Local Excision Of Rectal Cancer Research Articles

Multimodality Salvage of Recurrent Disease After Local Excision for Rectal Cancer

Local excision, alone or in combination with chemoradiation, is increasingly considered for rectal cancer. Higher risks of disease recurrence have been demonstrated after local excision. The aim of this study was to examine the outcomes of current-era multimodality salvage for recurrent rectal cancer after local excision. This was a single-institutional retrospective study. This study was conducted at a tertiary-referral cancer center between 1993 and 2011. Forty-six patients with recurrent rectal cancer after initial local excision were included. Multimodality salvage treatment was performed as appropriate. The primary outcomes measured were the pattern of disease recurrence, salvage treatments, and resultant overall and re-recurrence-free survival. After the initial local excision, recurrent disease was diagnosed after a median interval of 1.9 years: local/regionally in 67%, distantly in 18%, and both in 15%. Four patients (9%) had recurrence that was unsalvageable, 2 (4%) declined treatment, and 40 (87%) underwent surgical salvage. Preoperative chemoradiation was given in 30 (75%) patients. The R0 resection rate was 80%, requiring multivisceral resection (33%), total pelvic exenteration (5%), and metastasectomy (25%). The rate of sphincter preservation was 33%, and perioperative morbidity was 50%. The first site of failure after salvage was distant in 38% and was local only in 10%. The 5-year overall and 3-year re-recurrence-free survival were 63% and 43%. Pathologic stage at initial local excision, receipt of neoadjuvant chemoradiation before local excision, recurrence pattern after local excision, pathologic stage at salvage, and R0 resection at salvage influenced re-recurrence-free survival. This study was limited by the referral and selection biases inherent in a small study cohort. Failure after local excision for rectal cancer may not be salvageable. When feasible, multimodality treatment, including multivisceral resection, pelvic irradiation, and chemotherapy, was associated with potentially lasting treatment-related morbidities and only modest success in long-term disease control. These findings should be compared with the expected stage-specific outcomes of standard proctectomy for early-stage rectal cancer, when local excision is being considered.

A Stepwise Approach to Transanal Endoscopic Microsurgery for Rectal Cancer Using a Single-Incision Laparoscopic Port

Radical rectal resection with total mesorectal excision is the current standard of care for the operative treatment of rectal cancer. Local excision is an acceptable alternative in selected patients with early disease (T(is)0-T(1)) and low-risk features, in whom radical resection may be associated with unacceptably high morbidity. With recent data demonstrating favorable results in well-selected patients, the role of local excision for rectal cancer is expanding.1 (,) 2 Transanal endoscopic microsurgery (TEM), which requires the use of an operating anoscope, has been used for the local excision of mid-upper rectal tumors. We describe an alternative approach to TEM for rectal cancer. We present a stepwise technique for TEM using a single-incision laparoscopic (SILS) port. The patient is a 64 year-old male with a right anterolateral rectal polyp 7 cm from the anal verge, which on snare polypectomy demonstrated in-situ carcinoma with positive margins. Endoscopic ultrasound demonstrated uT(1) disease with no lymphadenopathy. He opted for local excision and underwent TEM. Our stepwise approach includes: (1) delineation of excision margins, (2) full thickness incision of the rectal wall, (3) circumferential dissection, and full thickness excision, and (4) suture repair. The procedure was performed without intraoperative or postoperative complications. Final pathology revealed in-situ carcinoma with widely negative margins. At 1- and 3-week follow-up visits, the patient was pain free with normal bowel activity and no rectal bleeding or genitourinary dysfunction. TEM using a SILS port is an effective technique for the local excision of mid-upper rectal cancer in well-selected patients.

Functional and Oncological Outcomes After Transanal Local Excision for Rectal Cancer. A Prospective Study

Background: Surgery for rectal cancer is impaired by a significant risk of perioperative morbidity, urinary and sexual disfunction due to nerve injuries and, obviously, the possibility of a temporary or even a permanent stoma. In order to mitigate the sequelae of such a major surgery, trans-anal local excision has been proposed in selected cases to treat rectal cancer. Aim of this prospective study is to investigate which patients might get a benefit from this less invasive treatment, evaluating both oncological and functional results.

Transanal endoscopic microsurgery for 135 patients with small nonadvanced low rectal cancer (iT1–iT2, iN0): short- and long-term results

Local excision of rectal cancer as an alternative to radical resection for patients with small nonadvanced low rectal cancer (SNALRC) (iT1-iT2, iN0) is debated. This study aimed to analyze the short- and long-term results for a series of 135 patients with SNALRC who underwent local excision by transanal endoscopic microsurgery (TEM). According to the study protocol, 135 patients classified by endorectal ultrasound, magnetic resonance imaging (MRI), and computed tomography (CT) imaging as having iT1 iN0 iM0 (n = 51) or iT2 iN0 iM0 (n = 84) low rectal cancer were enrolled in the study. All the patients with iT2 rectal cancer underwent neoadjuvant therapy. The definitive histologic findings showed 24 pT0 patients (17.8%), 66 pT1 patients (48.8%), and 45 pT2 patients (33.4%). Minor complications were observed in 12 patients (8.8%) and major complications in 2 patients (1.5%). During a median follow-up period of 97 months (range, 55-139 months), local recurrences occurred for four patients and distant metastases for two patients. The patients who experienced a recurrence had been preoperatively staged as iT2 and were low or nonresponders to neoadjuvant treatment (ypT2). At the end of the follow-up period, the disease-free survival rates were 100% for the iT1 patients and 93% for the iT2 patients The long-term results for adequate local excision by TEM with or without neoadjuvant radiochemotherapy in the treatment of SNALRC based on the current study protocol are not inferior to those reported in the literature for radical surgery with total mesorectal excision (TME).

Chemoradiation (CRT) Safety Analysis of ACOSOG Z6041: A Phase II Trial of Neoadjuvant (NEO) CRT followed by Local Excision (LE) in uT2 Rectal Cancer (RC)

Radical surgical resection of RC can lead to significant morbidity. Sphincter-sparing approaches, such as LE, result in less morbidity but has a higher local recurrence rate. This phase II major cooperative group study explores neo CRT followed by LE for uT2 RC. The specific aim of the present analysis is to report the toxicity results during the neo CRT.

Local excision of rectal cancer afterchemoradiation: feasibility depends on the primary stage

Local excision of rectal cancer afterchemoradiation: feasibility depends on the primary stage

Local Excision for Rectal Cancer—Safety and Efficacy Challenges

Local Excision for Rectal Cancer—Safety and Efficacy Challenges

Preoperative radiotherapy and local excision of rectal cancer with immediate radical re-operation for poor responders

Background and purpose To report an early analysis of prospective study exploring preoperative radiotherapy and local excision in rectal cancer. Materials and methods Mucosa at tumour edges was tattooed. Patients with cT1-3N0 tumour <3-4 cm were treated with either 5 × 5 Gy + 4 Gy boost ( N = 31) or chemoradiation (50.4 Gy + 5.4 Gy boost, 1.8 Gy per fraction + 5-fluorouracyl and leucovorin; N = 13). Thirteen patients from the short-course group were unfit for chemotherapy. The interval from radiation to full-thickness local excision was 6 weeks. The protocol called for conversion to a transabdominal surgery in case of ypT2-3 disease or positive margin. Results The postoperative complications requiring hospitalization were recorded in 9% of patients. The rate of pathological complete response was 41%. The rate of patients requiring conversion was 34%; however, 18% actually underwent conversion and the remaining 16% refused or were unfit. During the 14 months of median follow-up, local recurrence was detected in 7% of patients and all underwent salvage surgery. Of 19 patients in whom initially anterior resection was likely, 16% had abdominoperineal resection performed for a conversion or as a rescue procedure. Conclusion Our study suggests that the short-course radiation prior to local excision is a treatment option for high-risk patients.

Transanal endoscopic microsurgery for the treatment of rectal cancer: comparison of wound complication rates with and without neoadjuvant radiation therapy

Neoadjuvant therapy for rectal cancer has led to improved tumor downstaging and higher complete pathologic response rates. At the same time, the introduction of transanal endoscopic microsurgery (TEM) technique has renewed interest in local excision of rectal cancer. There has been concern that radiation may make the more radical local excision with TEM unsuitable. Our study compared morbidity rates and wound complication rates for patients undergoing TEM and local excision with and without neoadjuvant radiation to determine whether this could be accomplished safely. Data for all patients undergoing TEM are prospectively entered into a database. This database was queried for patients with rectal cancer undergoing TEM from November 1997 to June 2007. Of 64 patients identified, 2 were excluded because of previous radiation to the pelvis. The study enrolled 62 patients with a final pathologic diagnosis of rectal cancer: 43 treated using neoadjuvant therapy with radiation (XRT) and 19 patients treated with TEM alone. The patients in the XRT group were 67 years of age (range, 29-86 years) and included 13 women. The patients in the non-XRT group were 66 years of age (range, 40-89 years) and included 8 women. Neither group had any mortalities. The overall morbidity rate was 33% for the XRT group and 5.3% for the non-XRT group, and this difference was statistically significant (p < 0.05). The wound complication rates were 25.6% for the XRT group (11 patients) and 0% for the non-XRT group (p = 0.015). Nine patients in the XRT group (82%) had minor wound separations, and two patients (18%) had major wound separation. Ten patients with wound separations were treated as outpatients and administered long-term oral antibiotics. One patient required additional surgery (diverting stoma). Not unexpectedly, the wound complication rate was higher in the XRT group. However, 82% of those wounds were minor, and 91% were treated without any additional surgery or intervention. Although a significant concern, wound complications do not prohibit TEM treatment after neoadjuvant treatment.

Prognostic factors for 5-year survival after local excision of rectal cancer

To evaluate the prognostic factors for 5-year survival after local excision of rectal cancer, and to examine the therapeutic efficacy and surgical indications for this procedure. Clinical data, obtained from 106 local rectal cancer excisions performed between January 1980 and December 2005, were retrospectively analyzed. Survival analysis was performed using the Kaplan-Meier method, statistical comparisons were performed using the log-rank test, and multivariate analysis was performed using the Cox proportional hazards model. Transanal, transsacral, and transvaginal excisions were performed in 92, 12, and 2 cases, respectively. The rate of complication, local recurrence, and 5-year survival was 6.6%, 17.0%, and 86.7%, respectively. Univariate analysis showed that T stage, vascular invasion, and local recurrence were related to the prognosis of the cases (P < 0.05). Multivariate analysis showed that T stage [P = 0.011, 95% confidence interval (CI) = 1.194-3.878] and local recurrence (P = 0.022, 95% CI = 1.194-10.160) were the major prognostic factors for 5-year survival of cases after local excision of rectal cancer. Local rectal cancer excision is associated with few complications, and suitable for stages Tis and T1 rectal cancer. Prevention of local recurrence, active postoperative follow-up, and administration of salvage therapy are the effective methods to increase the efficacy of local excision of rectal cancer.

Is local excision adequate for stage I rectal cancer?

Rectal cancer is a significant source of morbidity and mortality in patients. Although survival rates have improved with advances in surgical techniques and adjuvant therapy, these interventions are nonetheless associated with significant morbidity. Local excision has been suggested as an alternative surgical option that enables preservation of the anal sphincter and maintenance of good function. The oncologic outcomes, however, limit the broad application of this approach. This article reviews the recent literature on the role of local excision for rectal cancer and provides insight into its use and limitations.

Benefits, Limitations, and Harm of Local Excision for Rectal Cancer

Benefits, Limitations, and Harm of Local Excision for Rectal Cancer

Outcomes after Local Excision for Rectal Cancer

Despite its widespread use, the role of local excision for early rectal cancer as a curative therapy remains controversial. Studies are often plagued with low patient numbers, limited follow-up, or heterogeneous populations. In addition, problems with inaccurate staging, inadequate resection margins, and patient selection have limited the ability to interpret, compare, and generalize results. This article will focus on reported outcomes of local excision for early rectal cancer and discuss suggested guidelines.

Outcome of Transanal Endoscopic Microsurgery and Adjuvant Radiotherapy in Patients with T2 Rectal Cancer

The use of transanal endoscopic microsurgery for local excision of rectal cancer has recently gained wide acceptance as a valid and safe alternative for the surgical treatment of T1 tumors. The adequacy of such treatment for T2 tumors, however, is still controversial. This study was designed to evaluate our results with local excision of T2 cancers. Patients with T2 cancer admitted to our hospital between 1995 and 2005 were offered surgery by transanal endoscopic microsurgery if found medically unfit or were unwilling to undergo radical surgery. Patients who were preoperatively staged as T1 tumor but were found to be pathologically T2 also were included. Overall, we performed 59 transanal endoscopic microsurgery operations for rectal cancers, of which 21 were for T2 cancers. In 16 (76 percent) of the T2 patients, the tumors were completely removed with clear margins by transanal endoscopic microsurgery and no additional surgery was performed, except for 2 patients who developed radiation-induced complications. Radical surgery was performed in a second operation in five patients because of involved margins and residual disease was found in two. At a median follow-up of three years, all 12 patients who received local excision and radiotherapy remained disease free, whereas a 50 percent recurrence rate was observed in patients who refused adjuvant radiotherapy. The results of this study support the feasibility of transanal endoscopic microsurgery for the treatment of selected patients with T2 rectal cancer. The addition of radiotherapy may decrease the rates of early local recurrence. However, at present, this treatment strategy should not be routinely considered for patients who may undergo radical procedures.

Radical surgery for early colorectal cancer—anachronism or oncologic necessity?

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. 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. 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.

When can local excision be considered adequate for treatment of non advanced low rectal cancer (NALRC)?

One major issue in local excision of NALRC is the extent and depth of tissue excision. In the last decade several improvements have occurred in the diagnosis and treatment of NARLC, including new imaging techniques (MRI with new specific contrast agents), neoadjuvant therapy and Transanal Endoscopic Microsurgery (TEM). Surgeons who are experienced with local excision of rectal cancer both by TEM and by traditional excision techniques know that this extent may be variable. An adequate local excision specimen should look like a truncated pyramid and including 1 cm of normal mucosa around the tumor with the base corresponding to the mesorectal fascia (“holy plane”) for posterior lesions, and the prostatic capsule or vagina for anterior ones. The volume of excised tissue should not be less than 60 cc. In a consecutive series of 210 pT0-1-2-3 N0 G1-2 rectal cancer patients the local recurrence rate and probability of survival at 90 months of follow up were 5% and 89%, respectively, after neoadjuvant therapy and TEM. 1 Electrocoagulation spots at one cm distance around the tumor after neoadjuvant radiochemotherapy. 2 Prostatic capsule after excision of an anteriorly located lesion. 3 Posterior wall of the vagina after excision of a tumor located on the left lateral wall of the rectum. 4 Excisional area. 5 The oral margin of the defect is removed for frozen section examination. 6 The aboral margin of the defect is removed for frozen section examination. 7 The oral margin of the defect is pulled caudally to start the suture. 8 Closure of the defect is completed with three continuous sutures and silver clips. 1 2

The role of local excision in rectal cancer after complete response to neoadjuvant treatment

Correlation between pathological response of primary tumour and mesorectal lymph node involvement was prospectively evaluated to assess the role of local excision (LE) in rectal cancer after complete response to neoadjuvant treatment. A series of 272 consecutive rectal cancer, submitted to neoadjuvant radiochemotherapy (RCT) and surgery with total mesorectal excision (TME) were analysed. Tumour downstaging (pT) and tumour regression grade (TRG) together with sex, age, location of the tumour, pre-treatment clinical stage, type of chemoradiation and operation performed entered in an univariate and multivariate analysis. Pathological complete response on primary tumour was found in 56 patients (20.6%). Lymph node metastases were found in 72 patients (26.5%). The rate of positive nodes was 1.8% for pT0 and TRG1 cases, respectively, to go up to 6.3% for pT1 and 24.1% for TRG 2 cases, respectively. At the univariate analysis, factors with a statistically significant correlation with the risk of lymph node metastasis were: clinical pre-treatment N stage (p<0.05), pT stage (p<0.001) and TRG (p<0.001). At the multivariate analysis, the best predictors of pathologic lymph node involvement were pT stage (p=0.0013 ) and TRG (p=0.0011). Because LE is an adequate technique to assess the tumour pathological response and nodal involvement in pT0 or TRG1 cases seems extremely infrequent, radical resection is probably not justified after pathological complete response. Prospective randomized trials are necessary to establish if, in these cases, LE can guarantee the same oncologic results offered by the currently adopted protocols of RCT followed by radical resections.

Local Excision after Radio(chemo)therapy for Rectal Cancer: is it Safe?

According to current opinion, local excision in rectal cancer should be limited to selected T1N0 tumours. Preoperative radio(chemo)therapy provides an opportunity for expanding the use of local excision for more advanced tumours. The key rationale of this approach is the correlation between the radiosensitivity and inherited low aggressiveness of rectal cancer and the correlation between the radiosensitivity of the primary tumour and the radiosensitivity of mesorectal nodal disease. This allows for a selection of local excision for radiosensitive tumours or conversion to abdominal surgery in radioresistant cases. Eleven reports including a total of 311 patients treated with preoperative radio(chemo)therapy and local excision have been published. In some series, the tumours were initially large and unresectable by the transanal approach. Pathological data suggest that local excision must involve all tissue invaded on pre-treatment examination with a margin, even in patients with a clinical complete response. The pooled analysis has shown a local recurrence rate of 1% (1/83) for patients achieving a pathological complete response, 8% (3/40) for ypT1, 11% (4/37) for ypT2 and 3/9 for ypT3. In conclusion, the results of preoperative radio(chemo)therapy and local excision are encouraging and warrant a population-based, multicentre controlled study.

Population-based study of local surgery for rectal cancer

The aim was to determine long-term survival and recurrence rates after local excision of rectal cancer from a prospectively registered population-based database. Swedish Rectal Cancer Registry data from 1995 to 2001, including 10 181 patients of whom 643 (6.3 per cent) had a local excision, were analysed. Complete 5-year follow-up data from 1995 to 1998 were available. Cumulative relative and cancer-specific survival rates, and rates of local recurrence and distant metastases, were calculated by actuarial methods. The 5-year cancer-specific survival rate for 256 patients with stage I disease who had local excision was 95.3 (95 per cent confidence interval 91.5 to 99.1) per cent. The 5-year local recurrence rate was 7.2 per cent. After adjustment for age, sex, tumour stage and preoperative radiotherapy, the relative risk of death from cancer was the same as that after major resection. Population-based results after local excision of rectal cancer are the same as those reported in controlled series for early-stage tumours after abdominal resection. A low relative survival and a high median age indicate the use of local excision in patients with a high level of co-morbidity. To achieve acceptable long-term results, optimal preoperative and postoperative staging is needed.

Bericht zum 1. Workshop zur lokalen Exzision von Rektumkarzinomen

To determine the significance of local excision (LE) of rectal cancer and discuss oncologic results, a 1st Workshop on LE of rectal cancer was held at the Department of General und Abdominal Surgery, Johannes Gutenberg-University Mainz, Germany. The option of broadening the indication for local excision after neoadjuvant radiochemotherapy (nRCT) of rectal cancer was to be assessed. Local excision of "low risk" T 1 carcinomas was rated as oncologically adequate therapy with good functional results and low complication rates. Transanal endoscopic microsurgical (TEM) resection was the preferrred technique. Pre-requisite for the achievement of low recurrence rates (5 %) is an R0 resection with a safety margin of at least 1 mm (R < or = 1 mm) without tumor fragmentation, because otherwise possible tumor cell displacement and RX resection may not allow an assessment of the resection margin. "high risk" tumors or T 2 carcinomas were not considered an indication for local excision. To identify additional histological risk factors for the oncological outcome (sm-level, tumor budding, mucinous component, perineural infiltration, etc.) the initiation of a multi-center register study (LERC = local excision of rectal cancer) was suggested and is now in preparation. If the finding after TEM resection is not a "low risk" T 1 carcinoma, but a "high risk" situation or a T 2 tumor, immediate reoperation is advised resulting in similar outcomes as compared to primary conventional surgery. A literature analysis of LE after neoadjuvant RCT of T 2/3 rectal cancers showed a local recurrence rate of 0 % for ypT 0 and of 5 % for ypT 1 findings (studies with small patient collectives and short follow-up periods). The lymph node status of T 2 / 3 carcinomas after nRCT is unclear. More advanced/primary not resectable tumors (T 3 / 4) showed lymph node metastases in 5 % for ypT 0 and in 12 % for ypT 1 findings after nRCT, suggesting that for earlier T categories lower rates can be expected. On the basis of these favourable results a prospective multi-center study will be initiated. A study protocol will be established during the 2nd Workshop on LE of rectal cancer in Mainz.