Transanal Local Excision Research Articles

Prognostic analysis for carcinoid tumours of the rectum: a single institutional analysis of 106 patients

Rectal carcinoid is a rare rectal tumour with a good prognosis. The aim of this study was to assess its clinicopathological characteristics and prognostic factors in a single institution. Clinical and pathological information was retrospectively collected in a single institution, and patients' outcomes were determined. Multivariate analyses were performed to find independent prognostic factors attributed to overall survival. A total of 106 patients with rectal carcinoid were included. In all, 66% of the patients underwent transanal local excision and 34% had transabdominal surgery. The 5-year survival rate was 87%. Muscularis invasion was the only independent prognostic factor for predicting 5-year survival (P = 0.00046). Tumour size was found to be significantly associated with muscular invasion (P = 0.00003). The area under the curve of tumour size in the receiver operating characteristic curve for predicting muscular invasion was 0.92. Patients with rectal carcinoid have a good prognosis. Muscular invasion is an independent risk factor of survival.

Transanal Endoscopic Video-Assisted Excision: Application of Single-Port Access

Transanal endoscopic microsurgery is a safe and efficacious surgical approach for local excision of benign adenomas and early-stage rectal cancer. However, utilization of the technique has been limited due to the unavailability of high-priced specialized instrumentation at many institutions and the technically demanding training required. To avoid these obstacles, we have explored an alternative approach called Transanal Endoscopic Video-Assisted excision, which combines the merits of singleport access and local transanal excision. A disposable single-incision port is inserted into the anal canal for transanal access. The port contains 3 cannulae for introducing instrumentation into the rectal lumen, and a supplementary cannula for carbon dioxide insufflation. Pneumorectum results in rectal distention and optimizes the visual field during the procedure. Standard laparoscopic instrumentation is utilized for visualization and transanal excision of rectal pathologies. Transanal endoscopic video-assisted excision is an innovative approach to local excision of benign and malignant rectal lesions. The approach averts several of the pitfalls commonly experienced with transanal endoscopic microsurgery. Continued investigation and development of this novel modality will be important in establishing its role in minimally invasive surgery.

New trends in rectal cancer surgery. Case of the practice

BACKGROUND: Sphincter preservation, disease control, and long-term survival are the main goals in the treatment of rectal cancer. Although transanal local excision is attractive because it is a sphincter sparing procedure, some contradictory data exist in the literature about its ability to locally control disease and provide overall survival comparable with radical procedures, even for patients with early stage tumor. In patients with early rectal cancer (T1), local excision may be an alternative approach in highly selected patiients. For more advanced rectal cancer, radical surgical resection is the treatment of choice. METHODS: We reviewed the literature to identify the current recurrence and survival rates of both techniques as well as the salvage surgery success, only 1 study was prospective, 5 were comparative, and 5 were case reports. We present a case report of a woman with local excision of rectal tumor. Five years later a rectal recurrence has showed up. We describe the case and make some conclusions.

Treatment of colorectal carcinoids: A new paradigm

It is often difficult to evaluate the grade of malignancy and choose an appropriate treatment for colorectal carcinoids in clinical settings. Although tumor size and depth of invasion are evidently not enough to stratify the risk of this rare tumor, the present guidelines or staging systems do not mention other clinicopathological variables. Recent studies, however, have shed light on the impact of lymphovascular invasion on the outcome of colorectal carcinoids. It has been revealed that the presence of lymphovascular invasion was among the strongest risk factors for metastasis along with tumor size and depth of invasion. Furthermore, tumors smaller than 1 cm, within submucosal invasion and without lymphovascular invasion, carry minimal risk for metastasis with 100% 5-year survival in the studies from Japan as well as from the USA. This would suggest that these tumors could be curatively treated by endoscopic resection or transanal local excision. On the other hand, colorectal carcinoids with either lymphovascular invasion or tumor size larger than 1 cm carry the risk for metastasis equivalent to adenocarcinomas. Therefore, it should be emphasized that histological examination of lymphovascular invasion is mandatory in the specimens obtained by endoscopic resection or transanal local excision, as this would provide useful information for determining the need for additional radical surgery with regional lymph node dissection. Although the present guidelines or TNM staging system do not mention the impact of lymphovascular invasion, this would be among the next promising targets in order to establish better guidelines and staging systems, particularly in early-stage colorectal carcinoids.

Local excision for early rectal cancer - is it proper surgical decision?

Sphincter preservation, disease control, and long-term survival are the main goals in the treatment of rectal cancer. Although transanal local excision is attractive because it is a sphincter spar ing procedure, some contradictory data exist in the literature about its ability to locally control disease and provide over all survival comparable with radical procedures, even for patients with early stage tumor. In patients with early rectal cancer (T1), local excision may be an alternative approach in highly selected patients. For more advanced rectal cancer, radical surgical resection is the treatment of choice. METHODS: We reviewed the literature to identify the current recurrence and survival rates of both techniques as well as the salvage surgery success, only 1 study was prospective, 5 were comparative, and 5 were case reports. We present a case report of a woman with local excision of rectal tumor. Five years later a rectal recurrence has showed up. We describe the case and make some conclusions. Scripta Scientifica Medica 2009; 41(2): 169-171.

The Value of High-Resolution Three-Dimensional Endorectal Ultrasonography in the Management of Submucosal Invasive Rectal Tumors

The aims of this prospective study were 1) to evaluate the accuracy of high-resolution three-dimensional endorectal ultrasonography in distinguishing slight from massive submucosal invasion of early rectal tumors, and 2) to determine the technology's role in treatment selection. A total of 142 consecutive patients with clinically possible pT1 rectal cancers underwent three-dimensional endorectal ultrasonography. Slight or massive irregularity of the hyperechoic submucosal layer was considered to characterize uT1-slight or uT1-massive tumors. Treatment was selected on the basis of ultrasonographic findings: endoscopic resection or full-thickness transanal local excision was selected for uT1-slight lesions, and radical resection was selected for uT1-massive tumors. Ultrasonographic staging was compared with histopathologic staging. One hundred twenty-six patients were included in the final analyses. Three-dimensional endorectal ultrasonography staged 77 lesions as uT0, 25 as uT1-slight, 20 as uT1-massive, and 4 as uT2. Histologically, adenomas were found in 75 patients and tumor invasion was found in 44 lesions (24 pT1-slight, 16 pT1-massive, 4 pT2). The overall kappa for the concordance between ultrasonographic and histopathologic stagings was 0.81 (95% confidence interval, 0.72-0.89). No invasive carcinomas remained undetected. The depth of invasion was correctly determined in 87.2% of both pT1-slight and pT1-massive lesions. Considering the complete series of 126 patients, the accuracy of this modality in selecting appropriate management was 95.2% (kappa, 0.84; 95% confidence interval, 0.71-0.96). Adequate surgery was performed in 87.5% of pT1 tumors. Three-dimensional endorectal ultrasonography is useful for assessing the depth of submucosal invasion in early rectal cancer and for selecting therapeutic options.

Association de radiothérapie et de chimiothérapie. Thérapie ciblée préopératoire dans le cancer du rectum non métastatique

Neoadjuvant chemoradiotherapy is considered at the present time as the standard treatment of most T3-4 rectal cancer. In France a combination of radiotherapy (45 Gy/5 weeks) with concurrent capecitabine (1,600 mg/m2) is the most popular protocol. Randomized trials try to optimize this approach using new cytotoxic drugs and/or radiation dose-escalation. The introduction of biotargeted therapies (anti-EGFR or antiangiogenic) is an attractive field especially selecting the treatment according to K-ras mutation. For T2 and 'early T3' present studies are using neoadjuvant chemoradiation followed by transanal local excision in case of good tumor response. In frail elderly patients, a new trend is to use mainly exclusive irradiation to control the tumor and avoid the excessive toxicity of open surgery in this group of patients. As rectal cancer is presenting many different clinical situations, an individualised treatment appears justified.

Contact X-ray Therapy for Rectal Cancer: Experience in Centre Antoine-Lacassagne, Nice, 2002–2006

To report the results of using contact X-ray (CXR), which has been used in the Centre-Lacassagne since 2002 for rectal cancer. A total of 44 patients were treated between 2002 and 2006 using four distinct clinical approaches. Patients with Stage T1N0 tumors were treated with transanal local excision (TLE) and adjuvant CXR (45 Gy in three fractions) (n = 7). The 11 inoperable (or who had refused surgery) patients with Stage T2-T3 disease were treated with CXR plus external beam radiotherapy (EBRT). Those with Stage T3N0-N2 tumors were treated with preoperative CXR plus EBRT (with or without concurrent chemotherapy) followed by surgery (n = 21). Finally, the patients with Stage T2 disease were treated with CXR plus EBRT followed by TLE (n = 5). The median follow-up was 25 months. In the 7 patients who underwent TLE first, no local failure was observed, and their anorectal function was good. Of the 11 inoperable patients who underwent CXR plus EBRT alone, 10 achieved local control. In the third group (preoperative CXR plus EBRT), anterior resection was performed in 16 of 21 patients. Complete sterilization of the operative specimen was seen in 4 cases (19%). No local recurrence occurred. Finally, of the 5 patients treated with CXR plus EBRT followed by TLE, a complete or near complete clinical response was observed in all. TLE with a R0 resection margin was performed in all cases. The rectum was preserved with good function in all 5 patients. These early results have confirmed that CXR combined with surgery (or alone with EBRT) can play a major role in the conservative and curative treatment of rectal cancer.

Transanal local excision for stage I low rectal carcinoma

Objective To assess the validity of transanal local excision for stage Ⅰ low rectal carcinoma.Methods The clinical data of 93 patients with stage Ⅰ low rectal carcinoma who underwent transanal excision (group A,n=45)or radical resection(group B,n=48)were retrospectively analyzed.Twenty-four T1 patients and 21 T2 patients in group A received postoperative adjuvant radiation therapy and adjuvant chemoradiotherapy,respectively.All patients in group B received radical surgery only.The 5-year survival rates,recurrence rates,and postoperative complications between the 2 groups were compared.Results The 5-year survival rates were 100%(24/24)for T1 patients,86%(18/21)for T2 patients in group A,and 100%(18/18)for T1 patients,93%(28/30)for T2 patients in group B,with no significantly statistical difference between the 2 groups(P＞0.05).The recurrence rates were 4%(1/24)for T1 patients,19%(4/21)for T2 patients in group A,and 0(0/18)for T1 patients,7%(2/30)for T2 patients in group B,with no significance between the 2 groups(P＞0.05).The incidence of postoperative complications in group A was 2%(1/45),which was significantly lower than that of 15%(7/48))in group B(P＜0.05).Conclusions Transanal local excision of early low rectal carcinoma,combined with postoperative chemotherapy for T1 patients or chemoradiotherapy for T2 patients, results in a low complication rate and good sphincter function,and provides satisfactory local control and 5-year survival rates. Key words: Rectal neoplasms; Local excision

Rectosigmoid cancer. Report on 442 cases

Between 1961 and 1980 442 patients with rectosigmoidal carcinoma were treated. As preparation for operation and technique changed in 1974, two groups were formed: those between 1961 and 1973 (n = 196) and those from 1974 to 1980 (n = 246). The average duration of treatment was reduced from 63 to 36 due to out-patient preoperative measures. Resection (continent and incontinent) was the standard procedure, with local transanal excision in occasional cases. Continence preserving resection increased two-fold when compared with amputation in the second period. The death rate in 337 resected tumours was 18.5% and could be reduced from 22% to 16%. The death rate unrelated to operation remained unchanged whereas the operative mortality after a curative procedure fell from 11% to 2%. The reduction in death rate directly due to the operation was particularly noticeable in the simultaneous abdomino-perineal rectal amputation. Only one out of 18 patients operated on in this way died due to massive pulmonary embolism.

Local excision and endoscopic posterior mesorectal resection versus low anterior resection in T1 rectal cancer

Rectum-preserving endoscopic posterior mesorectal resection (EPMR) removes the local lymph nodes in a minimally invasive manner and completes tumour staging after transanal local excision (TE). The aim of this study was to compare the morbidity and mortality of TE and EPMR with those of low anterior resection (LAR) in patients with T1 rectal cancer. Between 1996 and 2006 EPMR was performed 6 weeks after TE in 18 consecutive patients with a T1 rectal cancer. Morbidity and mortality were recorded prospectively and compared with those in a group of 17 patients treated by LAR. Lymph node involvement and local recurrence rate were analysed in both groups. Two major and three minor complications were noted after EPMR, and four major and four minor complications after LAR (P = 0.402 for major and P = 0.691 for minor complications). Median number of lymph nodes removed was 7 (range 1-22) for EPMR and 11 (range 2-36) for LAR (P = 0.132). Two of 25 patients with a low-risk rectal cancer were node positive. No patient developed locoregional recurrence. EPMR after TE is a safe option for T1 rectal cancer. This two-stage procedure has a lower morbidity than LAR and may reduce locoregional recurrence compared with TE alone.

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.

Transanal excision of a malignant fibrous histiocytoma of anal canal: A case report and literature review

Malignant fibrous histiocytoma, which is composed of spindle-shaped cells arranged in a pleomorphic and storiform pattern, is rarely found in the colorectum. Although complete surgical excision remains the main stem of therapy, an optimal treatment strategy according to the stage has not been elucidated. We report a case of a 63-year-old woman with an ulcerative lesion in the anorectal junction and a final diagnosis of malignant fibrous histiocytoma. We introduced an access for transanal local excision and adjuvant radiotherapy because the patient refused abdominoperineal resection. No local recurrences or distant metastases were observed 15 mo after the operation. To our knowledge, this is the first case reported in the English literature of a malignant fibrous histiocytoma treated with the transanal local excision and adjuvant radiotherapy. This report showed that this approach is selectively reserved for early-stage malignant fibrous histiocytoma and for those patients who refuse radical surgery because of the risk in a permanent colostomy.

Transanal Local Excision for Preoperative Concurrent Chemoradiation Therapy for Distal Rectal Cancer in Selected Patients

To evaluate the clinical course and outcomes of patients with T2 or T3 rectal cancer treated by transanal local excision after preoperative chemoradiation therapy (CRT). Between June 2000 and August 2004, seven patients underwent local excision of T2 or T3 rectal cancer after preoperative CRT. Preoperative clinical staging was on the basis of the findings of endorectal ultrasound. Computed tomography (CT) and digital rectal examination consisted of radiation therapy with 4 500 cGy/25 fractions, given over 5 weeks with 5-FU-based chemosensitization. Local excision was performed 4-7 weeks later. The mean age of the patients was 54.9 (35-70) years and the median follow-up period was 23 (5-57) months. The lesions were located 2-6 cm above the anal verge (median 3.0 cm). Pretreatment T staging was estimated as T3 in one patient, and T2 in six patients. Post-treatment T staging was estimated as complete remission (CR) in two patients, T1 in three patients, and T2 in two patients. Pathologic evaluation revealed tumor downstaging in six patients, including three (42.9%) with CR. No tumor cells were seen in the resection margin and there was no sign of recurrence in any of the patients. These findings support local excision after preoperative CRT as an effective alternative to radical resection in carefully selected patients with T2 and T3 distal rectal cancer.

Resultados alejados de la resección local transanal para cánceres de recto bajo bien seleccionados

to evaluate our results about local failure, total recurrence and survival. twenty-one patients underwent a complete local transanal excision for low rectal cancer in our institution during an 18-year period (1985-2003). Preoperative staging included clinical, endoscopic, CT, EUSR, and histopathological findings; pathological specimens were 4 T1, 13 T2 and 4 T3 tumors. None of the T1 patients received another treatment; 6 out of 13 T2 and all of T3 cases were treated with chemoradiotherapy. None of the latter underwent radical surgery. follow-up (median 74 months) proved 23.8% for total recurrence and 19.0% for local failure (out of all 3 T2 cases only one received chemoradiotherapy, and one T3 received adjuvant treatment). Five-year survival is 95.2%. this experience allows us to assert that local excision is a good choice in well-selected low rectal cancer patients; for T2 tumors chemoradiotherapy is necessary; in T3 patients radical surgery must be prompt.

80歳以上高齢者大腸癌の治療

The incidence of colorectal cancer is increasing. Surgery and chemotherapy for elderly patients are also increasing. We evaluated the characteristics of elderly colorectal cancer to clarify issues related to surgical therapy for elderly patients. We studied 67 patients (38 men, 29 women) over 80 years old on whom we operated for colorectal cancer from 1990 to 2004. We compared them with 130 patients aged from 70 to 74 who were operated on in the same period, examining clinicopathological factors, operative methods, preoperative morbidity, postoperative complications, chemotherapy and postoperative survival ratio. In the elderly patients aged over 80, the rate of Dukes' B was high, whereas the rate of Dukes' A was high in patients aged from 70 to 74. No significant differences were observed in operative methods for colon cancer but Hartmann's operation and transanal local excision were frequent for rectal cancer in patients aged over 80. The rate of lymph node dissection was low in patients aged over 80 with rectal cancer. A significant difference was observed in lymph node dissection of rectal cancer between patients aged over 80 and those aged from 70 to 74, but there was no significant difference in curative ratio. Preoperative morbidity were recognized in 76% of patients aged over 80. Postoperative complications occurred in 51% of patients aged over 80. There were many cases showing delirium, but no differences in other complications between patients aged over 80 and those aged from 70 to 74. There was no operative mortality in patients aged over 80. Even elderly patients can anticipate safe operations without postoperative complications or decreased quality of life, if the appropriate operative procedure is selected with regard to their general condition.

Anal Canal Carcinoma with Pagetoid Spread: Report of a Case

A 70-year-old man with a history of colon polyps was found to have a semipedunculated polyp in the anal canal. The patient was asymptomatic. The lesion was 14 mm in diameter and located 5 mm from the dentate line. Histological examination of biopsy specimens revealed well-differentiated adenocarcinoma of the anal canal. During transanal local excision of the tumor, an abnormality of the perianal skin was recognized. Although intraoperative frozen section of the perianal skin did not show malignancy, permanent sections of the perineal skin revealed Paget's cells in the epidermis. Pathological examination of the anal canal carcinoma revealed submucosally invasive well-differentiated adenocarcinoma with a positive distal surgical margin. Thus, we performed additional wide local excision of the perianal skin including the distal margin of the previous local excision. Pathological examination revealed continuance within the epidermis between the anal canal adenocarcinoma and Paget's cells in the perianal skin lesion. Scattered Paget's cells also formed some glandular structures. Thus, we concluded that the perianal skin lesion was Pagetoid spread of anal canal adenocarcinoma. This report shows that the perianal skin should be examined carefully in patients with anal canal carcinoma.

Endoscopic Posterior Mesorectal Resection After Transanal Local Excision of T1 Carcinomas of the Lower Third of the Rectum

The rectum-sparing transanal local excision is a well-established treatment of T1 carcinomas of the lower third of the rectum. A potentially increased locoregional recurrence rate by this procedure is tolerated because of the high morbidity and mortality risk of transabdominal rectal resection. Dorsoposterior extraperitoneal pelviscopy makes it possible to remove the relevant lymphatic drainage of the lower third of the rectum minimally invasively, in the sense of a rectum-sparing endoscopic posterior mesorectal resection. It has to be considered whether endoscopic posterior mesorectal resection in combination with transanal local excision allows for local radicality and an adequate tumor staging in T1 carcinomas of the lower third of the rectum, in terms of better-directed therapy planning compared with transanal local excision alone. We operated on 11 consecutive patients with T1 carcinomas of the lower third of the rectum by transanal local excision in combination with endoscopic posterior mesorectal resection as a two-stage procedure in the period from 1998 to 2005. It was possible to perform a complete excision of the primary and to resect the posterior part of the mesorectum in all cases. Postoperative morbidity consisted of two transient neurologic complications and a pulmonary embolism. There was no mortality. Histologic analysis revealed a median of eight (range, 4-20) lymph nodes. Two patients diagnosed with lymph-node metastases received adjuvant radiochemotherapy. After a median follow-up of 48 (range, 4-60) months, there was no evidence for locoregional recurrence. In one patient liver metastasis was detected eight months postoperatively. Radical excision of the primary tumor and an adequate tumor staging in T1 carcinomas of the lower third of the rectum seems to be achievable by means of transanal local excision and endoscopic posterior mesorectal resection.

Indications for colorectal resection for adenoma before and after polypectomy

Adenomas presenting in colon and rectum require different strategies. Those in the rectum are accessible to local endoanal excision while those in the colon can be removed by endoscopic polypectomy. Essentially the decision in both cases centres around the risk of malignancy. Does the tumour itself contain a focus of malignancy? Where invasion has been demonstrated in the tumour, are the regional lymph nodes involved? Rectal adenomas can be assessed by clinical examination, rectal ultrasound and magnetic resonance imaging. Colonic adenomas on the other hand, are assessed by endoscopic appearances amplified by chromo- and zoom-endoscopy techniques and by endoscopic endosonography. In both locations the decision for surgical resection may be necessary in two clinical circumstances: the preoperative assessment of invasion and following the histopathology report where invasion has been demonstrated. With any adenoma with malignant change, a surgical opinion should be obtained. The decision for surgery depends on the risk of failure of the local excision balanced by the risk of morbidity and mortality following major surgery. Patients' wishes in the light of discussion of clinical and pathological prognostic factors are crucial in making the decision. Surgery is more frequently applied for early colonic than rectal cancers. This is due to two main factors: resective colonic surgery has less complications and mortality than anterior resection and transanal local excision may be more radical than endoscopic colonic polypectomy because it excises the full-thickness rectal wall.

The management of rectal cancer in the elderly

The majority of patients with rectal cancer are elderly. Due to the increasingly aging population the number of people with colorectal cancer is increasing. As medical advances in the areas of local therapy, radiation therapy, and surgical technique, such as, laparoscopy are made more elderly patients are offered various types of treatment for rectal cancer. As the number of treatment options increase, the debate on how to treat elderly patients' with rectal cancer intensifies. A Medline search using "rectal cancer," "elderly," "local therapy," "radical surgery," and "radiation therapy" as key words was performed for English-language articles. Further references were obtained through cross-referencing the bibliography cited in each work. Numerous treatment options exists for elderly patients with rectal cancer. These range from transanal local excision to radical surgery. The best treatment option for a certain elderly patient is multifactorial and includes tumor stage, operative curability, preoperative functioning of the patient, patient comorbidities, quality of life goals, and patient preference. Age, taken as an independent variable, is not a contraindication to any specific type of therapy, including radical surgery with primary anastomsis. Patients' who meet the criteria for local resection should undergo this procedure. However, for tumors which are not amenable to local resection, these patients should be considered for radical surgery if this provides the best chance for cure. Elderly patients who can tolerate a major operation, and have good preoperative sphincter function should undergo a resection with primary anastomosis.