Paper
Abstract Aim The risk of lymph node metastasis after endoscopic resection of high‐risk T1 colorectal cancer prompts additional resection. However, age and comorbidities are considered in decision‐making and some surgeons opt for observation. We compared the long‐term outcomes of these approaches with the aim of clarifying the need for additional resection. Method This multicentre retrospective study included high‐risk T1 colorectal cancer patients treated with endoscopic submucosal dissection (ESD) between January 2013 and April 2021. Patients who met one or more of the following criteria were eligible for inclusion: submucosal invasion depth ≥1000 μm, vessel invasion, poor differentiation, budding grade 2/3 or a positive vertical margin. Patients were divided into resection (R) and observation (O) groups. Outcomes were evaluated based on overall survival (OS) and 5‐year cancer‐specific survival (CSS), with an additional stratified analysis using the age‐adjusted Charlson comorbidity index (ACCI). Results The study included 178 patients (group R, n = 131; group O, n = 47). Patients in group O were significantly older and had more comorbidities. Group R showed better 5‐year OS and CSS (OS 87.0% vs. 58.9%, p = 0.001; CSS 98.8% vs. 78.4%, p = 0.002). Stratification by ACCI revealed that benefits of additional resection remained for patients with ACCI ≤ 6 (OS 91.2% vs. 58.3%, p = 0.013; CSS 98.4% vs. 61.7%, p < 0.001) but not for those with ACCI ≥7 (OS 75.9% vs. 59.8%, p = 0.289; CSS 100% vs. 100%, p = 0.617). Conclusions Significant survival benefits were demonstrated in group R patients with high‐risk T1 cancer. However, the survival benefit of additional surgical resection was unconfirmed in patients with ACCI ≥ 7.