Staging of rectal carcinoma with transrectal ultrasonography

MRI Evaluation of Rectal Cancer: Staging and Restaging

Magnetic resonance imaging (MRI) plays an important role in the staging and restaging of rectal cancer. Multiplanar high-resolution (≤3-mm section thickness) T2-weighted images are the primary sequences used for rectal cancer staging. No preprocedural bowel cleansing regimen, intravenous contrast material, nor endorectal coil is necessary. MRI is highly accurate for differentiating T1-T2 disease from T3 and T4 disease, an important distinction as patients with T3 and T4 tumors typically undergo preoperative neoadjuvant chemoradiation before resection. At MRI, the muscularis propria appears as a thin black line encircling the outer wall of the rectum, and tumor extension through this line indicates T3 disease. Further tumor extension into adjacent organs indicates T4 disease. Endorectal ultrasound is generally preferred to differentiate T1 (submucosal involvement) from T2 (extension into but no disruption of muscularis propria) disease. MRI is also accurate in the assessment of tumor involvement of the mesorectal fascia. Tumor involvement of the mesorectal fascia increases the likelihood of recurrence following resection. MRI is less accurate for determination of lymph node status, though heterogeneous signal intensity and irregular margins are suggestive of node positive disease. Approximately 10%-30% of patients who undergo preoperative chemoradiation experience a complete pathologic response that is defined as no residual tumor found at histopathologic analysis of the resected specimen. The addition of diffusion-weighted images to T2-weighted images improves the accuracy of restaging examinations for determination of complete pathologic responders.

Learning curve of endorectal ultrasonography in preoperative staging of rectal carcinoma

Accurate preoperative staging of rectal carcinoma is essential for optimal treatment. This study was designed to evaluate the accuracy and learning curve of endorectal ultrasonography (ERUS) in the preoperative staging of rectal carcinoma. We retrospectively analyzed the records of patients with rectal carcinoma who underwent preoperative ERUS followed by curative surgery at the Shanxi Province Tumor Hospital between January, 2007 and March, 2010. The patients were divided into three groups, namely A, B and C, depending on whether the examination was performed between January and December, 2007, between January and December, 2008 or between January, 2009 and March, 2010, respectively. Five physicians with no prior experience in ERUS performed the examinations. We compared the ERUS staging with the pathological findings using the tumor-node-metastasis (TNM) classification. The accuracy of ERUS in T and N staging after each additional consecutive 20 patients was calculated for physicians D, E and F. A total of 319 patients underwent ERUS prior to surgery. There were 38 patients in group A, 135 in group B and 146 in group C. Two of the five physicians performed only 47 of the 319 examinations, whereas the remaining 272 patients were examined by physicians D (n=162), E (n=64) and F (n=46). The overall accuracy in assessing the extent of rectal wall invasion (T) was 67%, with 16% of the cases overstaged and 17% understaged and the accuracy in assessing nodal involvement (N) was 66%, with 11% of the cases overstaged and 23% understaged. The total T and N staging accuracy of physicians D, E and F was 75 and 72%; 59 and 59%; and 50 and 52%, respectively. For physicians D, E and F, the accuracy of T and N staging after each additional 20 patients was calculated and the curve of the accuracy reached a plateau after physician D completed 80 cases. Therefore, ERUS is a valuable tool for assessing the depth of tumor invasion and it appears that after ~80 cases a physician may be considered able to apply it efficiently.

Endorectal ultrasound does not reliably identify patients with uT3 rectal cancer who can avoid neoadjuvant chemoradiotherapy

PURPOSE

Neoadjuvant chemoradiation (NCRT) may be avoided in some patients with T3-staged rectal cancer undergoing radical resection. We aimed to evaluate the accuracy of endorectal ultrasound (ERUS) in the nodal staging of uT3 tumors and hence the decision for administration of NCRT.

METHODS

Patients with uT3-staged rectal cancer who underwent proctectomy were retrospectively identified. The accuracy of ERUS for detecting nodal involvement was determined for patients who did not undergo NCRT. In order to evaluate the impact of use of NCRT, oncologic outcomes, functional outcomes, and quality of life (QOL) were compared for patients who received NCRT (group A) and those who did not (group B).

RESULTS

For 384 patients who were included, ERUS overstaging rate for nodal involvement was 6.3% while understaging rate was 23.2%. For the 289 patients in group A and 95 in group B, Kaplan-Meier analysis showed similar 5-year local recurrence rates (3.5%), overall survival (76.9 vs 75.6%), and disease-free survival (87.9 vs 88.1%). Node positivity on final pathology was however associated with worse 5-year local recurrence (9.3 vs 4.3%). For patients undergoing restorative resection, NCRT was associated with worse functional outcomes but QOL was similar.

CONCLUSIONS

ERUS identification of nodal involvement used as a criterion for NCRT carries a greater risk for undertreatment than overtreatment. Undertreatment adversely affects oncologic outcomes. While there is functional impairment related to NCRT, its effect on QOL is non-significant. The decision for omitting neoadjuvant chemoradiation for uT3 rectal cancer should hence not be based on ERUS nodal staging alone.

Rectal cancer radiotherapy: towards European consensus

BACKGROUND AND PURPOSE

During the first decade of the 21st century several important European randomized studies in rectal cancer have been published. In order to help shape clinical practice based on best scientific evidence, the International Conference on 'Multidisciplinary Rectal Cancer Treatment: Looking for an European Consensus' (EURECA-CC2) was organized. This article summarizes the consensus about imaging and radiotherapy of rectal cancer and gives an update until May 2010.

METHODS

Consensus was achieved using the Delphi method. Eight chapters were identified: epidemiology, diagnostics, pathology, surgery, radiotherapy and chemotherapy, treatment toxicity and quality of life, follow-up, and research questions. Each chapter was subdivided by topic, and a series of statements were developed. Each committee member commented and voted, sentence by sentence three times. Sentences which did not reach agreement after voting round # 2 were openly debated during the Conference in Perugia (Italy) December 2008. The Executive Committee scored percentage consensus based on three categories: "large consensus", "moderate consensus", "minimum consensus".

RESULTS

The total number of the voted sentences was 207. Of the 207, 86% achieved large consensus, 13% achieved moderate consensus, and only three (1%) resulted in minimum consensus. No statement was disagreed by more than 50% of members. All chapters were voted on by at least 75% of the members, and the majority was voted on by >85%. Considerable progress has been made in staging and treatment, including radiation treatment of rectal cancer.

CONCLUSIONS

This Consensus Conference represents an expertise opinion process that may help shape future programs, investigational protocols, and guidelines for staging and treatment of rectal cancer throughout Europe. In spite of substantial progress, many research challenges remain.

Rectal cancer staging

Rectal cancer staging provides critical information concerning the extent of the disease. The information gained from staging is used to determine prognosis, to guide management, and to assess response to therapy. Accurate staging is essential for directing the multidisciplinary approach to therapy. This article focuses on the evolution of staging systems, the rational for staging, and current methods used to stage rectal cancer.

Multidisciplinary Rectal Cancer Management: 2nd European Rectal Cancer Consensus Conference (EURECA-CC2)

BACKGROUND AND PURPOSE

During the first decade of the 21st century a number of important European randomized studies were published. In order to help shape clinical practice based on best scientific evidence from the literature, the International Conference on 'Multidisciplinary Rectal Cancer Treatment: Looking for an European Consensus' (EURECA-CC2) was organized in Italy under the endorsement of European Society of Medical Oncology (ESMO), European Society of Surgical Oncology (ESSO), and European Society of Therapeutic Radiation Oncology (ESTRO).

METHODS

Consensus was achieved using the Delphi method. The document was available to all Committee members as a web-based document customized for the consensus process. Eight chapters were identified: epidemiology, diagnostics, pathology, surgery, radiotherapy and chemotherapy, treatment toxicity and quality of life, follow-up, and research questions. Each chapter was subdivided by a topic, and a series of statements were developed. Each member commented and voted, sentence by sentence thrice. Sentences upon which an agreement was not reached after voting round # 2 were openly debated during a Consensus Conference in Perugia (Italy) from 11 December to 13 December 2008. A hand-held televoting system collected the opinions of both the Committee members and the audience after each debate. The Executive Committee scored percentage consensus based on three categories: "large consensus", "moderate consensus", and "minimum consensus".

RESULTS

The total number of the voted sentences was 207. Of the 207, 86% achieved large consensus, 13% achieved moderate consensus, and only 3 (1%) resulted in minimum consensus. No statement was disagreed by more than 50% of the members. All chapters were voted on by at least 75% of the members, and the majority was voted on by >85%.

CONCLUSIONS

This Consensus Conference represents an expertise opinion process that may help shape future programs, investigational protocols, and guidelines for staging and treatment of rectal cancer throughout Europe.

Preoperative staging of rectal cancer

Preoperative staging is now an essential factor in the multidisciplinary management of rectal cancer because tumor stage is the strongest predictive factor for recurrence. Preoperative staging of rectal cancer can be divided into either local or distant staging. Local staging incorporates the assessment of mural wall invasion, circumferential resection margin involvement, as well as the nodal status for metastasis. Distant staging assesses for evidence of metastatic disease. The aim of this review is to consider the indications and limitations of the current preoperative imaging modalities for rectal cancer staging including clinical examination, endorectal ultrasound, magnetic resonance imaging, computed tomography and positron emission tomography–computed tomography, with respect to local and distant disease.

A new rectal ultrasonographic method for the staging of rectal cancer

PURPOSE

Radial transrectal ultrasound is the most frequently used method for preoperative staging of rectal cancer. Accuracy rates of transrectal ultrasound have fallen significantly to 64% and 70% for tumor and node staging, respectively. The use of a frontal probe may overcome the drawbacks of radial transrectal ultrasound. This study was designed to compare the accuracy of frontal transrectal ultrasound performed with a frontal probe with the classic procedure, which uses a radial probe, in the preoperative T and N staging of rectal cancer.

METHODS

Seventy-four patients with rectal adenocarcinoma underwent both techniques. Thirty patients had a neoadjuvant treatment. The staging accuracy of both methods was determined by comparing the results of each with the findings of surgical histopathologic evaluation.

RESULTS

Forty-six men and 28 women were recruited. Frontal transrectal ultrasound was performed in all patients. Staging was amenable in only 58 patients with the radial transrectal ultrasound because the tumors were either stenotic or too proximal. Frontal transrectal ultrasound was accurate in the T staging of 89% of the tumors, whereas radial transrectal ultrasound was accurate in only 69% (P = 0.004). The difference was even more significant when we compared accuracy among the 58 patients in whom both examinations were completed (P = 0.002). Both methods had similar accuracy for lymph node staging. Neoadjuvant treatment had no influence on accuracy. No overstaging of the tumor occurred with the frontal transrectal ultrasound. Understaging was more frequently encountered with radial transrectal ultrasound than with frontal transrectal ultrasound (26% vs. 11%, respectively; P = 0.036).

CONCLUSION

Compared with radial transrectal ultrasound, frontal transrectal ultrasound has a better accuracy for T staging of rectal cancer. Its advantage in overcoming the drawbacks of radial transrectal ultrasound may make this procedure the method of choice for rectal cancer staging.

Preoperative staging and treatment options in T1 rectal adenocarcinoma

BACKGROUND

Major rectal resection for T1 rectal cancer offers more than 95% cancer specific five-year survival to patients surviving the first 30 days after surgery. A significant further improvement by development of the surgical technique may not be possible. Improvements in the total survival rate have to come from a more differentiated treatment modality, taking patient and procedure related risk factors into account. Subgroups of patients have operative mortality risks of 10% or more. Operative complications and long-term side effects after rectum resection are frequent and often severe.

RESULTS

Local treatment of T1 cancers combined with close follow-up, early salvage surgery or later radical resection of local recurrences or with chemo-radiation may lead to fewer severe complications and comparable, or even better, long-term survival. Accurate preoperative staging and careful selection of patients for local or non-operative treatment are mandatory. As preoperative staging, at present, is not sufficiently accurate, strategies for completion, salvage or rescue surgery is important, and must be accepted by the patient before local treatment for cure is initiated.

RECOMMENDATIONS

It is recommended that polyps with low-risk T1 cancers should be treated with endoscopic snare resection in case of Haggitt's stage 1 or 2. TEM is recommended if resection margins are uncertain after snare resection for Haggitt's stage 3 and 4, and for sessile and flat, low-risk T1 cancers. Average risk patients with high-risk T1 cancers should be offered rectum resection, but old and comorbid patients with high-risk T1 cancers should be treated individually according to objective criteria as age, physical performance as well as patient's preference. All patients treated for cure with local resection or non-surgical methods should be followed closely.

[Management of superficial rectal cancers]

Superficial rectal cancers consist of Tis and T1 tumors as defined by the TNM classification system. Earlier detection of colorectal cancers through endoscopic screening should lead to an increase in the percentage of superficial cancers detected while still superficial; they may eventually represent more than a third of diagnosed rectal cancers. Endorectal ultrasound, ideally performed with a mini-probe, is the best pre-operative study to define the level of penetration into the rectal wall; depth of penetration and grade of differentiation are the major factors to be considered when contemplating local excision as an alternative to radical resection. Local excision can be performed endoscopically or by the classic transanal surgical approach. Each technique has pros and cons and the two are often complementary. Compared to the alternative of radical proctectomy, they have the decided advantages of zero mortality, minimal morbidity, and decreased expense. Pathologic examination of the resected specimen is the final determinant as to whether local resection is adequate therapy. When histologic prognostic factors are favorable (well-differentiated, absence of lymphatic or vascular invasion, superficial invasion of the submucosa (sm1), and clear resection margins), the risk of lymph node spread is negligible. When histologic prognostic factors are not favorable, a completion radical proctectomy should be performed.

Accuracy of endorectal ultrasonography in staging locally advanced rectal cancer after preoperative chemoradiation

AIM

The aim of our study was to determine the accuracy of endorectal ultrasonography (ERUS) in staging locally advanced rectal cancer after preoperative neoadjuvant chemoradiation and to point out the most common reasons for false interpretation.

METHODS

Forty-four patients with locally advanced rectal cancer received neoadjuvant chemoradiation followed by radical surgery. Restaging was done 1-2 weeks before surgery and the results of ERUS staging were compared with histopathology findings of the resected specimen.

RESULTS

The accuracy of ERUS for T stage after chemoradiation was 75% (33/44). Overstaging occurred in 18% (8/44) of patients, and 7% (3/44) were understaged. The majority of overstaging occurred in patients with ERUS T3 tumors, eventually found to have pathological pT0-pT2 staging. Five patients (11.4%) had complete histology regression and only one of these patients was staged correctly while others were overstaged. In the detection of perirectal lymph node metastases, ERUS was accurate in 68% of patients (30/44). Twenty percent (9/44) of patients were overstaged and 11% were (5/44) understaged.

CONCLUSIONS

ERUS provides a good accuracy rate for staging rectal cancer after neoadjuvant chemoradiation. However, it is insufficient in detection of complete pathological response.

Endorectal ultrasonography versus phased-array magnetic resonance imaging for preoperative staging of rectal cancer

AIM: To compare the diagnostic accuracy of pelvic phased-array magnetic resonance imaging (MRI) and endorectal ultrasonography (ERUS) in the preoperative staging of rectal carcinoma.

METHODS: Thirty-four patients (15 males, 19 females) with ages ranging between 29 and 75 who have biopsy proven rectal tumor underwent both MRI and ERUS examinations before surgery. All patients were evaluated to determine the diagnostic accuracy of depth of transmural tumor invasion and lymph node metastases. Imaging results were correlated with histopathological findings regarded as the gold standard and both modalities were compared in terms of predicting preoperative local staging of rectal carcinoma.

RESULTS: The pathological T stage of the tumors was: pT1 in 1 patient, pT2 in 9 patients, pT3 in 21 patients and pT4 in 3 patients. The pathological N stage of the tumors was: pN0 in 19 patients, pN1 in 9 patients and pN2 in 6 patients. The accuracy of T staging for MRI was 89.70% (27 out of 34). The sensitivity was 79.41% and the specificity was 93.14%. The accuracy of T staging for ERUS was 85.29% (24 out of 34). The sensitivity was 70.59% and the specificity was 90.20%. Detection of lymph node metastases using phased-array MRI gave an accuracy of 74.50% (21 out of 34). The sensitivity and specificity was found to be 61.76% and 80.88%, respectively. By using ERUS in the detection of lymph node metastases, an accuracy of 76.47% (18 out of 34) was obtained. The sensitivity and specificity were found to be 52.94% and 84.31%, respectively.

CONCLUSION: ERUS and phased-array MRI are complementary methods in the accurate preoperative staging of rectal cancer. In conclusion, we can state that phased-array MRI was observed to be slightly superior in determining the depth of transmural invasion (T stage) and has same value in detecting lymph node metastases (N stage) as compared to ERUS.

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.

Imaging and management of rectal cancer

Local staging and management of rectal cancer has evolved during the past decade. Imaging modalities used for staging rectal cancer include CT, endoscopic ultrasound, pelvic phased-array coil MRI, endorectal MRI, and PET. Each modality has its strengths and limitations. Evidence supports the use of both endoscopic ultrasound and CT in staging rectal cancer. MRI is the only reliable tool for determining the status of the circumferential resection margin, which is important for the assessment of the risk of local recurrence.

Preoperative staging of rectal carcinoma by endorectal ultrasound: is there a learning curve?

BACKGROUND AND AIMS

Endorectal ultrasound (ERUS) is becoming an essential tool in the management of rectal cancer. However, accuracy in the assessment of disease staging may be dependent on operator experience. The aim of this study was to determine if a learning curve exists.

MATERIALS AND METHODS

From October 1999 to December 2004, all patients with rectal cancer had a pre-operative ERUS performed by a single radiologist. ERUS staging was compared with post-operative pathology findings using the tumour, node, metastases (TNM) classification. The accuracy of ERUS in tumour (T) and node (N) staging after each additional consecutive ten patients was calculated.

RESULTS

One hundred and thirty one patients were investigated by ERUS, of which 36 were excluded, leaving 95 patients in the study (60 men). Overall accuracy for T staging was 71.6%. No improvement with experience was noted (p > 0.05). With regard to T staging, ERUS tended to overstage more frequently than understage (24.2 versus 4.2%). The sensitivity, specificity, positive predictive value and negative predictive value of uT3 staging were 96.6, 33.3, 70.4 and 85.7%, respectively. Overall accuracy of uN staging was 68.8%. ERUS tended to overstage nodal disease more frequently than understage (16.1 versus 15.1%). Sensitivity, specificity, positive predictive value and negative predictive value were calculated for ultrasound-detected nodal disease (73.2, 62.2, 74.5 and 60.5%, respectively). Nodal staging accuracy improved from 50% after assessment of 10 cases to 77% after 30 cases were examined.

CONCLUSIONS

ERUS is an accurate method for staging rectal cancer pre-operatively. Accurate assessment of tumour stage can be achieved immediately by an experienced radiologist without specific training in ERUS. Nodal staging accuracy tends to improve with experience but reaches a plateau after 30 cases.

Preoperative loco-regional imaging in rectal cancer

Preoperative staging of rectal cancer can influence the choice of surgery and the use of neoadjuvant therapy. This review evaluates the use of endorectal ultrasound (ERUS) and magnetic resonance imaging (MRI) in the local staging of rectal cancer. Staging for distant metastases is beyond the scope of this review. A MEDLINE search for published work in English between 1984-2004 was carried out by entering the key words of ERUS, MRI and preoperative imaging and rectal cancer. Initially, 867 articles were retrieved. Abstracts were reviewed and papers selected according to the inclusion criteria of a minimum of 50 patients and papers published in English. Papers focusing on preoperative chemoradiotherapy and distal metastases were excluded. Thirty-one papers were included in the systematic review. The examination techniques and images obtained are discussed and the respective accuracy is reviewed. ERUS and MRI have complementary roles in the assessment of tumour depth. Ultrasound has an overall accuracy of 82% (T1, 2, 40-100%; T3, 4, 25-100%) and is particularly useful for early localized rectal cancers. MRI has an accuracy of 76% (T1, 2, 29-80%; T3, 4, 0-100%) and is useful in more advanced disease by providing clearer definition of the mesorectum and mesorectal fascia. Both methods have similar accuracy in the assessment of nodal metastases. Ultrasound is more operator dependent and accuracies improve with experience, but it is more portable and accessible than MRI. Improvements in technology and increased operator experience have led to more accurate preoperative staging. ERUS and MRI are complementary and are most accurate for early localized cancers and more advanced cancers, respectively.

The role and value of endorectal ultrasonography in diagnosing T1 rectal tumors

Rectal carcinoma in 50% to 60% of cases is localized in the rectum and, if diagnosed early can be locally excised. The authors evaluated the diagnostic accuracy of the preoperative endorectal ultrasonography (ERUS) in the staging of rectal tumors and the usefulness of the method to assess patients' suitability for local excision. In the retrospective analysis, we analyzed 29 patients with rectal cancer. The depth of invasion into the rectal wall was assessed by ERUS and all patients were qualified for tumor excision with transanal endoscopic microsurgery (TEM). We analyzed overall accuracy of ERUS and the effectiveness of treatment. In the analyzed group, diagnostic accuracy of ERUS in assessing T1 carcinomas was 89.2%, sensitivity 92.3% and specificity 50%. Local excision with TEM was deemed to be curative in 86.2% patients with rectal tumors detected by ERUS. ERUS is an accurate method of preoperative assessment of T1 and T2 carcinomas and its diagnostic accuracy is sufficient to qualify patients for anal-saving operations.

Feasibility and accuracy of TRUS in the pre-treatment staging for rectal carcinoma in general practice

AIMS

Transrectal ultrasonography (TRUS) is the diagnostic tool of choice for local staging of rectal carcinoma. The accuracy in determining of tumour infiltration depth has been reported to reach 95% (on average, 85%). The aim of the study was to analyse the diagnostic accuracy of the TRUS in the clinical routine.

PATIENTS AND METHODS

From 01/01/2000 to 12/31/2003, all patients with rectal carcinoma were enrolled in a prospective multicenter observational study. In case of complete findings of pre-operative TRUS and post-operative histological investigation of the surgical specimen on the tumour infiltration depth, overall accuracy of TRUS was determined.

RESULTS

Overall, 13,610 patients with rectal carcinoma were enrolled in the study. Five thousand and fifty-six subjects (37%) underwent TRUS. In 3,501 patients, TRUS finding (uT-stage) could be compared with the result of the definitive histologic investigation (pT-stage). The accuracy of TRUS in all T-stages was 65.8%. The highest sensitivity was achieved in the T3-stage (74.9%), while in T2, T1, and T4, it was 59.6, 59.0 and 31.1%, respectively. In discriminating tumour growth limited to the rectal wall vs that through the rectal wall into the neighboring tissue, TRUS-associated accuracy was 76.5%. There were no differences between various tumour locations above the anocutaneous line.

CONCLUSIONS

Diagnostic accuracy of TRUS in determining depth of tumour infiltration within or through the rectum wall in the routinuous diagnostic of rectal carcinoma does not reach the excellent published study results. A considerable improvement of the qualitative outcome in using this specific diagnostic tool appears to be recommendable to utilize its advantages such as high accuracy, efficacy, and practicability in the diagnostic process and deriving consequences for a possible neoadjuvant treatment as well as optimal planning of the surgical approach.

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.

Clinical presentation, imaging, and staging of anal cancer

Perianal symptoms are common, and benign anorectal conditions have clinical features not too dissimilar to those associated with anal canal carcinoma. To avoid delayed diagnosis, physicians need to be cognizant of the possibility of anal canal carcinoma, which can be effectively treated with chemoradiation therapy without the need for mutilating surgery. Appropriate imaging studies should be obtained for accurate staging of the disease and for follow-up examinations after definitive treatment.