Update on the management of pT1 colorectal cancer

Abstract

With the implementation of CRC screening programs, the incidence of pT1 CRC has increased significantly: up to 40% of colon tumors detected in screening colonoscopies are pT1[1]-[2]. Traditionally, the treatment of choice for CRC is surgery with lymph node resection, but pT1 CRC has a very good prognosis with 5-year disease-free survival rates greater than 90%[3] and thanks to advanced endoscopy, it can be treated locally with a minimally invasive approach in many cases[4]-[6]. After resection of the lesion, an adequate histological description of the specimen will guide us to make the final decision in the management of pT1 CRC: whether endoscopic resection is considered curative or whether additional surgery will be required to prevent local recurrence, lymphatic dissemination and/or distant metastasis[7]. The decision to proceed with additional surgery or surveillance depends primarily on the estimated oncologic benefit of surgery, operative risk, and patient preferences. It must be taken into account that colorectal surgery carries a significant risk of morbidity and mortality for elderly patients[8].

Currently we base our decisions on histological criteria, but the natural history of pT1 CRC resected by endoscopy is really unknown and there are not enough quality prospective studies with results after long-term follow-up of pT1 CRC non-surgically managed, especially in the case of high-risk pT1, which would explain the great variability in the management of these patients[9].

In this thematic review we have analyzed the current state of management of pT1 CRC in the field of endoscopic diagnosis and treatment, histological evaluation and its prognostic implications. We have also reviewed the most recent evidence regarding surveillance: how to carry out adequate follow-up and determine the optimal frequency and the most appropriate surveillance method after local resection of pT1 CRC.

Keywords: Colorectal cancer, pT1 CRC, colonoscopy, polyp, endoscopic resection, colorectal surgery, high risk histological factors.