Role of endoscopy in the staging and management of colorectal cancer

Abstract

This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text. In preparing this guideline, a search of the medical literature was performed by using PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When limited or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time that the guidelines are drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. The recommendations were based on reviewed studies and were graded on the strength of the supporting evidence (Table 1).1Guyatt G.H. Oxman A.D. Vist G.E. et al.GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-926Crossref PubMed Google Scholar This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient's condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines.TABLE 1GRADE system for rating the quality of evidence for guidelines1Guyatt G.H. Oxman A.D. Vist G.E. et al.GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-926Crossref PubMed Google ScholarQuality of evidenceDefinitionSymbolHigh qualityFurther research is very unlikely to change our confidence in the estimate of effect⊕⊕⊕⊕Moderate qualityFurther research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate⊕⊕⊕○Low qualityFurther research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate⊕⊕○○Very low qualityAny estimate of effect is very uncertain⊕○○○ Open table in a new tab Colorectal cancer (CRC) is the third most commonly diagnosed cancer in American men and women and the second leading cause of cancer death.2Jemal A. Siegel R. Xu J. et al.Cancer statistics, 2010.CA Cancer J Clin. 2010; 60: 277-300Crossref PubMed Scopus (12308) Google Scholar This updated ASGE guideline focuses on the role of endoscopy in the staging and treatment of CRC. Recommendations for CRC screening and surveillance are discussed in previous documents by the Multi-Society Task Force endorsed by the ASGE.3Levin B. Lieberman D.A. McFarland B. et al.Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology.Gastroenterology. 2008; 134: 1570-1595Abstract Full Text Full Text PDF PubMed Scopus (1688) Google Scholar, 4Lieberman D.A. Rex D.K. Winawer S.J. et al.Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer.Gastroenterology. 2012; 143: 844-857Abstract Full Text Full Text PDF PubMed Scopus (1404) Google ScholarPresurgical localizationColonoscopy has an important role in the localization of malignant lesions for subsequent identification at the time of surgery. Preoperative endoscopic marking can be helpful in localizing flat, small, or subtle colonic lesions that may be difficult to identify by inspection or palpation during surgery. Marking techniques currently available include endoscopic tattooing and metallic clip placement.5Kethu S.R. Banerjee S. Desilets D. et al.Endoscopic tattooing.Gastrointest Endosc. 2010; 72: 681-685Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar, 6Kim S.H. Milsom J.W. Church J.M. et al.Perioperative tumor localization for laparoscopic colorectal surgery.Surg Endosc. 1997; 11: 1013-1016Crossref PubMed Scopus (88) Google Scholar, 7Montorsi M. Opocher E. Santambrogio R. et al.Original technique for small colorectal tumor localization during laparoscopic surgery.Dis Colon Rectum. 1999; 42: 819-822Crossref PubMed Scopus (74) Google Scholar Tattoos with India ink are visible at surgery for up to 5 months.5Kethu S.R. Banerjee S. Desilets D. et al.Endoscopic tattooing.Gastrointest Endosc. 2010; 72: 681-685Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar No guidelines exist on the optimal placement of tattoos or metallic clips; therefore, close communication with surgical colleagues involved in the subsequent resection is important.Staging of rectal cancerCRC is staged according to the TNM system established by the American Joint Committee on Cancer (Table 2).8Edge S.B. Compton C.C. The American Joint Committee on Cancer: the 7th edition of the AJCC cancer staging manual and the future of TNM.Ann Surg Oncol. 2010; 17: 1471-1474Crossref PubMed Scopus (6052) Google Scholar The primary clinical impact of staging rectal cancer is to differentiate T1N0 or T2N0 disease from T3 or TxN1-2 disease, for which chemoradiation is recommended in addition to surgical resection.9Engstrom P.F. Arnoletti J.P. Benson 3rd, A.B. et al.NCCN Clinical practice guidelines in oncology: rectal cancer.J Natl Compr Canc Netw. 2009; 7: 838-881PubMed Google Scholar Several meta-analyses have evaluated the staging accuracy of EUS,10Bipat S. Glas A.S. Slors F.J. et al.Rectal cancer: local staging and assessment of lymph node involvement with endoluminal US, CT, and MR imaging-a meta-analysis.Radiology. 2004; 232: 773-783Crossref PubMed Scopus (788) Google Scholar, 11Lahaye M.J. Engelen S.M. Nelemans P.J. et al.Imaging for predicting the risk factors-the circumferential resection margin and nodal disease-of local recurrence in rectal cancer: a meta-analysis.Semin Ultrasound CT MR. 2005; 26: 259-268Abstract Full Text Full Text PDF PubMed Scopus (249) Google Scholar, 12Puli S.R. Bechtold M.L. Reddy J.B. et al.Can endoscopic ultrasound predict early rectal cancers that can be resected endoscopically? A meta-analysis and systematic review.Dig Dis Sci. 2010; 55: 1221-1229Crossref PubMed Scopus (41) Google Scholar, 13Puli S.R. Bechtold M.L. Reddy J.B. et al.How good is endoscopic ultrasound in differentiating various T stages of rectal cancer? Meta-analysis and systematic review.Ann Surg Oncol. 2009; 16: 254-265Crossref PubMed Scopus (170) Google Scholar and some have compared the accuracy of EUS with that of magnetic resonance imaging (MRI) and CT.10Bipat S. Glas A.S. Slors F.J. et al.Rectal cancer: local staging and assessment of lymph node involvement with endoluminal US, CT, and MR imaging-a meta-analysis.Radiology. 2004; 232: 773-783Crossref PubMed Scopus (788) Google Scholar, 11Lahaye M.J. Engelen S.M. Nelemans P.J. et al.Imaging for predicting the risk factors-the circumferential resection margin and nodal disease-of local recurrence in rectal cancer: a meta-analysis.Semin Ultrasound CT MR. 2005; 26: 259-268Abstract Full Text Full Text PDF PubMed Scopus (249) Google Scholar In general, EUS was found to exhibit high sensitivity (80%-96%) and specificity (75%-98%) for the staging of T0 to T3 disease.10Bipat S. Glas A.S. Slors F.J. et al.Rectal cancer: local staging and assessment of lymph node involvement with endoluminal US, CT, and MR imaging-a meta-analysis.Radiology. 2004; 232: 773-783Crossref PubMed Scopus (788) Google Scholar, 11Lahaye M.J. Engelen S.M. Nelemans P.J. et al.Imaging for predicting the risk factors-the circumferential resection margin and nodal disease-of local recurrence in rectal cancer: a meta-analysis.Semin Ultrasound CT MR. 2005; 26: 259-268Abstract Full Text Full Text PDF PubMed Scopus (249) Google Scholar, 12Puli S.R. Bechtold M.L. Reddy J.B. et al.Can endoscopic ultrasound predict early rectal cancers that can be resected endoscopically? A meta-analysis and systematic review.Dig Dis Sci. 2010; 55: 1221-1229Crossref PubMed Scopus (41) Google Scholar, 13Puli S.R. Bechtold M.L. Reddy J.B. et al.How good is endoscopic ultrasound in differentiating various T stages of rectal cancer? Meta-analysis and systematic review.Ann Surg Oncol. 2009; 16: 254-265Crossref PubMed Scopus (170) Google Scholar EUS may have higher T-staging accuracy than other cross-sectional imaging tests,10Bipat S. Glas A.S. Slors F.J. et al.Rectal cancer: local staging and assessment of lymph node involvement with endoluminal US, CT, and MR imaging-a meta-analysis.Radiology. 2004; 232: 773-783Crossref PubMed Scopus (788) Google Scholar but nodal staging accuracy was modest for EUS (67% sensitivity, 78% specificity) and not statistically different among the 3 imaging modalities.10Bipat S. Glas A.S. Slors F.J. et al.Rectal cancer: local staging and assessment of lymph node involvement with endoluminal US, CT, and MR imaging-a meta-analysis.Radiology. 2004; 232: 773-783Crossref PubMed Scopus (788) Google Scholar, 11Lahaye M.J. Engelen S.M. Nelemans P.J. et al.Imaging for predicting the risk factors-the circumferential resection margin and nodal disease-of local recurrence in rectal cancer: a meta-analysis.Semin Ultrasound CT MR. 2005; 26: 259-268Abstract Full Text Full Text PDF PubMed Scopus (249) Google Scholar MRI may also have a role in guiding surgery because it shows the anatomic relationship between rectal tumors and the pelvic floor and sacrum. Correctly differentiating benign from malignant perirectal lymphadenopathy by EUS is difficult because inflammatory nodes may be present in the setting of rectal cancer; however, EUS-guided FNA (EUS-FNA) of perirectal lymph nodes may be helpful when the presence of nodal metastasis would change patient management.14Harewood G.C. Wiersema M.J. Nelson H. et al.A prospective, blinded assessment of the impact of preoperative staging on the management of rectal cancer.Gastroenterology. 2002; 123: 24-32Abstract Full Text Full Text PDF PubMed Scopus (162) Google Scholar The accuracy of EUS may be subject to publication bias and should be viewed with some caution.15Harewood G.C. Assessment of publication bias in the reporting of EUS performance in staging rectal cancer.Am J Gastroenterol. 2005; 100: 808-816Crossref PubMed Scopus (75) Google Scholar In clinical practice, other imaging modalities may have comparable staging accuracy. A 2011 prospective study of 90 subjects found a T2 staging accuracy of 76% to 77% for both EUS and MRI and T3 staging accuracy of 76% for EUS and 83% for MRI (P > .05). MRI did not visualize any T1 tumors, and EUS understaged all T4 tumors in that series.16Fernandez-Esparrach G. Ayuso-Colella J.R. Sendino O. et al.EUS and magnetic resonance imaging in the staging of rectal cancer: a prospective and comparative study.Gastrointest Endosc. 2011; 74: 347-354Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar The finding of a nontraversable malignant stricture in the rectum may be predictive of advanced tumor stage (T3, T4, or Tx, N1 or 2) and should be locally staged by radiographic cross-sectional imaging.17Miyamoto S. Boku N. Fujii T. et al.Macroscopic typing with wall stricture sign may reflect tumor behaviors of advanced colorectal cancers.J Gastroenterol. 2001; 36: 158-165Crossref PubMed Scopus (5) Google Scholar, 18Van Dam J. Rice T.W. Catalano M.F. et al.High-grade malignant stricture is predictive of esophageal tumor stage. Risks of endosonographic evaluation.Cancer. 1993; 71: 2910-2917Crossref PubMed Scopus (184) Google Scholar The reported accuracy of EUS restaging after neoadjuvant chemoradiation has been modest to poor: 38% to 75% for T staging and 57% to 84% for N staging.19Fleshman J.W. Myerson R.J. Fry R.D. et al.Accuracy of transrectal ultrasound in predicting pathologic stage of rectal cancer before and after preoperative radiation therapy.Dis Colon Rectum. 1992; 35: 823-829Crossref PubMed Scopus (81) Google Scholar, 20Huh J.W. Park Y.A. Jung E.J. et al.Accuracy of endorectal ultrasonography and computed tomography for restaging rectal cancer after preoperative chemoradiation.J Am Coll Surg. 2008; 207: 7-12Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar, 21Napoleon B. Pujol B. Berger F. et al.Accuracy of endosonography in the staging of rectal cancer treated by radiotherapy.Br J Surg. 1991; 78: 785-788Crossref PubMed Scopus (146) Google Scholar, 22Pastor C. Subtil J.C. Sola J. et al.Accuracy of endoscopic ultrasound to assess tumor response after neoadjuvant treatment in rectal cancer: can we trust the findings?.Dis Colon Rectum. 2011; 54: 1141-1146Crossref PubMed Scopus (40) Google Scholar, 23Radovanovic Z. Breberina M. Petrovic T. et al.Accuracy of endorectal ultrasonography in staging locally advanced rectal cancer after preoperative chemoradiation.Surg Endosc. 2008; 22: 2412-2415Crossref PubMed Scopus (45) Google Scholar, 24Rau B. Hunerbein M. Barth C. et al.Accuracy of endorectal ultrasound after preoperative radiochemotherapy in locally advanced rectal cancer.Surg Endosc. 1999; 13: 980-984Crossref PubMed Scopus (105) Google Scholar, 25Vanagunas A. Lin D.E. Stryker S.J. Accuracy of endoscopic ultrasound for restaging rectal cancer following neoadjuvant chemoradiation therapy.Am J Gastroenterol. 2004; 99: 109-112Crossref PubMed Scopus (130) Google Scholar A prospective study of 90 subjects comparing CT, MRI, and EUS for T and N staging after neoadjuvant therapy found similarly low accuracy for all 3 modalities. T staging accuracy was 37% by CT, 34% by MRI, and 27% by EUS. N staging was 62% by CT, 68% by MRI, and 65% by EUS.TABLE 2TNM staging classification of colorectal cancerPrimary tumor (T) TX Primary tumor cannot be assessed T0 No evidence of primary tumor Tis Carcinoma in situ: intraepithelial or invasion of lamina propria T1 Tumor invades submucosa T2 Tumor invades muscularis propria T3 Tumor invades through the muscularis propria into the subserosa or into nonperitonealized pericolic or perirectal tissues T4 Tumor directly invades other organs or structures and/or perforates visceral peritoneumRegional lymph nodes (N) NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Metastasis in 1-3 regional lymph nodes N2 Metastasis in ≥4 regional lymph nodesDistant metastasis (M) MX Distant metastasis cannot be assessed M0 No distant metastasis M1 Distant metastasis Open table in a new tab Endoscopic management of malignant colonic obstructionEndoscopic management of malignant obstruction is discussed in a recent ASGE Standards of Practice document.26Harrison M.E. Anderson M.A. Appalaneni V. et al.The role of endoscopy in the management of patients with known and suspected colonic obstruction and pseudo-obstruction.Gastrointest Endosc. 2010; 71: 669-679Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar Endoscopic alternatives to surgical decompression include placement of a self-expandable metal stent (SEMS), tumor debulking, and placement of a decompression tube. Even with successful endoscopic decompression, early surgical consultation is recommended because patients may deteriorate rapidly. Endoscopy should not be performed in patients with peritoneal signs or suspicion of perforation. Colonic SEMS may also be used as a "bridge to surgery" for patients with malignant obstruction who are surgical candidates. The success rate of single-stage elective surgery after colonic SEMS placement for decompression is 60% to 85%.27Varadarajulu S. Banerjee S. Barth B. et al.Enteral stents.Gastrointest Endosc. 2011; 74: 455-464Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar The major adverse events associated with colonic SEMS placement include obstruction, migration, and perforation.28Fisher D.A. Maple J.T. Ben-Menachem T. et al.Complications of colonoscopy.Gastrointest Endosc. 2011; 74: 745-752Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar In addition, dilation after colonic SEMS placement should be avoided because of the associated risk of perforation.28Fisher D.A. Maple J.T. Ben-Menachem T. et al.Complications of colonoscopy.Gastrointest Endosc. 2011; 74: 745-752Abstract Full Text Full Text PDF PubMed Scopus (232) Google ScholarEndoscopic resection of colorectal neoplasiaIn general, flat and polypoid lesions found at the time of colonoscopy should be removed.29Rex D.K. Bond J.H. Winawer S. et al.Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer.Am J Gastroenterol. 2002; 97: 1296-1308Crossref PubMed Scopus (859) Google Scholar Pedunculated lesions are usually removed by using standard snare polypectomy. Pedunculated polyps with cancer confined to the submucosa and without evidence of unfavorable histological factors have a 0.3% risk of cancer recurrence or lymph node metastasis after complete endoscopic removal, and surgery is not necessary.30Cranley J.P. Petras R.E. Carey W.D. et al.When is endoscopic polypectomy adequate therapy for colonic polyps containing invasive carcinoma?.Gastroenterology. 1986; 91: 419-427PubMed Google ScholarFor pedunculated polyps with unfavorable histological features (<1 mm cancer-free margin, poor histological differentiation, vascular or lymphatic invasion), invading the submucosa of the bowel wall below the polyp's stalk, or extending through the submucosa into the deeper wall layers, surgery is recommended because endoscopic removal is unlikely to be curative.31Morson B.C. Whiteway J.E. Jones E.A. et al.Histopathology and prognosis of malignant colorectal polyps treated by endoscopic polypectomy.Gut. 1984; 25: 437-444Crossref PubMed Scopus (340) Google Scholar, 32Muller S. Chesner I.M. Egan M.J. et al.Significance of venous and lymphatic invasion in malignant polyps of the colon and rectum.Gut. 1989; 30: 1385-1391Crossref PubMed Scopus (96) Google Scholar, 33Nascimbeni R. Burgart L.J. Nivatvongs S. et al.Risk of lymph node metastasis in T1 carcinoma of the colon and rectum.Dis Colon Rectum. 2002; 45: 200-206Crossref PubMed Scopus (550) Google Scholar The site of resection of such polyps should be inked with a tattoo to facilitate identification during surgery. In all cases of potential surgical referral, the risk of recurrent disease should be weighed against the operative risk in individual patients.Endoscopic removal of larger sessile or flat lesions may require more advanced techniques. EMR and endoscopic submucosal dissection (ESD) are reviewed in a 2008 ASGE Technology Status Evaluation Report.34Kantsevoy S.V. Adler D.G. Conway J.D. et al.Endoscopic mucosal resection and endoscopic submucosal dissection.Gastrointest Endosc. 2008; 68: 11-18Abstract Full Text Full Text PDF PubMed Scopus (263) Google Scholar EMR is indicated for sessile or flat neoplastic lesions confined to the mucosa or submucosa of the colon. Lesions that are 2 cm or smaller can often be removed en bloc, whereas larger lesions may require piecemeal resection. Typically, a solution is injected into the submucosa to lift the lesion for easier removal and to provide a cushion to help protect the deeper layers of the bowel wall from mechanical or electrocautery damage. The inability to raise the base of a polyp after submucosal solution injection can indicate the presence of cancer invading deep into the submucosa and precludes endoscopic resection of the lesion.35Kanamori T. Itoh M. Yokoyama Y. et al.Injection-incision-assisted snare resection of large sessile colorectal polyps.Gastrointest Endosc. 1996; 43: 189-195Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar, 36Uno Y. Munakata A. Tanaka M. The discrepancy of histologic diagnosis between flat early colon cancers and flat adenomas.Gastrointest Endosc. 1994; 40: 1-6Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar Lesions that do not lift can be technically difficult to remove by EMR even if the cause of the nonlifting sign is not invasive malignancy (eg, from fibrosis from a previous biopsy or previous attempts at endoscopic resection).37Kobayashi N. Saito Y. Sano Y. et al.Determining the treatment strategy for colorectal neoplastic lesions: endoscopic assessment or the non-lifting sign for diagnosing invasion depth?.Endoscopy. 2007; 39: 701-705Crossref PubMed Scopus (112) Google Scholar Therefore, EMR should be attempted only if complete resection of neoplastic lesions is anticipated.ESD was developed for en bloc resection of larger lesions (ie, >2 cm). After submucosal injection of a fluid cushion, the lesion is dissected from the deep layers of the bowel wall by using electrocautery knives. The adverse events of EMR and ESD in the removal of colorectal lesions are reviewed in a previous ASGE document.28Fisher D.A. Maple J.T. Ben-Menachem T. et al.Complications of colonoscopy.Gastrointest Endosc. 2011; 74: 745-752Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar The major adverse events are the same as those for standard polypectomy (ie, bleeding and perforation); however, the rate is higher.28Fisher D.A. Maple J.T. Ben-Menachem T. et al.Complications of colonoscopy.Gastrointest Endosc. 2011; 74: 745-752Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar The role of ESD for colorectal lesions is not well established. Compared with its use for gastric lesions, ESD in the colon is more technically challenging because of less space, difficult positioning, thinner bowel wall, and the presence of colonic folds.34Kantsevoy S.V. Adler D.G. Conway J.D. et al.Endoscopic mucosal resection and endoscopic submucosal dissection.Gastrointest Endosc. 2008; 68: 11-18Abstract Full Text Full Text PDF PubMed Scopus (263) Google Scholar EMR is widely used to remove benign flat neoplastic lesions in the colon including those with high-grade dysplasia. EMR can also be definitive treatment for intramucosal (T1mN0) CRC in which the risk of lymph node involvement is negligible.31Morson B.C. Whiteway J.E. Jones E.A. et al.Histopathology and prognosis of malignant colorectal polyps treated by endoscopic polypectomy.Gut. 1984; 25: 437-444Crossref PubMed Scopus (340) Google Scholar, 33Nascimbeni R. Burgart L.J. Nivatvongs S. et al.Risk of lymph node metastasis in T1 carcinoma of the colon and rectum.Dis Colon Rectum. 2002; 45: 200-206Crossref PubMed Scopus (550) Google Scholar, 38Fujimori T. Kawamata H. Kashida H. Precancerous lesions of the colorectum.J Gastroenterol. 2001; 36: 587-594Crossref PubMed Scopus (41) Google Scholar, 39Matsuda T. Gotoda T. Saito Y. et al.Our perspective on endoscopic resection for colorectal neoplasms.Gastroenterol Clin Biol. 2010; 34: 367-370Crossref PubMed Scopus (28) Google ScholarThe optimal technique to minimize the risk of residual neoplasia during piecemeal EMR is evolving. Residual polyp tissue may have contributed to previous reports of interval cancers after colonoscopy with polypectomy.4Lieberman D.A. Rex D.K. Winawer S.J. et al.Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer.Gastroenterology. 2012; 143: 844-857Abstract Full Text Full Text PDF PubMed Scopus (1404) Google Scholar, 40Winawer S.J. Zauber A.G. Fletcher R.H. et al.Guidelines for colonoscopy surveillance after polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society.Gastroenterology. 2006; 130: 1872-1885Abstract Full Text Full Text PDF PubMed Scopus (625) Google Scholar In general, the most important principle is to maximize potential for complete eradication on the initial resection attempt. This may necessitate referral to a center with expertise in advanced polypectomy. All visible adenomatous tissue should be endoscopically resected or ablated if snare excision is not feasible. Techniques to minimize residual polyp tissue include taking a small margin of surrounding mucosa at the polyp edges41Moss A. Bourke M.J. Williams S.J. et al.Endoscopic mucosal resection outcomes and prediction of submucosal cancer from advanced colonic mucosal neoplasia.Gastroenterology. 2011; 140: 1909-1918Abstract Full Text Full Text PDF PubMed Scopus (426) Google Scholar or tissue ablation. Tissue ablation has been described both prophylactically at the resection margins after a piecemeal removal and for the treatment of endoscopically visible residual polypoid tissue. Ablation techniques have been primarily described with argon plasma coagulation (APC),42Brooker J.C. Saunders B.P. Shah S.G. et al.Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps: a randomized trial and recommendations.Gastrointest Endosc. 2002; 55: 371-375Abstract Full Text Full Text PDF PubMed Scopus (251) Google Scholar, 43Regula J. Wronska E. Polkowski M. et al.Argon plasma coagulation after piecemeal polypectomy of sessile colorectal adenomas: long-term follow-up study.Endoscopy. 2003; 35: 212-218Crossref PubMed Scopus (127) Google Scholar, 44Zlatanic J. Waye J.D. Kim P.S. et al.Large sessile colonic adenomas: use of argon plasma coagulator to supplement piecemeal snare polypectomy.Gastrointest Endosc. 1999; 49: 731-735Abstract Full Text Full Text PDF PubMed Scopus (182) Google Scholar with 1 report of diathermy ablation with the snare tip.41Moss A. Bourke M.J. Williams S.J. et al.Endoscopic mucosal resection outcomes and prediction of submucosal cancer from advanced colonic mucosal neoplasia.Gastroenterology. 2011; 140: 1909-1918Abstract Full Text Full Text PDF PubMed Scopus (426) Google Scholar Estimates of short-term (2-6 months) residual/recurrence rates after piecemeal EMR are broad, ranging from 0% to 55%.45Khashab M. Eid E. Rusche M. et al.Incidence and predictors of "late" recurrences after endoscopic piecemeal resection of large sessile adenomas.Gastrointest Endosc. 2009; 70: 344-349Abstract Full Text Full Text PDF PubMed Scopus (146) Google Scholar Late recurrence (after 12 months) is less common, occurring in less than 5% in 1 study.45Khashab M. Eid E. Rusche M. et al.Incidence and predictors of "late" recurrences after endoscopic piecemeal resection of large sessile adenomas.Gastrointest Endosc. 2009; 70: 344-349Abstract Full Text Full Text PDF PubMed Scopus (146) Google Scholar A small, randomized study evaluating the use of prophylactic APC at piecemeal polypectomy sites where complete excision was thought to be achieved by the endoscopist produced a lower risk of recurrence in the APC group (1/10 vs 7/11, P = .02), that was statistically significant.42Brooker J.C. Saunders B.P. Shah S.G. et al.Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps: a randomized trial and recommendations.Gastrointest Endosc. 2002; 55: 371-375Abstract Full Text Full Text PDF PubMed Scopus (251) Google Scholar In a larger, more recent study of 479 patients with 514 colonic lesions evaluating the safety and efficacy of EMR, use of APC was an independent predictor of recurrence after presumed effective EMR.41Moss A. Bourke M.J. Williams S.J. et al.Endoscopic mucosal resection outcomes and prediction of submucosal cancer from advanced colonic mucosal neoplasia.Gastroenterology. 2011; 140: 1909-1918Abstract Full Text Full Text PDF PubMed Scopus (426) Google Scholar The authors of this study reported a 20% recurrence rate and did not prophylactically treat the polyp edges with APC, reserving APC for visible tissue not amenable to snare excision.Regardless of the technique used, close surveillance after piecemeal polypectomy is mandatory given the potential for recurrence. To facilitate surveillance, tattooing should be considered for polyps that cannot readily be identified by anatomic landmarks. A detailed review of endoscopic tattooing is available in a 2010 ASGE Technology Status Evaluation Report.5Kethu S.R. Banerjee S. Desilets D. et al.Endoscopic tattooing.Gastrointest Endosc. 2010; 72: 681-685Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar Ideally, the tattoo should be distinct from the polypectomy site to avoid fibrotic tissue reaction that can be associated with tattooing agents. No guidelines exist on the optimal placement of a tattoo, but some experts have suggested standardizing a tattoo injection to 3 cm downstream from the lesion.41Moss A. Bourke M.J. Williams S.J. et al.Endoscopic mucosal resection outcomes and prediction of submucosal cancer from advanced colonic mucosal neoplasia.Gastroenterology. 2011; 140: 1909-1918Abstract Full Text Full Text PDF PubMed Scopus (426) Google Scholar Photodocumentation of the polypectomy site in relation to the area of tattoo may be helpful during subsequent surveillance examinations to allow for accurate identification of the scar site if no visible tissue is found. Guidelines recommend a follow-up colonoscopy in 2 to 6 months after piecemeal EMR of large sessile lesions, with both endoscopic and pathological assessments to ensure complete removal.4Lieberman D.A. Rex D.K. Winawer S.J. et al.Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update