Management after Endoscopic Resection for T1 Colorectal Cancer: An Updated Evidence-based Review

Endoscopic resection (ER) is widely employed for early colorectal cancer.However, post-ER management of T1 colorectal cancer requires careful risk stratification for lymph node metastasis (LNM).Current European Society of Gastrointestinal Endoscopy (ESGE) guidelines and US Multi-Society Task Force (USMSTF) recommendations consider ER curative when adverse histopathologic features are absent, whereas additional oncologic surgery is recommended following noncurative ER.Recent data indicate that adverse features do not carry equal prognostic weight and should be interpreted in combination with resection quality and specimen accessibility.Deep submucosal invasion (DSI, 1,000 m) remains a criterion for noncurative ER in contemporary recommendations; however, emerging evidence suggests that DSI alone confers a relatively lower absolute risk of LNM compared with DSI accompanied by other high-risk histology.This review summarizes ESGE and USMSTF recommendations, integrates updated evidence on DSI and other adverse histologic predictors (lymphovascular invasion, poor differentiation, and tumor budding), and outlines a practical post-ER approach incorporating pathology, resection quality, patient surgical risk, and shared decision-making.