Early Rectal Cancer Research Articles

Risk of recurrence after endoscopic resection of nonpedunculated T1 colorectal cancer.

The long-term outcome after local excision of T1 colorectal cancer (CRC) remains unknown. The aim of this study was to examine clinical and histopathological risk factors for recurrence in patients with T1 CRC undergoing endoscopic resection. This was a retrospective registry-based population study on prospectively collected data of all patients with nonpedunculated T1 CRC undergoing only local excision (no salvage surgery) in Sweden between 2009 and 2018. Potential risk factors for recurrence, including age, sex, tumor location, resection margins, lymphovascular, perineural, and submucosal invasion, grade of differentiation, and mucinous subtype, were analyzed using univariate and multivariate cox regression. Median follow-up time was 60 months, and 28 /602 patients (4.7 %) had a recurrence (13 local and 18 distant). Recurrence rate stratified by submucosal invasion was: Sm1 3.5 % (14 /397), Sm2 6.0 % (8 /133), and Sm3 8.3 % (6 /72), with no significant differences. Resection margins, lymphovascular and perineural invasion, grade of differentiation, mucinous subtype, and age were not significant risk factors for recurrence. In contrast, rectal location was found to be a significant risk factor for tumor recurrence in multivariate analysis (hazard ratio 3.08, P = 0.006). The 3- and 5-year disease-free survival was 96.2 % and 91.1 %, respectively, in T1 CRC patients undergoing endoscopic resection. Tumor recurrence was rare (4.7 %) in this large population-based study on recurrence after local excision of nonpedunculated T1 CRC. Rectal location was an independent risk factor for recurrence, suggesting the need for strict surveillance after endoscopic resection of early rectal cancer.

When is transanal endoscopic surgery appropriate?

Rectal cancer is a complex medical diagnosis which requires critical decision-making on the part of physician and patient. Organ preservation with local excision for early stage rectal cancer, if done under the correct circumstances, allows for oncologically sound surgery with good patient outcomes. However, locally advanced disease as well as tumor location and size can change potential long-term outcomes. This article will investigate the technical and clinical aspects of transanal surgery and the decision-making algorithms for clinicians and patients.

Completion Total Mesorectal Excision After Transanal Local Excision of Early Rectal Cancer: A Systematic Review and Meta-analysis.

Completion total mesorectal excision is recommended when local excision of early rectal cancers demonstrates high-risk histopathological features. Concerns regarding the quality of completion resections and the impact on oncological safety remain unanswered. This study aims to summarize and analyze the outcomes associated with completion surgery and undertake a comparative analysis with primary rectal resections. Data sources included PubMed, Cochrane library, MEDLINE, and Embase databases up to April 2021. All studies reporting any outcome of completion surgery after transanal local excision of an early rectal cancer were selected. Case reports, studies of benign lesions, and studies using flexible endoscopic techniques were not included. The intervention was completion total mesorectal excision after transanal local excision of early rectal cancers. Primary outcome measures included histopathological and long-term oncological outcomes of completion total mesorectal excision. Secondary outcome measures included short-term perioperative outcomes. Twenty-three studies including 646 patients met the eligibility criteria, and 8 studies were included in the meta-analyses. Patients undergoing completion surgery have longer operative times (standardized mean difference, 0.49; 95% CI, 0.23-0.75; p = 0.0002) and higher intraoperative blood loss (standardized mean difference, 0.25; 95% CI, 0.01-0.5; p = 0.04) compared with primary resections, but perioperative morbidity is comparable (risk ratio, 1.26; 95% CI, 0.98-1.62; p = 0.08). Completion surgery is associated with higher rates of incomplete mesorectal specimens (risk ratio, 3.06; 95% CI, 1.41-6.62; p = 0.005) and lower lymph node yields (standardized mean difference, -0.26; 95% CI, -0.47 to 0.06; p = 0.01). Comparative analysis on long-term outcomes is limited, but no evidence of inferior recurrence or survival rates is found. Only small retrospective cohort and case-control studies are published on this topic, with considerable heterogeneity limiting the effectiveness of meta-analysis. This review provides the strongest evidence to date that completion surgery is associated with an inferior histopathological grade of the mesorectum and finds insufficient long-term results to satisfy concerns regarding oncological safety. International collaborative research is required to demonstrate noninferiority. CRD42021245101.

Research Perspective on Completion Total Mesorectal Excision After Transanal Local Excision of Early Rectal Cancer: A Systematic Review and Meta-analysis.

Funding/Support: None reported. Financial Disclosures: None reported. Correspondence: Tarik Sammour, F.R.A.C.S, Ph.D., Royal Adelaide Hospital, Port Rd Adelaide, South Australia 5000, Australia. E-mail: [email protected]

A Phase II trial of Higher RadiOtherapy Dose In The Eradication of early rectal cancer (APHRODITE): protocol for a multicentre, open-label randomised controlled trial

IntroductionThe standard of care for patients with localised rectal cancer is radical surgery, often combined with preoperative neoadjuvant (chemo)radiotherapy. While oncologically effective, this treatment strategy is associated with operative mortality...

EPIDEMIOLOGICAL ASPECTS OF COLORECTAL CANCER
 IN THE REPUBLIC OF KAZAKHSTAN

Relevance: Colorectal cancer is one of today’s most critical health issues globally and in the Republic of Kazakhstan. Taking leading positions
 in the general structure of oncopathology, this nosological form of tumors forces clinicians to develop ways to improve statistical indicators.
 ЭПИДЕМИОЛОГИЯ
 Онкология и радиология Казахстана, №1 (63) 2022 31
 Purpose of the article – to review the epidemiological aspects of colorectal cancer in the Republic of Kazakhstan in 2011-2020.
 Results: We revealed an increase in the share of early (I-II) stage colon and rectal cancer cases. The share of early stages of rectal cancer was
 61.5% in 2011 compared to 68.5% in 2020; in colon cancer, it was 36.5% and 53.1%, respectively.
 The share of advanced (locally advanced) stage III cases of visually accessible rectal cancer has decreased from 25.2% in 2011 to 18.3% in
 2020. The overall 5-year survival in 2020 amounted to 50.7% for colon cancer and 46.0% for rectal cancer, and these were the best rates in the
 entire decade. We also found territorial specifics in this pathology incidence.
 The one-year and overall mortality from these diseases have decreased, amounting to 29.2 in 2011 and 18.8 in 2020 for rectal cancer, 31.9 and
 19.8 for colon cancer, 4.5 and 3.9 in rectal cancer, 4.8 and 4.1 in colon cancer, respectively.
 Conclusions: An analytical assessment of the statistical indicators of colorectal cancer over the decade showed that there are regions that
 excel in incidence rates from year to year. At the same time, indicators of early diagnosis and overall 5-year survival have improved, and one-year
 and overall mortality has decreased.

EPIDEMIOLOGICAL ASPECTS OF COLORECTAL CANCER IN THE REPUBLIC OF KAZAKHSTAN

Relevance: Colorectal cancer is one of today’s most critical health issues globally and in the Republic of Kazakhstan. Taking leading positions in the general structure of oncopathology, this nosological form of tumors forces clinicians to develop ways to improve statistical indicators.
 The study aimed to review the epidemiological aspects of colorectal cancer in the Republic of Kazakhstan from 2011 to 2020.
 Methods: In a comparative aspect, the analytical assessment method was used to analyze the statistical indicators of the oncological
 service of the Republic of Kazakhstan for a decade, from 2011 to 2020.
 Results: We revealed an increase in the share of early (I-II) stage colon and rectal cancer cases. The percentage of early stages of rectal
 cancer was 61.5% in 2011 compared to 68.5% in 2020; in colon cancer, it was 36.5% and 53.1%, respectively.
 The share of advanced (locally advanced) stage III cases of visually accessible rectal cancer has decreased from 25.2% in 2011 to
 18.3% in 2020. The overall 5-year survival in 2020 amounted to 50.7%for colon cancer and 46.0%for rectal cancer, and these were the
 best rates in the entire decade. We also found territorial specifics in this pathology incidence.
 The one-year and overall mortality decreased from 2011 to 2020. The one-year mortality went down from 29.2 to 18.8 for rectal cancer
 and 31.9 to 19.8 for colon cancer; the overall mortality went from 4.5 to 3.9 for rectal cancer and 4.8 to 4.1 for colon cancer.
 Conclusions: An analytical assessment of the statistical indicators of colorectal cancer over the decade showed that there are regions
 that excel in incidence rates from year to year. At the same time, indicators of early diagnosis and overall 5-year survival have improved,
 and one-year and overall mortality has decreased.

Can CCRT/RT Achieve Favorable Oncologic Outcome in Rectal Cancer Patients With High Risk Feature After Local Excision?

PurposeThe oncologic outcome of concurrent chemoradiotherapy (CCRT) after local excision in patients with high-risk early rectal cancer as compared with radical operation has not been reported. The aim of this study is to compare the oncologic outcome between radical operation and adjuvant CCRT after local excision for high-risk early rectal cancer.Materials and MethodsFrom January 2005 to December 2015, 266 patients diagnosed with early rectal cancer and treated with local excision who showed high-risk characteristics were retrospectively analyzed. Propensity score matching was applied in a ratio of 1:4, comparing the CCRT/radiotherapy (RT) (n = 34) and radical operation (n = 91) groups. Univariate and multivariate analyses were performed to identify prognostic factors for survival.ResultsThe median follow-up period was 112 months. The 5-year disease-free survival rate and the 5-year overall survival of the radical operation group were significantly higher than those of the CCRT/RT group after propensity score matching (96.7% vs. 70.6%, p <0.001; 100% vs. 91.2%, p = 0.005, respectively). In a multivariate analysis, salvage therapy type and preoperative carcinoembryonic antigen (CEA) were prognostic factors for 5-year disease-free survival (p <0.001 and p = 0.021, respectively). The type of salvage therapy, the preoperative CEA, and the pT were prognostic factors for 5-year overall survival (p = 0.009, p = 0.024, and p = 0.046, respectively).ConclusionsPatients who undergo radical operations after local excision with a high-risk early rectal cancer had better survival than those treated with adjuvant CCRT/RT. Therefore, radical surgery may be recommended to high-risk early rectal cancer patients who have undergone local excision for more favorable oncologic outcomes.

Accuracy of MRI in early rectal cancer: national cohort study.

MRI plays a pivotal role in the staging of early rectal cancer, resulting in allocation of patients to surgery or organ-sparing treatment. In this large population-based retrospective cohort study, MRI substantially understaged pT3 and overstaged pT1 rectal cancer, in addition to unreliable nodal staging. Based on these findings, MRI is not adequate in allocating patients with rectal cancer to organ-sparing treatment.

Local recurrence at the site of the Lone Star device through implantation of exfoliated cells during local excision for early rectal cancer: A case report.

IntroductionInvasive procedures for colorectal cancer can cause iatrogenic tumor cell seeding. Implantation of these exfoliated cells in the surrounding tissue can result in locoregional cancer recurrence. This has been described in endoscopic procedures and major surgical resections, however recurrence in iatrogenic lesions of the anal canal during minimal invasive rectal surgery has not been shown in literature yet. This is the first reported case of recurrent rectal cancer that developed into an anal metastasis at the site where hooks of the Lone Star Retractor disrupted the epithelial lining of the anal canal during a local excision of early rectal cancer using TAMIS.Presentation of caseA 57 year old male was diagnosed with a high risk early stage rectal adenocarcinoma. He was treated with transanal minimally invasive surgery (TAMIS) with the use of a Lone Star retractor and he received subsequent chemo-radiotherapy. 23 months later the patient developed a bleeding mass bulging out of the anus. A true cut and incision biopsy was performed and the pathology report revealed localization of adenocarcinoma at the anal canal which was similar to the earlier diagnosed rectal carcinoma. The patient underwent an abdominal perineal resection and left-sided lymph node dissection.Discussion and conclusionThis shows that local recurrence through implantation of exfoliated tumor cells can occur in iatrogenic lesions of the anal canal not only in major but also in minimal invasive rectal surgery. Careful tissue handling and rectal washout may reduce the chance of this implantation metastasis.

The Role of Transanal Endoscopic Surgery for Early Rectal Cancer.

Transanal endoscopic surgery (TES), which is performed through a variety of transanal endoluminal multitasking surgical platforms, was developed to facilitate endoscopic en bloc excision of rectal lesions as a minimally invasive alternative to radical proctectomy. Although the oncologic safety of TES in the treatment of malignant rectal tumors has been an area of vigorous controversy over the past two decades, TES is currently accepted as an oncologically safe approach for the treatment of carefully selected early and superficial rectal cancers. TES can also serve as both a diagnostic and potentially curative treatment of partially resected unsuspected malignant polyps. In this article, indications and contraindications for transanal endoscopic excision of early rectal cancer lesions are reviewed, as well as selection criteria for the most appropriate transanal excisional approach. Preoperative preparation and surgical technique for complications of TES will be reviewed, as well as recommended surveillance and management of upstaged tumors.

New Frontiers in Management of Early and Advanced Rectal Cancer.

Simple SummaryRectal cancer has the capacity to present in a variety of forms. Depending on subtle differences in the characteristics of the tumor, it is possible for the treatment protocol to vary drastically. There are many tools available to optimize patients’ outcomes when treating rectal cancer of these various stages. Advances in early-stage, local presentation of rectal cancer focus on minimally invasive endoluminal surgery. Lesions completely responding to neoadjuvant chemoradiation non-operative surveillance have been explored. For rectal cancers patients with problematic pelvic anatomy, new platforms for resection, such as transanal total mesorectal excision and robotic total mesorectal excision, have been introduced. Late solid organ and peritoneal metastasis, originally thought to be a terminal disease, have undergone recent advances in hepatic and pulmonary metastasectomy, cytoreductive surgery, and intraperitoneal chemotherapy. Understanding these various therapeutic interventions will pave the way for improved patient outcomes.It is important to understand advances in treatment options for rectal cancer. We attempt to highlight advances in rectal cancer treatment in the form of a systematic review. Early-stage rectal cancer focuses on minimally invasive endoluminal surgery, with importance placed on patient selection as the driving factor for improved outcomes. To achieve a complete pathologic response, various neoadjuvant chemoradiation regimens have been employed. Short-course radiation therapy, total neoadjuvant chemotherapy, and others provide unique advantages with select patient populations best suited for each. With a clinical complete response, a “watch and wait” non-operative surveillance has been introduced with preliminary equivalency to radical resection. Various modalities for total mesorectal excision, such as robotic or transanal, have advantages and can be utilized in select patient populations. Tumors demonstrating solid organ or peritoneal spread, traditionally defined as unresectable lesions conveying a terminal diagnosis, have recently undergone advances in hepatic and pulmonary metastasectomy. Hepatic and pulmonary metastasectomy has demonstrated clear advantages in 5-year survival over standard chemotherapy. With the peritoneal spread of colorectal cancer, HIPEC with cytoreductive therapy has emerged as the preferred treatment. Understanding the various therapeutic interventions will pave the way for improved patient outcomes.

Report from 'ESCP 2021 Virtual': the 16th Scientific and Annual Conference of the European Society of Coloproctology, 22-24 September 2021.

Report from 'ESCP 2021 Virtual': the 16th Scientific and Annual Conference of the European Society of Coloproctology, 22-24 September 2021.

IMMUNOlogical microenvironment in REctal Adenocarcinoma Treatment (IMMUNOREACT 1; NCT04915326): preliminary results on prediction of presence of nodal metastasis in early rectal cancer

Background: Transanal local excision was recently indicated as potential alternative to radical surgery for early rectal cancer but, to minimize the recurrence rate after local excision, the accuracy of nodal staging should be increased. In early rectal cancers absence of CD8+ T-cell infiltration can predict nodal involvement. Field cancerization occurs in various epithelial carcinomas, including rectal cancer, meaning that some molecular events in carcinogenesis might occur even in normal tissues surrounding tumors.

Total Mesorectal Excision vs. Transanal Endoscopic Microsurgery Followed by Radiotherapy for T2N0M0 Distal Rectal Cancer: A Multicenter Randomized Trial

IntroductionTransanal endoscopic microsurgery (TEM) is an organ-preserving treatment alternative for patients with early rectal cancer. However, TEM alone is associated with greater risk of local recurrence and inferior survival in comparison with total meso-rectal excision (TME). As an important adjuvant therapy, radiotherapy can effectively reduce the local recurrence rate of rectal cancer. This study aimed to investigate whether TEM followed by radiotherapy can be a valid alternative to TME in T2N0M0 distal rectal cancer treatment.MethodsWe plan to recruit 168 participants meeting established inclusion criteria. Following informed consent, participants will randomly receive treatment protocols of TEM followed by radiotherapy (a total dose of 45–50.4 Gy given in 25–28 factions) or TME. Depending on post-operative pathology, the participants will receive either long-term follow-up or further treatment. The primary endpoint of this trial is 3-year local recurrence rate. The secondary end points include 3-year disease-free survival rate, 3-year overall survival rate, 3-year mortality rate, post-operative quality of life, post-operative safety index, intraoperative evaluation index and post-operative short-term evaluation index.DiscussionThis trial is the first prospective randomized trial to investigate the rectum preserving treatment by using transanal local excision followed by radiotherapy.Clinical trial registrationThe trial was prospectively registered at ClinicalTrials.gov NCT04098471 on September 20, 2019.

IMMUNOlogical microenvironment in REctal Adenocarcinoma Treatment (IMMUNOREACT) 5: preliminary results on gender difference in immune microenvironment of rectal cancer

Background: Immune microenvironment play a role in rectal cancer outcome. In early rectal cancers the absence of CD8+ T-cell infiltration can predict nodal involvement and a low stromal Foxp3(+) cell density was observed in those who had a pathological complete response (pCR) to neoadjuvant therapy. The immune microenvironment may be influenced by gender. The signaling governed by IFN type I has emerged as pivotal in orchestrating host defense against cancer and this pathway displays different activation between sexes.

Local Recurrence After Pure NOTES Transanal Total Mesorectal Excision for Early Rectal Cancer

Local Recurrence After Pure NOTES Transanal Total Mesorectal Excision for Early Rectal Cancer

Transanal endoscopic microsurgery in the treatment of patients with benign neoplasms and early rectal cancer

Introduction. Transanal endoscopic microsurgery (tem) is a method that allows the specialists to clearly visualize a tumor and bimanually remove the tumor using a set of special instruments. For a number of patients with a good tumor response to chemoradiation therapy (crt), tem is used as an advanced biopsy technique for tumor verification. The purpose of the study was to analyze the results of tem performed at a. Tsyb mrrc. Material and methods. Between 2015 and 2020, 64 patients (men – 42.2 % and women – 57.8 %) underwent tem. Forty patients had rectal cancer and 25 patients had benign rectal tumors. The indication for tem in patients with rectal cancer was the evidence of tis-t1 tumor by postoperative examination findings (mri and endosonography). Eleven patients with stage ii–iii rectal cancer received chemoradiation therapy. The indication for performing tem after rt in patients with rectal cancer was a good tumor response (mri trg1- 2). For statistical processing, commercial biomedical packages prism 3.1 and instat (graphpad software, inc., san diego, usa) were used. The significance of the differences between the indicators was assessed using the pearson χ2 test. Differences were considered significant if the p value was less than 0.05. Results. The median duration of surgery was 110 minutes (30–385). The volume of blood loss did not exceed 40 ml. Postoperative complications were observed in 15 cases (23.4 %). Grade 3 complications according to the clavien-dindo classification were observed in 5 (7.8 %) cases. Postoperative complications occurred more frequently in patients after crt (10.7 and 18.2 %; p=0.603), however, the differences were not statistically significant. At a median follow-up of 18 months (7–30), local relapses developed in 6 out of 26 (23 %) patients who underwent surgery alone. There were no signs of local recurrence in patients with adenocarcinomas after neoadjuvant chemotherapy and rectal adenomas. When comparing patients with the depth of tumor invasion tis-t1sm2 and t1sm3-t2, local relapses occurred in 1 of 21 (4.7 %) and 5 of 12 (41.6 %) cases, respectively (p=0.015). Conclusion. The analysis of the results of tem interventions in patients with rectal neoplasms allows us to conclude that this method of treatment is a priority for patients with benign rectal neoplasms and early rectal cancer. The method can also be used after rt or crt in patients with tumor invasion ≥t1sm3, provided a complete or almost complete tumor response to the treatment.

Latest evidence on the management of early‐stage and locally advanced rectal cancer: a narrative review

Rectal cancer is a challenging disease process to manage, with a rising incidence in young adults. Several clinical advances have been made in the past decade with regards to optimal treatment strategies in early-stage (T1-2, node negative tumours) and locally advanced cancers (T3-4 and/or nodal positivity) utilizing a multimodal approach of surgery, neoadjuvant chemoradiotherapy, and adjuvant chemotherapy, all aiming to optimize oncological outcomes, while minimizing associated morbidity. This narrative review aimed to summarize trial level evidence apropos the management of early and locally advanced rectal cancer. All relevant prospective clinical trials were identified through a computer-assisted search of PubMed, EMBASE, Medline databases between 1990 and 30 June 2021. With regards to early rectal cancer, there is limited trial-level evidence in the literature. Total mesorectal excision (TME) is the current standard of care, but local excision could be considered in select patients with pT1 tumours, or patients with near or complete clinical response to neoadjuvant CRT. As for locally advanced rectal cancer, the current standard of care consists of long-course chemotheradiotherapy or short-course radiotherapy, followed by TME. However, the role of total neoadjuvant therapy is promising, with respect to both oncological outcomes, as well as in reducing toxicity. Both induction and consolidation chemotherapy treatment approaches have been described in literature, with encouraging early results. The optimal management of rectal cancer is constantly evolving. More research is needed to investigate the long-term oncological and functional outcomes following new multimodal therapies in the management of early-stage and locally advanced rectal cancer.

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

PurposeThe standard of care for early rectal cancer is radical surgery; however, it carries high postoperative morbidity. This study aimed to assess the short-term and oncological outcomes of local excision and adjuvant radiotherapy in patients with high-risk pathological stage (p) T1 rectal cancer.MethodsFifty-five patients underwent local excision with adjuvant radiotherapy or radical resection for high-risk T1 rectal cancer. Patients with adenocarcinoma within 10 cm from the anal verge; pT1 with high-risk features (grade 3–4); a tumor size of ≥3 cm; a positive margin; a lymphovascular or perineural invasion; or a submucosal invasion depth of ≥SM2 were included.ResultsThe rates of postoperative complications and stoma formation were higher in the radical surgery group (P = 0.021 and P = 0.003, respectively). No significant differences were observed in the overall survival and disease-free survival (DFS) between the 2 groups (P = 0.301 and P = 0.076, respectively). Vascular invasion was a significantly poor prognostic factor for DFS (P = 0.033). The presence of 3 or more high-risk features was associated with a poor DFS (P = 0.002).ConclusionLocal excision with adjuvant radiotherapy significantly reduces the risk of complications and stoma formation. It is also an alternative option for patients with fewer than 3 high-risk features.