Recurrence rate during long-term follow up after cold and hot resection of large non-pedunculated polyps in the colorectum – results from the multicentric, randomized controlled CHRONICLE-trial

Aims As shown recently in two randomized controlled trials, cold resection of non-pedunculated colorectal polyps≥20 mm appears to be significantly safer than endoscopic mucosal resection (EMR) with the hot snare, but at the cost of a higher rate of residual adenoma at first follow-up (FU) endoscopy [1] [2]. Since guidelines recommend FU endoscopy within 6 months after piecemeal-EMR, with subsequent endoscopic resection of residual adenoma [3], we hypothesize that the significantly higher rate of residual adenoma after cold snare-EMR of 23.7% vs. 13.8% in the CHRONICLE-trial¹ should become similar in the long term for both resection techniques. Thus, the higher rate of residual adenoma after cold snare resection at first FU may be of less clinical relevance. We therefore performed a comparative analysis of the long-term FU data from the CHRONICLE trial.

Methods Comparative study of 4- and 12-month FU data from the prospective, randomized CHRONICLE trial. Primary endpoint for this analysis was the rate of residual adenoma at the second endoscopic FU.

Results Between 2021 and 2023 396 polyps in 363 patients (48.2% female) had been enrolled in this study. Data on first FU examination were available in 92.2% of the previously resected polyps. In the intention-to-treat dataset the rate of residual adenoma was 18.6% (68/365), followed by endoscopic re-resection in 62 (91.2%) cases (polypectomy/EMR in 35, Endoscopic full thickness resection (EFTR) in 5 and forceps resection in 22 cases). 6 cases (8.8%) were transferred for surgical treatment. Data on second FU endoscopy were currently available for 268 polyps (67.7%). The rate of residual adenoma was 13.6% (18/132; 95%-CI: 8,2-19,7%) in the cold and 10.3% (14/136; 95%-CI: 5,2-15,4%) in the hot EMR group (p=0.399). All but one case in the hot EMR group that underwent surgery were re-retreated endoscopically (polypectomy/EMR in 15, EFTR in 5 and forceps resection in 11 cases).

Conclusions Rates of residual adenoma at the second FU (after retreatment of recurrent neoplasia at the first FU endoscopy) were still high around 10%, but similar in both groups. Thus, the disadvantage of cold EMR with regards to recurrence was less relevant at this stage. Assuming good patient compliance, cold snare EMR with subsequent resection of residual adenoma in the first FU endoscopy may be considered for benign, large, non-pedunculated colorectal polyps. Efforts to reduce rates of residual/recurrent neoplasia (like margin coagulation) have to be intensified.

Conflicts of Interest

Alanna Ebigbo: lecture fees from Olympus Medical, FujiFilm, Pentax, Ambu, Falk Pharma and MedtronicAlexander Meining: consultancy from Ovesco Endoscopy AG and Olympus MedicalArmin Küllmer: lecture fees from Ovesco Endoscopy AG and Falk Pharma and consulting fees from KLS Martin Group, Tuttlingen, GermanyArthur Schmidt: lecture fees from Falk Pharma and Olympus MedicalFranz-Ludwig Dumoulin: lecture fees and travel grants from OlympusHans-Peter Allgaier: lecture fees and travel grants from Olympus.Helmut Messmann: consulting fees from Boston Scientific, CDx Diagnostics, Covidien, Erbe, Lumendi, Norgine, Olympus Medical, lecture fees from Covidien, Falk Pharma, Olympus Medical and travel grants from Amgen, Bayer, Falk Pharma, MSD, Novartis, Olympus medical and RocheIngo Steinbrück: lecture fees and travel grants from Olympus and Falk PharmaMartin Götz: consulting fees from Abbvie, Janssen and Galapagos, member of advisory board of Boehringer Ingelheim and Alexion, lecture fees from Abbvie, Takeda, Pentax, MSD and DGVSOliver Möschler: lecture fees from Olympus Medical and FujiFilmOliver Pech: lecture fees from Medtronic, Aohua, AbbVie, Falk Pharma and Boston ScientificAndreas Wannhoff: research grants from Fujifilm and OvescoHans-Dieter Allescher: participation in advisory boards from Bayer and BMS and fiduciary role in DGVS and DGEBVMarkus Brand: lecture fees from Abbvie, Takeda and Falk PharmaSandra Nagl: lecture fees from Falk Pharma, Pfizer and Sanofi Siegbert Faiss: lecture fees and consulting fees from Olympus and Ovesco Endoscopy AGStefan K. Gölder: Lecture fees from Astra Zeneca, Falk Pharma, Pfizer and Apollo Endosurgery, funding of educational events from Advanz, Abbvie, B. Braun, Fresenius, Lilly, MSD, Janssen, Roche and TakedaThomas Rösch: advisory fees for Olympus, lecture honoraria from Falk and Abbvie, and research support from Olympus, Erbe, Fujifilm, and MicrotechThomas von Hahn: lecture and consulting fees from OlympusViktor Rempel: lecture fees and travel grants from Olympus and lecture fees from Microtec

• References

• 1 Ferlitsch M, Moss A, Bisshops R. et al. Colorectal polypectomy and endoscopic mucosal resection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2024. Endoscopy 2024; 56 (07): 516-545
• 2 Schmiegel W, Buchberger B, Follmann M. et al. S3-Leitlinie Kolorektales Karzinom. Z Gastroenterol 2017; 55 (12): 1344-1498
• 3 O´Sullivan T, Cronin O, van Hattem WA. et al. Cold versus hot snare endoscopic mucosal resection for large (≥ 15 mm) flat non-pedunculated colorectal polyps: a randomised controlled trial. Gut 2024; 73 (11): 1823-1830

Publikationsverlauf

Artikel online veröffentlicht:
27. März 2025