Local excision of rectal cancer without adjuvant therapy: a word of caution

Total mesorectal excision for the treatment of rectal cancer

Introduction

In the surgical treatment of rectal cancer, a clear circumferential resection margin and distal resection margin should be obtained. The aim of this study was to determine the morbidity, mortality, survival outcome, and local failure after total mesorectal excision (TME) in the surgical treatment of rectal cancer.

Methods

This retrospective study was conducted on 101 patients treated for rectal cancer using low anterior resection (LAR), abdominoperinial resection (APR), or Hartmaan’s technique. In all operative procedures, total mesorectal excisions (TMEs) were done. The patients were treated from November 2000 to April 2011 in the South Egypt Cancer Institute (SECI) of Assuit University (Egypt). Neo-adjuvant therapy was given to those patients with serosalin filtration, lymph node involvement, and sexual and urinary function impairment. Data were analyzed using IBM-SPSS version 21, and survival rates were estimated using the Kaplan-Meier method.

Results

One hundred one patients were evaluable (61 males, 40 females). Regarding the operative procedure used, it was: (APR), LAR, Hartmaan’s technique in 15.8%, 71.3%, and 12.9% of patients, respectively. Operation-related mortality during the 30 days after surgery was 3%. The operations resulted in morbidity in 25% of the patients, anastomotic site leak in 5.9% of the patients, urinary dysfynction in 9.9% of the patients, and erectile dysfunction in 15.8% of the male patients. Regarding safety margin, the median distances were distal/radial margin, 23/12 mm, distal limit 7 cm. Median lymph nodes harvest 19 nodes. Primary tumor locations were anteriorly 23.8%, laterally 13.9%, posteriorly 38.6%, and circumferential 23.8%. Protective stoma 16.8%. Primary Tumor TNM classification (T1, T2, T3, and T4; 3, 28.7, 55.4, and 12.9%, respectively). Nodes Metastases (N0, N1, and N2; 57.4, 31.7, and 10.9%, respectively). TNM staging (I, II, III, and IV; 15.8, 29.7, 46.5, and 7.9%, respectively). Chemotherapy was administered to 67.3% of the patients. Radiotherapy (short course neoadjuvant, long course neoadjuvant, and adjuvant postoperative used in 33.7, 20.8, and 19.8% of patients, respectively). Survival 5-years CSS was 73% and 5-years RFS 71%. Mean operative time was 213 minutes. The average amount of intraoperative blood loss was 344 mL.

Conclusion

Total mesorectal excision (TME) represents the gold-standard technique in rectal cancer surgery. It is safe with neoadjuvent chemoradiotherapy and provides both maximal oncological efficiency (local control and long-term survival and maintenance of a good quality of life).

Influence of Preoperative Chemoradiotherapy on the Surgical Strategy According to the Clinical T Stage of Patients With Rectal Cancer

The aim of this study was to evaluate the pathologic responses and changes to surgical strategies following preoperative chemoradiotherapy (PCRT) in rectal cancer patients according to their clinical T stage (cT).The use of PCRT has recently been extended to less advanced disease.The authors enrolled 650 patients with cT2 to 4 mid and low rectal cancer who received both PCRT and surgical resection. The rate of total regression and the proportion of local excision were compared according to the cT category. The 3-year recurrence-free survival (RFS) rate was compared using the log-rank test according to patient cT category, pathologic stage, and type of surgical treatment.Patients with cT2 were older (P = 0.001), predominately female (P = 0.028), and had low-lying rectal cancer (P = 0.008). Pathologic total regression was achieved most frequently in cT2 patients (54% of cT2 versus 17.6% of cT3 versus 8.2% of cT4; P < 0.001). Local excision was performed on 42 cT2 (42%) and 24 cT3 (5.2%) patients (P < 0.001). The 3-year RFS rates differed according to both cT (P < 0.001) and ypT stage (P < 0.001). Among patients with ypT0 to 1 disease, the 3-year RFS did not differ according to the type of surgical treatment received (P = 0.5).Total regression of the primary tumor and a change in the surgical strategy after PCRT are most commonly seen in cT2 disease. Although PCRT is not generally indicated for cT2 rectal cancer, optimal surgical treatment may be achieved with the tailored use of PCRT.

Organ preservation for clinical T2N0 distal rectal cancer using neoadjuvant chemoradiotherapy and local excision (ACOSOG Z6041): results of an open-label, single-arm, multi-institutional, phase 2 trial

Background

Local excision is an organ-preserving treatment alternative for patients with stage I rectal cancer. However, local excision alone is associated with a high risk of local recurrence and inferior survival compared to transabdominal rectal resection. Here we investigate the oncologic and functional outcomes of neoadjuvant chemoradiotherapy and local excision for T2N0 rectal cancer.

Methods

This was a prospective, multi-institutional, single arm phase 2 trial for patients with clinically-staged T2N0 distal rectal cancer, treated with neoadjuvant chemoradiotherapy consisting of capecitabine (original dose 825mg/m², twice daily, on days 1-14 and 22-35) , oxaliplatin (50mg/m² weeks 1, 2, 4, 5), and radiation (5 days/week at 1.8 Gy/day for 5 weeks to a dose of 45 Gy, then a boost, for a total dose of 54 Gy) followed by local excision. Due to adverse events during chemoradiotherapy, the dose of capecitabine was reduced to 725 mg /m², twice daily, 5 days/week, for 5 weeks, and the total dose of radiation to 50.4 Gy. Patients were followed at scheduled intervals and evaluated for recurrence and survival. Anorectal function (ARF) and quality of life (QOL) were assessed at baseline and one year after surgery, using validated instruments. The primary endpoint was 3-year disease-free survival for all eligible patients and for patients who completed chemotherapy and radiation, and had ypT0, ypT1, or ypT2 tumors, and negative resection margins. This trial is registered with ClinicalTrials.gov, number NCT00114231.

Findings

Seventy-nine eligible patients were accrued to the trial, and started nCRT. Three patients did not complete nCRT or LE per-protocol. Four additional patients completed protocol treatment, but one had a positive margin and three had ypT3 tumours. Median follow-up was 56 months. Of the 79 patients, five (6%) developed distant recurrence, and three (4%) recurred locally. All but two underwent salvage surgery. Three-year disease-free survival and overall survival for the entire group were 88% (0.88 (95% CI: 0.81, 0.96) and 95% (95% CI: 0.90, 1.00), respectively. Overall 14 (29%) of 79 patients had grade 3-4 gastrointestinal adverse events, 12 (16%) of 79 patients had grade 3-4 pain as an adverse event, 12 (16%) of 79 patients had grade 3-4 hematological adverse events, and 9 (11%) of 79 patients had grade 3 dermatologic adverse events during chemoradiation. Six (8%) of the 77 patients who had surgery had grade 3 pain, 3(4%) of 77 patients had grade 3-4 hemorrhage, 3 (4%) of 77 patients had gastrointestinal adverse events, 2 (3%) of 77 patients had infectious/febrile neutropenia, 2 (3%) of 77 patients had hematological adverse events, and one (1%) had neurological adverse events. The rectum was preserved in 72 of the 79 (91%) patients. ARF and QOL were unchanged one year after surgery compared to baseline.

Interpretation

Most patients with T2N0 rectal cancer treated with nCRT and LE achieved organ preservation without deterioration of their quality of life. The estimated 3-year DFS rate was within the defined margin of efficacy. Our data suggest that nCRT followed by LE may be considered as an organ-preserving alternative in carefully selected patients with clinically-staged T2N0 tumours who refuse, or are not candidates for, transabdominal resection.

Use of Preoperative MRI to Select Candidates for Local Excision of MRI-Staged T1 and T2 Rectal Cancer: Can MRI Select Patients With N0 Tumors?

BACKGROUND

To minimize the recurrence rate after local excision of rectal cancer, the false-negative rate of nodal staging should be minimized.

OBJECTIVE

The purpose of this study was to develop a set of criteria using preoperative MRI that would minimize the false-negative rate for the diagnosis of regional lymph node metastasis.

DESIGN

A prospectively maintained colorectal cancer database and MRI images were retrospectively reviewed.

SETTINGS

This study was conducted at a multidisciplinary tertiary center.

PATIENTS

A total of 246 consecutive patients who underwent MRI and curative-intent surgery for MRI-staged T1/T2 rectal cancer from January 2008 to July 2012 were included.

MAIN OUTCOME MEASURES

MRI features significantly associated with lymph node metastasis were identified using a χ test. Five diagnostic criteria for lymph node metastasis were created based on these predictive MRI features, and their false-negative rates were compared using the generalized estimating equation method.

RESULTS

Small size/homogeneity of lymph nodes and no visible tumor/partially involved muscular layer were significantly associated with lower risks of lymph node metastasis. When tumor invasion depth was not considered, the false-negative rate did not decrease below 10%, even when the strictest criterion for morphologic evaluation of lymph nodes (not visible or <3 mm) was used. Adding invasion depth to the diagnostic criteria significantly decreased the false-negative rate as low as 1.8%.

LIMITATIONS

This study is limited by its small sample size and retrospective nature.

CONCLUSIONS

Assessing both the depth of tumor invasion and lymph node morphology may reduce the false-negative rate and can be helpful to better identify candidates suitable for local excision of early stage rectal cancer. However, strict MRI criteria for oncologic safety might result in considerable false-positive cases and limit the application of local excision.

ACR Appropriateness Criteria® Local Excision in Early Stage Rectal Cancer

Low anterior resection or abdominoperineal resection are considered standard treatments for early rectal cancer but may be associated with morbidity in selected patients who are candidates for early distal lesions amenable to local excision (LE). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. The panel recognizes the importance of accurate staging to identify patients who may be candidates for a LE approach. Patients who may be candidates for LE alone include those with small, low-lying T1 tumors, without adverse pathologic features. Several surgical approaches can be utilized for LE however none include lymph node evaluation. Adjuvant radiation±chemotherapy may be warranted depending on the risk of nodal metastases. Patients with high-risk T1 tumors, T2 tumors not amenable to radical surgery may also benefit from adjuvant treatment; however, patients with positive margins or T3 lesions should be offered abdominoperineal resection or low anterior resection. Neoadjuvant radiation±chemotherapy followed by LE in higher risk patients results in excellent local control, but it is not clear if this approach reduces recurrence rates over surgery alone.

The Role of Transanal Surgery in the Management of T1 Rectal Cancers

The management of T1 rectal cancers is based on finding the balance between optimal oncologic outcomes and acceptable functional results for the patient. While radical resection involving a proctectomy is considered the most oncologically adequate option, its adverse effects on patient reported outcomes makes this a less than ideal choice in certain circumstances. While local excision can circumvent some of the adverse functional outcomes, its inadequacy in assessing metastatic lymph node disease and the subsequent negative impact of untreated positive lymph nodes on patient prognosis is a cause for concern. As a result, the therapeutic strategy has to be based on patient and disease-related factors in order to identify the best treatment choice that maximizes survival benefit and preserves health-related quality of life. After adequate preoperative staging work up, in selected patients with favorable pathological features, local excision can be considered. These cancers can be removed by transanal local excision or transanal endoscopic microsurgery, depending on the location of the cancer and expertise available. While perioperative morbidity is minimal, close postoperative follow-up is essential.

Local excision for early rectal cancer: transanal endoscopic microsurgery and beyond

The goal of treatment for early stage rectal cancer is to optimize oncologic control while minimizing the long-term impact of treatment on quality of life. The standard of care treatment for most stage I and II rectal cancers is radical surgery alone, specifically total mesorectal excision (TME). For early rectal cancers, this procedure is usually curative but can have a substantial impact on quality of life, including the possibility of permanent colostomy and the potential for short and long-term bowel, bladder, and sexual dysfunction. Given the morbidity associated with radical surgery, alternative approaches to management of early rectal cancer have been explored, including local excision (LE) via transanal excision (TAE) or transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS). Compared to the gold standard of radical surgery, local procedures for strictly selected early rectal cancers should lead to identical oncological results and even better outcomes regarding morbidity, mortality, and quality of life.

Impact of technology on indications and limitations for transanal surgical removal of rectal neoplasms

Transanal surgery has and continues to be well accepted for local excision of benign rectal disease not amenable to endoscopic resection. More recently, there has been increasing interest in applying transanal surgery to local resection of early malignant disease. In addition, some groups have started utilizing a transanal route in order to accomplish total mesorectal excision (TME) for more advanced rectal malignancies. We aim to review the role of various transanal and endoscopic techniques in the local resection of benign and malignant rectal disease based on published trial data. Preliminary data on the use of transanal platforms to accomplish TME will also be highlighted. For endoscopically unresectable rectal adenomas, transanal surgery remains a widely accepted method with minimal morbidity that avoids the downsides of a major abdomino-pelvic operation. Transanal endoscopic microsurgery and transanal minimally invasive surgery offer improved visualization and magnification, allowing for finer and more precise dissection of more proximal and larger rectal lesions without compromising patient outcome. Some studies have demonstrated efficacy in utilizing transanal platforms in the surgical management of early rectal malignancies in selected patients. There is an overall higher recurrence rate with transanal surgery with the concern that neither chemoradiation nor salvage surgery may compensate for previous approach and correct the inferior outcome. Application of transanal platforms to accomplish transanal TME in a natural orifice fashion are still in their infancy and currently should be considered experimental. The current data demonstrate that transanal surgery remains an excellent option in the surgical management of benign rectal disease. However, care should be used when selecting patients with malignant disease. The application of transanal platforms continues to evolve. While the new uses of transanal platforms in TME for more advanced rectal malignancy are exciting, it is important to remain cognizant and not sacrifice long term survival for short term decrease in morbidity and improved cosmesis.

Replacing Transanal Excision with Transanal Endoscopic Microsurgery and/or Transanal Minimally Invasive Surgery for Early Rectal Cancer

The use of local resection of rectal polyps and early rectal cancer has progressed to become the standard of care in most institutions with a colorectal surgery specialist. The use of transanal excision (TAE) with anorectal retractors and standard instrumentation has been supplanted by the application of endoscopic techniques which allow direct video augmented visualization. The transanal endoscopic microsurgery method provides a 3D view and works under a constant flow of air to keep the rectal vault open. Instruments capable of accomplishing a surgical excision and suture closure work through a long 4 cm tube set at the anal canal. The newest version of TAE is transanal minimally invasive surgery which is similar to a single-site laparoscopic technique using a hand access port at the anal canal to maintain a seal for insufflation of the rectum, regular 2D video camera for visualization, and laparoscopic instrumentation through the port in the anus. Each of these techniques is described in detail and the outcomes compared, which show the progress being made in this area of colorectal surgery.

Local excision for early stage rectal cancer in patients over age 65 years: 2000-2009

BACKGROUND

Local excision of rectal cancer is an attractive option because it avoids the morbidity of radical resection. Concerns have arisen during the past decade, however, regarding substandard oncologic results.

OBJECTIVE

Using the most recent Survey of Epidemiology and End Results-Medicare data, we examined the change in the use of local excision for rectal cancer from 2000 to 2009 and examined patient, surgeon, and hospital factors related to its use.

DESIGN

This study is a retrospective cohort study.

SETTINGS

This study was conducted at a tertiary care medical center using Survey of Epidemiology and End Results-Medicare data.

PATIENTS

Patients with pathologic Tis, T1, or T2 rectal cancer who were >65 years of age and underwent primary radical resection or local excision between 2000 and 2009 were included in this study.

MAIN OUTCOME MEASURES

The change in the use of local excision for rectal cancer from 2000 to 2009 was the main outcome measured.

RESULTS

A total of 8966 patients were identified. The use of local excision decreased significantly between 2000 and 2009. Women and patients who were older and had more comorbidities were significantly more likely to undergo local excision. Having a colorectal surgeon perform the surgery increased the odds of local excision by 1.5 times (p < 0.001). Similar trends were seen in patients operated on at the National Cancer Institute (OR, 1.7; p <0.001) and teaching hospitals (OR, 1.2; p = 0.003). Younger surgeons were more likely to perform local excisions. For surgeons graduating in 1980-1989 or 1990 and after, the odds of local excision were 1.40 (p = 0.001) and 2.1 (p <0.001) compared with surgeons graduating before 1970.

LIMITATIONS

The study was limited by the retrospective design, and the data were collected by multiple healthcare officials in their representative institutions.

CONCLUSIONS

In patient >65 years of age, the odds of undergoing local excision for early stage rectal cancer decreased significantly between 2000 and 2009, coincident with evidence of oncologic inferiority. However, there was still significant variation in its use. More studies are needed to better understand these variations in an attempt to bring more uniformity to the use of local excision in early stage rectal cancer.

Rectal cancer: a review

Rectal cancer is the second most common cancer in large intestine. The prevalence and the number of young patients diagnosed with rectal cancer have made it as one of the major health problems in the world. With regard to the improved access to and use of modern screening tools, a number of new cases are diagnosed each year. Considering the location of the rectum and its adjacent organs, management and treatment of rectal tumor is different from tumors located in other parts of the gastrointestinal tract or even the colon. In this article, we will review the current updates on rectal cancer including epidemiology, risk factors, clinical presentations, screening, and staging. Diagnostic methods and latest treatment modalities and approaches will also be discussed in detail.

A critical review of the role of local excision in the treatment of early (T1 and T2) rectal tumors

The optimal treatment of early (T1 and T2) rectal adenocarcinomas remains controversial. Local excision and radical resection with total mesorectal excision are the two surgical techniques for excising early rectal cancer. Each has their respective benefits, with local excision allowing for decreased operative morbidity and mortality while radical resection provides an oncologically complete treatment through lymphadenectomy. Local excision can be accomplished via transanal endoscopic microsurgery or transanal excision. There is no significant difference in the recurrence rates (21% vs. 33%) or overall survival (80% vs. 66%) between the two local excision modalities; however, transanal endoscopic microsurgery does allow for a higher rate of R0 resection. Current selection criteria for local excision include well to moderately differentiated tumors without high-risk features such as lymphovascular invasion, perineural invasion, or mucinous components. In addition, tumors should ideally be <3 cm in size, excised with a clear margin, occupy less than 1/3 of the circumference of the bowel and be mobile/nonfixed. Despite these stringent inclusion criteria, local excision continues to be plagued with a high recurrence rate in both T1 and T2 tumors due to a significant rate of occult locoregional metastases (20% to 33%). For both tumor groups, the recurrence rate in the local excision group is more than double compared to radical resection. However, the overall survival is not significantly different between those with and without metastases. With intense postoperative surveillance, these recurrences can be identified early while they are confined to the pelvis allowing for salvage surgical options. Recently, neoadjuvant therapy followed by local excision has shown favorable short and long-term oncological outcomes to radical resection in the treatment of T2 rectal cancer. Ultimately, the management of early rectal cancer must be individualized to each patient's expectations of quality and quantity of life. With informed consent, patients may be willing to accept a higher failure rate and an increased post-operative surveillance regimen to preserve a perceived increased quality of life.

A critical review of the role of local excision in the treatment of early (T1 and T2) rectal tumors

The optimal treatment of early (T1 and T2) rectal adenocarcinomas remains controversial. Local excision and radical resection with total mesorectal excision are the two surgical techniques for excising early rectal cancer. Each has their respective benefits, with local excision allowing for decreased operative morbidity and mortality while radical resection provides an oncologically complete treatment through lymphadenectomy. Local excision can be accomplished via transanal endoscopic microsurgery or transanal excision. There is no significant difference in the recurrence rates (21% vs. 33%) or overall survival (80% vs. 66%) between the two local excision modalities; however, transanal endoscopic microsurgery does allow for a higher rate of R0 resection. Current selection criteria for local excision include well to moderately differentiated tumors without high-risk features such as lymphovascular invasion, perineural invasion, or mucinous components. In addition, tumors should ideally be <3 cm in size, excised with a clear margin, occupy less than 1/3 of the circumference of the bowel and be mobile/nonfixed. Despite these stringent inclusion criteria, local excision continues to be plagued with a high recurrence rate in both T1 and T2 tumors due to a significant rate of occult locoregional metastases (20% to 33%). For both tumor groups, the recurrence rate in the local excision group is more than double compared to radical resection. However, the overall survival is not significantly different between those with and without metastases. With intense postoperative surveillance, these recurrences can be identified early while they are confined to the pelvis allowing for salvage surgical options. Recently, neoadjuvant therapy followed by local excision has shown favorable short and long-term oncological outcomes to radical resection in the treatment of T2 rectal cancer. Ultimately, the management of early rectal cancer must be individualized to each patient's expectations of quality and quantity of life. With informed consent, patients may be willing to accept a higher failure rate and an increased post-operative surveillance regimen to preserve a perceived increased quality of life.

Analysis of 116 cases of rectal cancer treated by transanal local excision

BACKGROUND

The purpose of this research was to evaluate the therapeutic effects and prognostic factors of transanal local excision (TAE) for rectal cancer.

METHODS

We retrospectively analyzed 116 cases that underwent TAE for rectal cancer from 1995 to 2008. A Cox regression analysis was used to analyze prognostic factors.

RESULTS

The survival times for the patients were from 14 to 160.5 months (median time, 58.5 months). The 5-year and 10-year overall survival rates were 72% and 53%, respectively. In all 16 cases experienced local recurrence (13.8%). Pathological type, recurrence or metastasis, and depth of infiltration (T stage) were the prognostic factors according to the univariate analysis, and the latter two were independent factors affecting patient prognosis. For patients with T1 stage who underwent adjuvant radiotherapy, there was no local recurrence; for those in T2 stage, the local recurrence rate was 14.6%. In addition, there was no difference between the patients who received radiotherapy and those who did not (T1: P = 0.260, T2: P = 0.262 for survival rate and T1: P = 0.480, T2: P = 0.560 for recurrence).

CONCLUSIONS

The result of TAE for rectal cancer is satisfactory for T1 stage tumors, but it is not suitable for T2 stage tumors.

Clinical competence in the surgery of rectal cancer: the Italian Consensus Conference

BACKGROUND AND AIM

The literature continues to emphasize the advantages of treating patients in "high volume" units by "expert" surgeons, but there is no agreed definition of what is meant by either term. In September 2012, a Consensus Conference on Clinical Competence was organized in Rome as part of the meeting of the National Congress of Italian Surgery (I Congresso Nazionale della Chirurgia Italiana: Unità e valore della chirurgia italiana). The aims were to provide a definition of "expert surgeon" and "high-volume facility" in rectal cancer surgery and to assess their influence on patient outcome.

METHOD

An Organizing Committee (OC), a Scientific Committee (SC), a Group of Experts (E) and a Panel/Jury (P) were set up for the conduct of the Consensus Conference. Review of the literature focused on three main questions including training, "measuring" of quality and to what extent hospital and surgeon volume affects sphincter-preserving procedures, local recurrence, 30-day morbidity and mortality, survival, function, choice of laparoscopic approach and the choice of transanal endoscopic microsurgery (TEM).

RESULTS AND CONCLUSION

The difficulties encountered in defining competence in rectal surgery arise from the great heterogeneity of the parameters described in the literature to quantify it. Acquisition of data is difficult as many articles were published many years ago. Even with a focus on surgeon and hospital volume, it is difficult to define their role owing to the variability and the quality of the relevant studies.

A systematic review of local excision combined with chemoradiotherapy for early rectal cancer

AIM

Local excision of early rectal cancer is a less morbid alternative to major abdominal surgery. This review evaluates the role of local excision with neoadjuvant or adjuvant chemoradiotherapy to identify a select group of patients where local excision is appropriate without significantly compromising the oncological outcome.

METHOD

MEDLINE, PubMed and the Cochrane Central Register of Controlled Trials databases were searched to identify relevant articles investigating the role of local excision with adjuvant or neoadjuvant chemoradiotherapy in patients with T1/T2N0M0 disease. Eleven studies comprising 455 patients were selected. Oncological end-points included overall survival, disease-free and disease-specific survival, recurrence rates as well as perioperative morbidity and mortality.

RESULTS

At a range of 30.5-115.2 months, median overall survival, disease-specific and disease-free survival were 75% (66-80.6%), 89% (75-93.3%) and 74% (64-85.2%), respectively. Median local, distant and overall recurrence rates were 10% (4.8-25%), 4.7% (4-11.8%) and 13.1% (10.7-23.5%), respectively. Mortality was 0% in all studies except one (2.9%). Most reported complications were minor and were treated conservatively.

CONCLUSION

This systematic review provides data suggesting that selected patients with T1/T2N0M0 rectal cancer may undergo local excision without compromising the oncological outcome otherwise conferred by total mesorectal excision. It may be a particularly useful option in patients in whom radical surgery is contraindicated. Randomized trials comparing both management strategies to consolidate this finding may lead to a paradigm change in the management of early rectal cancer.

Transanal Endoscopic Microsurgery (TEM) for Rectal Cancer: University Hospital of North Tees Experience

Transanal endoscopic microsurgery (TEM) is a minimally invasive technique that is increasingly being used to treat early rectal cancer (T1/T2). We studied the outcomes of TEM for rectal cancer at our institution looking at the indication, recurrence rate, need for further radical surgery, 30-day and 12-month mortality and complication rate. We performed a retrospective analysis of prospectively collected data of cases between 2008 and 2012: 110 TEM procedures were performed during this period: 40 were confirmed rectal cancers and 70 were benign. We analysed the data for the 40 patients with confirmed rectal cancer. Thirty (75 %) of the subjects were male with a mean age of 71 ± 10 years (range 49-90 years) and 19 (48 %) patients were ASA 3 and 4. Nineteen (48 %) of cancers were pT1, eighteen (45 %) were pT2, two (5 %) were pT3 and one was yPT0. Mean specimen size was 66 ± 20 mm (range 33-120 mm) with a mean polyp size of 41 ± 24 mm (range 18-110 mm). The mean cancer size was 24 ± 13 mm (range 2-50 mm). Average distance from the anal verge was 70 ± 37 mm (range 10-150 mm), and the mean operating time was 72 ± 22 min (range 40-120 min), with an average blood loss of 28 ± 15 ml (range 10-50ml). Median hospital stay was 2 ± 1 days (range 1-7 days). Complete excision (R0) was achieved in 37 (93 %) patients. Minor post-operative complications included urinary retention in two and pyrexia in three patients. There were no 30-day or 12-month mortalities. Mean follow-up was 13 ± 11 months, range (3-40 months) Local recurrence occurred in two (5 %) patients, both underwent redo TEM. Twelve (30 %) patients underwent laparoscopic radical resections (seven AR and five APER) post-TEM. Post-operative histology confirmed pT0N0 in 7/12 patients. Three were lymph node-positive (T0N1), one was pT3N1 and the fifth was pT3N2. TEM is associated with quicker recovery, shorter hospital stay and fewer complications than radical surgery. It is a good alternative to radical surgery in early rectal cancer, especially for high-risk patients. Recurrent tumours can be treated with redo TEM.

Transanal endoscopic microsurgery: a review

Rectal adenomas and cancers occur frequently. Small adenomas can be removed colonoscopically, whereas larger polyps are removed via conventional transanal excision. Owing to technical difficulties, adenomas of the mid- and upper rectum require radical resection. Transanal endoscopic microsurgery (TEM) was first designed as an alternative treatment for these lesions. However, since its development TEM has been also used for a variety of rectal lesions, including carcinoids, rectal prolapse and diverticula, early stage carcinomas and palliative resection of rectal cancers. The objective of this review is to describe the current status of TEM in the treatment of rectal lesions. Since the 1980s, TEM has advanced substantially. With low recurrence rates, it is the method of choice for resection of endoscopically unresectable adenomas. Some studies have shown benefits to its use in treating early T1 rectal cancers compared with radical surgery in select patients. However, for more advanced rectal cancers TEM should be considered palliative or experimental. This technique has also been shown to be safe for the treatment of other uncommon rectal tumours, such as carcinoids. Transanal endoscopic microsurgery may allow for new strategies in the treatment of rectal pathology where technical limitations of transanal techniques have limited endoluminal surgical innovations.

A population-based comparison of overall and disease-specific survival following local excision or abdominoperineal resection for stage I rectal adenocarcinoma

PURPOSE

The use of local excision (LE) for early stage rectal adenocarcinoma is increasing due to the associated morbidity of radical resection. To determine if survival in stage I rectal cancer differs following LE or abdominoperineal resection (APR), we analyzed the Surveillance, Epidemiology, and End Results Database.

MATERIAL AND METHODS

We selected patients diagnosed between 1988 and 2002 with T1-2N0M0 rectal adenocarcinoma measuring ≤4 cm who underwent either local excision with (LE + RT) or without adjuvant radiation (LE alone) or APR alone. Overall survival (OS) and disease-specific survival (DSS) curves were calculated using the Kaplan-Meier method. Univariate and multivariate Cox regression was also performed to determine the effect of covariates on OS and DSS.

RESULTS

A total of 2,391 patients were identified including 981 (41 %) treated with APR, 1,018 (43 %) treated with LE alone, and 392 (16 %) treated with LE + RT. With a median follow-up of 69 months, there was no difference in OS or DSS seen between the three groups (p > 0.05 for all comparisons). When stratifying by T-stage, there was a significant difference in overall survival between LE alone and APR for T2 disease. However, there was no difference in DSS between these two subgroups. There were no other significant survival differences between all comparable subgroups.

CONCLUSIONS

In this large population-based study, there was no difference in long-term DSS between patients who underwent an APR compared to selected patients who underwent LE with or without adjuvant radiation. Although these data further reinforce the promising data regarding the selected use of LE, further prospective studies are needed to further elucidate the role of LE in this setting.

Validation of the effects of TGF-β1 on tumor recurrence and prognosis through tumor retrieval and cell mechanical properties

Background

In vivo, the transforming growth factor-beta1 (TGF-β1)-induced epithelial to mesenchymal transition (EMT) occurs in seconds during cancer cells intravasation and extravasation. Although it has been established that cellular stiffness can change as a cancer cell transformed, the precise relationship between TGF-β1-induced mesenchymal stem cell mechanics and cancer prognosis remains unclear. Accordingly, it is hard to define the effects of EMT on cell mechanical properties (CMs), tumor recurrence and metastasis risks. This study bridges physical and pathological disciplines to reconcile single-cell mechanical measurements of tumor cells.

Methods and results

We developed a microplate measurement system (MMS) and revealed the intrinsic divergent tumor composition of retrieval cells by cell stiffness and adhesion force and flow cytometry analysis. After flow cytometry sorting, we could measure the differences in CMs of the Sca-1⁺-CD44⁺ (mesenchymal-stem-cell-type) and the other subgroups. As well as the stiffer and heterogeneous compositions among tumor tissues with higher recurrence risk were depicted by MMS and atomic force microscopy (AFM). An in vitro experiment validated that Lewis lung carcinoma (LLC) cells acquired higher CMs and motility after EMT, but abrogated by SB-505124 inhibition. Concomitantly, the CD31, MMP13 and TGF-β1 enriched micro-environment in the tumor was associated with higher recurrence and distal lung metastasis risks. Furthermore, we report a comprehensive effort to correlate CMs to tumor-prognosis indicators, in which a decreased body weight gain ratio (BWG) and increased tumor weight (TW) were correlated with increased CMs.

Conclusions

Together, we determined that TGF-β1 was significantly associated with malignant tumor progressing. In terms of clinical applications, local tumor excision followed by MMS analysis offers an opportunity to predict tumor recurrence and metastasis risks.

[TEO: minimally invasive surgery of the rectum. A short review]

The equipment and technique of transanal endoscopic microsurgery was developed by Buess in the early 80s. The technique was more refined, and the indication was widened since then. Excellent oncological results can be achieved with good patient selection with this less invasive technique and the complication rate is very low in contrast to conventional techniques. Nowadays the transanal endoscopic microsurgery is the "gold standard" in the treatment of benign lesions and low risk T1 cancer of the rectum.

When is local excision appropriate for "early" rectal cancer?

Local excision is increasingly performed for “early stage” rectal cancer in the US; however, local recurrence after local excision has become a controversial issue in Western countries. Local recurrence is considered to originate based on the type of tumor and procedure performed, and in surgical margin-positive cases. This review focuses on the inclusion criteria of “early” rectal cancers for local excision from the Western and Japanese points of view. “Early” rectal cancer is defined as T1 cancer in the rectum. Only the tumor grade and depth of invasion are the “high risk” factors which can be evaluated before treatment. T1 cancers with sm1 or submucosal invasion <1,000 μm are considered to be “low risk” tumors with less than 3.2 % nodal involvement, and are considered to be candidates for local excision as the sole curative surgery. Tumors with a poor tumor grade should be excluded from local excision. Digital examination, endoscopy or proctoscopy with biopsy, a barium enema study and endorectal ultrasonography are useful for identifying “low risk” or excluding “high risk” factors preoperatively for a comprehensive diagnosis. The selection of an initial local treatment modality is also considered to be important according to the analysis of the nodal involvement rate after initial local treatment and after radical surgery.

TEM in the treatment of recurrent rectal cancer in elderly

Introduction

Transanal microscopic surgery is an important application of minimally invasive surgery of rectum, allowing realization of complex transanal intervention.

Patients and Methods

During the period between January 2002 and December 2010, seven patients, five men and two women, average age 75 years, with early rectal cancer recurrence were selected for this type of surgical palliative procedure. The selection of the patients is made by: transrectal ultrasonografy, colonoscopy and abdominal ultrasonografy, to rule out liver metastases, CT with and without enema, PET CT. Follow-up is approximately 12-30 months.

Results

The pathologic staging confirms the complete excision of recurrences. Then patients are referred for more complementary therapies.

Discussion

The significance of conservative treatment for local recurrence of rectum adenocarcinoma is still controversial because the recurrence is an expression of tumor spread not controlled by oncological surgical and radio/chemo therapy.

Conclusion

In selected subjects such as the elderly, based on equal oncological treatment, the reduction of surgical trauma, preservation of anatomical integrity and resolution of symptoms are important results.

Surgical management and chemoradiotherapy of T1 rectal cancer

T1 rectal cancer can be treated using various strategies. Endoscopic or transanal resection is the first choice of treatment when tumors are not associated with risk for lymph node metastasis. However, transabdominal resection with lymphadenectomy is recommended for tumors that do confer risk of lymph node metastasis. The prognosis after transabdominal resection is satisfactory, but various dysfunctions impair the postoperative quality of life. The standard treatment for T3-T4 rectal cancer is total mesorectal excision with preoperative chemoradiotherapy in Western countries and total mesorectal excision with laterallymph node dissection in Japan. Previous reports indicate that preoperative radiotherapy contributes to a lower rate of local recurrence, although overall survival is not affected. In addition, radiotherapy increases the prevalence of sexual dysfunction and fecal incontinence. The effect of perioperative chemoradiotherapy for T1-T2 rectal cancer remains unclear.

The management of patients with T1 adenocarcinoma of the low rectum: a decision analysis

BACKGROUND

Decision making for patients with T1 adenocarcinoma of the low rectum, when treatment options are limited to a transanal local excision or abdominoperineal resection, is challenging.

OBJECTIVES

The aim of this study was to develop a contemporary decision analysis to assist patients and clinicians in balancing the goals of maximizing life expectancy and quality of life in this situation.

DESIGN

We constructed a Markov-type microsimulation in open-source software. Recurrence rates and quality-of-life parameters were elicited by systematic literature reviews. Sensitivity analyses were performed on key model parameters.

PATIENTS AND SETTING

Our base case for analysis was a 65-year-old man with low-lying T1N0 rectal cancer. We determined the sensitivity of our model for sex, age up to 80, and T stage.

MAIN OUTCOME MEASURES

The main outcome measured was quality-adjusted life-years.

RESULTS

In the base case, selecting transanal local excision over abdominoperineal resection resulted in a loss of 0.53 years of life expectancy but a gain of 0.97 quality-adjusted life-years. One-way sensitivity analysis demonstrated a health state utility value threshold for permanent colostomy of 0.93. This value ranged from 0.88 to 1.0 based on tumor recurrence risk. There were no other model sensitivities.

LIMITATIONS

Some model parameter estimates were based on weak data.

CONCLUSIONS

In our model, transanal local excision was found to be the preferable approach for most patients. An abdominoperineal resection has a 3.5% longer life expectancy, but this advantage is lost when the quality-of-life reduction reported by stoma patients is weighed in. The minority group in whom abdominoperineal resection is preferred are those who are unwilling to sacrifice 7% of their life expectancy to avoid a permanent stoma. This is estimated to be approximately 25% of all patients. The threshold increases to 12% of life expectancy in high-risk tumors. No other factors are found to be relevant to the decision.

Oncologic outcomes and proper surveillance after local excision of rectal cancer

Purpose

The aim of this study was to analyze oncologic outcomes after transanal local excision (LE) to ensure adequate surveillance of recurrence in order to treat with curative intent.

Methods

Between January 2000 and June 2009, 102 patients who underwent transanal LE for rectal adenocarcinoma were retrospectively reviewed.

Results

Of the 102 patients, 53 (52.0%) were male. The mean age was 57 ± 11 years. Postoperative pathologic examination revealed 93 cases (91.2%) of pathologic T stage (pT)1 and 9 cases (8.8%) of pT2. Forty-eight patients (47.1%) underwent adjuvant postoperative radiotherapy. The median follow-up interval was 60 months (range, 3 to 146 months). Seven (6.9%) out of 15 patients who suffered recurrence had locoregional recurrence, three (2.9%) had systemic recurrence and five (4.9%) had both systemic and locoregional recurrence. The latter five patients and two of the three patients with systemic recurrence died because of the disease recurrence. On the other hand, only one of the seven patients with locoregional recurrence died because of disease recurrence.

Conclusion

Systemic recurrence after transanal LE results in fatal consequences. Therefore, not only is it important to identify ideal candidates for LE, but intensive postoperative surveillance is important as well to identify curable recurrence as soon as possible.

The Factors Effecting Lymphovascular Invasion in Adenocarcinoma of the Colon and Rectum

Adenocarcinomas of the colon and rectum are the most common gastrointestinal malignancy, and lymph node metastases are established as a prognostic factor. Lymphovascular invasion has been recognized as an indication of lymph node metastases. This prompted us to investigate the features of primary tumor that may serve as a risk factor for lymphovascular invasion in colorectal carcinoma. Clinical and pathologic tissue data of colorectal carcinoma treated in our hospital were retrieved from the computer files at Haydarpasa Numune Education and Research Hospital, from June 1998 to December 2010, retrospectively. We excluded all patients who have two-thirds distal rectal carcinoma to rule out neoadjuvant treatment bias. Tissues from the specimens were stained with standard hematoxylin and eosin. Clinical data including age and sex of patient, location and diameter of tumor, perineural invasion, peritumoral lymphocytic infiltration, tumor grade, lymphovascular invasion, Pathologic T level (pT), and lymph node metastasis were recorded. Lymphovascular invasion was present only in 43 patients out of 108. Only pT and lymph node metastases were found to be statistically significant related to lymphovascular invasion (p = 0.04 and p < 0.001). Perineural invasion, pT, and peritumoral lymphocytic infiltration are the factors with p < 0.2 in the univariate analysis that were investigated with multivariate analysis, but no factor was found as an independent prognostic factor for lymphovascular invasion. Lymphovascular invasion is significantly related to lymph node metastases. Only pT is found as a factor that increases the lymphovascular invasion.

Transanal endoscopic microsurgery for residual rectal cancer (ypT0-2) following neoadjuvant chemoradiation therapy: another word of caution

BACKGROUND

Significant tumor downstaging among patients with rectal cancer following neoadjuvant chemoradiation has raised the issue of offering patients with small residual cancers restricted to the bowel wall an alternative treatment strategy to total mesorectal excision. Transanal endoscopic microsurgery may allow proper primary tumor resection with promising oncological outcomes, less postoperative morbidity, and minimal long-term sexual, urinary, and fecal continence disorders in comparison with radical resection.

OBJECTIVE

The aim of this study was to determine the oncological outcomes of patients with residual rectal cancers restricted to the rectal wall (ypT0-2) following neoadjuvant chemoradiation and transanal endoscopic microsurgery.

DESIGN

This study considered a prospective cohort of patients with residual rectal cancers following neoadjuvant chemoradiation treated by transanal endoscopic microsurgery and no additional systemic therapy.

SETTINGS

This study was a single-institution experience.

PATIENTS

Patients with adenocarcinoma of the rectum located no more than 7 cm from the anal verge and endorectal ultrasound- or magnetic resonance-staged cT2-4N0-2M0 treated by neoadjuvant chemoradiation (50.4-54 Gy and 5-fluorouracil-based chemotherapy) were eligible for the study. Patients with small residual tumors (≤3 cm) radiologically staged ycT0-2N0 were treated by transanal endoscopic microsurgery.

INTERVENTIONS

Transanal endoscopic microsurgery was performed.

MAIN OUTCOME MEASURES

The primary outcome measured was local recurrence.

RESULTS

Of the 27 patients treated by transanal endoscopic microsurgery, 3 had ypT0, 6 had ypT1, and 18 had ypT2 cancers. All patients underwent R0 transanal endoscopic microsurgery excision. Local recurrence was observed in 4 (15%) patients after a median follow-up of 15 months. Only lymphovascular invasion was an independent predictive factor for local failure (p = 0.04). Tumor size, ypT status, T-status downstaging, lateral/radial margins, and tumor regression grade were not predictors of local failure.

LIMITATIONS

This study was limited by the small sample size and limited follow-up.

CONCLUSIONS

A local failure rate of 15% after transanal endoscopic microsurgery for patients with residual rectal cancers restricted to the bowel wall (ypT0-2) may limit the indication of this procedure to highly selected patients as an alternative to standard radical total mesorectal excision.

Organ-preserving therapy for rectal cancer

SUMMARY Total mesorectal excision has resulted in low local recurrence rates in rectal cancer patients; however, it is associated with a significant impairment in quality of life. The operation may be disfiguring and cause permanent effects on gastrointestinal, genitourinary and sexual function. Recently, researchers have identified subgroups of rectal cancer patients who may be able to forgo total mesorectal excision without compromising their oncological outcomes. Two groups of patients are candidates for organ preservation: those with early-stage disease that may be adequately addressed by a more limited resection, and those with locally advanced disease that has responded completely to neoadjuvant therapy. Additionally, radiation alone may be curative in both early and locally advanced disease. This article reviews the data regarding these approaches.

Update and debate issues in surgical treatment of middle and low rectal cancer

Based on a review of the literature, this paper provides an update on surgical treatment of middle and low rectal cancer and discusses issues of debate surrounding that treatment. The main goal of the surgical treatment of rectal cancer is radical resection of the tumor and surrounding lymphatic tissue. Local excision of early rectal cancer can be another treatment option, in which the patient can avoid possible complications related to radical surgery. Neoadjuvant chemoradiation therapy (CRT) has been recommended for patients with cT3-4N0 or any T N+ rectal cancer because CRT shows better local control and less toxicity than adjuvant CRT. However, recent clinical trials showed promising results for local excision after neoadjuvant CRT in selected patients with low rectal cancer. In addition, the "wait and see" concept is another modality that has been reported for the management of tumors that show complete clinical remission after neoadjuvant CRT. Although radical surgery for middle and low rectal cancer is the cornerstone therapy, an ultralow anterior resection with or without intersphincteric resection (ISR) has become an alternative standard surgical method for selected patients. Many studies have reported on the oncological safety of the ISR, but few of them have addressed the issue the functional outcome. Furthermore, an abdominoperineal resection (APR) has problems with high rates of tumor perforations and positive circumferential resection margins, and those factors have contributed to its having a high rate of local recurrence and a poor survival rate for rectal cancer compared with sphincter-saving procedures. Recently, great efforts have been made to reduce these problems, and the total levator excision or the extended APR concept has emerged. Surgical management for low rectal cancer should aim to radically excise the tumor and to preserve as much of the sphincter function as possible by using multidisciplinary approaches. However, further prospective clinical trials are needed for tailored treatment of rectal cancer patients.

Approach to rectal cancer surgery

Rectal cancer is a distinct subset of colorectal cancer where specialized disease-specific management of the primary tumor is required. There have been significant developments in rectal cancer surgery at all stages of disease in particular the introduction of local excision strategies for preinvasive and early cancers, standardized total mesorectal excision for resectable cancers incorporating preoperative short- or long-course chemoradiation to the multimodality sequencing of treatment. Laparoscopic surgery is also increasingly being adopted as the standard rectal cancer surgery approach following expertise of colorectal surgeons in minimally invasive surgery gained from laparoscopic colon resections. In locally advanced and metastatic disease, combining chemoradiation with radical surgery may achieve total eradication of disease and disease control in the pelvis. Evidence for resection of metastases to the liver and lung have been extensively reported in the literature. The role of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal metastases is showing promise in achieving locoregional control of peritoneal dissemination. This paper summarizes the recent developments in approaches to rectal cancer surgery at all these time points of the disease natural history.

Prediction in rectal cancer

The treatment of rectal cancer largely depends on disease stage at diagnosis, based on which patients can be classified as low, intermediate, or high risk. Prognostic and predictive markers, specific to each risk category, can be applied for optimal risk classification and subsequent treatment allocation. These markers are either histopathological, determined with imaging, or have a biomolecular background. This review provides an overview of the current status of treatment options and the use of prognostic and predictive markers in each risk category. An effort was made to identify those markers that are currently lacking in, but have the potential to improve, the clinical decision process by discussing the data from recent studies aimed at the development of new prognostic and predictive markers. At this moment, none of the markers studied has been proven to be of significant, independent value, justifying implementation in daily clinical practice. However, recent developments in imaging techniques and biomolecular research do show great potential.

Analysis of risk factors for lymph nodal involvement in early stages of rectal cancer: when can local excision be considered an appropriate treatment? Systematic review and meta-analysis of the literature

Background. Over the past ten years oncological outcomes achieved by local excision techniques (LETs) as the sole treatment for early stages of rectal cancer (ESRC) have been often disappointing. The reasons for these poor results lie mostly in the high risk of the disease's diffusion to local-regional lymph nodes even in ESRC. Aims. This study aims to find the correct indications for LET in ESRC taking into consideration clinical-pathological features of tumours that may reduce the risk of lymph node metastasis to zero. Methods. Systematic literature review and meta-analysis of casistics of ESRC treated with total mesorectal excision with the aim of identifying risk factors for nodal involvement. Results. The risk of lymph node metastasis is higher in G ≥ 2 and T ≥ 2 tumours with lymphatic and/or vascular invasion. Other features which have not yet been sufficiently investigated include female gender, TSM stage >1, presence of tumour budding and/or perineural invasion. Conclusions. Results comparable to radical surgery can be achieved by LET only in patients with T(1) N(0) G(1) tumours with low-risk histological features, whereas deeper or more aggressive tumours should be addressed by radical surgery (RS).

Meta-analysis of histopathological features of primary colorectal cancers that predict lymph node metastases

BACKGROUND

Treatment decisions for colorectal cancer vary based on lymph node status. While some histopathological features of the primary tumor correlate with lymph node spread, the relative influences of these risk factors are not well quantified.

OBJECTIVE

This study aims to systematically review published studies relating histopathological features of primary colorectal cancer to the presence of lymph node metastases and to determine how reliable certain factors might be at predicting nodal metastasis when only the primary lesion is available for study.

DATA SOURCES

Inclusive literature search using EMBASE and Ovid MEDLINE databases plus manual reference checks of all articles correlating lymphatic spread with colorectal cancer (any T stage) from 1984 to mid-2008 was performed.

STUDY SELECTION

This search generated two levels of screening utilized on 602 citations, yielding 123 articles for full review. Data reported from 76 articles were chosen.

MAIN OUTCOME MEASURES

The relative influence of each histopathological feature on the likelihood of lymphatic metastases was determined. Fixed-effects meta-analysis was performed, and results were reported as Mantel-Haenszel odds ratios (OR).

RESULTS

Of 42 histopathological features analyzed, only 40.4% were reported in >2 articles. The positive predictive values for the top quartile of most frequently reported risk factors were 25.5-86.4%. Among the commonly reported histopathological findings, lymphatic invasion (OR, 8.62) significantly outperformed tumor depth (T2 vs. T1; OR, 2.62) and overall differentiation (OR, 2.38) in predicting nodal spread. For the rectal cancer subset, risk factors differed from the overall colorectal group in predictive ability; poor differentiation at the invasive front (OR, 6.08) and tumor budding (OR, 5.82) were the most predictive.

LIMITATIONS

This literature search is limited by the small number of studies examining only rectal cancers and the potential changes in histological and/or surgical techniques over the study period.

CONCLUSIONS

No single histopathological feature of colorectal cancer reliably predicted lymph node metastases. Several risk factors that correlate highly with nodal disease are not routine components of standard pathology reports. Until further research establishes histopathological or molecular patterns for predicting lymph node spread, caution should be exercised when basing treatment decisions solely on these factors.

Management of local rectal cancer: evidence, controversies and future perspectives in radiotherapy

SUMMARY Rectal cancer comprises approximately 25% of all primary colorectal cancers. The optimal diagnostic and treatment approach for this heterogeneous malignancy is still contentious, and improvements in general multidisciplinary management are required. During recent years a number of randomized studies led by European investigators have shown optimization in preoperative staging, improvements in surgical technique and the histopathological assessment of the resected specimen, and the benefit of combined modality treatment. The main recommendations and the trends in research on radiotherapy and integrated treatments will be summarized with an overview on some relevant points about imaging and pathological staging.

Risk factors for lymph node metastasis in pT1 and pT2 rectal cancer: a single-institute experience in 943 patients and literature review

BACKGROUND

Local excision has become an alternative for radical resection in rectal cancer for selected patients. The purpose of this study was to assess the clinicopathologic factors determining lymph node metastasis (LNM) in patients with T1-2 rectal cancer.

METHODS

Between January 1995 and December 2009, a total of 943 patients with pT1 or pT2 rectal adenocarcinoma received radical resection at a single institution. Clinicopathologic factors were evaluated by univariate and multivariate analyses to identify risk factors for LNM.

RESULTS

A total of 943 patients (544 men and 399 women) treated for T1-2 rectal cancer were included in this study. LNM was found in 188 patients (19.9%). In multivariate analysis, lymphovascular invasion (LVI; P < 0.001, hazard ratio 11.472), poor differentiation (PD; P = 0.007, hazard ratio 3.218), and depth of invasion (presence of pT2; P = 0.032, hazard ratio 1.694) were significantly related to nodal involvement. The incidence for LNM lesions in the presence of LVI, PD, and pT2 was 68.8, 50.0, and 23.1%, respectively, while that for pT1 carcinomas with no LVI or PD was 7.5%.

CONCLUSIONS

LVI, PD, and pT2 are independent risk factors predicting LNM in pT1-2 rectal carcinoma.

The CARTS study: Chemoradiation therapy for rectal cancer in the distal rectum followed by organ-sparing transanal endoscopic microsurgery

Background

The CARTS study is a multicenter feasibility study, investigating the role of rectum saving surgery for distal rectal cancer.

Methods/Design

Patients with a clinical T1-3 N0 M0 rectal adenocarcinoma below 10 cm from the anal verge will receive neoadjuvant chemoradiation therapy (25 fractions of 2 Gy with concurrent capecitabine). Transanal Endoscopic Microsurgery (TEM) will be performed 8 - 10 weeks after the end of the preoperative treatment depending on the clinical response.

Primary objective is to determine the number of patients with a (near) complete pathological response after chemoradiation therapy and TEM. Secondary objectives are the local recurrence rate and quality of life after this combined therapeutic modality. A three-step analysis will be performed after 20, 33 and 55 patients to ensure the feasibility of this treatment protocol.

Discussion

The CARTS-study is one of the first prospective multicentre trials to investigate the role of a rectum saving treatment modality using chemoradiation therapy and local excision. The CARTS study is registered at clinicaltrials.gov (NCT01273051)

Accuracy of endoscopic ultrasound in staging and restaging patients with locally advanced rectal cancer undergoing neoadjuvant chemoradiation

BACKGROUND

To date, the role of endoscopic ultrasound (EUS) in restaging locally advanced rectal cancer (LARC) after neoadjuvant chemoradiotherapy (NAT) have not been thoroughly investigated.

AIM

To evaluate accuracy and clinical usefulness of EUS for both staging and restaging LARC.

METHODS

According to EUS staging, patients with LARC were enrolled in the study. Those who underwent surgery directly represented a control group useful for evaluating the accuracy of EUS in staging LARC. In the study group, EUS was repeated seven weeks after NAT, before surgery. The results of EUS were compared with the corresponding pTN stages.

RESULTS

From 2000 to 2006, 212 consecutive patients with RC underwent EUS staging. Among them EUS diagnosed 162 LARC (M/F = 93/69; mean age: 60 years [range 40-80]). The final study group included 85 patients with LARC. EUS restaging had an overall accuracy of 61% and 59% for T and N-stage, respectively. In the control group, the accuracy of EUS in staging LARC was 86% and 58% for T and N-stage, respectively.

CONCLUSION

EUS accurately stages LARC and enables appropriate decision-making, with selection of those patients who need NAT. On the other hand, EUS restaging of LARC after NAT has low accuracy and should not be used in clinical practice.

Local excision: is it an adequate substitute for radical resection in T1/T2 patients?

Local excision (LE) was historically developed to palliate patients with rectal adenocarcinoma who either are medically unfit or have adamantly refused to undergo transabdominal standard resection (SR) procedures. Over the years, the tradeoffs between the oncologic benefit and adverse functional sequelae associated with SR procedures have been increasingly recognized. In parallel, there has been growing interest in considering LE as an alternative to SR in select patients with early-stage disease. However, concerns regarding its oncologic adequacy remain. These concerns relate to the adequacy of tumor resection, the removal of mesorectal disease, the accuracy of preoperative selection, and the use of adjunctive treatment modalities. Evolving strategies that aim at improving the oncologic outcomes of LE for stage I T1/T2 rectal cancers include adoption of transanal endoscopic microsurgery and the addition of non-surgical modalities. Current evidence surrounding these approaches is examined to provide a basis for an informed discussion with patients. Key factors to be considered in formulating the treatment plan for an individual patient with T1/T2 rectal cancer are summarized.

Long-term functional results and quality of life after transanal endoscopic microsurgery

BACKGROUND

Of the few studies that have investigated quality-of-life (QoL) outcomes after transanal endoscopic microsurgery (TEM), the majority have reported only short-term follow-up data. This study assessed long-term clinical and instrumental outcomes (QoL, sexual, urinary and sphincter function) after TEM for extraperitoneal rectal cancer.

METHODS

Preoperative and postoperative anorectal function was assessed in consecutive patients with benign rectal lesions or early rectal cancer, based on clinical scores and anorectal manometry.

RESULTS

Between January 2000 and July 2005, 93 patients undergoing TEM completed the 60-month study protocol. The mean Wexner continence score increased from baseline at 3 months, began to decline within 12 months, and had returned to the preoperative value at 60 months. Urgency was reported by 65·0, 30·0 and 5 per cent of patients at 3, 12 and 60 months respectively (P < 0·050). A significant improvement was noted in various clinical and QoL scores at 12 and 60 months. Postoperative manometry values at 3 months were significantly lower than at baseline (P < 0·050), but had returned to preoperative values at 12 months. Tumour size of 4 cm or above was the only factor that significantly (P = 0·008) affected the rectal sensitivity threshold, the urge to defaecate threshold and the maximum tolerated volume at 3 months after TEM.

CONCLUSION

TEM had no long-term effect on anorectal function or QoL. Lower anal resting pressure at early follow-up was not associated with defaecation problems in patients who were continent before surgery.

Risk factors for recurrence after transanal endoscopic microsurgery for rectal malignant neoplasm

BACKGROUND

Indications and results of local excision of rectal lesions are currently under debate. Transanal endoscopic microsurgery (TEM), allowing a precise, full-thickness excision, could improve oncological results in early rectal tumors.

METHODS

A prospective database was analyzed with the intent to identify risk factors for recurrence after TEM.

RESULTS

Among 355 patients subjected to TEM, 107 had an adenocarcinoma: 48 pT1, 43 pT2, and 16 pT3. Comparing pre- and postoperative data, histological discrepancy was 20% and staging discrepancy was 34%. Mortality was nil, morbidity was 9%. Mean follow-up was 54.2 months (range = 12-164), follow-up rate was 100%. The 5-year disease-free survival rate was 85.9, 78.4, and 49.4% for pT1, pT2, and pT3, respectively (p = 0.006). Recurrence rate was 0% (0/26) in pT1sm1 cancers and 22.7% (5/22) in sm2-3 (p < 0.05). A submucosal infiltration represented a significant risk factor for recurrences: 0% sm1, 16.7% sm2, and 30% sm3. Recurrence in pT2 was 0% in patients who had neoadjuvant therapy and 26% in the others. At univariate analysis, diameter, sm stage, pT stage, tumor grading, margin infiltration, and lymphovascular invasion demonstrated statistical significance. Multivariate analysis indicated sm stage, pT stage, and tumor grading as independent predictors of recurrence.

CONCLUSIONS

TEM represents an effective curative treatment for pT1 sm1 rectal malignancies. pT1 sm2-3 patients should be considered high-risk cases if treated only by TEM. A consistent improvement in the preoperative assessment of the risk factors identified by the present study will be a crucial development for optimal treatment of early rectal cancers.

Characteristics of recurrence after curative resection for T1 colorectal cancer: Japanese multicenter study

BACKGROUND

Because the rate of recurrence after curative resection for T1 colorectal cancer is low, the characteristics of recurrence remain obscure. This multicenter study attempted to clarify the characteristics of recurrence after curative resection for T1 colorectal cancer.

METHODS

We analyzed the associations between recurrence and various clinicopathological features in 798 patients who had undergone curative resection alone for T1 colorectal cancer at 14 hospitals between 1991 and 1996.

RESULTS

The rate of lymph node metastasis (LNM) in patients with T1 colorectal cancer was 10.5% (84/798), and 18 (2.3%) of the 798 patients developed recurrence during the median follow-up of 7.8 years. The recurrence rates in patients with colon cancer with and without LNM were 3.6 and 1.3%, respectively (p = 0.19). These rates in patients with cancer of the rectum were 25.0 and 1.1% (p < 0.0001). Among various parameters, histological grade (p < 0.0001), location (p = 0.025), LNM (p < 0.0001), and venous invasion (p = 0.0013) were risk factors for recurrence. Among them, LNM (p = 0.0008) and histological grade (p = 0.041) were independent risk factors for recurrence after curative resection for T1 colorectal cancer. Time to recurrence was more likely to be shorter for patients with, than without nodal involvement. In patients with an unfavorable histological grade, all recurrences developed within 1 year.

CONCLUSIONS

The recurrence rate after curative resection for node-negative T1 colorectal cancer was very low. The effectiveness of surveillance to detect recurrence after curative resection for T1 colorectal cancer should be validated in further studies.

Transanal endoscopic microsurgery (TEM) for rectal tumor: the first French single-center experience

OBJECTIVE

Transanal endoscopic microsurgery (TEM) allows complete local excision of rectal tumor, especially in the middle and upper part of the rectum, and provides an alternative to conventional surgery. This is a report of the first French single-center experience to assess the feasibility and postoperative results for rectal tumor excised by TEM.

METHODS

From October 2007 to December 2008, 27 patients underwent TEM for excision of either rectal adenoma (n=19) or carcinoma (n=8). The median distance from the anal verge was 60mm (range: 10-140).

RESULTS

TEM excision was performed in 26/27 patients. Intraoperative technical difficulties were recorded in two patients (peritoneal perforation and gas leakage, respectively). The morbidity rate was 22% (n=6), including two patients (7%) with major complications (delayed rectal bleeding) requiring readmission to hospital for both, and surgical hemostasis for one. R0 resection rates for adenoma and carcinoma were 84% and 75%, respectively. Immediate salvage surgery was performed in one patient because of a T2R1 carcinoma. At the time of the median follow-up at nine months (range: 2.5-17.5), no patient had experienced a recurrence.

CONCLUSION

TEM is a safe and effective procedure with low morbidity for local rectal tumor resection. It allows local excision of benign tumors, especially those that are inaccessible to conventional local surgery resection, thereby avoiding radical surgery. In cases of carcinoma, its role in local surgery remains controversial and is yet to be defined.