Deciding on Surgery After Endoscopic Resection of T1-CRC? Repeat Colonoscopy and Biopsy Do Not Help

Deciding on Surgery After Endoscopic Resection of T1-CRC? Repeat Colonoscopy and Biopsy Do Not Help

Douglas K. Rex, MD, FASGE, reviewing Gijsbers KM, et al. Gastrointest Endosc 2020 Feb 24.

In general, when a flat or sessile T1 colorectal cancer is resected endoscopically, surgery is indicated if there has been piecemeal resection or there is poor differentiation, lymphovascular invasion, tumor <1 mm from the resection line, tumor invading the submucosa >1 mm, or tumor budding. 

In a multicenter prospective cohort study, 103 patients with endoscopically resected T1 cancers were enrolled. The tumor was considered obviously malignant endoscopically in 18% of cases, pedunculated in 23%, and rectosigmoid in 86%, and 45% of tumors were removed piecemeal.

After endoscopic resection and identification of cancer, patients underwent repeat colonoscopy and biopsy of the resection site.

After the endoscopic resection, and at a median of 45 days later, surgery was performed in 62% of patients, and the remainder had endoscopic resection of the site using the full-thickness resection device. 

The surgical or full-thickness resection identified cancer in the wall (intramural cancer) in 7 patients, of which the endoscopic biopsy samples were positive in 2 (28%). In addition, there were 7 cases of lymph node metastasis, of which 5 had no residual intramural cancer.

After endoscopic resection of a T1 cancer, colonoscopists sometimes repeat colonoscopy and perform a biopsy of the site. This practice seems to be undertaken in the hope that if the inspection and biopsy are negative, it could tilt the decision toward avoidance of surgery. However, these data indicate that practice is flawed and ineffective. The decision about adjuvant surgical resection should be made on the basis of piecemeal versus en bloc resection and an accurately and completely assessed histologic specimen.

Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.

Douglas K. Rex, MD, FASGE


Gijsbers KM, Post Z, Schrauwen RWM, et al. Low value of second-look endoscopy in detecting residual colorectal cancer after endoscopic removal. Gastrointest Endosc 2020 Feb 24. (Epub ahead of print) (

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