Resection For Early Rectal Cancer Research Articles

Lymphovascular invasion is a dominant risk factor for lymph node metastasis in T2 rectal cancer.

Background and study aims Surgical resection is standard treatment of T2 rectal cancer due to risk of concomitant lymph node metastases (LNM). Local resection could potentially be an alternative to surgical treatment in a subgroup of patients with low risk of LNM. The aim of this study was to identify clinical and histopathological risk factors of LNM in T2 rectal cancer. Patients and methods This was a retrospective registry-based population study on prospectively collected data on all patients with T2 rectal cancer undergoing surgical resection in Sweden between 2009 and 2021. Potential risk factors of LNM, including age, gender, resection margin, lymphovascular invasion (LVI), histologic grade, mucinous cancer, and perineural invasion (PNI) were analyzed using univariate and multivariate logistic regression. Results Of 1607 patients, 343 (21%) with T2 rectal cancer had LNM. LVI (odds ratio [OR] = 4.21, P < 0.001) and age < 60 years (OR = 1.80, P < 0.001) were significant and independent risk factors. However, PNI (OR = 1.50, P = 0.15), mucinous cancer (OR = 1.14, P = 0.60), histologic grade (OR = 1.47, P = 0.07) and non-radical resection margin (OR = 1.64, P = 0.38) were not significant risk factors for LNM in multivariate analyses. The incidence of LNM was 15% in the absence of any risk factor. Conclusions This was a large study on LNM in T2 rectal cancer which showed that LVI is the dominant risk factor. Moreover, low age constituted an independent risk factor, whereas gender, resection margin, PNI, histologic grade, and mucinous cancer were not independent risk factors of LNM. Thus, these findings may provide a useful basis for management of patients after local resection of early rectal cancer.

Report on the application of endoscopic intermuscular dissection for diagnostic resection of early rectal cancer

Objective: This report presents the initial outcomes of endoscopic intermuscular dissection (EID), a novel technique introduced by our team for the diagnostic resection of early rectal cancer, focusing on the postoperative status of the vertical margins. Methods: On January 26, 2024, a patient with early rectal cancer (cT1-2N0M0) underwent Endoscopic Intermuscular Dissection. The EID procedure consists of six steps: (1) mucosal incision; (2) submucosal dissection; (3) superficial muscular layer incision; (4) intermuscular dissection; (5) complete tumor removal; (6) wound management. Results: The patient was a 70-year-old male with rectal cancer (cT1-2N0M0). The tumor was located on the left anterior wall of the rectum, approximately 9 cm from the anal margin, and measured 20mm in size. The dissection rate was 2.68 mm²/minute, and the total duration of the surgery was 109 minutes. The patient was successfully discharged on the fifth day after surgery. Pathological examination of the post-endoscopic surgery specimen revealed pT1b, with negative vertical margins. Follow-up after more than one month showed good recovery with no complications such as bleeding, perforation, infection, or stricture occurring. Colonoscopy indicated the presence of a granulation tissue suggestive of inflammation. Conclusion: Endoscopic Intermuscular Dissection for the diagnostic resection of early rectal cancer is potentially safe and may achieve negative vertical margins.

Endoscopic and trans-anal local excision vs. radical resection in the treatment of early rectal cancer: A systematic review and network meta-analysis.

The management of early-stage rectal cancer in clinical practice is controversial. The aim of this network meta-analysis was to compare oncological and postoperative outcomes for T1T2N0M0 rectal cancers managed with local excision in comparison to conventional radical resection. A systematic review of Medline, Embase and Cochrane electronic databases was performed. Relevant studies were selected using PRISMA guidelines. The primary outcomes measured were 5-year local recurrence and overall survival. Secondary outcomes included rates of postoperative complication, 30-day mortality, positive margin and permanent stoma formation. Three randomized controlled trials and 27 observational studies contributed 8570 patients for analysis. Radical resection was associated with reduced 5-year local recurrence in comparison to local excision. This was statistically significant in comparison to trans-anal local excision (odds ratio (OR) 0.23; 95% confidence interval 0.16-0.30) and favourable in comparison to endoscopic techniques (OR 0.40; 95% confidence interval 0.13-1.23) although this did not reach clinical significance. Positive margin rates were lowest for radical resection. However, 30-day mortality rates, perioperative complications and permanent stoma rates all favoured local excision with no statistically significant difference between endoscopic and trans-anal techniques. Radical resection of early rectal cancer is associated with the lowest 5-year local recurrence rates and the lowest rate of positive margins. However, this must be balanced with its higher 30-day mortality and complication rates as well as the increased risk of permanent stoma. The emerging potential role of neoadjuvant therapy prior to local resection, and the heterogeneity of its use, as an alternative treatment for early rectal cancer further complicates the treatment paradigm and adds to controversy in this field.

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.

Nonsurgical Management Following Local Resection for Early Rectal Cancer in Patients with High-risk Factors: A Single-institute Experience.

Objective: Additional surgery is considered for patients at high risk for lymph node metastasis (LNM) after local resection for early rectal cancer. Several factors are considered as indications for additional surgery, although there are currently no definitive criteria. This study aimed to clarify the need for additional surgery based on the number of risk factors for LNM and to evaluate the significance of submucosal invasion on recurrence. Methods: Patients with early rectal cancer harboring risk factors for LNM who underwent local resection between March 2005 and December 2016 were retrospectively analyzed. Associations among the number of risk factors, prognosis, and additional treatment after local resection were investigated. Results: A total of 29 eligible patients were classified into the surgery (n = 10), chemoradiotherapy (n = 7), and no-additional-treatment (NAT, n = 12) groups. Among the 29 patients, 15 patients (52%) with only one risk factor did not relapse. The NAT group harbored fewer risk factors for LNM, and 8 of the 12 patients (67%) had only deep submucosal invasion. Local recurrence occurred in one patient in the chemoradiotherapy group. The estimated 5-year overall survival rates were 88.9%, 75.0%, and 81.5% in the surgery, chemoradiotherapy, and NAT groups, respectively. There were no disease-specific deaths in the overall cohort. Conclusions: In the present study, no recurrence occurred in patients who did not receive additional surgery with deep submucosal invasion as the only risk factor. A multicenter investigation is necessary to confirm the safety of nonsurgical options.

Decreased Overall Survival of Transanal vs. Transabdominal Resection of Early Rectal Cancer in Treatment Naïve Patients: A National Cancer Data Base Study

Previous data from the National Cancer Database (NCBD) showed increasing rates of transanal local excision for early rectal cancer despite a lack of evidence supporting its oncologic adequacy. The aim of this study is to update national trends, compare overall survival, and determine factors associated with survival in patients with stage I rectal cancer. Survival of 15, 149 patients with stage I rectal adenocarcinoma were examined retrospectively from 2004-2012. The rate of local excision over this time period was sustained at 22% (20.88 - 24.9%; p = 0.077). Five-year overall survival (OS) after transanal local excision was less than transabdominal standard resection (76.6% vs. 80.7%; p 4 cm, low volume centers, uninsured patients and increasing comorbidities. This is the first study of national data showing sustained use of transanal local excision over the past decade. Local excision has a lower 5-year OS compared to transabdominal standard resection. Transanal excision of early rectal cancer should be offered to select patients only after careful consideration of risk factors balanced against the decrease in overall survival.

Endoluminal loco-regional resection by TEM after R1 endoscopic removal or recurrence of rectal tumors

Purpose The aim of this study is to evaluate the safety and efficacy of endoluminal loco-regional resection (ELRR) by transanal endoscopic microsurgery (TEM) after R1 endoscopic resection or local recurrence of early rectal cancer after operative endoscopy. Material and methods Twenty patients with early rectal cancer were enrolled, including patients with incomplete endoscopic resection, or complete endoscopic resection of a tumor with unfavorable prognostic factors (group A, ten patients), and local recurrence after endoscopic removal (group B, ten patients). At admission, histology after endoscopic polypectomy was: TisR1(4), T1R0G3(1), T1R1(5) in group A, and TisR0(8), T1R0(2) in group B. All patients underwent ELRR by TEM with nucleotide-guided mesorectal excision (NGME). Results Mean operative time was 150 minutes. Complications occurred in two patients (10%). Definitive histology was: moderate dysplasia(4), pT0N0(3), pTisN0(5), pT1N0(6), pT2N0(2). Mean number of lymph-nodes was 3.1. Mean follow-up was 79.5 months. All patients are alive and disease-free. Conclusions ELRR by TEM after R1 endoscopic resection of early rectal cancer or for local recurrence after operative endoscopy is safe and effective. It may be considered as a diagnostic procedure, as well as a curative treatment option, instead of a more invasive TME.

Local resection of early rectal cancer.

The introduction of the National Danish screening programme for colorectal cancer will result in the detection of more early rectal cancers (ERC), which may be considered for local excision. For the low risk≤T1 cancer, the oncological outcome at local excision in smaller patient series has shown similar results to conventional surgery, but with a significantly lower rate of serious complications, morbidity and mortality. The challenge is correct preoperative staging, and a meticulous systematic histopathological staging of the excised specimen to distinguish the low risk from high-risk cases, where rescue surgery may be considered. The establishment of a regional or national clinical database is necessary to improve the local treatment of ERC.

The outcome of rectal cancer after early salvage TME following TEM compared with primary TME: a case-matched study

Transanal endoscopic microsurgery (TEM) allows locally complete resection of early rectal cancer as an alternative to conventional radical surgery. In case of unfavourable histology after TEM, or positive resection margins, salvage surgery can be performed. However, it is unclear if the results are equivalent to primary treatment with total mesorectal excision (TME). The aim of this retrospective study was to determine whether there is a difference in outcome between patients who underwent early salvage resection with TME after TEM, and those who underwent primary TME for rectal cancer. From 1997 to 2011, early salvage surgery with TME after TEM was performed in 25 patients in our institution. These patients were compared with 25 patients who underwent primary TME, matched according to gender, age (±2 years), cancer stage and operative procedure. Data were obtained from the patients' charts and reviewed retrospectively. No patients received preoperative chemotherapy. Perioperative data and oncological outcome were analysed. The Mann-Whitney U-test and Fisher's exact test were used to compare the results between the two groups. There was no significant difference between the two groups in median operating time (P = 0.39), median blood loss (P = 0.19) or intraoperative complications (P = 1.00). The 30-day mortality was 8 % (n = 2) among patients who underwent salvage TME after TEM, and no patients died in the primary TME group (P = 0.49). There was no significant difference between two groups of patients in the median number of harvested lymph nodes (P = 0.34), median circumferential resection margin (CRM) (P = 0.99) or the completeness of the mesorectal fascia plane. No local recurrences occurred among the patients with salvage TME, and there were 2 patients (8 %) with local recurrences among the patients with primary TME (P = 0.49). Distant metastasis occurred in one patient (4 %) after salvage TME and in 3 patients (12 %) with primary TME (P = 0.61). The median follow-up time was 25 months (3-126) for patients who underwent salvage TME and 19 months (3-73) for patients after primary TME. No difference was found in outcome between patients with rectal cancer undergoing salvage TME after TEM, those undergoing primary TME. In selected patients, TEM can therefore be chosen as a primary treatment, since failure of treatment and subsequent conventional resection appears not to compromise the outcome.

A comparison of transanal excision and endoscopic resection for early rectal cancer

To compare the outcomes of endoscopic resection with transanal excision in patients with early rectal cancer. Thirty-two patients with early rectal cancer were treated by transanal excision or endoscopic resection between May 1999 and December 2007. The patients were regularly re-examined by means of colonoscopy and abdominal computed tomography after resection of the early rectal cancer. Complications, length of hospital-stay, disease recurrence and follow up outcomes were assessed. Sixteen patients were treated by endoscopic resection and 16 patients were treated by transanal excision. No significant differences were present in the baseline characteristics. The rate of complete resection in the endoscopic resection group was 93.8%, compared to 87.5% in the transanal excision group (P = 0.544). The mean length of hospital-stay in the endoscopic resection group was 2.7 ± 1.1 d, compared to 8.9 ± 2.7 d in the transanal excision group (P = 0.001). The median follow up was 15.0 mo (range 6-99). During the follow up period, there was no case of recurrent disease in either group. Endoscopic resection was a safe and effective method for the treatment of early rectal cancers and its outcomes were comparable to those of transanal excision procedures.

Can depth of tumour invasion predict lymph node positivity in patients undergoing resection for early rectal cancer? A comparative study between T1 and T2 cancers

The present study investigated the risk of lymph node metastasis according to the depth of tumour invasion in patients undergoing resection for rectal cancer. The histology of patients undergoing oncological resection with regional lymphadenectomy for rectal cancer at St Marks Hospital from 1971 to 1996 was reviewed. Of the total number of 1549 patients, 303 patients with T(1) or T(2) rectal cancers were selected. The tumour type, grade, evidence of vascular invasion, depth of submucosal invasion (classed into 'sm1-3') were evaluated as potential predictors of lymph node positivity using univariate and multi-level logistic regression analysis. Tumour stage was classified as T(1) in 55 (18.2%) and T(2) in 248 (81.2%) patients. The incidence of lymph node metastasis in the T(1) group was 12.7% (7/55), compared to 19% (47/247) in the T(2) group. The node positive and negative groups were similar with regard to patient demographics, although the former contained a significantly higher number of poorly differentiated (P = 0.001) and extramural vascular invasion tumours (P = 0.002). There was no significant difference in the number of patients with sm1-3, or T(2) tumour depths within the lymph node positive and negative groups. On multivariate analysis the presence of extramural vascular invasion (odds ratio = 10.0) and tumour grade (odds ratio for poorly vs well-differentiated = 11.7) were independent predictors of lymph node metastasis. Whilst the degree of vascular invasion and poor differentiation of rectal tumours were significant risk factors for lymph node metastasis, depth of submucosal invasion was not. This has important implications for patients with superficial early rectal cancers in whom local excision is being considered.

Advances in minimally invasive surgery in the treatment of colorectal cancer

Colorectal cancer (CRC) is the second leading cause of cancer-related death in the USA. Surgery is the primary treatment for most patients with CRC. Over the past 15 years, minimally invasive techniques for colorectal surgery have been developed. There is growing evidence that these techniques have significant advantages in short-term outcomes (e.g., postoperative pain and length of hospital stay) with similar long-term recurrence and overall survival. While transanal local excision has been shown to be inferior to radical resection for early rectal cancer, transanal endoscopic microsurgery (TEM) is a minimally invasive technique that appears to facilitate local excision in appropriate patients. TEM combined with radiotherapy has demonstrated promising early results and is currently being investigated in clinical trials as a potential alternative to radical surgery. We summarize the current literature on these minimally invasive approaches to CRC.