Disclosures: The authors report no relevant financial disclosures.
April 29, 2022
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Deep submucosal invasion not strong predictor for lymph node metastasis, surgery in CRC

Disclosures: The authors report no relevant financial disclosures.
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Among patients with T1 colorectal cancer, deep submucosal invasion was not a significant independent predictor for lymph node metastasis and should not be considered the sole indicator for oncologic surgery.

“Guidelines consider [deep submucosal invasion (DSI)] a high-risk factor for [lymph node metastasis (LMN)] and strong indicator for radical surgery,” Liselotte W. Zwager, of the department of gastroenterology and hepatology at Amsterdam University Medical Center, and colleagues wrote in Gastroenterology. “Since DSI is the only factor that can be assessed optically before resection, its presence importantly shapes management decisions. “Currently, DSI is the most prevalent criterion to refrain from endoscopic resection or refer for additional surgery. However, studies have shown conflicting results on its predictive value and accumulating evidence suggests DSI is only a weak predictor for LNM in absence of other risk factors, with risks around 1.6% to 2.2%.”

HGI0422Zwager_Graphic_01
Among patients with T1 CRC, deep submucosal invasion was not a strong predictor for lymph node metastasis or surgery. Source: Adobe Stock

In a meta-analysis, Zwager and colleagues identified 67 studies, which included 21,238 patients with T1 CRC, to establish LNM risk for DSI. Studies were included if risk factors, poor differentiation, lymphovascular invasion and/or high-grade tumor budding were also included in multivariable analysis or the LNM-rate of DSI was described in absence of poor differentiation, lymphovascular invasion and tumor budding.

Investigators noted the overall LNM rate was 11.2%, which was significantly higher for DSI-positive cancers (OR = 2.58; 95% CI, 2.1-3.18). In a multivariable meta-analysis, eight studies (3,621 patients) did not include DSI as a significant predictor for LNM (OR = 1.73; 95% CI, 0.96-3.12); however, a significant correlation was noted between LNM and poor differentiation (OR = 2.14; 95% CI. 1.39-3.28), tumor budding (OR = 2.83; 95% CI, 2.06-3.88) and lymphovascular invasion (OR = 3.16; 95% CI, 1.88-5.33).

According to results from another series of eight studies (1,146 patients) that assessed DSI as a solitary risk factor, the absolute risk of LNM was 2.6% and the pooled incidence rate was 2.83 (95%CI, 1.66-4.78).

“These results importantly challenge the early perspective and oncological dogma of DSI seen as strong indicator for oncologic surgery,” the authors wrote. “In light of the expanding spectrum of local resection methods and increasing interest in organ-preservation, a management shift towards a local excision as initial approach for amenable DSI cases to guide shared decision-making is expected.”