Role of local excision in the treatment of rectal cancer

Does transanal local resection increase morbidity for subsequent total mesorectal excision for early rectal cancer?

AIM

Local excision is recommended for early rectal cancer (pT1). Complementary total mesorectal excision (cTME) is warranted when bad pathological features are present. The impact of a prior local resection on the outcome remains unclear. The aim of this study was to assess if prior local excision increases the morbidity of a subsequent cTME compared with primary TME.

METHODS

From 2001 to 2016 all patients who underwent TME after local excision for rectal adenocarcinoma were studied. All were matched (1:1) with patients who underwent primary TME, without neoadjuvant radiochemotherapy. The matching factors included age, sex, body mass index, American Society of Anesthesiologists score and type of surgery. Short-term morbidity and pathological examination of the resected specimen were compared.

RESULTS

Forty-one patients were included (14 women, 34%, mean age 65 ± 11 years), comprising classic transanal excision (66%) and transanal endoscopic microsurgery (34%), and were matched to 41 patients who had primary TME. cTME was significantly longer (315 min ± 87 vs 275 min ± 58, P = 0.03). The overall morbidity was 48.8% in the local excision group vs 31.7% in the control group (P = 0.18). Surgical morbidity was 31.7% vs 26.8% (P = 0.8). Anastomotic related morbidity was similar (local excision 17% vs TME 14.6%, P = 0.84) and the mean length of stay was similar (14 days) in both groups. There was a tendency to a worse quality of mesorectal excision in the cTME group (17% vs 5%, P = 0.15).

CONCLUSION

Local excision prior to TME for early rectal cancer tends to increase overall morbidity and may worsen the quality of the mesorectal plane but should be considered as a surgical approach in select cases.

Does a learning curve exist in endorectal two-dimensional ultrasound accuracy?

BACKGROUND

Aim of the study was to assess adequacy of Colorectal Surgical Society of Australia and New Zealand (CSSANZ) endorectal ultrasound (ERUS) training and whether a subsequent learning curve exists.

METHODS

A prospective audit of ERUS for staging rectal cancer by a single surgeon from commencement of consultant practice was performed. Data were recorded in a prospectively maintained database. The audit commenced on completion of CSSANZ training. T- and N-stage were assessed clinically, then by ERUS prior to treatment and finally by histology over 8 years.

RESULTS

The results were compared over three time periods: the first a single year, then two three-year periods. Two hundred and seventy-two patients were examined. Two hundred and thirty-three were assessable for T-stage (13 no tumour excision, 26 long course pre-operative radiotherapy) and 142 for N-stage (74 endoanal excision, 17 proximal mesorectum un-assessable). Overall accuracy was 82% for T-stage and 73% for N-stage. Accuracy for T- and N-staging did not change significantly over the three time periods (T: 82.1, 82.3, 81.6%, P = 0.14; N: 83.3, 67.9, 74.2%, P = 0.31). The utility of ERUS was demonstrated by clinical assessment not being possible in 32% of cases and where the two modalities disagreed was correct 82% of the time.

CONCLUSIONS

Endorectal ultrasound rectal cancer staging is accurate for T-stage. Competency in ERUS can be achieved in the CSSANZ fellowship and accuracy does not improve with further experience. An ERUS accreditation scheme should be established for future trainees.

Anal neoplasms

A variety of lesions comprise tumors of the anal canal, with carcinoma in situ and epidermoid cancers being the most common. Less common anal neoplasms include adenocarcinoma, melanoma, gastrointestinal stromal cell tumors, neuroendocrine tumors, and Buschke-Lowenstein tumors. Treatment strategies are based on anatomic location and histopathology. In this article different tumors and management of each, including a brief review of local excision for rectal cancer, are discussed in turn.

Transanal endoscopic microsurgery resection of rectal tumors: outcomes and recommendations

PURPOSE

Transanal endoscopic microsurgery provides a minimally invasive alternative to radical surgery for excision of benign and malignant rectal tumors. The purpose of this study was to review our experience with transanal endoscopic microsurgery to clarify its role in the treatment of different types of rectal pathology.

METHODS

A prospective database documented all patients undergoing transanal endoscopic microsurgery from October 1996 through June 2008. We analyzed patient and operative factors, complications, and tumor recurrence. For recurrence analysis, we excluded patients with fewer than 6 months of follow-up, previous excisions, known metastases at initial presentation, and those who underwent immediate radical resection following transanal endoscopic microsurgery.

RESULTS

Two hundred sixty-nine patients underwent transanal endoscopic microsurgery for benign (n = 158) and malignant (n = 111) tumors. Procedure-related complications (21%) included urinary retention (10.8%), fecal incontinence (4.1%), fever (3.8%), suture line dehiscence (1.5%), and bleeding (1.5%). Local recurrence rates for 121 benign and 83 malignant tumors were 5% for adenomas, 9.8% for T1 adenocarcinoma, 23.5% for T2 adenocarcinoma, 100% for T3 adenocarcinoma, and 0% for carcinoid tumors. All 6 (100%) recurrent adenomas were retreated with endoscopic techniques, and 8 of 17 (47%) recurrent adenocarcinomas underwent salvage procedures with curative intent.

CONCLUSIONS

Transanal endoscopic microsurgery is a safe and effective method for excision of benign and malignant rectal tumors. Transanal endoscopic microsurgery can be offered for (1) curative resection of benign tumors, carcinoid tumors, and select T1 adenocarcinomas, (2) histopathologic staging in indeterminate cases, and (3) palliative resection in patients medically unfit or unwilling to undergo radical resection.

Transanal endoscopic operation: a new proposal

PURPOSE

The transanal procedure for rectal cancer surgery is one of the many techniques currently available. Different techniques for local excision of rectal tumors include: conventional transanal technique, posterior access surgery, therapeutic colonoscopy, transanal endoscopic surgery.

METHODS

The aim of the present study is to describe a new method of transanal endoscopic resection, transanal endoscopic operation (TEO), and performed with the aid of a surgical proctoscope especially designed for this purpose and report the results obtained in 32 patients submitted to the TEO and to compare these results with those obtained with other techniques currently available. The average proportions of recurrence, post-operation complications and posterior resections were analyzed by means of a metanalysis. Data on the distance and size of rectal lesions, the operative timing and hospitalization time were distributed in graphs according to authors and techniques.

RESULTS

The results were favorable and equivalent to those described in the literature.

CONCLUSIONS

The surgical proctoscope specially designed for this study is efficient and has a low cost; the TEO is easily performed with the aid of this equipment; the final results were favorable and similar to those obtained with other available techniques for endoscopic transanal intestinal resection, which are of high cost and less availability.

Prognostic factors for 5-year survival after local excision of rectal cancer

AIM: To evaluate the prognostic factors for 5-year survival after local excision of rectal cancer, and to examine the therapeutic efficacy and surgical indications for this procedure.

METHODS: Clinical data, obtained from 106 local rectal cancer excisions performed between January 1980 and December 2005, were retrospectively analyzed. Survival analysis was performed using the Kaplan-Meier method, statistical comparisons were performed using the log-rank test, and multivariate analysis was performed using the Cox proportional hazards model.

RESULTS: Transanal, transsacral, and transvaginal excisions were performed in 92, 12, and 2 cases, respectively. The rate of complication, local recurrence, and 5-year survival was 6.6%, 17.0%, and 86.7%, respectively. Univariate analysis showed that T stage, vascular invasion, and local recurrence were related to the prognosis of the cases (P < 0.05). Multivariate analysis showed that T stage [P = 0.011, 95% confidence interval (CI) = 1.194-3.878] and local recurrence (P = 0.022, 95% CI = 1.194-10.160) were the major prognostic factors for 5-year survival of cases after local excision of rectal cancer.

CONCLUSION: Local rectal cancer excision is associated with few complications, and suitable for stages Tis and T1 rectal cancer. Prevention of local recurrence, active postoperative follow-up, and administration of salvage therapy are the effective methods to increase the efficacy of local excision of rectal cancer.

Brachytherapy and local excision for sphincter preservation in T1 and T2 rectal cancer

PURPOSE

To report long-term results of brachytherapy after local excision (LE) in the treatment of T1 and T2 rectal cancer at risk of recurrence due to residual subclinical disease.

METHODS AND MATERIALS

Between 1989 and 2007, 32 patients undergoing LE and brachytherapy were followed prospectively for a mean of 6.2 years. Estimates of local recurrence (LR), disease-specific survival (DSS), and overall survival (OS) were generated. Treatment-related toxicity and the effect of known prognostic factors were determined.

RESULTS

There were 8 LR (3 T1, 5 T2), of which 5 were salvaged surgically. Median time to the 8 LR was 14 months, and the 5-year rate of local control was 76%. Although there have been 9 deaths to date, only 5 were from disease. Five-year DSS and OS rates were 85% and 78%, respectively. There were 4 cases of Grade 2-3 radionecrosis and 1 case of mild stool incontinence. The sphincter was preserved in 27 of 32 patients.

CONCLUSION

Local excision and adjuvant brachytherapy for T1 and T2 rectal cancer is an appealing treatment alternative to immediate radical resection, particularly in the frail and elderly who are unable to undergo major surgery, as well as for patients wanting to avoid a permanent colostomy.

A new proctoscope for transanal endoscopic operations

Transanal access is one of many currently used procedures for rectal cancer treatment. The techniques used for local excision include conventional transanal excision, posterior access, therapeutic colonoscopy and transanal endoscopic approaches. The aim of the present study was to present a new surgical proctoscope for the endoscopic transanal excision of rectal lesions. A cylindrical proctoscope with a diameter of 4 cm was devised and built. The end inserted into the anus has a bevelled aspect and rounded borders, allowing correct exposure of the anal lesion. The rectoscope is fixed to the anal border with surgical thread through perforations in the external end. A base screw holds a fibre-light which illuminates the operative field. Part of the equipment is a guide which is positioned inside the rectoscope on insertion into the anus. In operations utilizing this proctoscope, 17 adenomas, 25 adenocarcinomas, 1 carcinoid and 1 endometrioma were excised. The diameter of the lesions varied from 1 to 6 cm. The range of procedures that are possible with this new proctoscope are similar to those achieved with conventional techniques which, however, require more expensive equipment. Hence, the present study demonstrates that this newly devised low-cost proctoscope is an efficient tool for the transanal endoscopic excision of rectal lesions.

Management of early rectal cancer

BACKGROUND

Early rectal cancer (ERC) is adenocarcinoma that has invaded into, but not extended beyond, the submucosa of the rectum (that is a T1 tumour). Local excision is curative for low-risk ERCs but for high-risk cancers such management is controversial.

METHODS

This review is based on published literature obtained by searching the PubMed and Cochrane databases, and the bibliographies of extracted articles.

RESULTS AND CONCLUSION

ERC presents as a focus of malignancy within an adenoma, as a polyp, or as a small ulcerating adenocarcinoma. Preoperative staging relies on endorectal ultrasonography and magnetic resonance imaging. Pathological staging uses the Haggitt and Kikuchi classifications for adenocarcinoma in pedunculated and sessile polyps respectively. Lymph node metastases increase with the Kikuchi level, with a 1-3 per cent risk for submucosal layer (Sm) 1, 8 per cent for Sm2 and 23 per cent for Sm3 lesions. Low-risk ERCs may be treated endoscopically or by a transanal procedure. Transanal excision or transanal endoscopic microsurgery may be inadequate for high-risk ERCs and adjuvant chemoradiotherapy may be appropriate. There is a low rate of recurrence after local surgery for low-risk ERCs but this increases to up to 29 per cent for high-risk cancers.

Radical surgery for early colorectal cancer--anachronism or oncologic necessity?

BACKGROUND AND AIMS

Because of their low morbidity and mortality, limited resection or local excision are accepted therapeutical approaches in early colorectal cancer treatment. Even though, recent publications report recurrence rates after local excision of rectal cancer in up to 30%. This prompted us to evaluate our data for T1N0 colorectal cancer treated by radical surgery regarding recurrence, morbidity, mortality, and survival rates.

MATERIALS AND METHODS

Clinical, histopathological, and surveillance data from our prospective "colorectal cancer database" from 1979 to 2005 were analyzed to evaluate outcome and prognosis of T1N0 colorectal cancer treated by radical surgery. Only curative resections were included in this study. All patients were followed in an internal surveillance program, which enabled us to prospectively assess morbidity, mortality, and survival. RESULTS A total of 105 T1N0 colon and 69 rectal carcinomas were included in the study. Overall morbidity was 25% (colon) and 34% (rectum). Thirty-day mortality was 1.9% (colon) and 4.3% (rectum). After a median follow-up of 92 and 87 month, no isolated local recurrence occurred. One patient developed both local recurrence and liver metastases. Distant metastases were seen in 4.9% (colon) and 7.5% (rectum). The 5- and 10-year overall survival was 86 and 71% (colon) and 82 and 68% (rectum), respectively.

CONCLUSION

Even if radical surgical approaches are associated with a higher rate of morbidity and mortality, our data show that radical surgery for T1N0 colorectal cancer results in excellent tumor control which is of paramount importance for the patients' prognosis and survival. Combining the data presented with those of the current literature suggests that local approaches to rectal cancer can be recommended for highly selected T1N0 tumors, in palliative situations, or if the patient is unfit for general surgery.

Can depth of tumour invasion predict lymph node positivity in patients undergoing resection for early rectal cancer? A comparative study between T1 and T2 cancers

OBJECTIVE

The present study investigated the risk of lymph node metastasis according to the depth of tumour invasion in patients undergoing resection for rectal cancer.

METHOD

The histology of patients undergoing oncological resection with regional lymphadenectomy for rectal cancer at St Marks Hospital from 1971 to 1996 was reviewed. Of the total number of 1549 patients, 303 patients with T(1) or T(2) rectal cancers were selected. The tumour type, grade, evidence of vascular invasion, depth of submucosal invasion (classed into 'sm1-3') were evaluated as potential predictors of lymph node positivity using univariate and multi-level logistic regression analysis.

RESULTS

Tumour stage was classified as T(1) in 55 (18.2%) and T(2) in 248 (81.2%) patients. The incidence of lymph node metastasis in the T(1) group was 12.7% (7/55), compared to 19% (47/247) in the T(2) group. The node positive and negative groups were similar with regard to patient demographics, although the former contained a significantly higher number of poorly differentiated (P = 0.001) and extramural vascular invasion tumours (P = 0.002). There was no significant difference in the number of patients with sm1-3, or T(2) tumour depths within the lymph node positive and negative groups. On multivariate analysis the presence of extramural vascular invasion (odds ratio = 10.0) and tumour grade (odds ratio for poorly vs well-differentiated = 11.7) were independent predictors of lymph node metastasis.

CONCLUSION

Whilst the degree of vascular invasion and poor differentiation of rectal tumours were significant risk factors for lymph node metastasis, depth of submucosal invasion was not. This has important implications for patients with superficial early rectal cancers in whom local excision is being considered.

Endoscopic posterior mesorectal resection as an option to combine local treatment of early stage rectal cancer with partial mesorectal lymphadenectomy

BACKGROUND AND AIMS

Low anterior resection and abdominoperineal resection with total mesorectal excision are the standard treatment in patients with low rectal cancer. Rectal resection remains a surgical intervention with considerable morbidity and long-term impairment of quality of life. Local excision of low rectal cancer is regarded as an alternative to radical surgery; however, occurrence of lymph node metastasis even in patients with highly differentiated early-stage rectal cancer may be underestimated.

PATIENTS AND RESULTS

In two patients with T1 rectal cancer, minimal-invasive partial excision of the mesorectum was performed after transanal excision of the tumor. The postoperative course was uneventful in both patients. Patients left the hospital on the fourth and fifth postoperative day without any complaints. In one patient, histo-pathological workup revealed a lymph node metastasis in the specimen.

DISCUSSION

The technique of "Endoscopic posterior mesorectal resection" represents an interesting option in the surgical treatment of rectal cancer, as it allows for the first time an organ preserving resection of local lymph nodes in the small pelvis. It may evolve as an efficient new staging procedure to identify patients with metastatic disease who may benefit from multimodal treatment or extended surgery.

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.

Transanal endoscopic microsurgery

TEM has been used effectively to treat large rectal polyps and early rectal malignancy for more than 20 years in Europe. Until recently, only a few specialized centers offered TEM in the United States, where it is now gaining popularity. Many hospitals have purchased equipment and are offering TEM; however, the equipment is expensive and the learning curve is steep. Therefore, it is essential that anyone performing TEM have an adequate number of cases to develop and maintain expertise in this technique. That being said, TEM remains unique when compared with laparoscopy and other minimally invasive techniques that incorporate less invasive methods of performing old operations. TEM allows surgeons to perform operations that were impossible before the development and acceptance of this technique.

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.

Is T classification still correlated with lymph node status after preoperative chemoradiotherapy for rectal cancer?

BACKGROUND

It is well known that the risk of lymph node involvement increases according to pathologic T classification in rectal cancers, but to the authors' knowledge, the correlation between risk of lymph node involvement and ypT classification in rectal cancers treated with preoperative chemoradiotherapy (CRT) remains unclear. The current study investigated the correlation between tumor involvement in regional lymph nodes and rectal mural tumor status in patients who underwent preoperative CRT for rectal cancer.

METHODS

Between October 2001 and February 2005, 282 patients underwent preoperative CRT followed by proctectomy for locally advanced rectal adenocarcinoma. Correlations between lymph node status and ypT classification, Dworak regression grade, and magnetic resonance (MR) volumetry findings were explored.

RESULTS

Lymph nodes harboring tumors were found in 87 of 282 (30.9%) patients. The rate of lymph node involvement was found to be correlated with ypT-classification (P < .001); positive lymph nodes were detected in 1 of 45 (2.2%) ypT0 patients, 1 of 13 (7.7%) ypT1 patients, 13 of 77 (16.9%) ypT2 patients, 69 of 140 (49.3%) ypT3 patients, and 3 of 7 (42.9%) ypT4 patients. The rate of lymph node involvement decreased as Dworak regression grade increased (P < .001); tumor-harboring lymph nodes were found in 62.3% of Grade 1 patients, 31.4% of Grade 2 patients, 16.1% of Grade 3 patients, and 2.2% of Grade 4 patients. There were no differences noted with regard to MR volumetry findings, including mean volume of pre- or post-CRT tumor and the tumor volume reduction rate between lymph node-negative and lymph node-positive patients.

CONCLUSIONS

Pathologic T classification is still the most reliable predictor of lymph node metastasis in rectal cancer patients who have undergone preoperative CRT. The risk of lymph node metastasis was found to be 3.4% in rectal cancer that had regressed to ypT0 or ypT1.

Endorectal ultrasound-directed biopsy: a useful technique to detect local recurrence of rectal cancer

AIMS

This study assesses the value of endorectal ultrasound (ERUS)-directed biopsy in detecting local recurrence of rectal cancer.

METHODS

We reviewed the records of patients undergoing ERUS by a single surgeon for surveillance after treatment of rectal adenocarcinoma. Lesions suggestive of local recurrence underwent ERUS-assisted core-needle biopsy (EAB) via a proctoscope after precise ERUS localization or direct ERUS-guided biopsy (EGB) via a B&K Medical probe.

RESULTS

From 1991 to 2003, 525 patients underwent 2,490 surveillance ERUS. Of these patients, 51 underwent 62 biopsy sessions: 36 EGB and 26 EAB. The mean age of patients was 67.2 years (range 38-93 years); 22 (43%) were female. Only 11 patients (22%) had undergone prior radical resection of their primary tumor. No patient experienced a complication from the biopsies despite five being anticoagulated. Of 39 patients whose cancer recurrence was documented during follow-up, 32 (82%) were diagnosed at the initial biopsy session, and in five (13%), recurrence was detected only with ERUS. The combined sensitivity, specificity, and accuracy of EAB and EGB in detecting recurrence was 83, 100, and 87%, respectively. In 26 patients with local recurrence, resection was performed with curative intent.

CONCLUSION

ERUS with biopsy is useful in detecting local recurrence after treatment of rectal cancer. It is safe, with a high diagnostic yield. It may be particularly useful in patients at higher risk for local recurrence (i.e., after endocavitary radiation and local excision) and may allow early detection of local recurrence, thereby permitting attempts at curative resection.

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.

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.

Endorectal ultrasound in the management of patients with malignant rectal polyps

PURPOSE

This study was designed to determine the efficacy of endorectal ultrasound in the management of patients with malignant rectal polyps removed by snare excision during colonoscopy.

METHODS

A retrospective review of the medical records and endorectal ultrasound images of 63 patients with endoscopically removed rectal polyps containing invasive adenocarcinoma subsequently staged by endorectal ultrasound. Patients underwent surgery or were followed at a single institution. The polyp characteristics and ultrasound images were compared with the presence of residual tumor in the surgical specimen in patients who underwent further surgery or with recurrence in patients who did not.

RESULTS

The morphology of the polyps was described in 31 patients (49 percent); they were sessile in 26 (41 percent) and pedunculated in 6 (9 percent). The margins were positive in 22 patients (35 percent), negative in 19 (30 percent), and not specified in 22 (35 percent). Most tumors were well or moderately differentiated; only 3 (5 percent) were poorly differentiated. Thirty-three patients underwent further surgery (3 low anterior resection, and 30 transanal excision); 30 had no further surgery. The accuracy of endorectal ultrasound in assessing the presence of residual cancer in the rectal wall in patients who had surgery was 54 percent, with a 39 percent positive predictive value and 65 percent negative predictive value. Endorectal ultrasound accurately identified metastatic lymph nodes in two of three patients who had radical surgery. Endorectal ultrasound was more useful than polyp morphologic or histologic criteria to determine the presence of residual cancer in the rectal wall.

CONCLUSIONS

Endorectal ultrasound does not definitely exclude the possibility of residual tumor in the rectal wall or mesenteric nodes of patients who had a malignant polyp snared endoscopically. Consequently, decisions regarding the definitive management of these patients cannot be based exclusively on the endorectal ultrasound images of the polypectomy site.

Changes in outcome with sphincter preserving surgery for rectal cancer in Korea, 1991-2000

AIM

To report the clinical and oncological data of patients operated on for rectal cancers 3-5 cm from the AV over a 10 year period, including the Sphincter preservation (SP) rate.

METHODS

We reviewed medical records of 304 patients with rectal cancers 3-5 cm from the AV who underwent surgical resection from January 1991 through December 2000. The 10 years were divided into three periods based on the introduction of new surgical techniques, specifically, ultralow anterior resection (ULAR) with double stapling in March 1994 and ULAR with coloanal anastomosis in April 1997. The rates of SP, complications and patient survival during these periods were compared.

RESULTS

The SP rate increased significantly over the 10 years, from 16.4% in period I (January 1991-February 1994), to 53.0% in period II (March 1994-March 1997), to 86.5% in period III (April 1997-December 2000) (p<0.001). Over time, the age of the patients increased (p=0.004), the length of the distal resection margin became shorter (p=0.005), and the rate of lymph node metastasis increased (p=0.016). The factors significantly influencing SP were the period (p<0.001) and the distance from the AV (p<0.001). Over time, morbidity did not increase, and overall and disease free survival rates did not decrease. In contrast, the overall survival of N2 cases significantly increased over time (p=0.0492).

CONCLUSION

Over 10 years, the SP rate in rectal cancers 3-5 cm from the AV was significantly increased by the introduction of the double stapling and coloanal anastomosis techniques. These surgical methods, however, had no effect on morbidity, disease free survival and overall survival rates.

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.

Long-term survival after local excision for T1 carcinoma of the rectum

PURPOSE

Many authors have reported high rates of local recurrence after local excision for early carcinoma of the rectum, which raises the question of whether oncologic resection gives better results. This study was designed to compare the long-term recurrence rate, long-term survival, and risk factors for T1 adenocarcinoma of the rectum treated with local excision or oncologic resection.

METHODS

We identified 144 patients who had T1 sessile adenocarcinoma in the lower third or middle third of the rectum. Patients who received adjuvant therapy or who had pedunculated lesions were excluded. Data included age, gender, size of lesion, histologic type of carcinoma, grade, presence of lymphovascular invasion, and depth of invasion. Outcomes were defined as five-year and ten-year cumulative probabilities of local recurrence, distant metastasis, overall survival, and cancer-free survival. The mean follow-up was 9.2 years; median follow-up was 8.1 years.

RESULTS

We compared 70 patients who underwent local excision with 74 patients who underwent oncologic resection. Among patients with lesions in the middle or lower third of the rectum, 1) the five-year and ten-year outcomes were significantly better for overall survival and cancer-free survival in the oncologic resection group, but there were no significant differences in local recurrence or distant metastasis; 2) the multivariate risk factors for long-term, cancer-free survival were invasion into the lower third of the submucosa, local excision, and older than aged 68 years; and 3) for lesions with invasion into the lower third of the submucosa, the oncologic resection group had lower rates of distant metastasis and better survival. Among patients with lesions in the lower third of the rectum, 1) the five-year and ten-year outcomes showed no significant differences in survival, local recurrence, or distant metastasis between the two groups; and 2) for lesions with invasion into the lower third of the submucosa, the oncologic resection group showed a trend of improved survival, which was not statistically significant, possibly because of low statistical power from the small sample size.

CONCLUSIONS

Patients who undergo local excision or oncologic resection for T1 carcinoma in the lower two-thirds of the rectum have a high incidence of local recurrence and distant metastasis. To improve the cure rate, the rate of recurrence must decrease. A randomized, controlled study is needed to determine whether adjuvant therapy may be beneficial.

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.

A current perspective on local excision of rectal cancer

Local excision of rectal cancer is appealing because of its technical ease and excellent functional results, but concern over inadequate pathologic staging and inferior treatment outcomes when compared with radical surgery remain a major hurdle for its widespread use. Local failure rates in modern series for local excision are 4%-18% for T1 rectal cancers and 22%-67% for T2 cancers, and cancer cure rates are only 70%-80%. In addition, data from the past decade suggest that preoperative staging with endorectal ultrasound, use of postoperative adjuvant chemotherapy/radiation therapy, and aggressive salvage surgery have not been reliable methods of limiting local tumor recurrence or improving long-term cure rates. At present, highly stringent criteria for patient selection are recommended, yet such stringency decreases the utility of the procedure. What are needed are new approaches to an old problem. Novel strategies under evaluation include enhanced imaging modalities for lymph node metastases, neoadjuvant chemotherapy/radiation therapy, and more liberal use of immediate salvage resection for high-risk pathologic features. Molecular profiling of tumors with genetic markers and better integration of traditional and gene-targeted systemic therapy are promising approaches for the future. This review of the literature evaluates the recent successes and failures of local excision of rectal cancer and provides a current perspective on the expanded use of local excision without compromising care.

Endorectal ultrasound detection of focal carcinoma within rectal adenomas

BACKGROUND

The misdiagnosis of a rectal adenoma by biopsy and subsequent finding of invasive cancer after transanal excision is associated with a number of pitfalls. Problems include suboptimal therapy for a potentially curable cancerous lesion, potential tumor transgression of the local site with increased chance for local recurrence, and increased potential for more radical surgery or adjuvant chemoradiation. The utility of endorectal ultrasound (ERUS) in guiding treatment decisions of rectal villous adenomas has been reported, but series are small and are from single institutions. To determine the utility of ERUS in the diagnosis of rectal adenomas, we compared diagnosis made by biopsy alone to diagnosis made by a combination of biopsy and ERUS.

METHODS

A systematic literature review was performed by way of a PubMed search to find articles with the following terms: "biopsy-negative rectal adenomas," "preoperative ERUS diagnosis," and "surgical histopathology." Five studies met the criteria, thus providing data for 258 adenomas. A quantitative meta-analysis was performed on the data.

RESULTS

Among the 258 biopsy-negative rectal adenomas, 24% had focal carcinoma on histopathology. ERUS correctly established a cancer diagnosis in 81% (95% confidence interval 69 to 90) of these misdiagnosed lesions. Thus, ERUS diagnosis of biopsy-negative rectal adenomas could be expected to decrease the need for additional surgery and other associated problems caused by misdiagnosis from 24% to 5%.

CONCLUSIONS

ERUS is a useful adjunct to biopsy in the preoperative workup of rectal villous adenomas, and we recommend its routine use. Accurate preoperative assessment allows the surgeon to counsel the patient appropriately regarding the best operation, the perioperative risks, and the chances of local recurrence.

Results of Long-Term Follow-Up for Transanal Excision for Rectal Cancer

Low anterior resection and abdominoperineal resection are the surgical techniques used most frequently in the treatment of rectal cancer. It is our hypothesis that selected patients with early T stage, well or moderate grade of differentiation, and small tumor size are good candidates for transanal excision in terms of minimal morbidity, low recurrence rate, and sphincter preservation. From January 1993 until August 2001 30 patients underwent transanal excision; three patients were excluded because they had histology other than adenocarcinoma. Factors analyzed included those related to the patient [age (years), gender, race, body mass index, and anal tone], tumor [size (cm), distance from the anal verge (cm), differentiation, and American Joint Committee on Cancer stage], and additional treatment. Median follow-up of the group was 40.7 months (range 0.6–99) and the primary end points were local and distant recurrence. Data are presented as mean (range). The median age of the group was 58.9 years (range 27–94); 52 per cent were female and 48 per cent were male. The mean body mass index was 25.9 (range 22.7–36.7). Preoperatively 81, 11, and 4 per cent of the patients had stage I, II, and III/IV cancer, respectively. Preoperative size of the tumor was 2.0 cm (1–3 cm), and distance from the anal verge was 5.0 cm (3–15 cm). Blood loss was 50 cm3 (5–200 cm3), and there were no operative complications. Tumor differentiation levels were well (37%) and moderate (63%). All patients had negative margins. Additional treatment consisted of radiation therapy in seven patients (six postoperative and one preoperative). Chemotherapy was given to seven patients (six postoperative and one preoperative). The local recurrence rate was 7.4 per cent (two patients), and 3.7 per cent recurred distantly (one patient). Transanal excision of low rectal cancer in selected patients is an acceptable alternative to formal resection. Important selection criteria include early T stage, well or moderate differentiation, relatively small tumor size, and negative microscopic margins. The roles of radiation and chemotherapy remain controversial.

Gasless, video endoscopic transanal excision for carcinoid and laterally spreading tumors of the rectum

BACKGROUND

The aim of this study is to determine whether gasless, video endoscopic transanal-rectal tumor excision (gasless VTEM) is a valid treatment for rectal carcinoid and laterally spreading tumors (LST).

METHODS

Eighty-four patients with an adenoma, adenocarcinoma (Tis/T1), or carcinoid tumor of the rectum were divided into three groups: (i) LST ( n = 17 patients), (ii) carcinoid ( n = 11), and (iii) control with other types of tumors ( n = 56).

RESULTS

The LST group had a longer median operating time than in the control group, whereas the carcinoid group had a shorter operating time. Two patients (11.7%) in LST group developed peritoneal entry during the operation, while 2 patients (3.6%) in the control group experienced postoperative complications. During a median follow-up length of 55.2 months, one patient in the LST group developed a recurrence.

CONCLUSIONS

Gasless VTEM is a simple, minimally invasive procedure used to treat LST and carcinoid tumors of the rectum. However, resection for the LST group had a high risk of peritoneal entry during operation.

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.

Gasless video endoscopic transanal excision of rectal tumors incompletely removed by colonoscopic snare polypectomy

BACKGROUND

This report describes an experience with gasless video transanal endoscopic microsurgery (VTEM) to excise rectal tumors previously incompletely removed with colonoscopic snare polypectomy.

METHODS

Gasless VTEM involves a modification of transanal endoscopic microsurgery (TEM) that incorporates a standard laparoscopic video camera and requires no CO(2) insufflation system. Nineteen patients who had had a rectal tumor removed incompletely by colonoscopic polypectomy with a diathermy snare were enrolled in this prospective study. The patients included 14 men and 5 women whose median age was 63.5 (range, 49-83) years. The rectal tumors included 4 adenomas, 11 adenocarcinomas (Tis, 7; T1, 4), and 4 carcinoid tumors. The median distance from the tumor margin to the dentate line was 5.8 (range, 2.0-13.0) cm.

RESULTS

All rectal lesions were successfully removed by gasless VTEM. No intraoperative complication occurred. The median operating time and blood loss were 40 (range, 15-145) minutes and 5 (range, 0-100) mL, respectively. The median maximal tumor diameter in 9 patients with residual tumors was 1.3 (range, 0.5-2.5) cm. There was no operative mortality. A postoperative complication (bleeding from a suture wound and transient incontinence) developed in 1 (5.3%) of the 19 patients. The median postoperative hospital stay was 5 (range, 2-10) days. Postoperative histology revealed a residual tumor in 10 (52.9%) of the 19 specimens. Complete excision of all tumors was confirmed histologically. During a median follow-up period of 59.5 (range, 12.3-94.9) months, no tumor recurred.

CONCLUSIONS

Gasless VTEM is useful and minimally invasive for the local removal of rectal tumors incompletely resected by colonoscopic snare polypectomy.

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.

A prospective, blinded assessment of the impact of preoperative staging on the management of rectal cancer

BACKGROUND & AIMS

The influence of preoperative staging of rectal carcinoma on therapeutic decisions is uncertain. The use of fine-needle aspiration (FNA) of perirectal nodes in this setting has not been evaluated. The aim of this prospective, blinded study of patients with rectal cancer was to assess the impact of preoperative staging on treatment decisions and compare the tumor (T), nodal (N) staging performance characteristics of pelvic computed tomography (CT), rectal endoscopic ultrasonography (EUS), and EUS FNA.

METHODS

Eighty consecutive patients with newly diagnosed rectal cancer were prospectively evaluated. Therapy decisions were recorded after sequential disclosure of staging information to the patient's surgeon.

RESULTS

In 31% of patients (95% confidence interval, 21%-42%), EUS staging information changed the surgeon's original treatment plan based on CT alone. The further addition of FNA changed therapy in one patient. T staging accuracy was 71% (CT) and 91% (EUS) (P = 0.02); N staging accuracy was 76% (CT), 82% (EUS), and 76% (EUS FNA) (P = NS).

CONCLUSIONS

Preoperative staging with EUS results in more frequent use of preoperative neoadjuvant therapy than if staging was performed with CT alone. The addition of FNA only changed the management of one patient, whereas FNA did not significantly improve N staging accuracy over EUS alone. FNA seems to offer the most potential for impacting management in those patients with early T stage disease, and its use should be confined to this subgroup of patients. EUS is more accurate than CT for determining T stage of rectal carcinoma.

Transanal excision of locally advanced rectal cancers downstaged using neoadjuvant chemoradiotherapy

BACKGROUND

Our institution has previously demonstrated a survival advantage conferred by preoperative neoadjuvant therapy for locally advanced rectal cancers. We now report our results using transanal excision as definitive surgical therapy in a selected group of patients who experienced significant downstaging of T3 rectal cancers after neoadjuvant therapy.

STUDY DESIGN

Seventy-four patients diagnosed with locally advanced (T3) rectal cancers were treated with neoadjuvant chemoradiotherapy. After neoadjuvant therapy, 11 (14.9%) patients who had significant downstaging of their tumors were selected to undergo transanal excision of their residual rectal cancers. Intraoperative cryostat evaluation was used to confirm negative margin status, and all patients were subsequently followed with routine endoscopy, transrectal ultrasonography, and digital rectal examinations.

RESULTS

Tumors were located between 1 cm and 7 cm from the anal verge (mean 4.3 +/- 0.6 cm), and were located in lateral, anterior, and posterior positions. Mean followup was 55.2 +/- 8.9 months (median 47.9 months). Imaging studies using CT, MRI, transrectal ultrasonography, or combination demonstrated suspicious lymph nodes in three patients. After neoadjuvant therapy, these lymph nodes were no longer demonstrated in two patients. There were no local recurrences, nodal metastases, or operative mortalities. One patient (9%) developed distant metastases (pulmonary nodules), and remains alive 30 months after transanal excision. One patient (9%) experienced sphincter laxity, which was successfully repaired, and is now asymptomatic. One patient (9%) developed postoperative urgency that resolved spontaneously.

CONCLUSIONS

In patients who have initial bulky (T3) lesions, and experience significant downstaging after neoadjuvant chemoradiotherapy, transanal excision appears to be a safe and effective treatment, preserving sphincter function and avoiding laparotomy.

Randomized clinical trials in rectal and anal cancer

Treatment of rectal cancer has changed dramatically over the past two decades. Radical surgery alone for resectable rectal cancer has been replaced by combined modality therapy. Interest in optimizing sphincter preservation and quality of life motivated surgeons to seek less radical surgery without compromising oncologic principles.