Local excision of rectal cancer: what is the evidence?

Surgical Issues in Rectal Cancer: A 2004 Update

Rectal cancer is a major health concern in the United States, with an estimated 40,570 new cases diagnosed in 2004. There are 4 major goals in the treatment of a patient with rectal cancer: local control; long-term survival; preservation of anal sphincter, bladder, and sexual function; and maintenance or improvement in quality of life. Recent advances have been made in preoperative staging, local and radical surgical therapy, the importance of distal and circumferential resection margins, postoperative preservation of the anal sphincter mechanism and genitourinary function, and the role of laparoscopy in the treatment of these patients. Our aim is to outline some of the important surgical issues surrounding the management of patients with early-stage (T1/T2 N0) or locally advanced (T3/T4 and/or N1) rectal cancer.

Outcome of local excision of rectal carcinoma

PURPOSE

This study was designed to determine the results of patients with rectal adenocarcinoma treated with local excision.

METHODS

A retrospective, chart review was conducted for all patients treated with local excision for rectal adenocarcinoma from 1984 to 1998.

RESULTS

Sixty-four patients were retained for analysis. The median follow-up was 37 (range, 9-125) months. There were 15 local failures with a median time to local failure of 12 months. Seven patients were salvaged with further operation (4 by repeat local excision, 4 by abdominoperineal resection, and 1 by low anterior resection). The incidence of local recurrence increased with advancing stage of the carcinoma (T1, 13 percent; T2, 24 percent; T3, 71 percent), histologic grade of differentiation, (well, 12 percent; moderately, 24 percent; poorly, 44 percent), and margin status (negative, 16 percent; close (within 2 mm), 33 percent; positive, 50 percent). Sixteen percent of carcinomas < or = 3 cm failed compared with 47 percent for carcinomas > 3 cm. Nine percent (1/11) of T2 patients treated with adjuvant radiation therapy recurred locally compared with 36 percent (5/14) without radiation therapy. Three of four T3 patients who received radiation therapy failed locally compared with two of three who did not. Using the Kaplan-Meier method, the overall survival at five years was 71 percent, and disease-free survival was 83 percent. Actuarial local failure was 27 percent and freedom from distant metastasis was 86 percent. The sphincter preservation rate was 90 percent at five years.

CONCLUSIONS

Local excision alone is an acceptable option for well-differentiated, T1 carcinomas, < or = 3 cm. Adjuvant radiation is recommended for T2 lesions. The high local recurrence rate in patients after local excision of T3 lesions with or without adjuvant radiotherapy would mandate a radical resection.

Transanal endoscopic microsurgery: indications and results after 100 cases

OBJECTIVE

Transanal endoscopic microsurgery (TEM), a minimally invasive technique has been employed in the excision of benign and well-selected malignant rectal tumours since June 1998. We present a prospective descriptive study and analyse the currently accepted indications.

PATIENTS AND METHODS

Over a 4-year period 100 patients underwent TEM for treatment of rectal tumours located between 4 and 18 cm from the anal verge.

RESULTS

TEM was performed in 71 cases for adenomas, 20 potentially curative excisions for pre-operative staged low-grade carcinoma, 3 palliative procedures for advance carcinoma, 5 carcinoids and 1 solitary ulcer. The local complication rate included wound breakdown in 7 patients, three of them requiring ileostomy. Conversion to laparotomy was performed in two patients. Five adenomas recurred and were successfully treated by TEM. Of the cancers, four patients required immediate salvage therapy by means of total mesorectal excision. Three patients underwent palliative TEM procedures combined with radiotherapy. A single cancer recurrence was treated by means of abdomino-perineal resection after radiotherapy.

CONCLUSIONS

TEM appears to be an effective method of excising benign tumours and selected T1 carcinomas of the rectum. The superior exposure of tumours higher in the rectum combined with the greater precision of excision make this minimally invasive technique an attractive surgical approach.

Treatment of T1–T2 rectal tumors by contact therapy and interstitial brachytherapy

BACKGROUND AND PURPOSE

We retrospectively analysed our experience of contact therapy alone and/or combined with interstitial brachytherapy as exclusive treatment of low lying rectal tumours.

PATIENTS AND METHODS

From 1971 to 2001, 124 patients (103 adenocarcinomas, 21 villous tumours) were treated by contact therapy alone or combined with interstitial brachytherapy. All patients were staged according to the Dijon classification. The average size of the lesions was 2.4 cm (max 7 cm), clinical aspect was polypoïd in 75% of the cases, flat in 17%. Sixty four patients received contact therapy in three fractions and 44 patients received four fractions, for an average delivered dose of 95 Gy. Interstitial brachytherapy boost delivered 24 Gy on a reference isodose of 55 cGy/h in 10 patients.

RESULTS

The local control was 83% for T1 and 38% for T2 tumours (p=0.004). For mobile tumours, the local control rate is 76%, significantly higher than for tumours with impaired mobility (55%, P=0.03). Thirty-nine patients experienced a local failure (31%). For patients amenable to surgery, a Miles procedure was performed in 25 patients. Ultimate local control rate is 93% for T1, 69% for T2 (P<0.05), 15 patients failed despite treatment for local recurrence (15%). No significant differences were observed in a comparison of adenocarcinoma and villous tumours according to initial and ultimate local control. The mean disease free survival rate for the whole population is 66 months. The 5-year disease free survival for T1a and T1b is, respectively, 82 and 78%, 40 and 25% for T2a and T2b, respectively. The overall 5-year survival for the whole group is 62.4%. At the end of the treatment, 75% of the patients described a very good sphincter function. No deleterious effect on continence was reported during the follow-up.

CONCLUSIONS

The control rate for T1 rectal cancer treated with contact therapy with or without brachytherapy is comparable to surgical series. The sphincter was preserved in 80% of the patients. Radiotherapy remains an efficient and cheap alternative to surgery, mainly for old and fragile patients, or refusing colostomy. The results of these approaches for tumors larger than 3 cm (T2) are not satisfactory. For patients not amenable to surgery, external beam radiation therapy and/or combined modality with chemoradiation should be discussed to increase the loco-regional control rate. A careful selection of patients based on rectal examination and trans-rectal ultrasound could select more accurately patients amenable to such an approach.

Transvaginal local excision of rectal carcinoma

PURPOSE

To recommend a new approach-transvaginal local excision of early rectal cancers-and report the results of the approach applied by dedicated surgeons at a specialized colorectal unit during a 10-year period.

METHODS

The surgical outcome of 18 patients undergoing transvaginal local resection between January 1991 and August 2001 was reviewed. Patients were identified according to the consultants' personal records and cross-referenced with the operating room logs. Data were collected retrospectively, and follow-up was performed on all patients.

RESULTS

A total of 18 patients underwent 18 procedures during the study period. Follow-up ranged from 2 months to 104 months. There were no treatment-related complications. Two patients suffered from recurrences at a median follow-up time of 35.7 months, but they underwent subsequent surgical treatment: APR (one) and LAR (one). No evidence of disease was found during a median follow-up of 20 months (12 and 28 months). No one died.

CONCLUSIONS

Transvaginal local excision is an alternative and feasible technique with low rates of death and complications for the treatment of rectal cancer in strictly selected cases.

Combining ultrasonic dissection and the Storz operation rectoscope

BACKGROUND

Transanal endoscopic microsurgery (TEM) allows a precise, full-thickness resection of rectal tumors anywhere within the rectum. Unfortunately, the standard TEM technique needs complex and rather expensive equipment, demands high skill, and is attended by bleeding and oozing that may be challenging. A modified TEM procedure combining the new Storz operation rectoscope and ultrasonic dissection has been developed to overcome the limitations of the original technique.

METHODS

The Storz operation rectoscope features a 5-mm telescope combined with a single-monitor display. Standard laparoscopic instruments and the LCSC5 Ultracision Maniple are used for dissection and coagulation. Full-thickness resection is performed most often. Closure of the defect is accomplished by interrupted 3-0 polydoxanone sutures secured by extracorporeal slipknots.

RESULTS

Altogether, 18 TEMs have been performed according to the modified technique: 9 for malignant and 9 for benign lesions. The median operating time was 92.5 min for resection of malignant lesions and 40 min for resection of benign lesions. Two postoperative complications occurred: a bleeding and a partial dehiscence. The median follow-up periods were 35 months for malignant disease and 19.5 months for benign disease. No recurrence was observed.

CONCLUSION

For tumors located up to 15 cm from the anal verge, TEM with the Storz rectoscope and ultrasonic dissection is indicated. Despite the complication described, coagulation is optimal and ultrasonic scissors allow working in a fairly bloodless field. The overall costs of the equipment are significantly lower.

Local excision of rectal tumors

Local excision is increasingly being used to treat rectal cancer. It appears to be an attractive option because of low morbidity and excellent functional results. Controversies remain regarding available techniques, selection criteria and results with or without adjuvant therapy. Role of salvage therapy remains uncertain. This review examines available evidence in an attempt to clarify the role of local excision in the management of rectal cancer.

Methods and results of sphincter-preserving surgery for rectal cancer

BACKGROUND

Sphincter preservation is the goal in the treatment of rectal cancer and should be considered in all patients with an intact sphincter. Sphincter preservation for tumors of the upper rectum is easily achieved, but surgical management of cancer of the mid and lower third of the rectum continues to evolve. Several recent advances may influence future treatment strategies.

METHODS

We reviewed the literature to identify the current methods of sphincter-preserving surgery and their oncologic and functional results.

RESULTS

Proctectomy with total mesorectal excision reduces the incidence of local recurrence to less than 10% while preserving genitourinary function. The use of preoperative radiotherapy may further diminish the risk of local recurrence. In selected patients, partial resection of the anal sphincter may avoid definitive colostomy without compromising oncologic outcome. In contrast, the role of local resection of rectal cancer remains controversial. Restoration of continuity by means of a colonic reservoir reduces stool frequency and urgency and improves continence when compared to a straight coloanal anastomosis. The transverse colpoplasty pouch may allow pouch construction in patients in whom it is currently impossible, but long-term follow-up is not yet available.

CONCLUSIONS

Sphincter-preserving surgery is possible for the majority of patients with rectal cancer. Optimal functional results may be obtained by a nerve-sparing operative technique and by use of a colonic reservoir for reconstruction following resection of mid or low rectal cancers.

Local excision carcinoma in early stage

AIM

To assess the validity of local excision for the early stage low rectal cancer as an effective treatment alternative to radical resection.

METHODS

A retrospective medical chart review was done in 47 patients with early stage low rectal carcinoma who underwent local excision from November 1980 through November 1999 at Cancer Hospital of Chinese Academy of Medical Sciences (CAMS). The patients were treated by either transanal (40 cases), trans-sacral (5 cases), or trans-vaginal (2 cases) excision of tumors and no death was related to surgery. Sixteen patients received postoperative radiotherapy.

RESULTS

T1 and T2 lesion was found in 36 (76.6 %) and 11 patients (23.4 %) respectively. The overall local tumor recurrence rate was 14.9 % (7/47), with an average recurrence time of 21 months. Among these 7 recurrent patients, there were 4 T1 and 3 T2 lesions. Microscopically, the surgical incisal margin was negative in 45 (95.7 %) and positive in 2 patients (4.3 %); Both of the later had developed local recurrence. The overall 5-year survival rate was 91.7 %, in which there were 94.4 % for T1 and 83.3 % for T2 tumors. T stage, intravessel tumor thrombosis, lymphocytic infiltration and histological grade were not found to be significant by related to the local recurrence and survival (P>0.05).

CONCLUSION

Local tumor excision was a safe procedure for the treatment of early stage low rectal carcinoma with minimal morbidity and mortality, which might serves as one of the primary surgical treatment methods for the disease of this kind.

Assessment of the accuracy of transrectal ultrasonography in anorectal neoplasia

BACKGROUND

Accurate preoperative staging of anorectal neoplasia is required to identify patients for whom local excision or adjuvant therapy may be appropriate. The objectives of this study were to review the accuracy of endoluminal transrectal ultrasonography (TRUS) in the staging of rectal cancers and to determine the learning curve before optimal staging accuracy can be achieved.

METHODS

The results of all TRUS examinations for the assessment of anorectal neoplasia performed by two colorectal surgeons at two teaching hospitals of the University of Sydney from 1991 to 2001 were collected prospectively.

RESULTS

Of the 433 patients examined by TRUS, 356 were included, of whom 263 (73.9 per cent) had nodal status assessed histologically. Of the 77 patients excluded, 50 had undergone radiotherapy before operation. TRUS achieved excellent accuracy when compared with histopathology reports using kappa statistics for standard Union Internacional Contra la Cancrum (UICC) staging (kappa = 0.89), tumour wall penetration (kappa = 0.70), lymph node detection (kappa = 0.66) and a proposed new staging system (kappa = 0.94). In addition, the increase in TRUS accuracy with operator experience demonstrates the need to perform 50 or more procedures before optimal accuracy is achieved.

CONCLUSION

TRUS provides an appropriate investigation with which to select patients with T1 tumours for local excision, and patients with T3 or T4 tumours for preoperative radiotherapy. The relative inaccuracy of staging T2 tumours by TRUS has led to a proposed alternative ultrasonographic staging system.

Long-term results of local excision for rectal cancer

OBJECTIVE

To review the authors' experience with local excision of early rectal cancers to assess the effectiveness of initial treatment and of salvage surgery.

SUMMARY BACKGROUND DATA

Local excision for rectal cancer is appealing for its low morbidity and excellent functional results. However, its use is limited by inability to assess regional lymph nodes and uncertainty of oncologic outcome.

METHODS

Patients with T1 and T2 adenocarcinomas of the rectum treated by local excision as definitive surgery between 1969 to 1996 at the authors' institution were reviewed. Pathology slides were reviewed. Among 125 assessable patients, 74 were T1 and 51 were T2. Thirty-one patients (25%) were selected to receive adjuvant radiation therapy. Fifteen of these 31 patients received adjuvant radiation in combination with 5-fluorouracil chemotherapy. Median follow-up was 6.7 years. One hundred fifteen patients (92%) were followed until death or for greater than 5 years, and 69 patients (55%) were followed until death or for greater than 10 years. Recurrence was recorded as local, distant, and overall. Survival was disease-specific.

RESULTS

Ten-year local recurrence and survival rates were 17% and 74% for T1 rectal cancers and 26% and 72% for T2 cancers. Median time to relapse was 1.4 years (range 0.4-7.0) for local recurrence and 2.5 years (0.8-7.5) for distant recurrence. In patients receiving radiotherapy, local recurrence was delayed (median 2.1 years vs. 1.1 years), but overall rates of local and overall recurrence and survival rates were similar to patients not receiving radiotherapy. Among 26 cancer deaths, 8 (28%) occurred more than 5 years after local excision. On multivariate analysis, no clinical or pathologic features were predictive of local recurrence. Intratumoral vascular invasion was the only significant predictor of survival. Among 34 patients who developed tumor recurrence, the pattern of first clinical recurrence was predominantly local: 50% local only, 18% local and distant, and 32% distant only. Among the 17 patients with isolated local recurrence, 14 underwent salvage resection. Actuarial survival among these surgically salvaged patients was 30% at 6 years after salvage. CONCLUSIONS The long-term risk of recurrence after local excision of T1 and T2 rectal cancers is substantial. Two thirds of patients with tumor recurrence have local failure, implicating inadequate resection in treatment failure. In this study, neither adjuvant radiotherapy nor salvage surgery was reliable in preventing or controlling local recurrence. The postoperative interval to cancer death is as long as 10 years, raising concern that cancer mortality may be higher than is generally appreciated. Additional treatment strategies are needed to improve the outcome of local excision.

Local therapy for rectal cancer

Local procedures for carefully selected distal rectal cancer offer significant advantages such as sphincter preservation and avoidance of radical surgery. However, since preoperative selection criteria including current imaging modalities are unable to definitively stage regional lymph node status, local therapies for rectal cancer have the inherent potential disadvantage of undertreating a fraction of patients due to unresected mesorectal/regional lymph node disease. Current available data suggests that the local approach may be appropriate only for carefully selected T1 tumors with favorable pathologic features. Inferior local control and survival reported for T2 tumors and T1 tumors with unfavorable features, despite the addition of chemoradiation, outweigh the advantages of the local approach. Patients with unfavorable tumors who are unable to tolerate radical resection or who refuse surgery may be treated with local excision with or without adjuvant chemoradiation. Other modalities, such as electrocoagulation and endocavitary radiation, may also be valuable in this setting, as well as preoperative chemoradiation followed by local excision. Regardless of the approach used, all patients undergoing local therapy of a rectal cancer require careful long-term follow-up, because these patients remain at significant risk for local recurrence and distant failure.