Early Rectal Carcinoma Research Articles

Transanal Minimally Invasive Surgery in the Treatment of Large Polyps and Early Rectal Carcinoma

Transanal Minimally Invasive Surgery in the Treatment of Large Polyps and Early Rectal Carcinoma

Performance of dual-layer spectrum CT virtual monoenergetic images to assess early rectal adenocarcinoma T-stage: comparison with MR.

To evaluate the image quality and utility of virtual monoenergetic images (VMI) of dual-layer spectrum computed tomography (DLSCT) in assessing preoperative T-stage for early rectal adenocarcinoma (ERA). This retrospective study included 67 ERA patients (mean age 62 ± 11.1 years) who underwent DLSCT and MR examination. VMI 40-200 keV and poly energetic image (PEI) were reconstructed. The image noise, signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and tumor contrast of different energy levels were calculated and compared, respectively. Two radiologists independently assess the image quality of the VMIs and PEI using 5-point scales. The diagnostic accuracies of DLSCT and HR-MRI for ERA T-staging were evaluated and compared. The maximum noise was observed at VMI 40 keV, and noise at VMI 40-200 keV in the arterial and venous phases showed no significant difference (all p > 0.05). The highest SNR and CNR were obtained at VMI 40 keV, significantly greater than other energy levels and PEI (all p < 0.05). Tumor contrast was more evident than PEI at 40-100 keV in the arterial phase and at 40 keV in the venous phase (all p < 0.05). When compared with PEI, VMI 40 keV yielded the highest scores for overall image quality, tumor visibility, and tumor margin delineation, especially in the venous phase (p < 0.05). The overall diagnostic accuracy of DLSCT and HR-MRI for T-stage was 65.67 and 71.64% and showed no significant difference (p > 0.05). VMI 40 keV improves image quality and accuracy in identifying lesions, providing better diagnostic information for ERA staging. Low-keV VMI from DLSCT can improve tumor staging accuracy for early rectal carcinoma, helping guide surgical intervention decisions, and has shed new light on the potential breakthroughs of assessing preoperative T-stage in RC. • Compared with PEI, low-keV VIM derived from DLSCT, particularly at the 40 keV, significantly enhanced the objective and subjective image quality of ERA. • Using VMI 40 keV helped increase lesion detectability, leading to improved diagnostic accuracy for ERA. • Low-keV VMI from DLSCT has shed new light on the potential breakthroughs of assessing preoperative T-stage in RC.

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.

&#8220;Watch and wait&#8220; strategy in the treatment of patients with rectal carcinoma.

Innovative treatment strategies which do not involve oncosurgical radical rectal resection have been explored within the last decades in the management of patients with rectal carcinoma. Resection of the rectum with total mesorectal excision is burdened not only with significant postoperative morbidity, but also with symptoms of bowel, urinary and sexual dysfunctions, which can significantly affect patients quality of life. The aim of these alternative strategies is to preserve the anatomy and function of the rectum (so called organ preservation approach). This approach includes three innovative strategies: &#8220;watch and wait&#8221; strategy, neoadjuvant radiochemotherapy completed with transanal rectal carcinoma excision (or excision of the scar remaining after neoadjuvant therapy) and neoadjuvant radiochemotherapy of an early rectal carcinoma. So far, evidence supporting the organ preservation approach is highly insufficient in the available literature. There are no clear indication criteria for these strategies, no unequivocal criteria for complete clinical response detection and vague recommendations regarding an optimal neoadjuvant regimen or patients follow-up. Organ preservation approach is therefore considered to be an experimental treatment strategy, which should be offered only to patients within clinical trials with a high-quality design and very careful long-term follow-up. Patients considered for &#8220;watch and wait&#8221; must be informed properly about the benefits and drawbacks of the strategy including the risk of rectal carcinoma recurrence in 30% of the patients.

A case of early rectal carcinoma with submucosal tumor-like morphology

Submucosal tumor (SMT)-like colorectal cancer is relatively rare. The patient was a 59-year-old man who underwent colonoscopy after a positive fecal occult blood test. Colonoscopy showed a protruded lesion of 10mm in the lower rectum. On initial observation, conventional endoscopy showed that the lesion was covered with normal mucosa and its surface was reddish with small dimples. A neuroendocrine tumor was suspected, and a biopsy was performed, but the pathological diagnosis was adenocarcinoma. Re-examination 3weeks later showed a depression at the surface of the lesion owing to the biopsy. Magnifying NBI showed a vessel pattern of uneven and irregular distribution, and an irregular surface pattern in the depressed area. Magnifying observations with crystal violet staining showed irregular pit patterns. The preoperative diagnosis was submucosal invasive cancer, and operation was performed. The final pathological diagnosis was well-differentiated tubular adenocarcinoma with deep submucosal invasion. The tumor was primarily localized in the submucosal layer and was covered by non-neoplastic mucosa except for the depressed area. The tumor was not exposed on the surface and was proliferating under the mucosa, which resulted in an SMT-like morphology. Our present case indicates that colorectal cancers should be differentially considered when SMT lesions are detected.

Long-term outcomes of endoscopic submucosal dissection and transanal endoscopic microsurgery for the treatment of rectal tumors.

Endoscopic submucosal dissection and transanal endoscopic microsurgery are good options for the treatment of rectal adenomas and early rectal carcinomas, but whether long-term outcomes of these procedures are comparable is not known. The aim of this study was to address this question. A retrospective single-center study evaluating 98 consecutive procedures between June 2008 and December 2017 was performed in a tertiary cancer center. Consecutive patients who had undergone either endoscopic submucosal resection or transanal endoscopic microsurgery for rectal adenomas and early rectal carcinomas were evaluated, and long-term recurrence and complication rates were compared. Both groups were similar regarding sex, age, preoperative surgical risk, and en bloc resection rate (95.7% in the endoscopic and 100% in the surgical group, P=0.81). Mean follow-up period was 37.6months. Lesions resected endoscopically were significantly larger (68.5mm) than those resected by transanal resection (44.5mm), P=0.003. Curative resections occurred in 97.2% of endoscopic resections and 85.2% of the surgical ones (P=0.04). Comparing resections that fulfilled histologic curative criteria, there were no recurrences in the endoscopic group (out of 69 cases) and two recurrences in the transanal group (8.3% of 24 cases), P=0.06. Late complications occurred in 12.7% of endoscopic procedures and 25.9% of surgical procedures (P=0.13). In our experience, endoscopic submucosal resection seems to have advantages over transanal endoscopic microsurgery, with similar en bloc resection rate and lower rate of late complications and recurrences. Multicenter randomized controlled trials are needed to support our findings.

Comparison between endoscopic submucosal dissection and transanal endoscopic microsurgery for the treatment of rectal tumor

Objective To compare the efficacy and safety between endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) for the treatment of rectal tumors, including rectal adenoma, early rectal carcinoma, and rectal neuroendocrine tumors (NET). Methods We conducted an analysis including 139 patients with rectal tumors who underwent ESD (87) or TEM (52). The size of the tumor, location of the tumor, en bloc resection, R0 resection, procedure time, hospital stay, complications, etc, between the two groups were evaluated and analyzed. Results There was no significant difference in tumor size [(7.8±3.4) cm vs. (6.9±3.5) cm, P=0.398], location [(7.8±3.4) cm vs. (6.9±3.5) cm, P=0.320], en bloc resection (100% vs. 100%), R0 resection (94.3% vs. 100.0%, P=0.053), perforation rate (6.9% vs. 0%, P=0.053) and the recurrence of the same location (0% vs. 0%) between the two groups. Procedure time [(42.1±27.3) min vs. (78.5±21.3) min, P=0.018], the use of antibiotics (32.2% vs. 100%, P=0.000) and hospital stay [(6.3±4.8) days vs. (13.7±2.9) days, P=0.021] in the ESD group were significantly shorter than ESD group. The volume of intraoperative bleeding of the patients in the TEM group was less than that in ESD group [(53.0±18.7) ml vs. (31.7±12.4) ml, P=0.033]. Conclusion ESD is a safe and effective therapy for rectal tumors. Key words: Rectal tumors; Endoscopic submucosal dissection; Transanal endoscopic microsurgery

肋骨転移をきたしたT1b直腸癌の1例

62歳，女性．検診で便潜血陽性を指摘され，当科に紹介となった．大腸内視鏡検査にて下部直腸に10mm大のI sp型腫瘍を認め，内視鏡的粘膜切除術を施行した．tub1，T1b（2,000μm），ly0，v1，budding grade1，HM0（250μm），VM0（500μm）であり，腹腔鏡補助下低位前方切除術+D2郭清術を施行した．病理組織学的に腫瘍の遺残は認めず，総合所見はT1b，N0，M0，Stage Iであった．術後6カ月のCT検査で両側第9肋骨に腫瘤を指摘され，FDG-PET検査を施行したところ，異常集積（SUVmax7.8）を認めた．CTガイド下生検を施行したところ高分化管状腺癌であり，直腸癌の転移と診断した．早期直腸癌術後で肝臓や肺転移を伴わない骨転移は稀であり，文献的考察を加え報告する．

Current Controversies in Transanal Surgery for Rectal Cancer.

Local surgery for rectal tumors has been traditionally limited due to technical issues for lower risk lesions. In the 1980s, Buess described the transanal endoscopic microsurgery (TEM) technique that enabled excision of lesions that were larger and in a higher location. TEM in a short time became the gold standard for the excision of large adenomas and early rectal carcinomas. Since the advent of TEM, and due to advances in minimal invasive technology, new devices and procedures have come to the surgical armamentarium, in many cases with only very slight differences between them. However, local surgery for rectal cancer still remains a challenge. An overview of the current status of minimal transanal invasive techniques is presented here and sheds some light on the controversies that the local management of rectal cancer still raises.

PWE-326 Extending the scope of tem – effect of radiotherapy on outcome in locally excised t2 rectal cancer

Introduction Local excision of rectal cancers by Endoscopic Microsurgery (TEM) has become accepted as a valid treatment modality for very early rectal carcinomas (stage T1). However its use in the treatment of more advanced carcinomas of stage T2 and above remains more controversial due to the higher rate of local recurrence principally from occult nodal metastases. There has been considerable interest in the use of TEM in combination with radiotherapy in these patients as an alternative to radical rectal resection. We present a review of 12 patients with T2 rectal cancers who have undergone the TEM procedure, 6 of whom had additional radiotherapy and 6 who did not either because they were not fit to undergo this or because they elected for subsequent radical surgery. Method The records of all patient who had undergone a TEM procedure for rectal carcinoma at Royal Preston Hospital were reviewed and all those with T2 pathological staging identified. Their treatments and outcomes were recorded. Results Out of the 12 patients in the study, 6 did not receive radiotherapy either because they elected for subsequent radical surgery (3 patients) or were unfit for further treatment and underwent close follow-up (3 patients). In the radiotherapy group, 2 patients had pre-op Long-Course Chemo-radiotherapy (LCCRT) with a good partial response, 2 were included in the national TEM and Radiotherapy in Early Rectal cancer (TREC) trial and had pre-op Short Course radiotherapy (SCRT) and 2 had adjuvant LCCRT + Papillon contact radiotherapy following TEM. Median follow-up was 20 months. Patients not undergoing radial surgery had 3 monthly MR and sigmoidoscopy for 1 year and 6 monthly MR and sigmoidoscopy for a further 2 years. In the no-radiotherapy group, 1 of the 3 patients who underwent subsequent radical surgery had involved mesorectal lymph nodes and 1 of those undergoing close follow-up without radical surgery developed mesorectal nodal recurrence. In radiotherapy group 1 patient, in the TREC trial, elected for subsequent radical surgery and had no residual disease and 5 for close follow-up with no recurrences to date. There was no 90 day surgical mortality in either group. Conclusion Whilst the numbers in the study where not sufficient for valid statistical comparison, the lack of any tumour recurrence in the group receiving radiotherapy does support the use of TEM with radiotherapy as a promising alternative treatment modality for stage T2 rectal carcinoma particularly in patients who are high risk for radical surgery, have a near-complete response to pre-op radiotherapy or are keen to avoid a permanent stoma. Disclosure of interest None Declared.

How useful is endorectal ultrasound in the management of early rectal carcinoma?

Endorectal ultrasonography (EUS) is used to T stage early rectal tumours and select patients to whom transanal endoscopic microsurgery (TEM) could be offered. Published papers have shown that EUS can have good accuracy, but there is little literature on how EUS influences patient management. The study aim is to ascertain the value of EUS in the management of early rectal tumours. Patients with adenomas/early rectal carcinoma being considered for TEM were prospectively studied. Each patient underwent EUS. The surgeon recorded the expected T stage, confidence level of the T stage and management plan for each patient on a proforma before and after the ultrasound result was revealed. Comparison was made between the ultrasound stage and final pathological stage where available. Ninety-six patients were referred over 2 years. Nine were out of reach of the rigid probe and were excluded. Proformas were completed on 53/87 patients (age range 28-87 years, mean age 66 years, 30 males/23 females). Forty-eight patients had a pathological report to compare with the EUS T stage. Ultrasound agreed with the pathological T staging in 43 patients (90%). Patient management was changed in five patients. In 30% of (16/53) patients, EUS increased the confidence level for T staging. Although EUS has a high accuracy in predicting the T stage of early rectal cancers, it never changes the management plan for lesions thought to be benign. It seldom changes the pre-operative selection process when clinical examination is considered with other imaging modalities (MRI/CT). EUS should be reserved for answering specific questions in difficult cases rather than for all patients.

Diagnostic modalities for early rectal cancer - review of the literature

Rectal carcinoma represents a significant health problem in the modern world. Its high rate of occurrence and mortality in the late stages of the disease stresses the need for better diagnostic, prognostic and predictive methods. We present a review of the literature concerning the staging modalities, including the characteristics of early rectal carcinoma. Endoscopy, endoluminal ultrasound and magnetic resonance imaging play a major role in the preoperative staging and the restaging of rectal carcinoma. The new devices and technologies improve the diagnostic process thus providing an option for new management strategies and better results.

Hybrid ESD of an Early Rectal Carcinoma (LST-Nongranular Type)

A certain group of flat lesions with a size > 10 mm that show a very flat surface are called ‘NonGranular Laterally Spreading Tumors.’ They are difficult to detect, and the risk of submucosal invasion is high when they are present; more than 20% in lesions >2 cm. Their endoscopic resection can be challenging, and they represent, as well, one of the main indications for colorectal endoscopic submucosal dissection. The hybrid resection technique, which consists of a circumferential resection followed by snare resection, is one alternative approach for lesions <3 cm. This article is part of an expert video encyclopedia.

Minimally invasive treatment in early rectal carcinoma

Radiotherapy alone and local excision combined with radiotherapy have been alternative treatments of early rectal carcinoma resection.Compared with radical surgery,both radiotherapy alone and local excision combined with radiotherapy can get satisfactory effect,and prevent the high rate of complications and adverse reactions,which will improve the quality of life for patients with rectal carcinoma and should be recommended. Key words: Rectal neoplasms; Radiotherapy; Local excision

Endoscopic submucosal dissection for early large low rectal carcinomas and its precancerous lesions

Objective To evaluate the therapeutic value of endoscopic submucosal dissection （ESD） for early large low rectal carcinomas and its precancerous lesions. Methods The clinical data, pathology, complications and follow-up results of 24 cases of early large low rectal carcinomas and precancer- ous lesion, which were larger than 5em in diameter and treated by ESD, were retrospectively analyzed. Results The mean diameter of the lesions was 5.54 （5-7）cm, and the mean procedure time was 85 （45- 180）rain. The en bloc resection rate was 91.7% （22/24）, and histologically en bloc resection rate was 83.3% （20/24）. With regard to complication, 3 cases of postoperative hemorrhage （12. 5% ） and 2 cases of perforation （8. 3% ） were recorded, and no local reeurrenee or metastasis was Observed during＇the follow- up of 16-47 months. Conclusion ESD is effective for the treatment of large nonpeduneulated low rectal tumors. The ESD procedure facilitates a more precise pathologic diagnosis and reduees recurrence through en bloc resection, which also retains the function of the anus. Key words: Rectal cancer; Precancerous lesion; Endoscopic submucosal dissection

Expression of hMLH1 in rectal intraepithelial neoplasm and early rectal carcinoma

To explore whether the abnormality of hMLH1 gene may be an early event of carcinogenesis in rectal carcinoma, and to evaluate the diagnostic value in differentiation between intraepithelial neoplasm and early stage of colorectal carcinoma. The expression of hMLH1 protein in 28 cases with early invasive rectal carcinoma(EIRC), 36 cases with rectal intraepithelial neoplasm(RIEN), and 30 cases with normal rectal mucosa(NRM) which were collected through surgical operations were detected by PV-9000 immunohistochemical method. The positive expression rates of hMLH1 protein were 100%(30/30), 77.8%(28/36), and 39.3%(11/28) in NRM, RIEN, and EIRC respectively. The difference was statistically significant between RIEN and EIRC(P=0.002), and the difference was also statistically significant between RIEN and NRM(P=0.006). The positive expression of hMLH1 was not related to age, gender, tumor maximum diameter, dysplasia, tumor types, and distance from the anal verge in RIEV group(P>0.05). In EIRC group, hMLH1 was associated with tumor differentiation(P<0.05). hMLH1 gene deletion may be an early event during carcinogenesis of rectal carcinoma, which may be useful in differentiation of intraepithelial neoplasm from early rectal carcinoma.

Early Lower Rectal Carcinoma with Synchronous Isolated Lateral Pelvic Lymph Node Metastasis: Report of a Case

Early Lower Rectal Carcinoma with Synchronous Isolated Lateral Pelvic Lymph Node Metastasis: Report of a Case

A Case of Lung Metastasis 2 Years after Surgery for Early Rectal Carcinoma in Adenoma with a Micropapillary Carcinoma Component

症例は73歳男性．粘血便を主訴に来院し，精査にて直腸Raに径6.5cmの1型腫瘍を認め，腹腔鏡補助下低位前方切除術を施行した．病理組織学的には大部分は中等度から高度異型の管状絨毛腺腫であり，一部に高～中分化腺癌を認めた．癌の中央部分ではmicropapillary carcinoma（以下MPC）成分を認め，粘膜下層への浸潤をともなっていた．軽度のリンパ管侵襲を認めたが，リンパ節転移や他臓器転移は認めなかった．術後約2年目に単発性肺転移を認め，胸腔鏡補助下左肺上葉部分切除術を施行した．MPCはリンパ管様の空隙に囲まれた線維血管性間質を欠く微小乳頭状癌胞巣を組織学的特徴とする癌であり，再発や遠隔臓器への転移が高頻度で，悪性度の高い組織型であることが示唆されている．大腸癌での報告は少ないが，大腸癌においてもMPC成分を有する場合は，通常型の大腸癌に比較し，悪性度が高い可能性があり，厳重な経過観察が必要であると考えられた．

Confocal chromolaser endomicroscopy: a supplemental diagnostic tool prior to transanal endoscopic microsurgery of rectal tumors?

Due to diagnostic advancements, preoperative staging of rectal tumors was significantly improved. However, difficulties in obtaining accurate results can sometimes be observed in the staging of adenomas and early rectal carcinomas (pT1/2). The aim of this study was to test if confocal chromolaser endomicroscopy (cCLEM) can help minimize this diagnostic gap. cCLEM generates optical transversal sections at x1,000 magnification and allows for evaluation of the mucosal microarchitecture and differentiation of normal mucosa from adenomas and carcinomas. Cases with conflicting preoperative findings (adenoma vs. > or =uT2 categories), undetectable tumors after inadequate (R1/RX) snare polypectomy of carcinomas, and extremely flat adenoma areas were studied. By cCLEM, in > or =uT2 carcinomas with an adenoma histology, malignoma-suspicious areas were identified and selected biopsies were done. In addition, re-epithelialized polypectomy areas of carcinomas were visualized and targeted reoperations could be carried out. Furthermore, the dignity and extension of extremely flat adenomas were determined and marked by clips for additional therapy. In cases with rectal tumors, conflicting or unclear findings, and flat extending adenomas, the utilization of cCLEM should be considered. Especially in cases with early rectal carcinomas, unnecessary second operations and also recurrences can be minimized or even avoided by selective usage of cCLEM.

Transanal endoscopic microsurgery: indications, results and controversies

Transanal endoscopic microsurgery (TEM) was introduced in 1983 as a minimally invasive technique allowing the resection of adenomas and early rectal carcinomas unsuitable for local or colonoscopic excision which would otherwise require major surgery. After 25 years, there is still much debate about the procedure. This article presents the TEM technique, indications, results and complications, focusing on its role in rectal cancer. The controversial points addressed include long-term results, TEM in high-risk T1 lesions, TEM associated with combined modality therapy (CMT) for invasive rectal cancer and salvage therapy after TEM. The future perspectives for TEM are promising and its association with CMT will probably expand the select group of patients who will benefit from the procedure.