Comparison between Local Excision and Radical Resection for the Treatment of Rectal Cancer in ypT0-1 Patients: An Analysis of the Clinicopathological Factors and Survival Rates

Survival prognostic in different age groups of patients undergoing local versus radical excision for rectal cancer: a study based on the SEER database

Age significantly affects the prognosis of patients with rectal cancer after radical excision (RE), and local excision (LE) is an alternative surgical procedure to RE. To compare the survival prognosis in different age groups of LE versus RE for rectal cancer. Patients diagnosed with rectal adenocarcinoma treated by LE or RE from 2010 to 2017 were obtained from the SEER database. The primary outcomes are 5-year OS and CSS. A total of 11,170 patients were eventually included, and there were 490 patients in LE and RE groups, respectively, after 1:1 propensity score matching. The 5-year OS and CSS after LE were significantly better in < 50 years and 50-66 years groups than in > 66 years group (5-year OS: 95.70% vs 88.40% vs 67.00%, P < 0.001; 5-year CSS: 95.70% vs 96.30% vs 82.60%, P < 0.001). No statistical significance was found for the differences in 5-year OS and CSS between LE and RE in < 50, 50-66, and > 66 years group (P > 0.05). Multivariate analysis showed age > 66 years, poorly differentiated or undifferentiated (Grade III/IV), and tumor size 3 to 5 cm was independent risk factors for 5-year OS after LE; age > 66 years, perineural invasion, and tumor size 3 to 5 cm were the 5-year CSS independent risk factors for after LE. We found that the survival prognosis of younger rectal cancer patients treated with LE was significantly better than older (> 66 years) patients, and the survival prognosis of rectal cancer patients in the three age groups was similar between LE and RE.

Radical vs. Local Excision in Rectal Carcinoma T1N0M0: Recurrence and Mortality Rates

Local transanal excision of early rectal carcinoma is an appealing treatment because of its low morbidity rates and better functional results than radical resection. However, this treatment approach is controversial due to its association with local recurrence when compared to the latter. This review aims to compare the local recurrence and mortality rates of local vs. radical excision in patients with T1N0M0 rectal carcinoma, based on data in the literature in the last 20 years. A PubMed, Cochrane, and Google Scholar search of published literature in the last 20 years was performed. A total of 12 studies were identified. Three were prospective, one was a population-based propensity matching study, one was a nationwide cohort study, one was a meta-analysis, and the remaining studies were retrospective/observational. The mean local recurrence rate within five years from the studies selected for local excision (LE: 12.8%) was nearly double that of radical excision (RAD: 5.0%). The five-year mean survival rate for both LE and RAD groups from the studies selected was 86%, which was equal for both groups. The main predictors of poor outcomes were older age and the presence of two or more comorbid conditions. There is a consensus amongst studies that LE is associated with inferior oncological outcomes such as postoperative complications and recurrence when compared to RAD. The higher local recurrence rates in LE are attributed to occult lymph node disease and inadequate adjunctive therapy due to suboptimal staging. There is no difference in the five-year survival rate when compared to RAD. A longer follow-up period is needed to determine whether the survival rates diverge after five years.

Surgical Treatment of Low-Lying Rectal Cancer: Updates

Despite innovative advancements, distally located rectal cancer remains a critical disease of challenging management. The crucial location of the tumor predisposes it to a circumferential resection margin (CRM) that tends to involve the anal sphincter complex and surrounding organs, with a high incidence of delayed anastomotic complications and the risk of the pelvic sidewall or rarely inguinal lymph node metastases. In this regard, colorectal surgeons should be aware of other issues beyond total mesorectal excision (TME) performance. For decades, the concept of extralevator abdominoperineal resection to avoid compromised CRM has been introduced. However, the complexity of deep pelvic dissection with poor visualization in low-lying rectal cancer has led to transanal TME. In contrast, neoadjuvant chemoradiotherapy (NCRT) has allowed for the execution of more sphincter-saving procedures without oncologic compromise. Significant tumor regression after NCRT and complete pathologic response also permit applying the watch-and-wait protocol in some cases, now with more solid evidence. This review article will introduce the current surgical treatment options, their indication and technical details, and recent oncologic and functional outcomes. Lastly, the novel characteristics of distal rectal cancer, such as pelvic sidewall and inguinal lymph node metastases, will be discussed along with its tailored and individualized treatment approach.