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

Quality of life after transanal endoscopic microsurgery and total mesorectal excision in early rectal cancer

OBJECTIVE

Total mesorectal excision (TME) is the gold standard in rectal cancer, if curation is intended. Transanal endoscopic microsurgery (TEM) is a much safer technique and seems to have comparable survival in early rectal cancer. The impact of both procedures on quality of life has never been compared. In this study we compared quality of life after TEM and TME.

METHOD

Fifty-four patients underwent TEM for a T1 carcinoma. Only patients without known locoregional or distant recurrences were included, resulting in 36 eligible patients in whom quality of life after TEM was studied. The questionnaires used included the EuroQol EQ-5D, EQ-VAS, EORTC QLQ-C30 and EORTC QLQ-CR38. The results were compared with a sex-and age-matched sample of T+N0 rectal cancer patients who had undergone sphincter saving surgery by TME and a sex- and age matched community-based sample of healthy persons.

RESULTS

Thirty-one patients after TEM returned completed questionnaires (overall response rate 86%). Quality of life was compared with 31 TME patients and 31 healthy controls. From the patients' and social perspective quality of life did not differ between the three groups. Compared with TEM, significant defecation problems were seen after TME (P < 0.05). A trend towards better sexual functioning after TEM, compared with TME, was seen, especially in male patients, although it did not reach statistical significance.

CONCLUSION

Transanal endoscopic microsurgery and TME do not seem to differ in quality of life postoperatively, but defecation disorders are more frequently encountered after TME. This difference could play a role in the choice of surgical therapy in (early) rectal cancer. Further prospective studies are needed to confirm our conclusions.

Local excision of rectal tumours by transanal endoscopic microsurgery

BACKGROUND

Transanal endoscopic microsurgery (TEM) allows locally complete excision of rectal tumours and provides an alternative to conventional surgery for benign tumours. However, its role in the curative treatment of invasive carcinoma is controversial. The aim of this study was to determine the morbidity and long-term results for rectal tumours excised by TEM.

METHODS

Between February 1993 and January 2005, 200 patients underwent TEM for excision of adenomas (148) or carcinomas (52). The median tumour distance from the anal verge was 8 (range 1-16) cm.

RESULTS

Mortality and morbidity rates were 0.5 and 14.0 per cent respectively. At a median follow-up of 33 (range 2-133) months, local recurrence had developed in 11 patients (7.6 per cent) with an adenoma. Histological examination of carcinomas revealed pathological tumour (pT) stage 1 in 31 patients, pT2 in 17 and pT3 in four. Immediate salvage surgery was performed in seven patients (13 per cent). At a median follow-up of 34 (range 1-102) months, eight patients (15 per cent) with carcinomas had developed local recurrence. The overall and disease-free 5-year survival rates for patients with carcinomas were 76 and 65 per cent respectively.

CONCLUSION

TEM is an appropriate surgical treatment option for benign rectal tumours. For carcinomas, it is oncologically safe provided that resection margins are clear, but strict patient selection is required.

Is the increasing rate of local excision for stage I rectal cancer in the United States justified?: a nationwide cohort study from the National Cancer Database

OBJECTIVE

Determine rates of local excision (LE) over time, and test the hypothesis that LE carries increased oncologic risks but reduced perioperative morbidity when compared with standard resection (SR).

SUMMARY BACKGROUND DATA

Despite the lack of level I/level II evidence supporting its oncologic adequacy, LE is performed for stage I rectal cancer.

METHODS

Surgical therapy for 35,179 patients with stage I rectal cancer diagnosed in 1989 to 2003 was examined over time, utilizing the National Cancer Database. A special study then analyzed perioperative outcomes, local recurrence and survival in 2124 patients diagnosed between 1994 and 1996, including 765 (T1, 601; T2, 164) treated by LE and 1359 (T1, 493; T2, 866) treated by SR.

RESULTS

From 1989 to 2003, the use of LE has increased (T1, 26.6-43.7%; T2, 5.8-16.8%; P < 0.001 both). The special study demonstrated significantly lower 30-day morbidity after LE versus SR (5.6% vs. 14.6%; P < 0.001). After adjusting for patient and tumor characteristics, the 5-year local recurrence after LE versus SR was 12.5 versus 6.9% (P = 0.003; hazard ratio = 0.38; 95% CI, 0.23-0.62) for T1 tumors, and 22.1 versus 15.1% (P = 0.01; hazard ratio = 0.69; 95% CI, 0.44-1.07) for T2 tumors. The 5-year overall survival (T1, 77.4% vs. 81.7%, P = 0.09; T2, 67.6% vs. 76.5%, P = 0.01) was influenced by age and comorbidities but not the type of surgery.

CONCLUSIONS

This study provides the best evidence for both the increasing use and the associated risks of LE versus SR. For each individual patient, the benefits of LE must be balanced against the heightened risk of local failure.

Function and quality of life after transanal excision of rectal polyps and cancers

PURPOSE

The purpose of this study was to determine the functional outcomes and health-related quality of life of patients after transanal excision of rectal cancers or polyps and to assess the relationship between functional outcomes and health-related quality of life.

METHODS

All patients having a transanal excision at the Mount Sinai Hospital from 1989 to 2002 were included if the indication for surgery was a benign or malignant neoplasm. Physician charts were reviewed, and patients and their physicians were contacted to obtain follow-up information. Continence was assessed by using the Continence Score described by Jorge and Wexner and the Fecal Incontinence Quality of Life instrument by Rockwood and Lowry.

RESULTS

Eighty-two patients fit the inclusion criteria (42 males; mean age, 71 +/- 13.7 years). Of these, 29 had villous adenomas, 2 had carcinoids, and 1 had a hyperplastic polyp. Fifty had cancers, including 34 with T1, 14 with T2, and 2 with T3 cancers. Seven patients had a low anterior resection or abdominoperineal resection within two months of transanal excision because of advanced features of cancer. Five patients had salvage abdominoperineal resections or low anterior resections for local recurrences. Five patients died of rectal cancer (including 3 who had salvage surgery) and an additional seven patients died of other causes. Functional results were assessed in 58 of 61 eligible patients. The mean Continence Score postoperatively was 3.5 +/- 3.9 compared with 2.4 +/- 3.7 preoperatively (P = 0.03). The mean Fecal Incontinence Quality of Life scores after surgery in all patients were 3.9 +/- 0.3, 3.6 +/- 0.6, 3.7 +/- 0.3, 3.7 +/- 0.6 in the domains of lifestyle, coping, depression, and embarrassment, respectively, after surgery, indicating high quality of life. Using Spearman's correlation, we found that the continence scores after surgery correlated well with the Fecal Incontinence Quality of Life scores. In the domains of lifestyle (Spearman's correlation = -0.69), coping and behavior (Spearman's correlation = -0.7), and embarrassment (Spearman's correlation = -0.61) but did not correlate well with the domain of depression (Spearman's correlation = -0.17).

CONCLUSIONS

Although functional results are worsened in a minority of patients after transanal excision, quality of life is high in the majority of patients.

Local therapy for rectal cancer: still controversial?

PURPOSE

Many considerations, such as morbidity, sexual and urinary dysfunction, or risk of definitive stoma have led to the increased popularity of local therapy in the therapeutic strategy for rectal cancer. However, its role in curative intent is still controversial with oncologic long-term results lower than those obtained by radical surgery.

METHODS

MEDLINE, EMBASE, LILACS, Abstract books, and reference lists from reviews were searched with English language publications to review the current status of evidence for local therapy in rectal cancer, looking especially at the oncologic results and patient selection. We have focused on the new strategies combining neoadjuvant and adjuvant treatment to explain their place in the management of rectal cancer.

RESULTS AND CONCLUSIONS

The key to potentially curative local treatment for rectal cancer is patient selection by identifying the best candidates with preoperative tumor staging and clinical and pathologic assessment of favorable features. Low-risk T1 is suitable for local excision alone. Limited data suggest that adjuvant chemoradiotherapy may be helpful in patients with unfavorable T1 and T2 lesions, achieving a local recurrence rate<20 percent. However, the efficacy of salvage surgery after local excision is uncertain.

Organ preservation for rectal cancer

Organ preservation with maintenance of function in the treatment of rectal cancer is highly valued by patients. Although most patients with resectable rectal cancer can undergo a sphincter-sparing radical procedure, there are patient, tumor, surgeon, and treatment factors that influence the ability to restore intestinal continuity after radical resection. Although population-based data suggest that the rate of sphincter preservation is lower than could be obtained at expert centers, there are patients in whom low anterior resection with colo-anal anastomosis is not technically feasible and/or oncologically sound. Additionally, resection with ultralow anastomosis results in functional compromise in many patients. Local treatment of rectal cancer aims to decrease the morbidity and the functional sequelae associated with radical resection; however, local excision is associated with a higher rate of local recurrence than is radical resection. Strict selection criteria are essential when considering local excision, and patients should be informed of the risk of local recurrence. The use of adjuvant therapy with local excision, particularly in patients with T2 lesions, has promise but should be considered only as part of a clinical trial.

Transanal endoscopic microsurgical excision of pT2 rectal cancer: results and possible indications

PURPOSE

In previous studies, local excision was predominantly established for "low-risk" pT1 rectal cancer. The results obtained with T2 tumors are unclear; recurrence rates of 0 to 67 percent were reported. This study was designed to determine the value of local excision for T2 rectal carcinomas, prognostic factors, and the need for reoperation.

METHODS

After local excision of 649 patients with rectal tumors, pT2 carcinoma was found in 44 patients. In general, immediate reoperation was recommended; however, 24 patients declined further surgery or were not reoperated because of comorbidities. The results were analyzed separately for local R0 resection of low-risk carcinomas and for prognostically unfavorable criteria (R1/RX/R < or = 1mm/G3-4/L1/V1). Reoperation was performed within four weeks. Recurrences also were divided by previous local R0 resection of low-risk tumors as well as by unfavorable results and were analyzed in a long-term, follow-up study. Patients with palliative therapy were excluded, and follow-up was obtained in 90 percent (20 transanal endoscopic microsurgical excision alone, 17 transanal endoscopic microsurgical excision and reoperation).

RESULTS

Local recurrence rates after local R0 resection alone of low-risk T2 carcinomas were 29 percent, whereas patients with unfavorable criteria developed recurrences in 50 percent. After immediate reoperation, the local recurrence risk in patients without lymph node filiae was significantly reduced to 7 percent.

CONCLUSIONS

Local R0 resection of low-risk pT2 carcinomas represents an inadequate therapy. In pT2N0M0 rectal carcinomas, the recurrence rate can be reduced through immediate reoperation to a level similar to primary radical surgery. An initial poor local resection result (R1/RX/R < or = 1 mm/G3-4/L1/V1) has no negative influence on further oncologic outcome.

Population-based analyses of lymph node metastases in colorectal cancer

BACKGROUND & AIMS

The potential presence of lymph node metastases in patients with colorectal cancer (CRC) limits the application of minimally invasive techniques of resection. We used data from the National Cancer Institute's Surveillance, Epidemiology, and End Results registry to better understand the underlying risk of lymph node metastases and factors that influence this risk in a population-based fashion.

METHODS

In a cohort of 124,180 CRC patients diagnosed from 1988 through 2002 treated with radical surgery without neoadjuvant irradiation, we assessed the proportion of patients who were lymph node positive and determined factors that influenced the risk of lymph node metastases including patient characteristics, anatomic location, and histopathologic factors.

RESULTS

Among all patients, the proportion of lymph node metastases was 34.5%. The overall proportion of node positivity was 8% for T1 tumors, 18.5% for T2 tumors, 42% for T3 tumors, and 50% for T4 tumors. Nodal metastases were noted in 7% of proximal T1 colon tumors, 7.5% of distal T1 colon tumors, and 10.1% of T1 rectal tumors. Patients with poorly differentiated tumors were much more likely to be node positive (52%) than patients with well-differentiated tumors (20%) (P<.0001).

CONCLUSIONS

Even patients with superficial CRCs have a significant risk of nodal metastases. This risk should be considered when balancing the risks and benefits of minimally invasive techniques such as local excision or endoscopic resection for the treatment of CRC.

[Transanal endoscopic microsurgery (TEM). Current situation and future expectations]

Transanal endoscopic microsurgery (TEM) uses specific equipment that allows resection of large rectal adenomas and incipient malignancies in the rectal ampulla. TEM aims to provide an alternative to conventional abdominal surgery (low anterior resection or abdominoperineal amputations), which carries not inconsiderable morbidity and mortality. Application of the technique of endoanal excision is limited by the height and extension of the lesions. In this review, the authors present their own experience with this technique and that described in the literature. The protocol for selecting candidates for TEM, their preoperative preparation, equipment, characteristics of the surgical technique, postoperative complications, and follow-up are described. The collaboration of a multidisciplinary team is essential when developing this technique. TEM-associated morbidity is low and mortality is practically nil. TEM is the technique of choice in large rectal adenomas and malignant rectal tumors in stages pT1 localized in the rectal ampulla. The frequency of recurrence is similar to that in abdominal surgery. The technique does not cause complications of urinary or sexual dysfunction and fecal incontinence is minimal. In more advances stages of rectal cancer, the results of better patient selection and future studies on the possible application of neoadjuvant therapy associated with TEM are required.

Transanal endoscopic microsurgery for carcinoma of the rectum

BACKGROUND

The authors present their experience with rectal cancers managed by transanal endoscopic microsurgery (TEM).

METHODS

This prospective study investigated patients undergoing primary TEM excision for definitive treatment of rectal cancer between January 1996 and December 2003 by a single surgeon in a tertiary referral colorectal surgical unit.

RESULTS

For this study, 52 patients (30 men and 22 women) underwent TEM excision of a rectal cancer. Their mean age was 74.3 years (range, 48-93 years). The median diameter of the lesions was 3.44 cm (range, 1.6-8.5 cm). The median distance of the lesions from the anal verge was 8.8 cm (range, 3-15 cm), with the tumor more than 10 cm from the anal verge in 36 patients. The median operating time was 90 min (range, 20-150 min), and the median postoperative stay was 2 days. All patients underwent full-thickness excisions. There were 11 minor complications, 2 major complications, and no deaths. The mean follow-up period was 40 months (range, 22-82 months). None of the pT1 rectal cancers received adjuvant therapy. Eight patients with pT2 rectal cancer and two patients with pT3 rectal cancer received postoperative adjuvant therapy. The overall local rate of recurrence was 14%, and involved cases of T2 and T3 lesions, with no recurrence after excision of T1 cancers. Three patients died during the follow-up period, but no cancer-specific deaths occurred.

CONCLUSIONS

The findings warrant the conclusion that TEM is a safe, effective treatment for selected cases of rectal cancer, with low morbidity and no mortality. The TEM procedure broadens the range of lesions suitable for local resection to include early cancers (pTis and pT1) and more advanced cancers only in frail people.

The influence of histopathologic criteria on the long-term prognosis of locally excised pT1 rectal carcinomas: results of local excision (transanal endoscopic microsurgery) and immediate reoperation

PURPOSE

Local excision of early rectal cancer is a controversial issue, which is in part because of differences in the evaluation of histopathologic criteria. This prospective study was designed to determine prognostic factors for recurrences and the need for reoperation.

METHODS

In 105 of 118 patients with pT1 carcinomas and local excision, results of recurrence rates and ten-year cancer-free survival were studied separately according to different histologic criteria (R0, R1, Rx, R < or = 1 mm, high-/low-risk situation), tumor localization (anterior, posterior, lateral wall and third of rectum), size, and degree of resection (full-thickness/partial wall). Patients were grouped into local excision (n = 89) and local excision followed by reoperation (n = 21). Risk classification was performed by division into "low-risk" carcinomas after local R0-resection (Group A) and unfavorable histologic results after local resection (R1, Rx, R < or = 1 mm, high-risk situation; Group B).

RESULTS

Local recurrence rates after local R0-resection of low-risk carcinomas were 6 percent, whereas patients in Group B with local resection were 39 percent. The recurrence risk in those patients was significantly reduced to 6 percent by reoperation (P = 0.015). In addition, ten-year, cancer-free survival was 93 percent in Group B after reoperation compared with 89 percent in patients of Group A after local excision alone.

CONCLUSIONS

Local R0-resection in cases with low-risk pT1 carcinomas represents an oncologically adequate therapy, which results in similar survival rates compared with primary radical surgery of pT1N0M0 rectal carcinomas. High recurrence rates are observed in tumors with unfavorable histologic result (Group B) requiring further treatment. In these cases immediate reoperation reduces the recurrence rate to 6 percent.

The Kraske procedure: a critical analysis of a surgical approach for mid-rectal lesions

BACKGROUND AND OBJECTIVES

To analyze the Kraske procedure as an approach to mid-rectal disease.

METHODS

Twenty-two patients underwent a Kraske procedure at either Duke University Medical Center, the Durham Veterans Administration Medical Center, or the Durham Regional Hospital between 1992 and 1997. The clinical and pathologic characteristics of these patients were retrospectively analyzed and compared with previous published series.

RESULTS

Of the 22 patients, 13 underwent resection of an adenocarcinoma and 9 underwent resection of a villous adenoma. Post-operative complications included four fecal fistulas (two of which required a temporary diverting colostomy), two wound infections, two cases of urinary retention, and one case of transient fecal incontinence.

CONCLUSIONS

The Kraske procedure minimizes exposure of mid-rectal lesions without the morbidity of a major laparotomy. However, it does carry a moderate complication rate and thus should be utilized selectively in managing patients with mid-rectal tumors not amenable to other treatment options.

Endoscopic posterior mesorectal resection after transanal local excision of T1 carcinomas of the lower third of the rectum

PURPOSE

The rectum-sparing transanal local excision is a well-established treatment of T1 carcinomas of the lower third of the rectum. A potentially increased locoregional recurrence rate by this procedure is tolerated because of the high morbidity and mortality risk of transabdominal rectal resection. Dorsoposterior extraperitoneal pelviscopy makes it possible to remove the relevant lymphatic drainage of the lower third of the rectum minimally invasively, in the sense of a rectum-sparing endoscopic posterior mesorectal resection. It has to be considered whether endoscopic posterior mesorectal resection in combination with transanal local excision allows for local radicality and an adequate tumor staging in T1 carcinomas of the lower third of the rectum, in terms of better-directed therapy planning compared with transanal local excision alone.

METHODS

We operated on 11 consecutive patients with T1 carcinomas of the lower third of the rectum by transanal local excision in combination with endoscopic posterior mesorectal resection as a two-stage procedure in the period from 1998 to 2005.

RESULTS

It was possible to perform a complete excision of the primary and to resect the posterior part of the mesorectum in all cases. Postoperative morbidity consisted of two transient neurologic complications and a pulmonary embolism. There was no mortality. Histologic analysis revealed a median of eight (range, 4-20) lymph nodes. Two patients diagnosed with lymph-node metastases received adjuvant radiochemotherapy. After a median follow-up of 48 (range, 4-60) months, there was no evidence for locoregional recurrence. In one patient liver metastasis was detected eight months postoperatively.

CONCLUSIONS

Radical excision of the primary tumor and an adequate tumor staging in T1 carcinomas of the lower third of the rectum seems to be achievable by means of transanal local excision and endoscopic posterior mesorectal resection.

Neoadjuvant and adjuvant therapy for rectal cancer

The currently available evidence from randomized clinical trials clearly supports the use of adjuvant therapy in general and preoperative combined modality therapy in particular as effective means of decreasing the rates of local recurrence, improving sphincter preservation rates, and probably im-proving overall survival when managing patients with locally advanced adenocarcinomas of the lower two thirds of the rectum. A radical surgical approach with adequately performed, sharp TME remains the standard of care for those patients. There is clearly a need to develop and validate surrogate biomarkers for the identification of patients who respond favorably to preoperative treatment. There is still a significant fraction of rectal cancer patients who ultimately die from their disease. The armamentarium of avail-able therapies is evolving rapidly, and hopefully local control rates and overall survival of rectal cancer patients will continue to improve in the near future.

Local excision of stratified T1 rectal cancer

BACKGROUND

Local excision has been accepted therapy for T1 rectal cancers. A recent study demonstrated that primary tumors with deeper submucosal invasion were associated with a higher rate of lymph node metastases than those with shallow invasion. Our aim was to determine the effect of the depth of submucosal penetration on recurrence and mortality rates following transrectal excision of T1 tumors.

METHODS

This was a 34-year retrospective review of patients who had transrectal excision with clear margins for T1 rectal cancer. Tumors were stratified into submucosal (SM) levels, and recurrence and mortality rates were determined.

RESULTS

Of 101 patients with T1 rectal cancer undergoing local excision, 31 had a full-thickness transrectal excision. Eight (26%) of the 31 patients developed a local recurrence, 2 of whom had both a local and distant recurrence. Four patients (13%) died from metastatic rectal cancer.

CONCLUSIONS

The recurrence rate for transrectal excision of T1 rectal cancer is high. It may be beneficial for patients with early rectal cancer to have postoperative chemoradiation therapy or a more radical surgical procedure.

Local recurrence after transanal endoscopic microsurgery for rectal polyps and early cancers

BACKGROUND

Transanal endoscopic microsurgery (TEM) allows for local excision of rectal neoplasms with greater exposure than transanal excision and less morbidity than transabdominal approaches. This study examines the implications of the procedure with respect to predictors of recurrence.

METHODS

We performed a retrospective analysis of 144 consecutive TEMs from 1993 to 2004.

RESULTS

The study comprises 107 patients presenting for TEM with benign disease and 32 patients with cancer. Patients had a mean age of 64+/-14 (SD) years. TEM was performed for recurrent lesions in 17% of cases. Pathologic classification of the lesions after TEM was benign adenoma in 45%, adenoma with high-grade dysplasia (HGD) in 17%, cancer in 33%, and other in 4%. Complications occurred in 10%, and local recurrence occurred in 15% of patients. Median follow-up was 44 months, with a median time to recurrence of 14 months. Positive margins did not influence lesion recurrence. Recurrence of cancers correlated with the depth of tumor invasion (P<.05). On multivariate analysis, independent predictors of recurrence were lesion size and the presence of HGD within adenomas (P<.05). Five-year neoplastic recurrence probabilities were 11% for benign adenomas, 35% for adenomas with HGD, and 20% for cancers (P=.31); invasive recurrence probabilities were 0% for benign adenomas, 15% for adenomas with HGD, and 13% for cancers (P<.05).

CONCLUSIONS

Close endoscopic follow-up is warranted after TEM for both benign and malignant disease, with special attention to lesions with HGD. TEM can be performed safely for early rectal cancer with careful patient selection.

Outcomes for early rectal cancer managed with transanal endoscopic microsurgery: a 5-year follow-up study

BACKGROUND

This study aimed to evaluate the long-term risk of local and distant recurrence as well as the survival of patients with early rectal cancer treated using transanal endoscopic microsurgery (TEM).

METHODS

The study reviewed 69 patients with Tis/T1/T2 rectal cancer treated using full-thickness excision between 1991 and 1999. The pathology T-stages included 25 Tis, 23 T1, and 21 T2. The median follow-up period was 6.5 years (range 5-10.2 years).

RESULTS

The overall local recurrence rate was 8.7%. The 5-year local recurrence rate was 8% for Tis, 8.6% for T1, and 9.5% for T2. All six patients with recurrence were managed surgically. The 5-year disease-specific survival rate was 100% for Tis, 100% for T1, and 70% for T2. The overall cancer-related mortality rate was 7.2%.

CONCLUSIONS

After local excision of early rectal cancer, a substantial local recurrence rate is observed. Patients with recurrent Tis/T1 cancers who undergo a salvage operation may achieve good long-term outcome. Local treatment without adjuvant therapy for T2 rectal cancers appears inadequate.

Endoscopic ultrasound staging of rectal cancer: diagnostic value before and following chemoradiation

BACKGROUND

Endoscopic ultrasound (EUS) has been shown to be a reliable tool for staging rectal cancer. Nevertheless, the accuracy of EUS after chemoradiation remains unclear; therefore the purpose of the present paper was to compare the accuracy of EUS staging for rectal cancer before and following chemoradiation.

METHODS

Patients with rectal cancer undergoing EUS staging were stratified into two groups. Group I consisted of 66 patients who underwent surgery following EUS staging without preoperative chemoradiation. Group II consisted of 25 patients who had EUS evaluation following chemoradiation. The EUS staging was compared to surgical/pathological staging.

RESULTS

The accuracy of the T staging for group I was 86% (57/66). Inaccurate staging was mainly associated with overstaging EUS T2 tumors. The accuracy of the N staging for group I was 71% (47/66). The accuracy of EUS for a composite T and N staging relevant to treatment decisions in group I was 91%. In group II, the accuracy of T and N staging was 72% (18/25) and 80% (20/25), respectively. Overstaging EUS T3 tumors accounted for most inaccurate staging. The EUS staging predicted post-chemoradiation T0N0 stage correctly in only 50% of cases.

CONCLUSIONS

Preoperative staging of rectal cancer by EUS is a useful modality in determining the need for preoperative chemoradiation. The EUS T staging following chemoradiation appears to be less accurate. Detection of complete response may be insufficient for selecting patients for limited surgical intervention.

Surgical Treatment of Rectal Cancer: Local Resection

Local treatment of rectal cancer aims to decrease the morbidity and the functional sequela associated with radical surgery without compromising local tumor control and long-term survival. Local excision is associated with a higher rate of local recurrence compared with radical surgery, and salvage radical surgery cannot guarantee equivalent long-term survival compared with radical surgery as the primary form of therapy. Therefore, strict criteria for patient selection are critical for local excision to be successful. Selecting the optimal therapy for an individual patient with rectal cancer is crucial and requires consideration of both tumor and patient characteristics. Endorectal ultrasonography is essential for the accurate assessment of rectal wall invasion and nodal metastasis. Only patients with well- or moderately differentiated T1 tumors without blood vessel or lymphatic vessel invasion are candidates for curative local excision as the only form of treatment. Tumors penetrating the muscularis propria should not be treated by local excision alone. These patients can be asked to participate in a trial of chemoradiation followed by local excision. Otherwise, they should undergo radical surgery. The tumor should be removed by full-thickness local excision with an adequate normal margin for pathologic evaluation. Final decisions regarding the treatment strategy should be based on the pathology of the surgical specimen. Intense, close follow-up is critical for early diagnosis of local recurrences as many of them may be surgically salvaged by radical resection. Local treatment can also be used for palliation of patients with histological unfavorable or advanced tumors, and those who are medically unfit for radical surgery.

Can pathological complete response in the primary tumour following pre-operative pelvic chemoradiotherapy for T3-T4 rectal cancer predict for sterilisation of pelvic lymph nodes, a low risk of local recurrence and the appropriateness of local excision?

INTRODUCTION

Local excision is considered inappropriate treatment for T3-T4 rectal adenocarcinomas, as it cannot provide prognostic information regarding lymph node involvement and has a high risk of pelvic recurrence. Preoperative chemoradiation (CRT) studies in rectal cancer suggest that a pathological complete response (pCR) in the primary tumour provides an excellent long-term outcome. If downstaging to stage pT0 predicts a tumour response within the perirectal and pelvic lymph nodes, this may allow local excision to be performed without increased risk of pelvic recurrence. This retrospective study aimed to determine the incidence of involved lymph nodes following pCR (ypT0) after preoperative CRT and total mesorectal excision.

METHOD

The outcome and treatment details of 211 patients undergoing preoperative CRT for clinically staged T3-T4 unresectable rectal adenocarcinomas between 1993 and 2003 at Mount Vernon Hospital were reviewed.

RESULTS

Data were recorded from the 143 patients who completed treatment with a median follow-up of 25 months. Twenty-three patients (18%) were found to have had a pCR. Four out of 23 patients (17%) had involved lymph nodes. No pelvic recurrences developed after a ypCR. Overall survival was similar for patients with ypT0 or residual tumour.

CONCLUSION

Pathological complete response in the primary tumour failed to predict a response in the perirectal lymph nodes (p=0.08). The degree of response predicted a lymph node response (p=0.02). The detection of ypCR identified patients with a low rate of pelvic recurrence. This may in the future allow selection of patients for whom local excision can be performed without a higher risk of local relapse.

Endoscopic ultrasonography and magnetic resonance in preoperative staging of rectal cancer: comparison with histologic findings

The development of new surgical techniques and use of neoadjuvant therapy have increased the need for accurate preoperative staging of rectal cancer. We compared the ability of endoscopic ultrasonography (EUS) and two magnetic resonance imaging (MRI) coils to locally stage rectal carcinoma before surgery. Forty-nine patients with histologically proven rectal carcinoma were T and N staged by EUS and either body coil MRI or phased-array coil MRI. After radical surgery, the preoperative findings were compared with histologic findings on the surgical specimen. For T stage, accuracies were 70% for EUS, 43% for body coil MRI, and 71% for phased-array coil MRI. For N stage, accuracies were 63% for EUS, 64% for body coil MRI, and 76% for phased-array coil MRI. For T stage, EUS had the best sensitivity (80%) and the same specificity (67%) as phased-array coil MRI. For N stage, phased-array coil MRI had the best sensitivity (63%) and the same specificity (80%) as the other methods. EUS and phased-array coil MRI provided similar results for assessing T stage. No method provided satisfactory assessments of local N stage, although phased-array coil MRI was marginally better in assessing this important parameter. Although none of the results differed significantly, phased-array coil MRI seems to be the best single method for the preoperative staging of rectal cancer.

Minimally invasive surgery for early lower GI cancer

Two technical developments in colorectal surgery-i.e. transanal endoscopic microsurgery (TEM) and laparoscopic surgery for colorectal disease-are now available for the treatment of early lower GI cancer. Benign lesions and early-stage tumours of the rectosigmoid are amenable for a transanal approach. Transanal endoscopic microsurgery is performed using a rectoscope 4 cm in diameter with a four-port insert. After installation of a pneumorectum, lesions up to 25 cm from the anal verge, including circumferential lesions, can be removed with a recurrence rate of 0-5% for adenomas, 3% for low-risk T1 carcinomas, and 8% for all carcinomas. Laparoscopic-assisted colonoscopic polypectomy, laparoscopic wedge resection or laparoscopic-assisted colostomy have a 67-100% success rate for avoiding a formal bowel resection for benign tumours that cannot be treated by colonoscopy alone. Early colonic cancer requires laparoscopic colectomy guided by preoperative colonoscopy or preoperative endoscopic tattooing for localisation of the affected segment.

T1 adenocarcinoma of the rectum: transanal excision or radical surgery?

BACKGROUND

Recent studies suggest local excision may be acceptable treatment of T1 adenocarcinoma of the rectum, but there is little comparative data with radical surgery to assess outcomes and quantify risk. We performed a retrospective evaluation of patients with T1 rectal cancers treated by either transanal excision or radical resection at our institution to assess patient selection, cancer recurrence, and survival.

METHODS

All patients who underwent surgery for T1 adenocarcinomas of the rectum (0-15 cm from anal verge) by either transanal excision (TAE) or radical resection (RAD) between January 1987 and January 2004 were identified from a prospective database. Data were analyzed using Fisher exact test, Kaplan-Meier method, and log-rank test.

RESULTS

Three hundred nineteen consecutive patients with T1 lesions were treated by transanal excision (n = 151) or radical surgery (n = 168) over the 17-year period. RAD surgery was associated with higher tumor location in the rectum, slightly larger tumor size, a similar rate of adverse histology, and a lymph node metastasis rate of 18%. Despite these features, patients who underwent RAD surgery had fewer local recurrences, fewer distant recurrences, and significantly better recurrence-free survival (P = 0.0001). Overall and disease-specific survival was similar for RAD and TAE groups.

CONCLUSION

Despite a similar risk profile in the 2 surgical groups, patients with T1 rectal cancer treated by local excision were observed to have a 3- to 5-fold higher risk of tumor recurrence compared with patients treated by radical surgery. Local excision should be reserved for low-risk cancers in patients who will accept an increased risk of tumor recurrence, prolonged surveillance, and possible need for aggressive salvage surgery. Radical resection is the more definitive surgical treatment of T1 rectal cancers.

Contemporary Applications of Transanal Endoscopic Microsurgery: Technical Innovations and Limitations

PURPOSE

Transanal endoscopic microsurgery (TEM) is a minimally invasive procedure used to transanally excise select benign and malignant tumors of the rectum. In properly selected patients, TEM can provide for decreased postoperative morbidity without compromising oncologic outcome. This report summarizes the recent literature concerning TEM, comprehensively analyzes the authors' experience with TEM, and describes recent technical innovations and indications.

PATIENTS AND METHODS

Thirty-two consecutive patients scheduled for TEM were identified from our prospectively maintained colorectal service database. Clinicopathologic factors, postoperative complications, and oncologic outcomes were analyzed for all patients. In addition, a PubMed literature search was performed with use of the key words "transanal endoscopic microsurgery," "TEM," "rectal tumor," and "rectal cancer."

RESULTS

Transanal endoscopic microsurgery was performed for rectal adenocarcinoma (n = 17; 53%), adenoma (n = 12; 38%), and carcinoid tumors (n = 3; 9%). Median tumor location was 9 cm from the anal verge (range, 3-15 cm). Of the 32 attempted TEM procedures, 27 (84%) were completed. Reasons for inability to complete TEM included narrow rectal lumen or contour of bony pelvis prohibiting passage of the operating proctoscope into the upper rectum and inability to maintain the proctoscope in the rectal lumen with carbon dioxide insufflation because of the distal location of the tumor. Innovations used in the excision of rectal tumors via TEM included the use of the harmonic scalpel, closure of the rectal defect with an extracorporeal slip knot, and a hybrid approach incorporating TEM and traditional transanal techniques.

CONCLUSION

Transanal endoscopic microsurgery provides for low morbidity and does not appear to impair oncologic outcome in properly selected patients.

Tumor budding and evidence-based treatment of T2 rectal carcinomas

BACKGROUND

The validity of the histological criteria in deciding additional bowel resection after local excision of T2 rectal carcinomas is questioned.

METHODOLOGY

In 72 T2 colorectal carcinomas resected by major surgery, the associations between lymph node metastasis (LNM) and clinicopathologic parameters were examined statistically, a prediction formula for LNM was constructed and decision analysis was attempted.

RESULTS

Multivariate analysis showed that female gender and a greater number of tumor budding were significantly associated with LNM. The probability of LNM can be calculated as follows; Z = 0.037 x (budding number) + 2.08 x (SEX; male, 1; female, 2) - 5.736; Probability = 1/1 + e(-Z). When a 75-year-old patient has pulmonary complications, the operative risk is assumed to be over 2%. If a number of tumor budding is 0, the risk of LNM is calculated as 2.4% in a male and 17.1% in a female patient. On the assumption that the risk of liver metastasis is half of that of LNM, and the salvageabilities after LNM and liver metastasis are 20% and 50%, respectively, observation policy is justified for a male patient, whereas additional surgery should be undertaken for a female patient.

CONCLUSIONS

A number of tumor budding may be useful for determining the individualized treatment of T2 rectal carcinomas.

Advances in Treatment of Colorectal Cancer

The purpose of this review is to provide the practicing surgeon with an outline of several significant developments in colorectal cancer treatment that have affected the care of patients. This review is not intended to report on every important publication of the past few years nor is it intended to be encyclopedic. The author simply hopes to provide a useful reference for surgeons in their daily practice.

Transanal excision vs. major surgery for T1 rectal cancer

PURPOSE

The purpose of this national study was to examine the long-term results of transanal excision compared with major surgery of T1 rectal cancer.

METHODS

This prospective study from the Norwegian Rectal Cancer Project included all 291 patients with a T1M0 tumor within 15 cm from the anal verge treated by anterior resection, abdominoperineal resection, Hartmann's procedure, or transanal excision in the period from November 1993 to December 1999.

RESULTS

Two hundred fifty-six patients were treated by major surgery and 35 patients by transanal excision. None of the patients had neoadjuvant therapy. Macroscopic tumor remnants (R2) occurred in 17 percent (6/35) of the transanal excisions, while major surgery obtained 100 percent R0 resections. Eleven percent of the patients treated with major surgery had glandular involvement. There were no significant differences according to tumor localization, size, or differentiation between Stage I and Stage III tumors. Patients treated with transanal excision were older than patients having major surgery (mean age, 77 vs. 68 years, P < 0.001). After curative resection (R0, R1, Rx) the five-year rate of local recurrence was 12 percent (95 percent confidence interval, 0-24) in the transanal excision group compared with 6 percent (95 percent confidence interval, 2-10) after major surgery (P = 0.010). The overall five-year survival was 70 percent (95 percent confidence interval, 52-88) in the transanal excision group compared with 80 percent (95 percent confidence interval, 74-85) in the major surgery group (P = 0.04) and the five-year disease-free survival was 64 percent (95 percent confidence interval, 46-82) in the transanal excision group compared with 77 percent (95 percent confidence interval, 71-83) in the major surgery group (P = 0.01).

CONCLUSIONS

The main problem of transanal excision for early rectal cancer in the present study was the inability to remove all the malignancy. Patients treated with transanal excision had significantly higher rates of local recurrence compared with patients who underwent major surgery. Patients who had transanal excision had inferior survival, but they were older than those who had major surgery.

Surgical salvage of recurrent rectal cancer after transanal excision

PURPOSE

This study examines surgical salvage of locally recurrent rectal cancer following transanal excision of early tumors.

METHODS

Through retrospective review of a colorectal database we identified 50 patients who underwent attempted surgical salvage for local recurrence following initial transanal excision of T1 or T2 rectal cancer. Eight patients had resectable synchronous distant disease. Clinicopathologic variables were associated with extent of surgery required for salvage and outcome.

RESULTS

Salvage procedures included abdominoperineal resection (31), low anterior resection (11), total pelvic exenteration (4), and transanal excision (3). One patient had unresectable disease at exploration, requiring diverting ostomy. Of the 49 patients who underwent successful salvage, 27 (55 percent) required an extended pelvic dissection with en bloc resection of one or more of the following structures: pelvic sidewall and autonomic nerves (18); coccyx or portion of sacrum (6); prostate (5); seminal vesicle (5); bladder (4); portion of the vagina (3); ureter (2); ovary (1); and uterus (1). Complete pathologic resection (R0) was accomplished in 47 of 49 patients. Of the eight patients with distant and local recurrence, two underwent synchronous resection and six had delayed metastasectomy. With a median follow-up of 33 months, 29 patients had recurred or died of disease at the time of this analysis. Five-year disease-specific survival was 53 percent. Factors predictive of survival included evidence of any mucosal recurrence on endoscopy, low presalvage carcinoembryonic antigen, and absence of poor pathologic features (lymphovascular and perineural invasion). Patients who required an extended pelvic resection had a worse survival rate.

CONCLUSION

Pelvic recurrence following transanal excision of early rectal cancer is often locally advanced, requiring an extended pelvic dissection with en bloc resection of adjacent pelvic organs to achieve salvage. The long-term outcome in patients undergoing resection is less than expected, considering the early stage of their initial disease. When contemplating local excision for early rectal cancer, the risk of local recurrence, the extent and morbidity of surgery required for salvage, and the modest cure rate following salvage should be considered.

Is local excision of T2/T3 rectal cancers adequate?

In selected patients, local excision of rectal cancer may be an alternative to radical surgery such as abdominoperineal excision of the rectum or anterior resection. Local excision carries lower mortality and morbidity, without the functional disturbance or alteration in body image that can be associated with radical surgery. There are several techniques of local therapy for rectal cancer, with most experience being available in transanal excision. Transanal endoscopic microsurgery is also used but experience with this newer technique is limited. Patient selection is the most important factor in successful local excision; however, specific criteria for selecting patients have not been universally accepted. Review of the published literature is difficult because of the variation in adjuvant therapy regimes and follow-up strategies, as well as results reported in terms of local recurrence and survival rates. There is increasing evidence to suggest that local excision should be restricted to patients with T1-stage rectal cancer without high-risk factors. The place for local excision in patients with T2 or high-risk T1 tumours requires prospective, randomised multicentre trials comparing radical surgery with local excision, with or without adjuvant therapy. Local excision for T3 tumours should be restricted to the palliative setting or patients unfit for radical surgery.

The management of rectal cancer in the elderly

INTRODUCTION

The majority of patients with rectal cancer are elderly. Due to the increasingly aging population the number of people with colorectal cancer is increasing. As medical advances in the areas of local therapy, radiation therapy, and surgical technique, such as, laparoscopy are made more elderly patients are offered various types of treatment for rectal cancer. As the number of treatment options increase, the debate on how to treat elderly patients' with rectal cancer intensifies.

METHODS

A Medline search using "rectal cancer," "elderly," "local therapy," "radical surgery," and "radiation therapy" as key words was performed for English-language articles. Further references were obtained through cross-referencing the bibliography cited in each work.

DISCUSSION

Numerous treatment options exists for elderly patients with rectal cancer. These range from transanal local excision to radical surgery. The best treatment option for a certain elderly patient is multifactorial and includes tumor stage, operative curability, preoperative functioning of the patient, patient comorbidities, quality of life goals, and patient preference.

CONCLUSION

Age, taken as an independent variable, is not a contraindication to any specific type of therapy, including radical surgery with primary anastomsis. Patients' who meet the criteria for local resection should undergo this procedure. However, for tumors which are not amenable to local resection, these patients should be considered for radical surgery if this provides the best chance for cure. Elderly patients who can tolerate a major operation, and have good preoperative sphincter function should undergo a resection with primary anastomosis.

Recurrence after transanal excision of T1 rectal cancer: should we be concerned?

PURPOSE

Transanal excision is an appealing treatment for low rectal cancers because of its low morbidity, mortality, and better functional results than transabdominal procedures. However, controversy exists about whether it compromises the potential for cure. Several, recent reports of high recurrence rates after local excision prompted us to review our results of transanal excision alone in patients with T1 rectal cancers.

METHODS

All patients with T1 low rectal cancer undergoing local excision alone between 1980 through 1998 were reviewed for local recurrence, distant metastasis, disease-free interval, results of salvage surgery, and overall and disease-free survival. Demographics, tumor size, distance from anal verge, and preoperative endoluminal ultrasound results also were recorded. Patients with poorly differentiated tumors, perineural or lymphovascular invasion, or with mucinous component were excluded.

RESULTS

Fifty-two patients underwent transanal excision during the study period. Five-year recurrence was estimated to be 29.38 percent (95 percent confidence interval, 15.39-43.48). For 52 patients, five-year, cancer-specific and overall survival rates were 89 and 75 percent respectively. Fourteen of 15 patients with recurrence underwent salvage treatment with 56.2 percent (95 percent confidence interval, 35.2-90) five-year survival rate. Gender, preoperative staging by endorectal ultrasound, distance from the anal verge, tumor size, location, and T1 status discovered after transanal excision of a villous adenoma did not influence local recurrence or tumor-specific survival.

CONCLUSIONS

Transanal excision for T1 rectal tumors with low-grade malignancy has a high rate of recurrence. Although overall cancer survival rates might be regarded as satisfactory, this high recurrence and low salvage rate raises the issue about the role of transanal excision alone for early rectal cancer and the possible need for adjuvant therapy or increased role of resective surgery.

Transanale endoskopische Mikrochirurgie beim pT1-Low-risk-Rektumkarzinom

BACKGROUND

The association between submucosal infiltration and tumor recurrence was analyzed by long-term follow-up of patients with pT1 "low risk" rectal carcinoma.

PATIENTS AND METHODS

Forty patients with pT1 rectal cancer of the upper and middle rectum were treated by transanal endoscopic microsurgery. All carcinomas fulfilled the low-risk criteria, and were completely resected. No further treatment was carried out. Follow-up data were available for all 40 patients, with a median follow-up of 5.4 years.

RESULTS

Two patients (5.0%) developed local tumor recurrence after 14 and 18 months, respectively, and had curative rectal resection after neoadjuvant radiochemotherapy. In the histology of the initial specimens, both patients had deep submucosal infiltration (sm3). Another patient, primarily sm2 without local recurrence, developed a metachronous singular liver metastasis which was curatively resected. The risk of developing a recurrent tumor was significant for sm3 carcinomas (sm1+sm2 vs sm3, P=0.046).

CONCLUSION

Transanal endoscopic microsurgery is an excellent method of treating low-risk pT1 carcinomas of the rectum. Deep submucosal infiltration (sm3) seems to be an additional high-risk factor for developing local recurrence.

Preoperative evaluation and postoperative follow-up for patients with rectal cancer

Rectal cancer has a wide variety of presentations. In most cases, it is the surgeon who is faced with the challenge of determining the extent of disease and advising the patient how to proceed with treatment. Utilizing diagnostic tests of the highest accuracy and relevance will help in the selection of the best initial therapy, which is critical for achieving the highest cure rate while also avoiding over-treatment and unnecessary morbidity. Following curative treatment, surveillance testing for detection of recurrence is traditionally done, but the efficacy of this practice has been questioned. Surveillance will detect a number of asymptomatic recurrences that are treatable by potentially curative salvage surgery, but to what extent early detection improves salvage therapy is not well established. In this brief review, the goals, methods, and expected benefits of rectal cancer staging and surveillance are assessed.

Immediate radical resection after local excision of rectal cancer: an oncologic compromise?

PURPOSE

Local excision for early-staged rectal cancers is controversial. Preoperative understaging is not uncommon and radical resection after local resection may be needed for a curative treatment. The aim of this study was to determine the frequency and outcome of radical resection (within 30 days) after local excision for rectal adenocarcinoma.

METHODS

All locally excised rectal cancers (curative intent) that required radical surgery within 30 days were reviewed (1980-2000). T2-3N0-1 stage cancers were each matched to three primary radical surgery controls for stage, age (+/- 5 years), gender, date (+/- 1 years), and type (abdominoperineal resection or low anterior resection) of operation. T1N0-1 cancers were compared with stage-matched rectal cancers treated by either primary radical surgery (n = 78) or local excision alone (n = 77).

RESULTS

Fifty-two locally excised rectal adenocarcinomas (29 transanal and 23 polypectomies) were followed by radical surgery (24 abdominoperineal resection and 28 low anterior resection) within 7 (range, 1-29) days. Radical surgery was performed because of a cancerous polyp (n = 42), positive margins (5), lymphovascular invasion (3), and T3-staged cancer (2). Twelve of 52 cancers (23 percent) were found to have nodal involvement and 15 of 52 (29 percent) showed residual cancer in the resected specimen. The T2-3N0-1 stage controls were well matched. No significant difference in tumor location, size, adjuvant therapy, or length of follow-up was noted. Local and distant recurrence occurred in 2 of 4 T2-3N1 tumors and in 2 of 11 T2-3N0 cancers and were comparable to the matched controls, as was survival, with the exception of shorter survival in T3N1 cases, but numbers were too small for a definitive conclusion. Length of follow-up was not different. For T1 cancers, the controls were also comparable regarding patient and tumor demographics and adjuvant therapy. Nodal involvement was 21 percent in T1 study cases and 15 percent in T1 primary radical-surgery controls, with a trend toward location in the lower third of the rectum in both groups (58 percent and 50 percent, respectively). Local recurrence rates were 3 percent in the study group, 5 percent for patients undergoing primary radical surgery, and 8 percent for local excision alone. Distant metastasis (11 percent, 12 percent, and 13 percent, respectively) and overall five-year survival were also not significantly different (78 percent, 89 percent, and 73 percent, respectively).

CONCLUSIONS

Nodal involvement in attempted locally excised rectal cancers is not uncommon. Local excision of rectal tumors followed by radical surgery within 30 days in cancer patients does not compromise outcome compared with primary radical surgery. Even after radical surgery for superficial T1 rectal cancers, recurrence rates are not insignificant. Future improvements in preoperative staging may be helpful in selecting tumors for local excision only.

Long-Term Results of Local Excision with and Without Chemoradiation for Adenocarcinoma of the Rectum

The role of local excision for rectal carcinoma remains controversial. We reviewed 285 patients undergoing curative resection for rectal cancer between 1984 and 2001. Surgical procedures were local excision (LE; n = 49), abdominoperineal resection (APR; n = 124), and low anterior resection (LAR; n = 112). Median follow-up for all patients was 6.2 years. For patients undergoing local excision, postoperative tumor stages were Tis (22%), T1 (41%), T2 (18%), and T3 (18%). Twelve patients received postoperative radiation >/= 45 Gy, and 4 patients received adjuvant chemotherapy. Of the 49 patients who underwent LE, the 5- and 10-year overall survival rates were 76% and 42%, respectively. The 5- and 10-year disease-free survival rates were 69% and 58%, respectively. The incidence of local recurrence was 16% and the incidence of distant recurrence was 6%. For the 11 patients who experienced disease recurrence, the median time to recurrence was 13 months (range, 1-59 months). Of the 8 patients who developed local recurrence, 4 refused salvage treatment, 2 underwent salvage APR, and 2 underwent repeat excision. Of the 4 who underwent salvage surgery, one is alive with no evidence of disease, one developed distant disease, and 2 died with unknown disease status. Adjuvant therapy did not affect survival or recurrence rates in patients undergoing LE compared with other surgeries. The rate of local failure (16%) is comparable to that observed in the Cancer and Leukemia Group B (CALGB) 8984 prospective study and suggests that highly selected patients undergoing local excision can expect good local control of rectal cancer.

Outcome of salvage abdominoperineal resection after failed endocavitary radiation in patients with rectal cancer

PURPOSE

Endocavitary radiation is a treatment option for selected patients with rectal cancer, but concern exists for the effectiveness of salvage abdominoperineal resection. This study was designed to examine outcomes after salvage abdominoperineal resection for recurrence after endocavitary radiation.

METHODS

A prospective database was used to identify patients undergoing abdominoperineal resection after endocavitary radiation from 1985 to 2001. Office records and a tumor registry were used for disease status and survival data. Survival was calculated using the Kaplan-Meier method and groups compared using the Mantel-Haenszel test.

RESULTS

Thirty-eight patients underwent salvage abdominoperineal resection. The mean time to recurrence after completion of endocavitary radiation was 21 +/- 27 months, with 29 percent having persistent disease, 63 percent recurrent disease, and 8 percent a second primary. At abdominoperineal resection, 47 percent had tumor transection, specimen perforation, or injury to the genitourinary or gynecologic tract. Nine patients (24 percent) had positive radial margins. The mean time to perineal wound healing was 56 +/- 74.1 days postoperatively, with 36.8 percent taking more than 60 days. Seventeen patients (45 percent) re-recurred at a mean of 21 +/- 25 months after salvage, with a local control rate of 26 percent at 45 +/- 37 months of follow-up. Median disease-specific survival from completion of endocavitary radiation was 115.5 months, with a five-year, disease-specific survival rate of 66 percent. Patients with recurrent disease after endocavitary radiation had significantly (P = 0.025) better disease-specific survival than those with persistent disease (median survival 115 vs. 25 months).

CONCLUSIONS

Although technically difficult and associated with a high morbidity, abdominoperineal resection can salvage a significant fraction (55 percent) of patients failing endocavitary radiation. A high index of suspicion for recurrence and a tenacious approach to its diagnosis are essential for optimal outcomes.

Lymph node metastasis in T1 adenocarcinoma of the colon and rectum

The biology of colorectal cancer differs according to location within the large intestine. To evaluate the clinical significance of tumor location as a risk factor for lymph node metastasis (LNM), we performed a detailed pathological review of T1 adenocarcinomas of the colon and rectum. T1 adenocarcinomas of the colon and rectum treated by radical resection (n=428) were identified from prospective clinical databases at two institutions. Tumor location was assigned as right colon (cecum to transverse), left colon (splenic flexure to sigmoid), or rectum (0-18 cm from AV). Pathology slides were reviewed, extent of submucosal invasion (sm width, sm depth) was quantified using an optical micrometer, and morphologic features of the cancer and its infiltrating margin were recorded. The overall rate of LNM was 10%. On univariate analysis, LNM was significantly more common in the rectum (27/176, 15%) compared to the left colon (13/160, 8%, p=.04) or right colon (3/92, 3%, p=.003). However, on multivariate analysis, deep submucosal invasion and lymphovascular invasion were independent and significant risk factors, whereas tumor location was not. T1 colorectal cancers have a progressively higher risk of LNM as their location becomes more distal. However, the increasing rate of LNM observed in cancers of the left colon and rectum is explained by a higher prevalence of high-risk pathologic features. In early colorectal cancers, tumor morphology is the strongest clinical predictor of metastatic behavior.