Role Of Local Excision Research Articles

The Role of Local Excision after Neoadjuvant Therapy for Locally Advanced Rectal Cancer: A Different Perspective.

The Role of Local Excision after Neoadjuvant Therapy for Locally Advanced Rectal Cancer: A Different Perspective.

Is local excision an appropriate treatment modality in patients presenting with early-stage (cT1 N0 M0) rectal adenocarcinoma?

BackgroundPrior studies evaluating the safety and efficacy of local excision relative to surgical resection in early-stage rectal adenocarcinoma have primarily included low rectal cancers treated with abdominoperineal resection as control comparison cohorts. The role of local excision in early-stage rectal adenocarcinoma is incompletely defined. MethodsWe queried the National Cancer Database to identify patients with cT1 N0 M0 rectal adenocarcinoma between 2004 and 2019. Patients undergoing abdominoperineal resection were excluded. Multivariable regression was used to identify factors associated with use of local excision instead of low anterior resection. Patients undergoing local excision were propensity score matched for age, sex, demographic characteristics, Charlson-Deyo comorbidity class score, and tumor grade and size to those undergoing low anterior resection. Short-term clinical outcomes and 5-year overall survival for matched cohorts were compared by standard methods. ResultsA total of 5,693 patients met inclusion criteria; 1,973 patients underwent local excision and 3,720 low anterior resection. Age (adjusted odds ratio 1.26; 95% confidence interval, 1.17–1.37), tumor histology (poorly differentiated histology: adjusted odds ratio 0.66; 95% confidence interval, 0.51–0.86), and size (>4 cm: adjusted odds ratio 0.20; 95% confidence interval, 0.16–0.25) were associated with choice of intervention. On comparison of matched cohorts, patients undergoing LE demonstrated shorter hospital stay (2.4 ±9.8 vs 5.6 ±8.1 days; P < .001) and lower readmission rate (4% vs 7%; P = .002) but higher margin-positive resection rates (8% vs 2%; P < .001). Overall survival profiles for patients undergoing local excision were comparable with those for low anterior resection. ConclusionIn patients with cT1 N0 M0 rectal adenocarcinoma, local excision is associated with a higher margin-positive resection rate than low anterior resection but affords accelerated postprocedure recovery and comparable rates of overall survival.

Management of rectal cancer: the 2016 French guidelines.

Rectal cancer is a malignant disease requiring multidisciplinary management. In view of the increasing number of studies published over the past decade, a comprehensive update is required to draw recommendations for clinical practice mandated by the French Research Group of Rectal Cancer Surgery and the French National Coloproctology Society. Seven questions summarizing the treatment of rectal cancer were selected. A search for evidence in the literature from January 2004 to December 2015 was performed. A drafting committee and a large group of expert reviewers contributed to validate the statements. Recommendations include the indications for neoadjuvant therapy, the quality criteria for surgical resection, the management of postoperative disordered function, the role of local excision in early rectal cancer, the place of conservative strategies after neoadjuvant treatment, the management of synchronous liver metastases and the indications for adjuvant therapy. A level of evidence was assigned to each statement. The current clinical practice guidelines are useful for the treatment of rectal cancer. Some statements require a higher level of evidence due to a lack of studies.

The role of local excision in management of benign and malignant lesions of ampullary and peri-ampullary region

The role of local excision in management of benign and malignant lesions of ampullary and peri-ampullary region

PTH-308 High quality local excision for early rectal cancer achieving low recurrence rates: preservation of the rectum is possible

Introduction The role of local excision for early rectal cancer continues to be a topic of debate due to high local recurrence rates. The quality of local excision is an important factor determining risk of local recurrence. Small T1 (Sm1 and Sm2) tumours can be adequately treated with trans-anal excision using specialised techniques such as trans-anal endoscopic microsurgery (TEM) or trans-anal endoscopic operation (TEO). Current practice dictates radical surgery (RS) for all other rectal tumours to achieve acceptable oncological outcomes. Method A retrospective analysis of prospectively kept data from a single centre case series of patients treated with TEM for early rectal cancer. We analysed data for patients who had rectal preservation without subsequent RS, and were followed up with regular clinical examination, blood tests, CT chest/abdomen/pelvis and MRI rectum. All local excisions were approved by the local MDT and performed by 2 trained consultant colorectal surgeons. Results Sixty eight patients underwent TEM for early rectal cancer between June 2009 and August 2013, 25 patients went on to have RS and 1 TEM was converted intra-operatively to RS. Forty two patients (61.8%), 31 males (73.8%), were followed up with rectal preservation. The mean age was 74 years (S. D =/- 9.8) and ASA grades of patients: ASA I 2.4%; ASA II 35.7%; ASA III 54.8%; and ASA IV 7.1%. The median height of tumour was 7cm (range 1–15), operative time was 90 min (range 30 – 320), and in all cases blood loss was minimal. Median length of stay was 2 days (range 1–17). Median tumour size was 20mm (range 2–50) and the pathological stage was T1 in 20/42 (45.2%) (Sm1 5/20[25%], Sm2 8/20[40%], Sm3 7/20[35%]), T2 in 17/42 (40.5%) and T3 in 3/42 (7.1%) patients. Two patients (4.8%) had no residual tumour following neo-adjuvant therapy/polypectomy. The TEM specimen contained lymph nodes in 6/42 cases (14.3%), positive in 2/42 (4.8%). The overall local recurrence rate was 9.5% (4/42 unfit or unwilling for RS, 2 with involved margins). The local recurrence rate with clear margins was 5.3%. Recurrence rate for T0, T1, T2 and T3 disease was 0% (0/2), 0% (0/19), 6.2% (1/16) and 33.3% (1/3) respectively when excluding recurrences with positive margins. The median length of follow up 17 months (range 3–60) and rectal cancer specific mortality was 2.4% (1 patient unfit for radical surgery with T3 disease). Conclusion This case series demonstrates a very low recurrence rate in contrast to most of the published series. We believe the technique and quality of surgery is an important factor contributing to local recurrence following local resection. We propose that further studies should be considered for identifying additional patients in whom rectal preservation can be safely offered. Disclosure of interest None Declared.

The role of local excision in invasive adenocarcinoma of the ampulla of Vater.

The role of local excision in invasive adenocarcinoma of the ampulla of Vater.

The role of local excision in invasive adenocarcinoma of the ampulla of Vater.

Ampulla of Vater carcinomas are rare malignancies that have been traditionally treated with radical surgical resection. Given the mortality associated with pancreaticoduodenectomy, some patients may benefit from local resection. A single-institution outcomes analysis was performed to define the role of local resection. Patients undergoing local resection (ampullectomy) for ampullary carcinomas at Duke University between 1976 and 2010 were analyzed retrospectively. Time-to-event analysis was conducted analyzing all patients undergoing surgery, with and without adjuvant chemoradiation therapy (CRT). Overall survival (OS), local control (LC), metastases-free survival (MFS), and disease-free survival (DFS) were studied using Kaplan-Meier analysis. A total of 17 patients with invasive carcinoma underwent ampullectomy. The 3-and 5-year LC, MFS, DFS and OS rates were 36% and 24%, 68% and 54%, 31% and 21%, and 35% and 21%, respectively. Patients receiving adjuvant CRT did not appear to have improved outcomes compared with surgery alone, although this group tended to have poorer histological grade, more advanced tumor staging and involved surgical margins. Ampullectomy for invasive ampullary adenocarcinomas is a safe procedure but does not offer satisfactory long-term results, mostly due to high local failure rates. Adjuvant CRT therapy does not appear to offer increased local control or survival benefit following ampullectomy, although these results may suffer from selection bias and small sample size. Local resection should be limited to benign ampullary lesions or patients with very small, early tumors with favorable histologic features where radical resection is not feasible.

Is Local Excision After Complete Pathological Response to Neoadjuvant Chemoradiation for Rectal Cancer an Acceptable Treatment Option?

The role of local excision in patients with good histological response to neoadjuvant chemoradiation for locally advanced rectal cancer is unclear, mainly because of possible regional nodal involvement. This study aims to evaluate the correlation between pathological T and N stages following neoadjuvant chemoradiation for locally advanced rectal cancer and the outcome of patients with mural pathological complete response undergoing local excision. This investigation was conducted as a retrospective analysis. Between January 1997 and December 2007, 320 patients with T3 to 4Nx, TxN+ or distal (≤ 6 cm from the anus) T2N0 rectal cancer underwent neoadjuvant concurrent chemoradiation followed by surgery. Radiotherapy was standard and chemotherapy consisted of common fluoropyrimidine-based regimens. After chemoradiation, 93% patients had radical surgery, 6% had local excision, and 3% did not have surgery. In the 291 patients undergoing radical surgery, the pathological T stage correlated with the N stage (P = .036). We compared the outcome of patients with mural complete pathological response (n = 37) who underwent radical surgery (group I) and those (n = 14) who had local excision only (group II). With a median follow-up of 48 months, 4 patients in group I had a recurrence and none in group II had a recurrence; one patient died in group I and none died in group II. Disease-free survival, pelvic recurrence-free survival, and overall survival rates were similar in both groups. In this retrospective study, nodal metastases were rare in patients with mural complete pathological response following neoadjuvant chemoradiation (3%), and local excision did not compromise their outcome. Therefore, local excision may be an acceptable option in these patients.

Recurrences after Local Excision for Early Rectal Adenocarcinoma

PurposeThe role of local excision in treating rectal cancer patients continues to be controversial. The aim of this study was to evaluate the long-term oncological results of local excision for early rectal adenocarcinomas and review the outcomes of salvage therapy on rectal cancer patients.Materials and MethodsBetween March 1992 and September 2005, 35 consecutive patients with early-stage primary rectal adenocarcinomas were treated by local excision with curative intent. The mean tumor distance from the anal verge was 5 cm (range, 1-10 cm).ResultsThe median follow-up was 66 months (range, 17-161 months). Pathological examination revealed 23 cases of T1 and 12 cases of T2. Recurrence had developed in 10 patients (6 local recurrences, 4 systemic recurrences). Purely extrapelvic recurrence was observed in only two (5.7%) patients. Of the eight recurrent patients with surgical salvage, five survived with no evidence of disease at the time of this analysis. The 5-year local recurrence-free and disease-free survival rates were 79.6% and 67.9%, respectively.ConclusionLocal excision alone of early-staged rectal adenocarcinomas, even in the ideal candidate, is followed by a relatively higher local recurrence rate than previously reported and may not be a valid modality. Either the use of adjuvant therapy with local excision, even in patients with T1 lesions or the use of preoperative therapy followed by local excision has good promise.

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.

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.

Role of local excision in the treatment of rectal cancer.

Local excision (LE) of properly selected rectal cancers can provide long-term survival, with minimal morbidity, negligible mortality, and excellent functional results. The role of LE has evolved over the past century. Initially, to avoid the excessive mortality of abdominal surgery, aggressive LE was performed to control the symptoms of rectal cancer. As abdominal surgery became safer, LE was restricted for use in palliation or high-risk patients. Better preoperative tumor staging resulted in an expanded role for LE, including curative-intent treatment of selected T(1-2) rectal cancers. Techniques for LE include snare polypectomy, transanal excision, transanal endoscopic microsurgery, and posterior approaches. The high local recurrence rate and compromised survival reported in modern series, despite efforts to properly select patients with cancers suitable for LE, have convinced the authors to restrict the use of curative-intent LE in good-risk patients only to the most favorable rectal cancers. Close follow-up after LE is critical, because radical surgical salvage is usually possible if recurrence is identified promptly. Whether adjuvant chemoradiation can expand the role of curative intent LE remains controversial.

Local Surgical Treatment of Rectal Cancer

Patients with cancer of the lower third of the rectum can avoid both the morbidity of an APR and the need for a permanent colostomy by having the cancer removed by local excision. If the surgeon clinically suspects that a patient has an early cancer, the first step should be local excision of the tumor. The pathological features of the cancer specimen will then indicate the next step in treatment. This can range from no further therapy to proctectomy with or without an anastomosis (Table 2). Patients with a low risk of local failure can be treated by excision alone. Those with a higher risk of local failure should undergo APR or LAR or enter a protocol to determine the role of local excision and adjuvant chemoradiation.