Examples of using composite survival to inform decision making in patients with malignant polyps

still make difficult decisions based on the balance of risk.

This problem has been known and debated for over 30 years.[41] As the role of endoscopy has grown and developed, guidelines have been formulated to help clinicians make benefi‐ cial choices. Unfortunately the small scale and heterogeneity for published work had pre‐ vented any guidelines from gaining universal acceptance. The focus on tumour grade in the American guidance has been challenged by work from Japan that emphasises the impor‐ tance of quantitative measures of the depth of invasion. Japanese work has also shown lym‐ phatic invasion, vascular invasion and tumour budding to be of high prognostic significance, but concerns about reproducibility have prevented their universal adoption. It is also unclear which observed prognostic factors are truly significant and which are cofounding. None of the prognostic factors identified are highly specific and clinicians must

The solution to this problem will surely come from improved pre-operative staging. En‐ do-anal ultra sound and targeted contrast MRI have both shown promise for rectal tu‐ mours. Sentinel node mapping in the colon has also been investigated but remains

Until highly accurate pre-operative staging of nodal disease is possible effort must be made to refine the classification of malignant polyps to identify the truly significant prognostic factors. It is the opinion of the authors that an individualised prediction model comparing operative surgical risk and risk of progressive disease should be used to counsel patients re‐ garding future strategies. Creation of a national or international database would facil;itate

Compsite Survival without further

resection

**6. Conclusion**

experimental. [42]

better predictive models.

Lesion Kikuchi Sm3 Haggit level 1 Kikuchi Sm2 Kikuchi Sm1

For locally excised T1 and T2 tumours adjuvant chemoradiotherapy has been used with suc‐ cess to prevent local recurrence if further surgery is not deemed appropriate. The role of ad‐ juvant therapy in malignant polyps is unexplored at this time.

#### **5.8. Calculating the survival advantage**

As the nodal status of these patients is unknown prior to surgery, mortality is a composite of the mortality of those with and without nodal disease. The contribution from each group will be in proportion to the risk of nodal disease.

cM = R.NM + (1-R).nM

Where cM= Composite mortality

R =Risk of nodal disease

NM =Mortality of those with nodal disease

nM =Mortality of those without nodal disease

The best course of action can be discerned by calculating the difference between cM with and without surgery. Tables 7-9 contain sample composite survival figures and number needed to treat at five years for various stages of malignant polyp.

Using this method we can see that for a patient with a Sm3 lesion (25% of nodal disease) and a predicted operative mortality of 2% there will be an absolute risk reduction of mortality at 5 years of 16% (NNT 6.25) if 5 year survival of node positive patients is 75% and a 4.5% re‐ duction (NNT 21.05) if 5 year survival of node positive patients is 27%. In stage IIIa (75% five year survival) disease the absolute risk is reduced by 10% (NNT 1), but this disappears for stage IIIc. There has been considerable debate regarding the need to resect Sm2 lesions. In this model the benefit from resection disappears once operative mortality reaches 5% for IIIa lesions and 10% for IIIc lesions. Clearly careful though needs to be given to risk when choosing to operate on these patients.

Obviously this model makes no account of operative morbidity. For patients with IIIc disease and Sm3 lesions there is a survival advantage to operating; however the deci‐ sion to subject 40 patients to major surgery to save 1 life at five years needs careful consideration.


**Table 7.** Examples of using composite survival to inform decision making in patients with malignant polyps

### **6. Conclusion**

The anatomical location of the draining nodes in rectal lesions has also encouraged more ex‐ tensive use of imaging to predict local nodal metastases. Endoanal Ultrasound and MRI both have the ability to detect enlarged local nodes; however distinguishing between the commonly found reactive nodes and metastases can be difficult. Micrometastases have also been detected in radiologically normal nodes. The use of new contrast agents may improve accuracy but currently histological examination remains the gold standard for detecting no‐

For locally excised T1 and T2 tumours adjuvant chemoradiotherapy has been used with suc‐ cess to prevent local recurrence if further surgery is not deemed appropriate. The role of ad‐

As the nodal status of these patients is unknown prior to surgery, mortality is a composite of the mortality of those with and without nodal disease. The contribution from each group

The best course of action can be discerned by calculating the difference between cM with and without surgery. Tables 7-9 contain sample composite survival figures and number

Using this method we can see that for a patient with a Sm3 lesion (25% of nodal disease) and a predicted operative mortality of 2% there will be an absolute risk reduction of mortality at 5 years of 16% (NNT 6.25) if 5 year survival of node positive patients is 75% and a 4.5% re‐ duction (NNT 21.05) if 5 year survival of node positive patients is 27%. In stage IIIa (75% five year survival) disease the absolute risk is reduced by 10% (NNT 1), but this disappears for stage IIIc. There has been considerable debate regarding the need to resect Sm2 lesions. In this model the benefit from resection disappears once operative mortality reaches 5% for IIIa lesions and 10% for IIIc lesions. Clearly careful though needs to be given to risk when

Obviously this model makes no account of operative morbidity. For patients with IIIc disease and Sm3 lesions there is a survival advantage to operating; however the deci‐ sion to subject 40 patients to major surgery to save 1 life at five years needs careful

juvant therapy in malignant polyps is unexplored at this time.

**5.8. Calculating the survival advantage**

152 Colonoscopy and Colorectal Cancer Screening - Future Directions

will be in proportion to the risk of nodal disease.

NM =Mortality of those with nodal disease

choosing to operate on these patients.

consideration.

nM =Mortality of those without nodal disease

needed to treat at five years for various stages of malignant polyp.

dal disease. [15]

cM = R.NM + (1-R).nM

R =Risk of nodal disease

Where cM= Composite mortality

This problem has been known and debated for over 30 years.[41] As the role of endoscopy has grown and developed, guidelines have been formulated to help clinicians make benefi‐ cial choices. Unfortunately the small scale and heterogeneity for published work had pre‐ vented any guidelines from gaining universal acceptance. The focus on tumour grade in the American guidance has been challenged by work from Japan that emphasises the impor‐ tance of quantitative measures of the depth of invasion. Japanese work has also shown lym‐ phatic invasion, vascular invasion and tumour budding to be of high prognostic significance, but concerns about reproducibility have prevented their universal adoption. It is also unclear which observed prognostic factors are truly significant and which are cofounding. None of the prognostic factors identified are highly specific and clinicians must still make difficult decisions based on the balance of risk.

The solution to this problem will surely come from improved pre-operative staging. En‐ do-anal ultra sound and targeted contrast MRI have both shown promise for rectal tu‐ mours. Sentinel node mapping in the colon has also been investigated but remains experimental. [42]

Until highly accurate pre-operative staging of nodal disease is possible effort must be made to refine the classification of malignant polyps to identify the truly significant prognostic factors. It is the opinion of the authors that an individualised prediction model comparing operative surgical risk and risk of progressive disease should be used to counsel patients re‐ garding future strategies. Creation of a national or international database would facil;itate better predictive models.


**Risk Of Nodal**

5

10

15

20

25

30

after resection.

**Disease/% Operative Survival/ %**

99 98 95 90 85

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No Resection/% 95.25 95.25 95.25 95.25 95.25

Resection/% 97.80 96.85 94.00 89.25 84.50

Survival Advantage/% 2.55 1.60 - - -

**NNT 39.22 62.50** - - -

No Resection/% 90.50 90.50 90.50 90.50 90.50

Resection/% 96.60 95.70 93.00 88.50 84.00

Survival Advantage/% 6.10 5.20 2.50 - -

**NNT 16.39 19.23 40.00** - -

No Resection/% 85.75 85.75 85.75 85.75 85.75

Resection/% 95.40 94.55 92.00 87.75 83.50

Survival Advantage/% 9.65 8.80 6.25 2.00 -

**NNT 10.36 11.36 16.00 50.00** -

No Resection/% 81.00 81.00 81.00 81.00 81.00

Resection/% 94.20 93.40 91.00 87.00 83.00

Survival Advantage/% 13.20 12.40 10.00 6.00 2.00

**NNT 7.58 8.06 10.00 16.67 50.00**

No Resection/% 76.25 76.25 76.25 76.25 76.25

Resection/% 93.00 92.25 90.00 86.25 82.50

Survival Advantage/% 16.75 16.00 13.75 10.00 6.25

**NNT 5.97 6.25 7.27 10.00 16.00**

No Resection/% 71.50 71.50 71.50 71.50 71.50

Resection/% 91.80 91.10 89.00 85.50 82.00

Survival Advantage/% 20.30 19.60 17.50 14.00 10.50

**NNT 4.93 5.10 5.71 7.14 9.52**

**Table 9.** 5 year survival, survival advantage with further resection and number needed to treat if 5 year survival is 75%

**Table 8.** 5 year survival, survival advantage with further resection and number needed to treat if 5 year survival for node positive patients is 88% after resection.


**Risk Of Nodal**

5

10

15

20

25

30

node positive patients is 88% after resection.

**Disease/% Operative Survival/ %**

154 Colonoscopy and Colorectal Cancer Screening - Future Directions

99 98 95 90 85

No Resectio /% 95.25 95.25 95.25 95.25 95.25

Resection/% 98.45 97.50 94.65 89.90 85.15

Survival Advantage/% 3.20 2.25 - - -

**NNT 31.25 44.44** - - -

No Resection/% 90.50 90.50 90.50 90.50 90.50

Resection/% 97.90 97.00 94.30 89.80 85.30

Survival Advantage/% 7.40 6.50 3.80 - -

**NNT 13.51 15.38 26.32** - -

No Resection/% 85.75 85.75 85.75 85.75 85.75

Resection/% 97.35 96.50 93.95 89.70 85.45

Survival Advantage/% 11.60 10.75 8.20 3.95 -

**NNT 8.62 9.30 12.20 25.32** -

No Resection/% 81.00 81.00 81.00 81.00 81.00

Resection/% 96.80 96.00 93.60 89.60 84.00

Survival Advantage/% 15.80 15.00 12.60 8.60 3.00

**NNT 6.33 6.67 7.94 11.63 33.33**

No Resection/% 76.25 76.25 76.25 76.25 76.25

Resection/% 96.25 95.50 93.25 89.50 85.75

Survival Advantage/% 20.00 19.25 17.00 13.25 9.50

**NNT 5.00 5.19 5.88 7.55 10.53**

No Resection/% 71.50 71.50 71.50 71.50 71.50

Resection/% 95.70 95.00 92.90 89.40 85.90

Survival Advantage/% 24.20 23.50 21.40 17.90 14.40

**NNT 0.04 0.04 0.05 0.06 0.07**

**Table 8.** 5 year survival, survival advantage with further resection and number needed to treat if 5 year survival for

**Table 9.** 5 year survival, survival advantage with further resection and number needed to treat if 5 year survival is 75% after resection.


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**Table 10.** 5 year survival, survival advantage with further resection and number needed to treat if 5 year survival in node positive patients is 27% after resection.

### **Author details**

Josef M. Taylor and Kenneth B. Hosie\*

\*Address all correspondence to: kenneth.hosie@nhs.net

Department of Surgery, Derriford Hospital, Plymouth, United Kingdom

## **References**

**Risk Of Nodal**

5

10

15

20

25

30

node positive patients is 27% after resection.

Josef M. Taylor and Kenneth B. Hosie\*

\*Address all correspondence to: kenneth.hosie@nhs.net

Department of Surgery, Derriford Hospital, Plymouth, United Kingdom

**Author details**

**Disease/% Operative Survival/ %**

156 Colonoscopy and Colorectal Cancer Screening - Future Directions

99 98 95 90 85

No Resection/% 95.25 95.25 95.25 95.25 95.25 Resection/% 95.30 94.35 91.50 86.75 82.00 Survival Advantage/% 0.05 - - - - **NNT 2000.00** - - - -

No Resection/% 90.50 90.50 90.50 90.50 90.50 Resection/% 91.60 90.70 88.00 83.50 79.00 Survival Advantage/% 1.10 0.20 - - - **NNT 90.91 500.00** - - -

No Resection/% 85.75 85.75 85.75 85.75 85.75 Resection/% 87.90 87.05 84.50 80.25 76.00 Survival Advantage/% 2.15 1.30 - - - **NNT 46.51 76.92** - - -

No Resection/% 81.00 81.00 81.00 81.00 81.00 Resection/% 84.20 83.40 81.00 77.00 73.00 Survival Advantage/% 3.20 2.40 0.00 - - **NNT 31.25 41.67** - - -

No Resection/% 76.25 76.25 76.25 76.25 76.25 Resection/% 80.50 79.75 77.50 73.75 70.00 Survival Advantage/% 4.25 3.50 1.25 - - **NNT 23.53 28.57 80.00** - -

No Resection/% 71.50 71.50 71.50 71.50 71.50 Resection/% 76.80 76.10 74.00 70.50 67.00 Survival Advantage/% 5.30 4.60 2.50 - - **NNT 18.87 21.74 40.00** - -

**Table 10.** 5 year survival, survival advantage with further resection and number needed to treat if 5 year survival in


[14] Ueno H, Mochizuki H, Hashiguchi Y, Shimazaki H, Aida S, et al. Risk factors for an adverse outcome in early invasive colorectal carcinoma. Gastroenterology 2004;127 385-394.

the Annual Meeting of the Association for Academic Surgery, Boston, MA, Novem‐

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[28] Latkauskas T, Rudinskaite G, Kurtinaitis J, Janciauskiene R, Tamelis A, et al. The im‐ pact of age on post-operative outcomes of colorectal cancer patients undergoing sur‐

[29] Ruiz-Tovar J, Jimenez-Miramon J, Valle A, Limones M. Endoscopic resection as unique treatment for early colorectal cancer. Rev Esp Enferm Dig 2010;102 435-441.

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**Chapter 7**

**Desmoplastic Reaction in Biopsy Specimens of**

**Defining the Level of Sub-Mucosal Invasion**

Shigeki Tomita, Kazuhito Ichikawa and

Additional information is available at the end of the chapter

Takahiro Fujimori

**1. Introduction**

http://dx.doi.org/10.5772/51900

tion of deep submucosal invasive CRC.

be a prognostic marker in CRC patients.

**T1 Stage Colorectal Cancer Plays a Critical Role in**

Observation of the mucosal crypt patterns using chromoendoscopy with magnification has been reported to be the most reliable method for determining whether a colorectal cancer (CRC) is early or advanced tumour. Moreover, brand-new endoscopic system have the capa‐ bility to enhance visibility by the capillary pattern, which may prove to be reliable for detec‐

Early CRC is defined as a tumour whose invasion is limited to the mucosa or submucosa. The endoscopic mucosal resection and endoscopic mucosal dissection (EMR/ESD) have be‐ come useful for early CRC. However, EMR/ESD is applicable only to intramucosal carcino‐ ma, and additional surgery is required if the resected lesion reveals submucosal invasion by pathological diagnosis. Therefore, endoscopist and surgical pathologist considered that it would be very useful to predict the depth of invasion of submucosal invasive CRC before EMR/ESD. On the other hand, desmoplastic reaction (DR) which is characterized by the infiltration of eosinophilic myofibroblasts in the stroma of invasive carcinoma is suggested to

Here we describe that detection of DR in pre-treatment biopsy specimens is useful for pre‐ dicting the depth of submucosal invasion and evaluation of submucosal depth with head in‐ vasion or stalk invasion in post EMR/ESD specimen is useful for predicting the lymph node metastasis and discuss relevant issues in arriving at the correct differential diagnosis based

> © 2013 Tomita et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

on histological findings for gastrointestinal endoscopist and surgical pathologist.

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