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Liu JN, Chen H, Fang N. Current status of endoscopic resection for small rectal neuroendocrine tumors. World J Gastroenterol 2025; 31:106814. [DOI: 10.3748/wjg.v31.i19.106814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2025] [Revised: 03/21/2025] [Accepted: 04/27/2025] [Indexed: 05/21/2025] Open
Abstract
Rectal neuroendocrine tumor (rNET) is an indolent malignancy often detected during colonoscopy screening. The incidence of rNET has increased approximately 10-fold over the past 30 years. Most rNETs detected during screening endoscopy are small, measuring < 10 mm. Current guidelines recommend endoscopic resection for small, well-differentiated rNET using modified endoscopic submucosal resection (mEMR) or endoscopic submucosal dissection. However, the optimal endoscopic treatment method remains uncertain. This paper summarizes the evidence on mEMR with submucosal stretching, mEMR without submucosal stretching, endoscopic submucosal dissection and endoscopic full-thickness resection. Given that rNETs often exhibit submucosal invasion, achieving adequate resection depth is crucial to ensure histological complete resection. mEMR with submucosal stretching appears favorable due to its high rate of histological complete resection, safety and convenience. Risk factors associated with lymph node and distant metastases are also discussed. A treatment algorithm is proposed to facilitate clinical decision-making.
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Affiliation(s)
- Jian-Ning Liu
- Department of Gastroenterology, The Third Affiliated Hospital, Jiangxi Medical College, School of Queen Mary, Nanchang University, Nanchang 330009, Jiangxi Province, China
| | - Hui Chen
- Endoscopic Center, Xijing Hospital of Digestive Diseases, Air Force Medical University (Fourth Military Medical University), Xi’an 710032, Shaanxi Province, China
| | - Nian Fang
- Department of Gastroenterology, The Third Affiliated Hospital, Jiangxi Medical College, School of Queen Mary, Nanchang University, Nanchang 330009, Jiangxi Province, China
- Department of Gastroenterology, The First Hospital of Nanchang, Nanchang 330009, Jiangxi Province, China
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Park BS, Cho SH, Son GM, Kim HS, Kim SJ, Park SB, Choi CW, Kim HW, Shin DH. Tumor grade 2 as the independent predictor for lymph node metastasis in 10-20 mm sized rectal neuroendocrine tumor. KOREAN JOURNAL OF CLINICAL ONCOLOGY 2021; 17:37-43. [PMID: 36945210 PMCID: PMC9942737 DOI: 10.14216/kjco.21006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 06/17/2021] [Accepted: 06/23/2021] [Indexed: 11/07/2022]
Abstract
Purpose Rectal neuroendocrine tumors (NETs) <10 mm are endoscopically resected, while those ≥20 mm are treated with radical surgical resection. The choice of treatment for 10-20 mm sized rectal NETs remains controversial. This study aimed to verify factors predicting lymph node metastasis (LNM) of 10-20 mm sized rectal NET and utilize them to decide upon the treatment strategy. Methods Twenty-eight patients with 10-20 mm sized rectal NETs treated at Pusan National University Yangsan Hospital from January 2009 to September 2020 were divided into LNM (+) and LNM (-) groups, and their respective data were analyzed. Results Seven patients (25%) had LNM while 21 patients (75%) did not. Endorectal ultrasound findings showed tumor size was significantly larger in the LNM (+) than in the LNM (-) group (15 mm vs. 10 mm, P=0.018); however, pathologically, there was no significant difference in tumor size (13 mm vs. 11 mm, P=0.109). The mitotic count (P=0.011), Ki-67 index (P=0.008), and proportion of tumor grade 2 patients (5 cases, 71% vs. 1 case, 5%; P=0.001) were significantly higher in the LNM (+) group. In multivariate analysis, tumor grade 2 was the independent factor predicting LNM (odds ratio, 61.32; 95% confidence interval, 3.17-1,188.64; P=0.010). Conclusion Tumor grade 2 was the independent factor predicting LNM in 10-20 mm sized rectal NETs. Therefore, it could be considered as the meaningful factor in determining whether radical resection is necessary.
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Affiliation(s)
- Byung-Soo Park
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Sung Hwan Cho
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Gyung Mo Son
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hyun Sung Kim
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Su Jin Kim
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Su Bum Park
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Cheol Woong Choi
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hyung Wook Kim
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Dong Hoon Shin
- Department of Pathology, Pusan National University Yangsan Hospital, Yangsan, Korea
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Kang HS, Kwon MJ, Kim TH, Han J, Ju YS. Lymphovascular invasion as a prognostic value in small rectal neuroendocrine tumor treated by local excision: A systematic review and meta-analysis. Pathol Res Pract 2019; 215:152642. [PMID: 31585816 DOI: 10.1016/j.prp.2019.152642] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 08/26/2019] [Accepted: 09/15/2019] [Indexed: 02/07/2023]
Abstract
Because rectal neuroendocrine tumors (NETs) are usually small-sized despite of malignant potential, endoscopic resection techniques are recommended. It is unclear whether the lymphovascular invasion (LVI) in the endoscopic resected specimens of small rectal NETs should be indicated for completion surgery. We performed a systematic review and meta-analysis for the incidence of LVI in small rectal NETs (≤20 mm) treated by endoscopic resection and its prognostic impacts. We searched the relevant literature published before January 2019. A total of 21 publications including 1816 patients were enrolled. Overall prevalence of LVI in small rectal NETs was 21.8%. Immunohistochemical method significantly increased the detection rate of LVI up to 35.8% compared than H&E staining only (13.2%). Tumor size more than 5 mm was a risk factor for LVI in small rectal NET, whereas tumor grade did not influence the risk. The LVI in the endoscopic resected specimens was a risk factor for subsequent lymph node metastasis. Separately analyzed in detail, the vascular invasion had a stronger impact on lymph node metastasis than the lymphatic invasion. The prognosis of endoscopically treated rectal NET with LVI was excellent with only 0.3% of recurrence rate during the 5-year follow-up period. LVI is highly prevalent and a risk factor for lymph node metastasis in the small rectal NETs. Endoscopically treated small rectal NETs had excellent short-term prognoses despite of LVI. Immediate completion radical surgery is not absolutely necessary for the LVI-positive small rectal NETs. However, long-term follow-up is recommended for any delayed recurrence.
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Affiliation(s)
- Ho Suk Kang
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Gyeonggi-do, Republic of Korea
| | - Mi Jung Kwon
- Department of Pathology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Gyeonggi-do, Republic of Korea.
| | - Tae-Hwan Kim
- Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Gyeonggi-do, Republic of Korea
| | - Junhee Han
- Department of Statistics, Hallym University, Chuncheon, Republic of Korea
| | - Young-Su Ju
- Department of Occupational and Environmental Medicine, Hallym University Sacred Heart Hospital, Anyang, Gyeonggi-do, Republic of Korea
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Leon P, Balduzzi A, Troian M, de Manzini N. Trans-anal full-thickness endoscopic resection of a rectal neuroendocrine neoplasm performed with a TEO ® (Karl Storz microsurgery device) and laparoscopic indocyanine-green-guided lymphatic sampling - a video vignette. Colorectal Dis 2017; 19:399-400. [PMID: 28208236 DOI: 10.1111/codi.13631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 11/22/2016] [Indexed: 02/08/2023]
Affiliation(s)
- P Leon
- Department of General Surgery, Cattinara Hospital, University of Trieste, Trieste (TS), Italy
| | - A Balduzzi
- Department of General Surgery, Cattinara Hospital, University of Trieste, Trieste (TS), Italy
| | - M Troian
- Department of General Surgery, Cattinara Hospital, University of Trieste, Trieste (TS), Italy
| | - N de Manzini
- Department of General Surgery, Cattinara Hospital, University of Trieste, Trieste (TS), Italy
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Kwon MJ, Kang HS, Soh JS, Lim H, Kim JH, Park CK, Park HR, Nam ES. Lymphovascular invasion in more than one-quarter of small rectal neuroendocrine tumors. World J Gastroenterol 2016; 22:9400-9410. [PMID: 27895428 PMCID: PMC5107704 DOI: 10.3748/wjg.v22.i42.9400] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 09/10/2016] [Accepted: 10/10/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To identify the frequency, clinicopathological risk factors, and prognostic significance of lymphovascular invasion (LVI) in endoscopically resected small rectal neuroendocrine tumors (NETs).
METHODS Between June 2005 and December 2015, 104 cases of endoscopically resected small (≤ 1 cm) rectal NET specimens at Hallym University Sacred Heart Hospital in Korea were retrospectively evaluated. We compared the detected rate of LVI in small rectal NET specimens by two methods: hematoxylin and eosin (H&E) and ancillary immunohistochemical staining (D2-40 and Elastica van Gieson); in addition, LVI detection rate difference between endoscopic procedures were also evaluated. Patient characteristics, prognosis and endoscopic resection results were reviewed by medical charts.
RESULTS We observed LVI rates of 25.0% and 27.9% through H&E and ancillary immunohistochemical staining. The concordance rate between H&E and ancillary studies was 81.7% for detection of LVI, which showed statistically strong agreement between two methods (κ = 0.531, P < 0.001). Two endoscopic methods were studied, including endoscopic submucosal resection with a ligation device and endoscopic submucosal dissection, and no statistically significant difference in the LVI detection rate was detected between the two (26.3% and 26.8%, P = 0.955). LVI was associated with large tumor size (> 5 mm, P = 0.007), tumor grade 2 (P = 0.006). Among those factors, tumor grade 2 was the only independent predictive factor for the presence of LVI (HR = 4.195, 95%CI: 1.321-12.692, P = 0.015). No recurrence was observed over 28.8 mo regardless of the presence of LVI.
CONCLUSION LVI may be present in a high percentage of small rectal NETs, which may not be associated with short-term prognosis.
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Yang DH, Park Y, Park SH, Kim KJ, Ye BD, Byeon JS, Myung SJ, Yang SK. Cap-assisted EMR for rectal neuroendocrine tumors: comparisons with conventional EMR and endoscopic submucosal dissection (with videos). Gastrointest Endosc 2016; 83:1015-22; quiz 1023-.e6. [PMID: 26460225 DOI: 10.1016/j.gie.2015.09.046] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Accepted: 09/08/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS The incidence of rectal neuroendocrine tumors (NETs) is increasing, and most small rectal NETs can be treated endoscopically. Cap-assisted EMR (EMR-C) was suggested as an effective treatment for rectal NETs in a few studies. We aimed to compare the outcomes of conventional EMR, EMR-C, and endoscopic submucosal dissection (ESD) for the treatment of rectal NETs. METHODS A total of 138 rectal NETs were treated endoscopically by a single endoscopist at Asan Medical Center. We analyzed 122 rectal NETs that had been removed by using EMR (n = 56), EMR-C (n = 34), or ESD (n = 32). RESULTS The histologic complete resection rate was higher in the EMR-C group than in the EMR group (94.1% vs 76.8%, P = .032). Intraprocedural bleeding tended to be more frequent in the EMR-C group than in the EMR group (8.8% vs 0%, P = .051). No differences in the rates of adverse events or histologic complete resections were observed between the EMR-C group and the ESD group for 6-mm to 8-mm NETs; however, the procedure time was significantly shorter in the EMR-C group (3.9 ± 1.1 minutes) than in the ESD group (19.0 ± 12.1 minutes) (P < .001). There was no recurrence in any of the 3 groups. CONCLUSIONS EMR-C is the preferable technique for endoscopic resection of small rectal NETs.
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Affiliation(s)
- Dong-Hoon Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Yangsoon Park
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sang Hyoung Park
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Kyung-Jo Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Byong Duk Ye
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Seung-Jae Myung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Suk-Kyun Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Kim JS, Kim YJ, Chung JW, Kim JH, Kim KO, Kwon KA, Park DK, An JS. Usefulness of endoscopic resection using the band ligation method for rectal neuroendocrine tumors. Intest Res 2016; 14:164-71. [PMID: 27175117 PMCID: PMC4863050 DOI: 10.5217/ir.2016.14.2.164] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 10/19/2015] [Accepted: 10/20/2015] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Rectal neuroendocrine tumors (NETs) are among the most common of gastrointestinal NETs. Due to recent advances in endoscopy, various methods of complete endoscopic resection have been introduced for small (≤10 mm) rectal NETs. However, there is a debate about the optimal treatment for rectal NETs. In our study, we aimed to evaluate the efficacy and feasibility of endoscopic resection using pneumoband and elastic band (ER-BL) for rectal NETs smaller than 10 mm in diameter. Methods A total of 55 patients who were diagnosed with rectal NET from January 2004 to December 2011 at Gil Medical Center were analyzed retrospectively. Sixteen patients underwent ER-BL. For comparison, 39 patients underwent conventional endoscopic mucosal resection (EMR). Results There was a markedly lower deep margin positive rate for ER-BL than for conventional EMR (6% [1/16] vs. 46% [18/39], P=0.029). Four patients who underwent conventional EMR experienced perforation or bleeding. However, they recovered within a few days. On the other hand, patients whounderwent endoscopic resection using a pneumoband did not experience any complications. In multivariate analysis, ER-BL (P=0.021) was independently associated with complete resection. Conclusions ER-BL is an effective endoscopic treatment with regards to deep margin resection for rectal NET smaller than 10 mm.
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Affiliation(s)
- Ju Seung Kim
- Department of Internal Medicine, Gachon University College of Medicine, Gil Medical Center, Incheon, Korea
| | - Yoon Jae Kim
- Department of Internal Medicine, Gachon University College of Medicine, Gil Medical Center, Incheon, Korea
| | - Jun-Won Chung
- Department of Internal Medicine, Gachon University College of Medicine, Gil Medical Center, Incheon, Korea
| | - Jung Ho Kim
- Department of Internal Medicine, Gachon University College of Medicine, Gil Medical Center, Incheon, Korea
| | - Kyoung Oh Kim
- Department of Internal Medicine, Gachon University College of Medicine, Gil Medical Center, Incheon, Korea
| | - Kwang An Kwon
- Department of Internal Medicine, Gachon University College of Medicine, Gil Medical Center, Incheon, Korea
| | - Dong Kyun Park
- Department of Internal Medicine, Gachon University College of Medicine, Gil Medical Center, Incheon, Korea
| | - Jung Suk An
- Department of Pathology, Gachon University College of Medicine, Gil Medical Center, Incheon, Korea
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Choi JH, Cha JM. Are Small Rectal Neuroendocrine Tumors Safe? Intest Res 2015; 13:103-4. [PMID: 25931993 PMCID: PMC4414750 DOI: 10.5217/ir.2015.13.2.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 03/11/2015] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jae Ho Choi
- Department of Internal Medicine, Kyung Hee University Hospital at Gang Dong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jae Myung Cha
- Department of Internal Medicine, Kyung Hee University Hospital at Gang Dong, Kyung Hee University School of Medicine, Seoul, Korea
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