Abstract
BackgroundAfter local excision of early rectal cancer, revision radical resection is recommended for patients with high-risk pathologic stage T1 (pT1) or pT2 cancer, but the revision procedure has high morbidity rates. We evaluated the efficacy of adjuvant concurrent chemoradiotherapy (CCRT) for reducing recurrence after local excision in these patients.MethodsEighty-three patients with high-risk pT1 or pT2 rectal cancer underwent postoperative adjuvant CCRT after local excision. We defined high-risk features as pT1 having tumor size ≤3 cm, and/or resection margin (RM) ≤3 mm, and/or lymphovascular invasion (LVI), and/or non-full thickness excision such as endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD), or unknown records regarding those features, or pT2 cancer. Radiotherapy was administered with a median dose of 50.4 Gy in 1.8 Gy fraction size over 5–7 weeks. Concurrent 5-fluorouracil and leucovorin were administered for 4 days in the first and fifth weeks of radiotherapy.ResultsThe median interval between local excision and radiotherapy was 34 (range, 11–104) days. Fifteen patients (18.1 %) had stage pT2 tumors, 22 (26.5 %) had RM of ≥3 mm, and 21 (25.3 %) had tumors of ≥3 cm in size. Thirteen patients (15.7 %) had LVI. Transanal excision was performed in 58 patients (69.9 %) and 25 patients (30.1 %) underwent EMR or ESD. The median follow-up was 61 months. The 5-year overall survival (OS), locoregional relapse-free survival (LRFS), and disease-free survival (DFS) rates for all patients were 94.9, 91.0, and 89.8 %, respectively. Multivariate analysis did not identify any significant factors for OS or LRFS, but the only significant factor affecting DFS was the pT stage (p = 0.027).ConclusionsIn patients with high-risk pT1 rectal cancer, adjuvant CCRT after local excision could be an effective alternative treatment instead of revision radical resection. However, patients with pT2 stage showed inferior DFS compared to pT1.
Highlights
After local excision of early rectal cancer, revision radical resection is recommended for patients with high-risk pathologic stage T1 or pT2 cancer, but the revision procedure has high morbidity rates
Radical surgery has been the standard of treatment for patients with rectal cancer and adjuvant concurrent chemoradiotherapy (CCRT) is often recommended in order to decrease the risk of recurrence for patients with locally advanced rectal cancer
Local excision should be performed in patients with no evidence of lymphadenopathy on pretreatment imaging because lymph node metastasis has been reported at rate of 17 to 31 % in patients with pathologic stage T1 and pT2 rectal cancers [7]
Summary
After local excision of early rectal cancer, revision radical resection is recommended for patients with high-risk pathologic stage T1 (pT1) or pT2 cancer, but the revision procedure has high morbidity rates. Radical surgery has been the standard of treatment for patients with rectal cancer and adjuvant concurrent chemoradiotherapy (CCRT) is often recommended in order to decrease the risk of recurrence for patients with locally advanced rectal cancer. Local excision should be performed in patients with no evidence of lymphadenopathy on pretreatment imaging because lymph node metastasis has been reported at rate of 17 to 31 % in patients with pathologic stage T1 (pT1) and pT2 rectal cancers [7]. The efficacy of adjuvant CCRT after local excision remains controversial, and evidence is lacking, as there are few published reports so far
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