Treatment Of Early Rectal Cancer Research Articles

Endoscopic intermuscular dissection: insights from China on minimally invasive treatment for early rectal cancer.

Endoscopic intermuscular dissection: insights from China on minimally invasive treatment for early rectal cancer.

Early Rectal Cancer and Local Excision: A Narrative Review.

A rise in the incidence of early rectal cancer consequent to bowel-screening programs around the world and an increase in the incidence in young adults has led to a growing interest in organ-sparing treatment options. The rectum, being the most distal portion of the large intestine, is a fertile ground for local excision techniques performed with endoscopic or surgical techniques. Moreover, the advancement in endoscopic optical evaluation and the better definition of imaging techniques allow for a more precise local staging of early rectal cancer. Although the local treatment of early rectal cancer seems promising, in clinical practice, a significant number of patients who could benefit from local excision techniques undergo total mesorectal excision (TME) as the first approach. All relevant prospective clinical trials were identified through a computer-assisted search of the PubMed, EMBASE, and Medline databases until January 2024. This review is dedicated to endoscopic and surgical local excision in the treatment of early rectal cancer and highlights its possible role in current and future clinical practice, taking into account surgical completion techniques and chemoradiotherapy.

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.

Patients’ perspectives and the perceptions of healthcare providers in the treatment of early rectal cancer; a qualitative study

BackgroundShared decision-making has become of increased importance in choosing the most suitable treatment strategy for early rectal cancer, however, clinical decision-making is still primarily based on physicians’ perspectives. Balancing quality of life and oncological outcomes is difficult, and guidance on patients’ involvement in this subject in early rectal cancer is limited. Therefore, this study aimed to explore preferences and priorities of patients as well as physicians’ perspectives in treatment for early rectal cancer.MethodsIn this qualitative study, semi-structured interviews were performed with early rectal cancer patients (n = 10) and healthcare providers (n = 10). Participants were asked which factors influenced their preferences and how important these factors were. Thematic analyses were performed. In addition, participants were asked to rank the discussed factors according to importance to gain additional insights.ResultsPatients addressed the following relevant factors: the risk of an ostomy, risk of poor bowel function and treatment related complications. Healthcare providers emphasized oncological outcomes as tumour recurrence, risk of an ostomy and poor bowel function. Patients perceived absolute risks of adverse outcome to be lower than healthcare providers and were quite willing undergo organ preservation to achieve a better prospect of quality of life.ConclusionPatients’ preferences in treatment of early rectal cancer vary between patients and frequently differ from assumptions of preferences by healthcare providers. To optimize future shared decision-making, healthcare providers should be aware of these differences and should invite patients to explore and address their priorities more explicitly during consultation. Factors deemed important by both physicians and patients should be expressed during consultation to decide on a tailored treatment strategy.

Local resection versus radical resection for early-stage rectal cancer: a systematic review and meta-analysis.

The optimal surgical approach for early-stage rectal cancer remains controversial. Radical resection is considered to be the gold standard for rectal cancer treatment. More and more studies show that local resection can replace traditional radical resection in the treatment of early rectal cancer. This research aimed to compare the efficacy of local excision and radical surgery for early-stage rectal cancer and report the evidence-based clinical advantages of both techniques. The clinical trials comparing oncological and perioperative local and radical resection outcomes for early-stage rectal cancer were searched from 7 national and international databases. Finally, 3 randomized controlled trials and 14 cohort studies were included. In terms of oncology and perioperative outcomes, there were no statistically significant differences between the radical resection group and the local resection group in terms of OS (HR = 1.05, 95% CI (0.98, 1.13), DFS [HR = 1.18, 95% CI (0.93, 1.48), p = 0.168), distant metastasis rate (RR = 1.04, 95% CI (0.49, 2.20), p = 0.928), and mortality rate (RR = 1.52, 95% CI (0.80, 2.91), p = 0.200). However, there were significant differences in the outcomes of complications (RR = 2.85, 95% CI (2.07, 3.92), p < 0.001), length of hospital stays (WMD = 5.41, 95% CI (3.94, 6.87), p < 0.001), stoma rate (RR = 7.69, 95% CI (2.39, 24.77), p = 0.001), local recurrence rate (RR = 0.48, 95% CI (0.27, 0.86), p = 0.013), operative time (WMD = 74.68, 95% CI (68.00, 81.36), p < 0.001), blood loss (WMD = 156.36, 95% CI (95.48, 217.21, p < 0.001), and adverse events (RR = 1.59, 95% CI (1.05, 2.41), p = 0.027). Local excision may be a viable alternative to radical resection for early-stage rectal cancer, but higher quality clinical studies are needed to confirm this.

Transanal endoscopic microsurgical submucosal dissection (TEM-ESD): A novel approach to the local treatment of early rectal cancer

BackgroundComplete local resection is currently the treatment of choice for low-risk early rectal cancer; however, the ideal resection technique for such tumours is still debated. Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) is a new technique which combines the ergonomic advantages of transanal endoscopic microsurgery (TEM) with the minimally invasive approach of endoscopic submucosal dissection (ESD). The aim of our study was to assess the feasibility, safety, and long-term outcomes of TEM-ESD in treating early rectal cancer. Materials and methodsWe retrospectively analysed all cases of rectal adenocarcinomas treated with TEM-ESD in Karlsruhe Municipal Hospital between 2012 and 2019, as well as the perioperative and follow-up data of the patients. ResultsWe identified 40 cases (19 low-risk and 21 high-risk carcinomas) matching our criteria. The median size of the lesions was 3.8 cm and the median operating time 48.5 min. En bloc resection was possible in all cases, while histologically complete resection was confirmed in 18 of 19 low-risk tumours and in 30 out of all lesions. The resection was curative in 19 cases. No scarring of the mesorectum was reported during the completion of total mesorectal excision for high-risk tumours. There was only 1 case of local recurrence among patients treated with curative intent, with an overall survival rate of 100% and a disease-free survival rate of 96% at both 2 and 5 years for these patients. ConclusionTEM-ESD is a safe and feasible therapeutic option for resecting early rectal cancer, offering very good long-term outcomes.

A Meta-analysis of Transanal Endoscopic Microsurgery versus Total Mesorectal Excision in the Treatment of Rectal Cancer.

Background Transanal endoscopic microsurgery (TEMS) has been suggested as an alternative to total mesorectal excision (TME) in the treatment of early rectal cancers. The extended role of TEMS for higher stage rectal cancers after neoadjuvant therapy is also experimented. The aim of this meta-analysis was to compare the oncological outcomes and report on the evidence-based clinical supremacy of either technique. Methods Medline, Embase, and Cochrane databases were searched for the randomized controlled trials comparing the oncological and perioperative outcomes of TEMS and a radical TME. A local recurrence and postoperative complications were analyzed as primary end points. Intraoperative blood loss, operation time, and duration of hospital stay were compared as secondary end points. Results There was no statistical difference in the local recurrence or postoperative complications with a risk ratio of 1.898 and 0.753 and p -values of 0.296 and 0.306, respectively, for TEMS and TME. A marked statistical significance in favor of TEMS was observed for secondary end points. There was standard difference in means of −4.697, −6.940, and −5.685 with p -values of 0.001, 0.005, and 0.001 for blood loss, operation time, and hospital stay, respectively. Conclusion TEMS procedure is a viable alternative to TME in the treatment of early rectal cancers. An extended role of TEMS after neoadjuvant therapy may also be offered to a selected group of patients. TME surgery remains the standard of care in more advanced rectal cancers.

Preservation of the rectum is possible in early rectal cancer with neoadjuvant radiotherapy, delay and local excision-a 12-year single-centre experience of the evolution of early rectal cancer treatment.

Treatment of early rectal cancer (ERC) is undergoing a revolution towards rectum preservation. Adjuvant and neoadjuvant therapy alongside local excision (LE) means that organ preservation is a real possibility for most patients and a viable alternative for frailer patients. This study presents our 12-year experience as a specialist regional ERC unit, evolving towards organ preservation. Data were collected prospectively between 2006 and 2018 for all patients referred to the regional ERC multidisciplinary team with suspected or confirmed ERC. Patients considered suitable for LE, or those declining radical surgery, were offered LE or neoadjuvant short-course radiotherapy (SCRT), delay and LE with subsequent rescue surgery or contact brachytherapy for unfavourable histopathology. In all, 102 patients underwent LE. Ten patients were excluded (N=92). 45 patients underwent LE directly and 47 patients received SCRT and LE. After SCRT and LE, a pathological complete response was achieved in 44.7%. This approach also resulted in a lower rate of lymphovascular invasion (22.2% vs. 6.4%), fewer distant recurrences (4.4% vs. 0%) and a better disease-specific mortality (11.1% vs. 0%) (P<0.05). Although statistically insignificant, fewer patients required rescue surgery after SCRT (15.6% vs. 4.3%). Organ preservation with a good oncological outcome is better achieved by neoadjuvant radiotherapy, delay and LE. To achieve this, careful patient selection, thorough preoperative investigation, experienced surgical technique and a deep appreciation of tumour biology managed via a dedicated ERC network is paramount.

Outcomes of completion total mesorectal excision are not compromised by prior transanal minimally invasive surgery.

AimTransanal minimally invasive surgery (TAMIS) is used increasingly often as an organ‐preserving treatment for early rectal cancer. If final pathology reveals unfavourable histological prognostic features, completion total mesorectal excision (cTME) is recommended. This study is the first to investigate the results of cTME after TAMIS.MethodData were retrieved from the prospective database of the Elisabeth‐TweeSteden Hospital. Completion TME patients were case matched with a control group of patients undergoing primary TME (pTME). Primary and secondary outcomes were surgical outcomes and oncological outcomes, respectively.ResultsFrom 2011 to 2017, 20 patients underwent cTME and were compared with 40 patients undergoing pTME. There were no significant differences in operating time (238 min vs 226 min, P = 0.53), blood loss (137 ml vs. 158 ml, P = 0.88) or complications (45% vs 55%, P = 0.07) between both groups. There was no 90‐day mortality in the cTME group. The mesorectal fascia was incomplete in three patients (15%) in the cTME group compared with no breaches in the pTME group (P = 0.083). There were no local recurrences in either group. In three patients (15%), distant metastases were detected after cTME compared with one patient (2.5%) in the pTME group (P = 0.069). After cTME patients had a 1‐ and 5‐year disease‐free survival of 85% compared with 97.5% for the pTME group (P = 0.062).ConclusionCompletion TME surgery after TAMIS is not associated with increased peri‐ or postoperative morbidity or mortality compared with pTME surgery. After cTME surgery patients have a similar disease‐free and overall survival when compared with patients undergoing pTME.

The treatment of early rectal cancer in the era of adjuvant and neo-adjuvant therapy

The accurate staging of rectal cancer improves the stratification of patients for adjuvant therapy. Staging of tumor with endoluminal ultrasonography (EUS) shows a good correlation with histology (κ = 0.85; 95% confidence interval 0.76-0.95). Overall pT and pN stage accuracy of EUS was 92% and 65% respectively. The staging of local disease can be further augmented by EUS guided fine needle aspiration of extra rectal lesions lying within or outside of the mesorectum. In a systematic review of local excision after neoadjuvant therapy a total of 22 unique studies reporting on 1068 patients were analysed. At a median follow-up of 54 months, ypT0 tumours had a pooled local recurrence rate of 4% and a median disease-free survival rate of 95%. Outcomes for ≥ ypT1 tumours were much worse with pooled local recurrence and disease-free survival of 22% and 68%, respectively. In a review of 22 studies, 804 patients who underwent local excision followed by adjuvant therapy either for unfavourable histology, prohibitive comorbidity or patient choice. the pooled local recurrence was 5.8% for pT1 tumours, 13.8% for pT2 tumours and 33.7% for pT3 tumours. In addition, the response to radiotherapy may be enhanced by aspirin, metformin and statins.

Does previous transanal excision for early rectal cancer impair surgical outcomes and pathologic findings of completion total mesorectal excision? Results of a systematic review of the literature

Transanal excision (TAE) is increasingly used in the treatment of early rectal cancer because of lower rate of both postoperative complications and postsurgical functional disorders as compared with total mesorectal excision (TME) OBJECTIVE: To compare in a meta-analysis surgical outcomes and pathologic findings between patients who underwent TAE followed by completion proctectomy with TME (TAE group) for early rectal cancer with unfavorable histology or incomplete resection, and those who underwent primary TME (TME group). The Medline and Cochrane Trials Register databases were searched for studies comparing short-term outcomes between patients who underwent TAE followed by completion TME versus primary TME. Studies published until December 2016 were included. The meta-analysis was performed using Review Manager 5.0 (Cochrane Collaboration, Oxford, UK). Meta-analysis showed that completion TME after TAE was significantly associated with increased reintervention rate (OR=4.28; 95% CI, 1.10-16.76; P≤0.04) and incomplete mesorectal excision rate (OR=5.74; 95% CI, 2.24-14.75; P≤0.0003), as compared with primary TME. However there both abdominoperineal amputation and circumferential margin invasion rates were comparable between TAE and TME groups. This meta-analysis suggests that previous TAE impaired significantly surgical outcomes and pathologic findings of completion TME as compared with primary TME. First transanal approach during completion TME might be evaluated in order to decrease technical difficulties.

Tumor volume predicts local recurrence in early rectal cancer treated with radical resection: A retrospective observational study of 270 patients

ObjectiveRadical resection is regarded as the primary treatment for early rectal cancer, and tumor volume is an independent predictor of many other types of cancer. The purpose of the present study is to assess the effect of tumor volume on the survival of patients with early rectal cancer treated with radical surgery. MethodsA total of 270 patients with histologically confirmed stage T1/2 N0 rectal cancer who underwent radical resection between September 2006 and September 2014 were enrolled in this study. The tumor volume was measured based on the preoperative pelvic MRI. The clinical significance of tumor volume with respect to patients' outcomes was evaluated, and the multivariate Cox proportional regression model was used to analyse the risk factors for survival of these patients. ResultsThe median follow-up period was 57.6 months. The tumor volume was significantly correlated with preoperative Hb, CEA level and number of retrieved lymph nodes (all p < 0.05). The large tumor group had a lower disease-free survival (DFS) rate than the small tumor group (5-year DFS rate: 80.4% vs 89.6%, p = 0.042), whereas there was no difference in the overall survival rate. The 5-year local recurrence rates for patients in the large and small tumor groups were 10.5% and 3.0%, respectively (p = 0.030). Additionally, the tumor volume was an independent clinical predictor for both DFS and local recurrence-free survival (LRFS). ConclusionIn conclusion, the tumor volume is significantly associated with DFS and LRFS of patients with stage T1/2 N0 rectal cancer who underwent radical resection alone. Tumor volume may be considered an important indicator for neoadjuvant or adjuvant therapeutic interventions.

Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up.

Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up.

Органосохраняющее лечение раннего рака прямой кишки

Aim of review. To generalize scientific data and to develop modern concept on the issue of diagnosis, staging and treatment of early rectal cancer. Summary. The world-wide issues of early rectal cancer are discussed in the review. Diagnostic methods and staging of the early cancer and premalignant states are discussed. Prospects of improvement of early rectal cancer treatment approach are outlined, advantages of the rectum-preserving techniques are justified. Conclusion. Early rectal cancer is rarely observed neoplasm that may be the main cause for diagnostic and staging difficulties. So far the choice of surgical method for early rectal cancer is a subject for discussion, at the same time the choice of method is determined not only by the tumor invasion depth, but also by the presence of risk factors for regional lymph node involvement.

Tu1738 - Multimodal Endoscopic Evaluation Guides Treatment Decisions for Early Rectal Cancers and Complex Rectal Neoplasms

Introduction There is wide variation in the treatment of early rectal cancers and complex rectal neoplasms. With increasing emphasis on minimally invasive techniques and organ preservation, we aimed to evaluate the utility of a standardised, structured and rational assessment of rectal tumours to inform decision making for patients referred to a tertiary unit specialising in early rectal cancer. Method Since 2012, our unit has employed a standard approach to the assessment of rectal lesions which includes multimodal endoscopic assessment of all lesions using white light, magnification chromoendoscopy and colonoscopic high frequency miniprobe ultrasound to inform treatment decisions. Patients can then be allowed a fully informed decision regarding treatment options, which include advanced endoscopic resection, minimally invasive transanal endoscopic microsurgery (TEMS) or laparoscopic segmental oncological resection, all of which are offered by our unit. Results 191 patients (mean age 71 years) with rectal tumours were referred to our unit for an assessment regarding suitability for local resection. Multimodal endoscopic evaluation assessed 128 lesions as benign and 63 as malignant. 125 lesions with a mean size of 70.9 mm were treated with endoscopic resection: 108 adenomas, 9 adenocarcinomas and 5 neurendocrine tumours. 92% were performed without general anaesthesia and 78% as day cases. There were 2 small perforations treated endoscopically with clips with no adverse sequelae. The recurrence rate was 10%, all managed endoscopically. At last surveillance 97% of patients were free from recurrence. None required a major resection. 37 patients underwent TEMS as curative treatment or for patients unfit for, or refusing major resection. Only 3 patients with benign neoplasms had TEMS. The few remaining patients were either directed to major surgical resection, palliative options or declined treatment. Conclusion A standardised rational approach employing multimodal endoscopic evaluation for assessing complex rectal neoplasms results in high rates of safe, effective organ preserving treatment with almost no patients with benign disease subjected to a surgical procedure. Disclosure of Interest None Declared

Experience of minimally invasive treatment for early rectal cancer

Experience of minimally invasive treatment for early rectal cancer

National audit of a system for rectal contact brachytherapy

Abstract Background and purpose Contact brachytherapy is used for the treatment of early rectal cancer. An overview of the current status of quality assurance of the rectal contact brachytherapy systems in the UK, based on a national audit, was undertaken in order to assist users in optimising their own practices. Material and methods Four UK centres using the Papillon 50 contact brachytherapy system were audited. Measurements included beam quality, output and radiation field size and uniformity. Test frequencies and tolerances were reviewed and compared to both existing recommendations and published reviews on other kV and electronic brachytherapy systems. External validation of dosimetric measurements was provided by the National Physical Laboratory. Results The maximum host/audit discrepancy in beam quality determination was 6.5%; this resulted in absorbed dose variations of 0.2%. The host/audit agreement in absorbed dose determination was within 2.2%. The median of the radiation field uniformity measurements was 2.7% and the host/audit agreement in field size was within 1mm. Test tolerances and frequencies were within the national recommendations for kV units. Conclusions The dosimetric characterisation of the Papillon 50 was validated by the audit measurements for all participating centres, thus providing reassurance that the implementation had been performed within the standards stated in previously published audit work and recommendations for kV and electronic brachytherapy units. However, optimised and standardised quality assurance testing could be achieved by reducing some methodological differences observed.

TAMIS, transanal minimally invasive surgery

Diseases of the lower and middle third of the rectum, the so called "no-man's territory" traditionally represent a major surgical problem. Minimally invasive surgical techniques significantly contribute to the safe and precise management of this part of the rectum. Traditional laparoscopic instruments via a specifically designed operative anoscope with single-port surgical technique are used during TAMIS (transanal endoscopic minimally invasive surgery). Since the description of the procedure in 2009 a number of case series have proven the feasibility and safety of the technique in the treatment of rectal adenomas. Furthermore, TAMIS seems to be sufficient in the primary treatment of early rectal cancers, as well. Recent studies also challenge the rigid protocols of the management of advanced rectal adenocarcinomas. Transanal wide local excision techniques (including TAMIS) with low morbidity rates seem to be effective in cases of histologically proven pCR (complete pathological response) after neoadjuvant treatment by selecting the group of patients not requiring radical TME (total mesorectal excision). Finally, TAMIS technique provide a suitable way for down-up transanal TME (TaTME), which technique is expected to potentially improve surgical grade in selected cases of advanced rectal cancer surgeries. In this paper we demonstrate our initial experiences with TAMIS at a single institution, as well as summarize the relevant literature.

Practice parameters for early rectal cancer management: Italian Society of Colorectal Surgery (Società Italiana di Chirurgia Colo-Rettale; SICCR) guidelines.

The introduction of new technologies for diagnosis and screening programs led to an increasing rate of early detection of colorectal cancer. This, associated with the evolution of endoscopic techniques of local excision, led to the assessment of new strategies to reduce morbidity related to treatment, especially for early rectal cancer (ERC). Nevertheless, the definition of ERC and its staging and treatment algorithm are still under debate. The Italian Society of Colorectal Surgery developed practice guidelines to provide recommendations on the diagnosis, staging and treatment of ERC. A systematic review on the topic was performed by a multidisciplinary group of experts selected based on their clinical and scientific expertise in endoscopy, endoscopic ultrasound, magnetic resonance and surgery, with the aid of an external international audit.

Current status of local treatment for early rectal cancer in Japan: a questionnaire survey by the 81st Congress of the Japanese Society for Cancer of the Colon and Rectum (JSCCR) in 2014.

The aim of this questionnaire survey was to assess the change in treatment modality over time and the current status of clinical outcomes of local treatment in Japanese patients with pathological T1 (pT1) rectal tumors. A questionnaire survey was conducted by the 81st Congress of the Japan Society for Cancer of the Colon and Rectum. Clinical and pathological outcomes of all eligible patients undergoing local treatment were retrospectively collected from the medical records of each participating hospital. A total of 1371 pT1 patients from January 2006 to December 2008 (Period A), and 659 patients in 2013 (Period B) were registered. Approximately 70 % of patients underwent radical surgery in both periods. The rate of patients undergoing laparoscopic surgery increased from 46.5 % in Period A to 84.7 % in Period B. The indications for local excision were comparable with those for endoscopic intervention in 78 % of institutions. The rate of endoscopic submucosal dissection (ESD) increased from 20.1 % in Period A to 37.9 % in Period B, whereas local excision decreased from 36.9 to 24.1 %. Few patients received adjuvant therapy, and approximately 40 % of patients underwent additional surgery in both periods. Local recurrence was observed in 9.2 % of patients in Period A, with the median follow-up period being 59 months. Eighty-two percent of patients with local recurrence underwent salvage surgery. Local treatment with various modalities was properly performed for early rectal cancer. The number of less invasive modalities, such as laparoscopic surgery and ESD, increased between study periods.