From the Guidelines
The best treatment approach for a patient with adenocarcinoma of the sigmoid colon with invasion of the stalk and proximity to the resection margin after polypectomy is surveillance colonoscopy in 1 year, as the cancer is well-differentiated and the margin is close but not positive, according to the most recent guidelines 1. This recommendation is based on the latest guidelines from the Chinese Society of Clinical Oncology (CSO), which suggest that for T1-stage colon adenocarcinomas with submucosal invasion <1 mm, endoscopic treatment can be considered, and follow-up endoscopy can be performed within 1 year after endoscopic treatment if the margin is negative 1. The patient's cancer is well-differentiated, and the margin is close but not positive, which suggests that the risk of residual cancer cells at the polypectomy site is low. However, it is essential to note that the patient should undergo complete staging workup, including a colonoscopy to rule out synchronous lesions, and baseline CEA (carcinoembryonic antigen) level, to assess for metastatic disease. Some studies suggest that surgical resection may be considered in certain cases, particularly if the polyp is sessile or has unfavorable histologic features 1. However, the most recent guidelines prioritize surveillance colonoscopy for patients with well-differentiated adenocarcinoma and close margins, as in this case 1. Key considerations for the treatment approach include:
- The type of polyp (pedunculated or sessile) and its size
- The degree of submucosal invasion
- The presence of lymphovascular invasion
- The grade of differentiation of the tumor
- The margin status after polypectomy. In this case, the patient's cancer is well-differentiated, and the margin is close but not positive, which supports the recommendation for surveillance colonoscopy in 1 year 1.
From the Research
Treatment Approach for Adenocarcinoma of the Sigmoid Colon
The patient in question has undergone colonoscopy and had 7 adenomas removed, with the largest being a pedunculated polyp at 30 cm in the sigmoid colon. Pathologic examination of the polyp demonstrated well-differentiated adenocarcinoma invading the stalk and extending to a distance of 0.5 mm from the resection line.
Considerations for Treatment
- The patient's condition suggests a high risk of recurrence or metastasis, as evidenced by the invasion of the stalk and proximity to the resection margin 2.
- Endoscopic full-thickness resection (eFTR) is a viable treatment option for T1 colorectal cancers, including those in the sigmoid colon, and has been shown to be relatively safe and effective 3.
- The European Society of Gastrointestinal Endoscopy has published guidelines on the endoscopic management of colorectal adenomas, which include recommendations for endoscopic resection techniques and their indications 4.
- Advanced endoscopic resection techniques, such as eFTR and endoscopic submucosal dissection, have expanded the possibilities for endoscopic treatment of colorectal neoplasms 5.
Appropriate Treatment Options
- Surgical resection of the sigmoid colon (Option A) may be considered, especially given the patient's high risk of recurrence or metastasis.
- Endoscopic full-thickness resection at the polypectomy site (Option B) could be a viable alternative to surgical resection, especially if the patient is a good candidate for eFTR.
- Surveillance colonoscopy in 3 months (Option C) or 1 year (Option D) may not be sufficient, given the patient's high risk of recurrence or metastasis.
Most Appropriate Option
Based on the available evidence, Option A (Surgical resection of the sigmoid colon) or Option B (Endoscopic full-thickness resection at the polypectomy site) may be the most appropriate treatment approach, depending on the patient's individual circumstances and the availability of eFTR 2, 4, 5, 3.