Significance of biopsies before large colorectal endoscopic resections and histopathological features of high risk lesions
Methods ERs of large (≥2 cm) CSNL were included. Sensitivity and specificity of HGD on biopsy and higher risk morphology (laterally spreading tumour (LST) non-granular/LST mixed nodular type/IIc component) for diagnosing covert invasive adenocarcinoma and confirmed HGD after ER were calculated and compared (Mcnemar’s test). In addition, 50 high risk lesions (containing HGD or invasive adenocarcinoma) were subjected to more detailed histopathological analysis.
Results Results from prior biopsy sampling were available for 291 lesions (mean size 62.8 mm). Histopathology after ER revealed HGD in 85 (29%) and invasive adenocarcinoma in 26 (9%). Sensitivity and specificity of HGD on biopsy (n=60) for invasive adenocarcinoma were 50% (95% CI 32%–68%) and 82% (95%–CI 77%–86%), and for confirmed HGD after ER were 47% (95% CI 37%–57%) and 90% (95% CI 85%–94%) respectively. Sensitivity and specificity of high risk morphology (n=124) for HGD after ER were 71% (95% CI 60%–79%) and 69% (95% CI 62%75%) respectively. The sensitivity of high risk morphology was significantly higher than HGD on biopsy sampling (p=0.002).
Detailed histopathological analysis of high risk lesions revealed invasive adenocarcinoma in 40% but a further 18% had non-invasive areas with cytological and architectural features indistinguishable from invasive adenocarcinoma. HGD was multifocal in 56%. The mean size of the focus of HGD was only 5.6 mm, and of adenocarcinoma was 11.0 mm. Mean lesion size was 53.6 mm.
Conclusion Biopsy sampling of large CSNL has no value in excluding high risk lesions and morphology alone has higher sensitivity for high risk lesions. Histopathological analysis of high risk lesions reveals that areas of HGD or adenocarcinoma are very small relative to the lesion size and many contain non-invasive areas which would be cytologically indistinguishable from invasive adenocarcinoma on a biopsy. Despite this, biopsy sampling remains extremely common. Understanding of these findings and improved education regarding accurate lesion assessment may help reduce rates of inappropriate sampling.