Outcomes of Local Excision plus Chemoradiotherapy in Patients with T1 Rectal Cancer

Short- and long-term outcomes of local excision with adjuvant radiotherapy in high-risk T1 rectal cancer patients

Purpose

Methods

Results

Conclusion

Prognostic Factors and Treatment of Recurrence after Local Excision of Rectal Cancer

PURPOSE

Indications for local excision in patients with rectal cancer remain controversial. We reviewed factors affecting survival rate and treatment effectiveness in cancer recurrence after local excision among patients with rectal cancer.

MATERIALS AND METHODS

A total of 831 patients was enrolled. Of these, 391 patients were diagnosed with primary rectal cancer and underwent local excision. A retrospective observational study was performed on patients who underwent full-thickness local excision for rectal cancer.

RESULTS

The median duration of follow-up was 61 months. The overall recurrence rate was 11.5%. The rate of local recurrence was 5.1%. Five-year overall survival rate among recurrent patients was 66.8%; the rate among patients who underwent salvage operation due to recurrence was 84.7%, compared with 44.2% among patients treated with non-operative management (p<0.001). Multivariate analysis of disease-free survival identified distance from the anal verge (p=0.038) and histologic grade (p=0.047) as factors predicting poor prognosis. Multivariate analysis of overall survival showed that age (p<0.001), serum carcinoembryonic antigen (CEA) levels (p=0.001), and histologic grade (p=0.013) also affected poor prognosis. In subgroup analysis of patients with recurrence, 25 patients underwent reoperation, while 20 patients did not. For 5-year overall survival rate, there was a significant difference between 84.7% of the reoperation group and 44.2% of the non-operation group (p<0.001).

CONCLUSION

The risk factors affecting overall survival rate after local excision were age 65 years or older, preoperative CEA level 5 or higher, and high histologic grade. In cases of recurrence after local excision of rectal cancer, salvage operation might improve overall survival.

Transanal minimal invasive surgery (TAMIS): safety and feasibility for the resection of benign and malignant lesions of the rectum

Objectives

Radical surgery for rectal tumours has high morbidity. Local excision of such tumours can be achieved without compromising oncologic safety. However tumours that are not accessible to local excision can be approached using Transanal Minimal Invasive Surgery (TAMIS). The aim of our study was to assess feasibility of TAMIS procedure in terms of complications, operating time, resection margin positivity, hospital stay and local recurrence rate.

Material and Methods

Forty eight patients with benign adenomas or early stage adenocarcinoma, within 4 to 12 cm from anal verge who were subjected to TAMIS over a period of 3 years were included in the study. Short and long term outcomes were assessed.

Results

TAMIS was performed for 36 benign adenomas and 12 adenocarcinomas, which were located at an average distance of 6.2 cm from anal verge. The mean operating time was 72 minutes. There were no intraoperative complications.1 (2.08%) patient suffered post operative bleeding, which was managed conservatively. 2 (4.16%) patients developed acute urinary retention who required indwelling catheterisation. Resection margin was positive in 3 (6.25%) benign cases. Average hospital stay was 2.7 days. Local recurrence occurred in 2 (4.16%) villous adenoma patients (after 11 and 13 months), whereas in malignant patients there was no recurrence at a follow up period ranging between 12 to 36 months.

Conclusion

TAMIS is a safe and feasible procedure for benign tumours and early rectal cancers, located in low and middle rectum.

Recurrence Outcomes Less Favorable in T1 Rectal Cancer than in T1 Colon Cancer

BACKGROUND

With the implementation of screening programs worldwide, diagnosis of early-stage colorectal cancer steadily increased, including T1 cancer. Current T1 cancer treatment does not differ according to anatomic location. We therefore compared the disease-free survival of T1 cancer arising from the rectum versus the colon.

METHODS

The hospital-based study included subjects with T1 cancer at National Taiwan University Hospital from 2005 to 2014. Clinical, colonoscopy, and histopathology were reviewed for patients with a mean follow-up time of 7.1 (0.7-12.9) years. We conducted Kaplan-Meier analysis to compare the risk of recurrence by cancer location and Cox regression analysis to identify risk factors for T1 cancer recurrence.

RESULTS

The final cohort included a total of 343 subjects with T1 cancer (mean age, 64.9 ± 11.7 years; 56.1% male), of whom 25 underwent endoscopic resection alone. Of the subjects who underwent surgery, 50 had lymph node metastasis and 268 did not. Kaplan-Meier analysis showed that the risk of recurrence was higher in T1 rectal cancer than T1 colon cancer (p = .022). Rectal location and larger neoplasm size were independent risk factors for recurrence, with hazard ratios of 4.84 (95% confidence interval, 1.18-19.92), and 1.32 (95% confidence interval, 1.06-1.65), respectively. The occurrence of advanced histology did not differ between T1 rectal and colon cancers (p = .58).

CONCLUSION

T1 cancers arising from the rectum had less favorable recurrence outcomes than those arising from the colon. Further studies are needed to examine whether adjuvant radiotherapy or chemotherapy can reduce the risk of recurrence in T1 rectal cancer.

IMPLICATIONS FOR PRACTICE

Current T1 colorectal cancer treatment and surveillance do not differ according to anatomic location. Clinical, colonoscopy, and histopathology were reviewed for 343 patients with T1 cancer with a mean follow-up time of 7.1 years. Kaplan-Meier analysis showed that the risk of recurrence was higher in T1 rectal cancer than T1 colon cancer. Moreover, the rectal location was an independent risk factor for recurrence. T1 cancers from the rectum had less favorable recurrence outcomes than those arising from the colon. It is critical to clarify whether adjuvant therapy or more close surveillance can reduce recurrence risk in T1 rectal cancer.

Oncological Outcomes of Transanal Endoscopic Microsurgery Plus Adjuvant Chemoradiotherapy for Patients with High-Risk T1 and T2 Rectal Cancer

Background: Radical surgery is recommended for high-risk pathological stage T1 (pT1) or pT2 rectal cancer after transanal endoscopic microsurgery (TEM). However, in clinical practice, many patients may unfit or decline radical surgery. In recent years, adjuvant chemoradiotherapy (CRT) after TEM was considered as an alternative to radical surgery for these patients. This study aimed to assess oncological outcomes of adjuvant CRT after TEM for high-risk early rectal cancer. Materials and Methods: We collected retrospectively data of 97 patients who underwent TEM with pT1 and pT2 between January 2008 and December 2018. Of these, 35 patients were excluded. Of the remaining 62 patients, 42 were managed by TEM alone and 20 by TEM plus adjuvant CRT. Demographics, recurrence, and survival were analyzed between the two groups. Results: At a median follow-up of 52.5 months, the 3-year local recurrence-free survival and disease-free survival (DFS) in TEM alone group were significantly lower than those in TEM+CRT group (66.6% versus 93.3%, P = .035; 63.7% versus 93.3%, P = .022). Although the 3-year overall survival in TEM+CRT group was higher than TEM alone group (100% versus 83.3%), the difference was not statistically significant (P = .13). The local recurrence rate in TEM alone was 31%, compared with 5% in TEM+CRT group (P = .025). Multivariate analysis showed that adjuvant CRT was an independent prognostic factor for DFS (hazard ratio: 0.094; 95% confidence interval: 0.001-0.764; P = .027). Conclusions: Our study suggests that adjuvant CRT after TEM may be an alternative for pT1 high-risk and T2 rectal cancer who are not suitable or unwilling to undergo salvage radical surgery.

Local recurrence after local excision of early rectal cancer: a meta-analysis of completion TME, adjuvant (chemo)radiation, or no additional treatment

BACKGROUND

The risks of local recurrence and treatment-related morbidity need to be balanced after local excision of early rectal cancer. The aim of this meta-analysis was to determine oncological outcomes after local excision of pT1-2 rectal cancer followed by no additional treatment (NAT), completion total mesorectal excision (cTME) or adjuvant (chemo)radiotherapy (aCRT).

METHODS

A systematic search was conducted in PubMed, Embase and the Cochrane Library. The primary outcome was local recurrence. Statistical analysis included calculation of the weighted average of proportions.

RESULTS

Some 73 studies comprising 4674 patients were included in the analysis. Sixty-two evaluated NAT, 13 cTME and 28 aCRT. The local recurrence rate for NAT among low-risk pT1 tumours was 6·7 (95 per cent c.i. 4·8 to 9·3) per cent. There were no local recurrences of low-risk pT1 tumours after cTME or aCRT. The local recurrence rate for high-risk pT1 tumours was 13·6 (8·0 to 22·0) per cent for local excision only, 4·1 (1·7 to 9·4) per cent for cTME and 3·9 (2·0 to 7·5) per cent for aCRT. Local recurrence rates for pT2 tumours were 28·9 (22·3 to 36·4) per cent with NAT, 4 (1 to 13) per cent after cTME and 14·7 (11·2 to 19·0) per cent after aCRT.

CONCLUSION

There is a substantial risk of local recurrence in patients who receive no additional treatment after local excision, especially those with high-risk pT1 and pT2 rectal cancer. The lowest recurrence risk is provided by cTME; aCRT has outcomes comparable to those of cTME for high-risk pT1 tumours, but shows a higher risk for pT2 tumours.

Radiation therapy for rectal cancer

Radiotherapy (RT) has remained an important pillar in the multi-modality management of rectal cancer. Adjuvant RT with concurrent chemotherapy (chemo-RT) was once the standard of care for locally advanced rectal cancer, but with time, that has now changed and neoadjuvant chemo-RT followed by total mesorectal excision (TME) surgery is the new standard. Alternatively, neoadjuvant RT alone remains an option and clinicians are tasked to choose between the two. In an era of personalised oncological management, it is unsurprising that the treatment for rectal cancer is following suit and upcoming trials are studying ways to improve outcomes and minimise toxicity for patients while tailoring treatments specific to each patient's tumour. We review the evolution of the role of RT in rectal cancer and look forward to what the future holds.