Local excision of rectal cancer without adjuvant therapy: a word of caution

Depth of tumor invasion independently predicts lymph node metastasis in T2 rectal cancer

OBJECTIVE

The aim of this study was to identify risk factors of lymph node metastasis (LNM) for T2 rectal cancer.

METHODS

From a prospectively maintained single-institution database, we identified 346 consecutive pT2 rectal cancers treated with total mesorectal excision from 1998 to 2009. Univariate and multivariate analyses were performed to identify risk factors associated with overall and intermediate/apical LNM. The incidence of overall and intermediate/apical LNM was analyzed by tree analysis.

RESULTS

Age, tumor location, pathological features, and depth of invasion were independent predictors for overall LNM. Tumor location, pathological features, and depth of invasion were independent predictors for intermediate/apical LNM. Tree analysis showed that the incidence of LNM was 7.7% for upper rectal cancer with favorable pathological features, and 3.4% for mid/lower rectal cancer without other identified risk factors. The incidence of intermediate/apical LNM was 5.7% for superficial T2 rectal cancer with favorable pathological features, and 3.1% for deep T2 rectal cancer locating in upper rectum with favorable pathological features.

CONCLUSIONS

Depth of invasion is an independent predictor for LNM in T2 rectal cancer. Using tree analysis, we identified a subset of patients with low risk of LNM who may be candidates of local excision.

Risk factors of nodal involvement in T2 colorectal cancer

PURPOSE

Because of the adverse consequences of radical resection of T2 colorectal cancer, criteria are needed for selection of patients who can safely undergo local excision without requiring additional radical surgery. We therefore conducted a retrospective study of patients with T2 colorectal cancer to identify risk factors for nodal involvement that might be used in selecting patients for local excision.

METHODS

We reviewed records from consecutive patients who had undergone curative resection of T2 colorectal cancer at the Department of Surgery, National Defense Medical College, Saitama, Japan, between 1985 and 2005. Data on conventional clinicopathologic variables were retrieved from pathology reports at the time of surgery, and archived slides were evaluated regarding potential risk factors such as extent of poorly differentiated component (grade I-III), myxoid cancer stroma, tumor budding, and growth pattern and invasion depth in the muscularis propria.

RESULTS

A total of 244 patients (139 men and 105 women) treated for T2 colorectal cancer were included. Nodal involvement was found in 7 (8.4%) of 83 patients classified as grade I on the poorly differentiated component vs. 47 (29.2%) of 161 patients classified as grade II or III (P < .001). Of 148 patients negative for myxoid cancer stroma, 30 (16.9%) had nodal involvement vs. 24 (36.4%) of 42 patients who were positive for myxoid cancer stroma (P = .0011). According to multiple variable logistic analysis, significant independent risk factors for nodal involvement included poorly differentiated component (P = .002), myxoid cancer stroma (P = .032), and lymphovascular invasion (P = .022).

CONCLUSIONS

Poorly differentiated component, myxoid cancer stroma, and lymphovascular invasion are significant independent risk factors for nodal involvement in T2 colorectal cancer. We need further study to validate these results on another data set, especially in patients with rectal cancer, and to confirm whether local resection of T2 rectal cancer is able to predict the nodal involvement before laparotomy.

ACR Appropriateness Criteria: local excision in early-stage rectal cancer

Low anterior resection or abdominoperineal resection is considered standard treatment for early rectal cancer. These procedures, however, carry a risk of morbidity and mortality that may not be warranted for early distal lesions, which may be treated with local excision. Emerging data has investigated the efficacy of local excision in patients with early stage rectal cancers. An expert panel designated by the American College of Radiology has reviewed supporting data, from a few prospective multi-institutional trials and a number of single-institution, retrospective reviews. The consensus recognizes the importance of accurate staging to identify patients who may be candidates for a local excision approach. Optimal candidates for local excision alone include small, low-lying T1 tumors, without adverse pathologic features. A number of procedures may be safely used including transanal, posterior trans-sphincteric, posterior proctotomy, transanal excision, or transanal microsurgery. It is important to note that none of these include lymph node evaluation, and depending on the risk of lymph node metastases, adjuvant radiation with or without chemotherapy may be warranted. Patients with positive margins or T3 lesions are at high risk of local recurrence and should be offered immediate APR or LAR. However, patients with high-risk T1 tumors, T2 tumors, or those who are not amenable to more radical surgery may benefit from adjuvant treatment. Data have also reported excellent local control rates for neoadjuvant radiation +/- chemotherapy followed by local excision in higher risk patients, but it is not yet clear if this approach reduces recurrence rates over surgery alone.

Proposed objective criteria for "grade 3" in early invasive colorectal cancer

To establish objective criteria for "grade 3" (G3) in T1 (TNM staging) colorectal cancer (CRC), a total of 296 T1 CRC cases were reviewed. The incidence of nodal involvement differed most greatly between G3 and non-G3 (21/27 [27%] and 6/162 [3.7%], respectively; P < .0001), when G3 was applied to tumors containing either or both of the following: (1) 10 or more solid cancer nests in the microscopic field of a 4x objective lens and (2) a mucin-producing component fully occupied the microscopic field of a 40x objective lens. Regarding G3, vascular invasion, and tumor budding as indicating the risk of metastasis, nodal involvement rate was 21.0% in the tumors with 1 or more risk factors, whereas it was only 1.7% in the no-risk tumors (P < .0001). In patients treated with local excision only, nodal recurrence occurred in 3 (20%) of 15 risk-positive patients, whereas none of 42 patients without risk factors had nodal recurrence (P = .016). In cases of locally excised T1 CRC, G3 as determined by the proposed criteria, vascular invasion, and budding would comprise a useful combination of parameters for determining the indication for additional laparotomy.

Multidisciplinary teams in the management of rectal cancer

A myriad of advances in the treatment of rectal cancer have been achieved over the last few decades. The introduction of total mesorectal excision (TME) has resulted in significant improvements in local recurrence. Surgical education on the technique has made it the standard of care. Radiation and chemotherapy combined with TME have improved results even further with stage II and III cancers. Sphincter-sparing techniques, reservoir procedures, local treatment advances, minimally invasive techniques, surgery for metastatic disease, newer chemotherapies, and extended resections for locally advanced and recurrent lesions, have all benefited the patient with rectal cancer. The goal and responsibility of colorectal surgeons treating rectal cancer patients is to understand and coordinate the wide variety of modalities available to optimize survival, minimize morbidity, and maximize quality of life for those with this difficult problem. Coordination of specialists in this time of evolution in rectal cancer treatment becomes more important than ever. Here the authors briefly review the role of the multidisciplinary team, discuss a model multidisciplinary team approach and look at evidence supporting team use as we begin this issue devoted to the multidisciplinary management of rectal cancer.

Local treatment for rectal cancer

The treatment of rectal cancer includes both radical resection and local therapy. Radical resection remains the standard treatment, but is associated with increased morbidity and mortality, as well as the potential need for a temporary and occasionally, a permanent ostomy. The benefits of local treatment include a less invasive procedure with maintenance of bowel function and avoidance of a stoma. However, the efficacy of local treatment is now being challenged as the rates of recurrence after local excision alone appear to be much higher than previously thought. Although the primary goal of an oncologic resection is disease eradication, each case must be individualized to determine an optimal care plan.

Could a wait and see policy be justified in T3/4 rectal cancers after chemo-radiotherapy?

Chemoradiotherapy (CRT) followed by total mesorectal excision is the standard when MRI staging demonstrates threatened surgical margins in locally advanced rectal cancer (LARC). Interest in non-surgical management of LARC as an alternative to a resection has been provoked by published excellent long-term outcomes of patients who achieve clinical complete responses (cCR) after CRT. The present retrospective study aimed to determine whether similar rates of local disease control are seen in a UK cancer centre in patients with T3-4 tumours, who obtained a cCR after preoperative CRT, but did not undergo surgery.

METHOD

The outcome and treatment details of 266 patients who underwent CRT for clinically staged T3-4 rectal adenocarcinomas between 1993 and 2005 were reviewed.

RESULTS

Fifty-eight patients did not proceed to surgery, 10 of whom were identified as having a cCR. Six of these 10 patients subsequently developed intrapelvic recurrent disease with a median time to local progression of 20 months. Local relapse preceded the development of metastatic disease or occurred simultaneously. No patients underwent salvage resection.

CONCLUSION

CRT alone in cT3/T4 rectal cancers has a high rate of local relapse even after cCR. Delaying or avoiding surgery might be appropriate for cT1 or cT2 tumours, or elderly and frail patients with co-morbidity, but these results do not support the current uncritical move to extrapolate this approach to all surgically fit patients with rectal cancer.

Anal neoplasms

A variety of lesions comprise tumors of the anal canal, with carcinoma in situ and epidermoid cancers being the most common. Less common anal neoplasms include adenocarcinoma, melanoma, gastrointestinal stromal cell tumors, neuroendocrine tumors, and Buschke-Lowenstein tumors. Treatment strategies are based on anatomic location and histopathology. In this article different tumors and management of each, including a brief review of local excision for rectal cancer, are discussed in turn.

Randomized clinical trials in rectal and anal cancers

This article reviews randomized clinical trials (RCTs) published between April 2001 and November 2008 on the management of patients with rectal cancer. In total, the authors reviewed 78 RCTs on therapy for rectal cancer. Of these, five met the authors' criteria for level 1a evidence. The article discusses the major RCTs and relevant findings that have impacted clinical management most and includes most but not all RCTs on therapy for rectal cancer published during this period.

Is total mesorectal excision always necessary for T1-T2 lower rectal cancer?

BACKGROUND

The goal of this multicenter study was to clarify the determinants of local excision for patients with T1-T2 lower rectal cancer.

METHODS

Data from 567 consecutive patients who underwent radical resection for T1-T2 lower rectal cancer at 12 institutions between 1991 and 1998 were reviewed. Rates of lymph node metastasis were investigated using a tree analysis, which was hierarchized using independent risk factors for nodal involvement.

RESULTS

The independent risk factors for lymph node metastasis were female gender, depth of tumor invasion, histology other than well-differentiated adenocarcinoma, and lymphatic invasion. According to the first three parameters that can be obtained preoperatively, only 0.99% of the patients without risk factors had lymph node metastasis. On the other hand, even if the lower rectal cancer was at stage T1, women with histological types other than well-differentiated adenocarcinoma had an approximately 30% probability of having lymph node metastasis. Lymphatic invasion was most useful to predict nodal involvement among patients with T2 lower rectal cancer. The rates of lymph node metastasis in T2 patients with and without lymphatic invasion were 32.9% and 9.1%, respectively.

CONCLUSIONS

Gender is one of the most important predictors for lymph node metastasis in patients with early distal rectal cancer. Three parameters, including depth of tumor invasion, histology, and gender, are useful determinants for local excision. Additional studies are required to establish the minimum optimal treatment for T2 lower rectal cancer.

Recurrences after local excision for early rectal adenocarcinoma

PURPOSE

The 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 METHODS

Between 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).

RESULTS

The 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.

CONCLUSION

Local 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.

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

AIM: To compare the outcomes of endoscopic resection with transanal excision in patients with early rectal cancer.

METHODS: 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.

RESULTS: 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.

CONCLUSION: 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.

Long-term results of local excision for T1 rectal carcinoma: the experience of two colorectal units

BACKGROUND

Local excision for early rectal cancer has low morbidity and good functional results. Its use is limited by the inability to assess regional lymph nodes and by the uncertainty of oncologic outcome.

METHODS

We conducted a retrospective chart review of all patients who underwent local excision of early rectal cancer in two colorectal units between 1995 and 2007. The retrieved and analyzed data were patient age and gender, tumor size, tumor distance from the anal verge, tumor differentiation, and additional treatment.

RESULTS

There were 42 patients with T1 rectal cancer: 24 underwent transanal endoscopic microsurgery and 18 had a transanal excision. The surgical margins were free of tumor in 39 patients (93%), they were involved by tumor in one (2%) and margin status was unclear in two (5%). Seven patients (16%) had postoperative complications. There was no postoperative mortality. The mean hospital stay was 67 h. Thirty-nine patients (93%) were followed up for 57 months (mean). Two patients had local recurrence, at 7 and 41 months post-surgery. They had a tumor that invaded into the lower third of the submucosa, sm3. Both received chemoradiotherapy, and underwent an abdominoperineal resection and a low anterior resection. One of them died of metastatic disease 13 months later and the other is alive with no evidence of disease. Another two patients had salvage low anterior resection, one for suspected local recurrence and one for lymphovascular invasion: the specimens were tumor free. Six patients died of unrelated causes.

CONCLUSIONS

Local excision of early rectal cancer is a feasible and acceptable alternative to radical resection. It has low complication and recurrence rates and a short postoperative hospital stay.

Technologic innovations in surgery: a philosophic reflection on their impact on operations for cancer

Technologic advances this past half-century have clearly had a positive effect on our ability to both diagnose and treat human cancer as well as on the operative treatment of other diseases. However, the impact of these innovations on the surgical treatment of cancer is not as clear as it is for many other problems that are managed surgically. This review is an "opinion piece" that attempts to assess the successes and failures of technologic innovations that have been introduced for the purpose of improving the operative treatment of cancer.

Transanal endoscopic operation: a new proposal

PURPOSE

The transanal procedure for rectal cancer surgery is one of the many techniques currently available. Different techniques for local excision of rectal tumors include: conventional transanal technique, posterior access surgery, therapeutic colonoscopy, transanal endoscopic surgery.

METHODS

The aim of the present study is to describe a new method of transanal endoscopic resection, transanal endoscopic operation (TEO), and performed with the aid of a surgical proctoscope especially designed for this purpose and report the results obtained in 32 patients submitted to the TEO and to compare these results with those obtained with other techniques currently available. The average proportions of recurrence, post-operation complications and posterior resections were analyzed by means of a metanalysis. Data on the distance and size of rectal lesions, the operative timing and hospitalization time were distributed in graphs according to authors and techniques.

RESULTS

The results were favorable and equivalent to those described in the literature.

CONCLUSIONS

The surgical proctoscope specially designed for this study is efficient and has a low cost; the TEO is easily performed with the aid of this equipment; the final results were favorable and similar to those obtained with other available techniques for endoscopic transanal intestinal resection, which are of high cost and less availability.

Transanal endoscopic microsurgery versus total mesorectal excision of T1 rectal adenocarcinomas with curative intention

PURPOSE

After total mesorectal excision (TME) for rectal cancer, pathology is standardized with margin status as a predictor for recurrence. This has yet to be implemented after transanal endoscopic microsurgery (TEM) and was investigated prospectively for T1 rectal adenocarcinomas.

PATIENTS AND METHODS

Eighty patients after TEM were compared to 75 patients after TME. The study protocol included standardized pathology. TEM patients were eligible when excision margins were negative.

RESULTS

TEM was safer than TME as reflected by operating time, blood loss, hospital stay, morbidity, re-operation rate and stoma formation (all P<0.001). Mortality after TEM was 0% and after TME 4%. At 5 years after TEM and TME, both overall survival (TEM 75% versus TME 77%, P=0.9) and cancer-specific survival (TEM 90% versus TME 87%, P=0.5) were comparable. Local recurrence rate after TEM was 24% and after TME 0% (HR 79.266, 95% CI, 1.208 to 5202, P<0.0001).

CONCLUSION

For T1 rectal adenocarcinomas TEM is much saver than TME and survival is comparable. After TEM local recurrence rate is substantial, despite negative excision margins.

Transanal endoscopic microsurgery: indications, results and controversies

Transanal endoscopic microsurgery (TEM) was introduced in 1983 as a minimally invasive technique allowing the resection of adenomas and early rectal carcinomas unsuitable for local or colonoscopic excision which would otherwise require major surgery. After 25 years, there is still much debate about the procedure. This article presents the TEM technique, indications, results and complications, focusing on its role in rectal cancer. The controversial points addressed include long-term results, TEM in high-risk T1 lesions, TEM associated with combined modality therapy (CMT) for invasive rectal cancer and salvage therapy after TEM. The future perspectives for TEM are promising and its association with CMT will probably expand the select group of patients who will benefit from the procedure.

Treatment for patients with rectal cancer and a clinical complete response to neoadjuvant therapy: a decision analysis

PURPOSE

A clinical complete response to neoadjuvant therapy occurs in a subset of patients with rectal cancer. Management of these patients is controversial and tension exists between the recurrence risk with observation, and the impact of surgery on quality-of-life. Therefore, the objective was to develop a decision-analytic model to evaluate the relative benefits of surgery vs. observation in rectal cancer patients who achieve clinical complete response after neoadjuvant chemoradiation.

METHODS

Clinically relevant inputs and events, including the ability to identify complete responders, likelihood of relapse and of salvage surgery after relapse, and utilities for each health state, were simulated by use of a Markov state-transition model. Transition probabilities and health-state utilities were derived from the literature and expert consensus. One-way and two-way sensitivity analyses were performed to assess the robustness of model results to assumptions. The primary outcome was quality-adjusted life expectancy.

RESULTS

In the base-case analysis, the quality-adjusted life expectancy with surgery exceeded observation (5.63 vs. 5.34 quality-adjusted life-years). Sensitivity analysis demonstrated that observation was preferred to surgery if the ability to correctly identify patients with true complete responses exceeded 58 percent, if quality-of-life after surgery was poor (utility <0.81), or if the relative reduction in recurrence risk with surgery was <43 percent when compared with observation.

CONCLUSIONS

Our model outlines the issues associated with surgery vs. observation, and suggests that surgery is beneficial for the average patient with rectal cancer with a clinical complete response after neoadjuvant therapy. Current limitations in the clinical assessment of patient response to chemoradiation constitute an important factor influencing our results, and therefore warrant further investigation.

Brachytherapy and local excision for sphincter preservation in T1 and T2 rectal cancer

PURPOSE

To report long-term results of brachytherapy after local excision (LE) in the treatment of T1 and T2 rectal cancer at risk of recurrence due to residual subclinical disease.

METHODS AND MATERIALS

Between 1989 and 2007, 32 patients undergoing LE and brachytherapy were followed prospectively for a mean of 6.2 years. Estimates of local recurrence (LR), disease-specific survival (DSS), and overall survival (OS) were generated. Treatment-related toxicity and the effect of known prognostic factors were determined.

RESULTS

There were 8 LR (3 T1, 5 T2), of which 5 were salvaged surgically. Median time to the 8 LR was 14 months, and the 5-year rate of local control was 76%. Although there have been 9 deaths to date, only 5 were from disease. Five-year DSS and OS rates were 85% and 78%, respectively. There were 4 cases of Grade 2-3 radionecrosis and 1 case of mild stool incontinence. The sphincter was preserved in 27 of 32 patients.

CONCLUSION

Local excision and adjuvant brachytherapy for T1 and T2 rectal cancer is an appealing treatment alternative to immediate radical resection, particularly in the frail and elderly who are unable to undergo major surgery, as well as for patients wanting to avoid a permanent colostomy.

Local excision for rectal carcinoma

Local excision is an alternative approach to radical proctectomy for rectal cancer, but from an oncologic standpoint, it is a compromise, and its role remains controversial. Careful patient selection is essential because local excision is generally considered only for early rectal cancer with no evidence of nodal metastasis, parameters that can be predicted by clinical examination, and various radiologic modalities with variable accuracy. In this review, we present the literature evaluating the oncologic adequacy of local excision, including transanal endoscopic microsurgery and the results of salvage surgery after local excision. An overview of local excision in the context of perioperative adjuvant therapies is included. Finally, we suggest a treatment algorithm for local excision in rectal cancer.

Laparoscopic and minimally invasive resection of malignant colorectal disease

Minimally invasive surgery for colorectal cancer is a burgeoning field of general surgery. Randomized controlled trials have assessed short-term patient-oriented and long-term oncologic outcomes for laparoscopic resection. These trials have demonstrated that the laparoscopic approach is equivalent to open surgery with a shorter hospital stay. Laparoscopic resection also may result in improved short-term patient-oriented outcomes and equivalent oncologic resections versus the open approach. Transanal excision of select rectal cancer using endoscopic microsurgery is promising and robotic-assisted laparoscopic surgery is an emerging modality. The efficacy of minimally invasive treatment for rectal cancer compared with conventional approaches will be clarified further in randomized controlled trials.

Local excision for more advanced rectal tumors

Over the past 20 years, local excision (LE) of T1 rectal cancer was increasingly established and represents an oncologically established technique. In contrast, the situation for T2 tumors is less clear and has only been investigated in small patient collectives. LE for T2 tumors is thus discussed controversially.

MATERIALS AND METHODS

In addition to our own patients with T2 rectal cancer treated locally (n=40), we have analysed the local recurrence (LR) rates after LE alone (n=124), after immediate conventional radical reoperation (n=29), after adjuvant (chemo)-radiotherapy (n=294) and those after neoadjuvant chemoradiotherapy (nCRT) (n=269) using a PubMed search.

RESULTS

LR rates of low-grade T2 tumors after R0 resection by LE alone was 19%. If additional prognostically unfavorable findings were present, the LR rate rose to 52%. By immediate radical reoperation the LR rate was decreased to 7%, whereas that after adjuvant therapy was 16%. In contrast, LE of more advanced tumors after nCRT resulted in LR rates of 9%.

DISCUSSION

LE alone of T2 rectal cancer should not be performed, and after adjuvant chemoradiotherapy the risk of developing LR was also high. In cases with unexpected T2 finding after LE, immediate conventional reoperation can represent an adequate oncological therapy, because it reveals comparable results to those obtained by primary radical resection. First results after nCRT followed by LE showed favorable results with low LR rates. If the indication for LE of T2 cancers can be extended to patients after nCRT in the future will have to be determined in prospective mutlticentre studies.

[Management of superficial rectal cancers]

Superficial rectal cancers consist of Tis and T1 tumors as defined by the TNM classification system. Earlier detection of colorectal cancers through endoscopic screening should lead to an increase in the percentage of superficial cancers detected while still superficial; they may eventually represent more than a third of diagnosed rectal cancers. Endorectal ultrasound, ideally performed with a mini-probe, is the best pre-operative study to define the level of penetration into the rectal wall; depth of penetration and grade of differentiation are the major factors to be considered when contemplating local excision as an alternative to radical resection. Local excision can be performed endoscopically or by the classic transanal surgical approach. Each technique has pros and cons and the two are often complementary. Compared to the alternative of radical proctectomy, they have the decided advantages of zero mortality, minimal morbidity, and decreased expense. Pathologic examination of the resected specimen is the final determinant as to whether local resection is adequate therapy. When histologic prognostic factors are favorable (well-differentiated, absence of lymphatic or vascular invasion, superficial invasion of the submucosa (sm1), and clear resection margins), the risk of lymph node spread is negligible. When histologic prognostic factors are not favorable, a completion radical proctectomy should be performed.

Long-term follow-up of local rectal cancer surgery by transanal endoscopic microsurgery

BACKGROUND

In 1997 we launched a prospective program of transanal endoscopic microsurgery (TEM) for the treatment of rectal cancer.

METHODS

Suitability for TEM was based on endorectal ultrasound results, classified as follows: (I) benign tumors; (II) adenocarcinomas uT0 and uT1 with uN0; (III) adenocarcinomas uT2- uN0, low histological grade with intention to cure; and (IV) advanced stage adenocarcinomas with palliative care

RESULTS

Transanal endoscopic microsurgery was performed in 218 patients: 122 adenomas, and 96 adenocarcinomas: group II-72, group III-19, and group IV-5. Follow-up was >24 months (median 59 months) in 61 patients. Nine were lost to follow-up, and so 52 patients were studied: group II-38, group III-11, and group IV-3. The Kaplan-Meier probability of nonrecurrence of adenocarcinoma by group was 93% in tumors in situ (Tis) and T1; and 77.8% in T2. The Kaplan-Meier probability of survival by group was 100% in Tis and T1 and 82% in T2.

CONCLUSIONS

Rates of recurrence and long-term survival in Tis and T1 adenocarcinomas treated with TEM are similar to those in previously published reports using conventional surgery. Further studies are required in T2 adenocarcinomas to determine a definitive strategy.

Long-term results of transanal excision after neoadjuvant chemoradiation for T2 and T3 adenocarcinomas of the rectum

INTRODUCTION

Traditionally, selected early distal rectal cancers have been considered for treatment by transanal excision (TAE) with acceptable oncologic results. With the frequent use of neoadjuvant chemoradiation (NCR) for the treatment of locally advanced rectal cancer, there is growing interest in the application of TAE for such lesions. We report our experience of TAE for T2 and T3 rectal cancers following NCR.

MATERIAL AND METHODS

Between July 1994 and August 2006, 44 patients were identified as having undergone full-thickness TAE of pretreatment ultrasound-staged T2 and T3 rectal cancers that were treated with NCR. Fifteen patients were deemed medically unfit for radical resection, and 29 would have required abdominoperineal resection but were opposed to colostomy.

RESULTS

Our patient population consisted of 26 men and 18 women, with a median age of 69 (range, 43-89) and a median follow up of 64 months (6-153). Thirty-one patients had a clinical complete response (cCR) to NCR of which 19 (61%) had a pathologic CR (pCR). Seven (16%) of 44 patients sustained disease recurrence of which two were local only, two local and systemic, and three systemic only. Only four (9%) patients had died of disease at current follow up. Overall 5-year survival rates for T2/T3N0 and T2/T3N1 patients were 84% and 81%, respectively. Five patients underwent radical resection immediately following TAE for either positive margins or residual cancer. There was minimal morbidity with no perioperative mortality associated with TAE.

CONCLUSIONS

TAE of T2 and T3 rectal cancers following NCR is a safe alternative to radical resection in a highly select group of patients for which recurrence and survival rates comparable to radical resection can be achieved. This study supports ongoing efforts to assess this approach in prospective, multi-center trials.

Oncological outcome after local excision of rectal carcinomas

BACKGROUND

Local excision (LE) of T1 rectal cancer yields low recurrence rates. However, more frequent recurrences with unknown states of high-risk T1/T2 tumors are risk factors. The purpose of this study was to evaluate if, after LE, immediate reoperation is required, or awaiting salvage surgery is sufficient.

METHODS

150 T1 and 42 T2 tumors were treated by LE. Immediate reoperation was attempted for unfavorable pT1 (G3-4/L1/V1/R1/Rx/R < or =1 mm) and all pT2 tumors. Three groups were formed. Group A included low-risk pT1 tumors after complete (R0) LE; unfavorable pT1 and all T2 tumors were divided in groups B (immediate reoperation) and C (salvage surgery).

RESULTS

Groups A (n = 93) and B (n = 39) showed high tumor-free (TFS) and tumor-related survival (TRS) rates: group A 92% and 98%; group B 86% and 89%. In group C (n = 43), the TFS und TRS were significantly lower with 54% and 72%. Group A showed low recurrence rates and a wide range of International Union Against Cancer (UICC) stages. In group B, similarly low recurrence rates were found, but, in contrast, all recurrences were UICC IV. Group C had significantly higher recurrences rates and, in addition, two-thirds of these patients showed advanced UICC stages (III-IV).

CONCLUSIONS

LE of low-risk T1 tumors represents an adequate therapy. Immediate reoperation after LE of pT1 tumors with unfavorable histological finding or pT2 tumors can avoid local recurrences. Thereafter, high TFS rates can be expected in these patients, but metastases cannot be prevented and adjuvant measures are necessary. Awaiting recurrences as in group C leads to bad oncological outcomes with high recurrences and low survival rates.

Risk factors for lymph node metastasis in submucosal invasive colorectal cancer

BACKGROUND

Recent studies have shown a 7-15% lymph node (LN) metastasis rate in submucosal invasive colorectal cancer (SICC). Identifying risk factors for LN metastasis is crucial in selecting therapeutic modalities for SICC. We assessed the possibility of and the risk factors for LN metastasis in SICC.

METHODS

We performed a retrospective study on 168 SICC patients who underwent curative resection between June 1989 and December 2004 at Asan Medical Center. The level of submucosal invasion was classified into upper third (sm1), middle third (sm2), and lower third (sm3). The following carcinoma-related variables were assessed: tumor size, tumor location, depth of submucosal invasion, cell differentiation, lymphovascular invasion, neural invasion, and tumor cell dissociation (TCD).

RESULTS

The overall LN metastasis rate was 14.3%. Significant predictors of LN metastasis both univariately and multivariately were sm3 (p = 0.039), poorly differentiated cancer (p = 0.028), and TCD (p = 0.045). Lymphovascular invasion was a risk factor for LN metastasis in univariate analysis (p = 0.019); however, in multivariate analysis, lymphovascular invasion could not predict LN metastasis. No statistical difference was observed in the risk of LN metastasis with regard to tumor location, size, and neural invasion.

CONCLUSION

The depth of submucosal invasion, cell differentiation, and tumor cell dissociation were significant pathologic predictors of LN metastasis in SICC. Because SICC is associated with a considerable risk of LN metastasis, local excision may be performed carefully in SICC without adverse features.

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

BACKGROUND AND AIMS

Because of their low morbidity and mortality, limited resection or local excision are accepted therapeutical approaches in early colorectal cancer treatment. Even though, recent publications report recurrence rates after local excision of rectal cancer in up to 30%. This prompted us to evaluate our data for T1N0 colorectal cancer treated by radical surgery regarding recurrence, morbidity, mortality, and survival rates.

MATERIALS AND METHODS

Clinical, histopathological, and surveillance data from our prospective "colorectal cancer database" from 1979 to 2005 were analyzed to evaluate outcome and prognosis of T1N0 colorectal cancer treated by radical surgery. Only curative resections were included in this study. All patients were followed in an internal surveillance program, which enabled us to prospectively assess morbidity, mortality, and survival. RESULTS A total of 105 T1N0 colon and 69 rectal carcinomas were included in the study. Overall morbidity was 25% (colon) and 34% (rectum). Thirty-day mortality was 1.9% (colon) and 4.3% (rectum). After a median follow-up of 92 and 87 month, no isolated local recurrence occurred. One patient developed both local recurrence and liver metastases. Distant metastases were seen in 4.9% (colon) and 7.5% (rectum). The 5- and 10-year overall survival was 86 and 71% (colon) and 82 and 68% (rectum), respectively.

CONCLUSION

Even if radical surgical approaches are associated with a higher rate of morbidity and mortality, our data show that radical surgery for T1N0 colorectal cancer results in excellent tumor control which is of paramount importance for the patients' prognosis and survival. Combining the data presented with those of the current literature suggests that local approaches to rectal cancer can be recommended for highly selected T1N0 tumors, in palliative situations, or if the patient is unfit for general surgery.

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

OBJECTIVE

The present study investigated the risk of lymph node metastasis according to the depth of tumour invasion in patients undergoing resection for rectal cancer.

METHOD

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.

RESULTS

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.

CONCLUSION

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.

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

Background

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.

Methods

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.

Results

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.

Conclusion

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.

Transanal endoscopic microsurgery: local recurrence rate following resection of rectal cancer

OBJECTIVE

Transanal endoscopic microsurgery (TEM) is a safe and effective treatment for the excision of benign rectal adenomas. In recent years it has been used for the excision of malignant lesions, although its use in this context remains controversial. The aim of this study was to investigate the local recurrence of rectal cancers following local excision by TEM.

METHOD

Forty-two patients with rectal cancer were treated by TEM between 1998 and 2005. However, six patients went on to have immediate radical surgery and are excluded from the study. Of the remaining 36 the treatment intention was for cure in 16 (38.1%), compromise in 17 patients unfit for radical surgery (40.5%), and palliation in three (7.1%).

RESULTS

The mean age of patients was 75 years (range 41-90). The mean lesion area was 15 cm(2) (range 0.8-42) and mean distance from the dentate line was 6.6 cm (range 0-11). The mean follow up was 34 months (range 4-94). During the follow-up period there have been eight local recurrences (22%). The recurrence rates were 26% (6/23) for pT1, 22% (2/9) for pT2 and 0% (0/4) for pT3 lesions. The mean time to recurrence was 18.3 months (range 5-42).

CONCLUSION

Transanal endoscopic microsurgery is a safe procedure with obvious advantages over radical procedures. However, in this study the local recurrence rate is high. The recurrence rate may be an acceptable compromise in elderly or medically unfit patients but is hard to justify for curative intent.

Local excision and transanal endoscopic microsurgery in the management of rectal cancer with a focus on early carcinoma

Transanal endoscopic microsurgery (TEMS) will play an even greater role in the treatment of rectal cancer as the UK national colorectal cancer screening program becomes national. With more rectal tumors being uncovered at earlier stages, a greater emphasis will be placed on treatment options that do not involve radical surgery and the possibility of a stoma. This article reviews the data surrounding TEMS, focusing on its current role in the treatment of early rectal cancer but with a view on how this option may develop in the future, particularly with regards to the more advanced rectal cancers and in view of the improved chemoradiotherapy regimens available. The data is reviewed and some of the more controversial issues discussed.

Management of early rectal T1 and T2 cancers

The treatment of rectal cancer has undergone a tremendous surgical evolution over the past century. Initially, in the 19th century, the only possible safe treatment was a diverting colostomy, which then evolved first to local treatment, primarily via the Lisfranc and Kraske procedures (posterior approach), and later, in the 20th century, to the abdominal-perineal resection popularized by Miles. Subsequently, anterior resection and low anterior resection gained a solid foothold as the most efficacious ways to treat most cancers of the rectum. In the past 3 decades, transanal excision has reemerged as a popular treatment option for T1 and selected T2 rectal adenocarcinomas, allowing less morbidity for early cancers. The selection criteria for this treatment have often included mobile tumor, size <4 cm, favorable histology without lymphovascular invasion, and anatomic accessibility with the ability to achieve 1-cm circumferential margins. Although the use of transanal excision for T1 rectal cancer increased from 26% to approximately 44% between 1989 and 2003, multiple recent retrospective studies have suggested that locoregional recurrence after this procedure is as high as 18% for T1 cancers and 47% for T2 cancers. Of interest, limited available prospective data reveal much better results (4-5% locoregional recurrence rate for T1 and 14-16% for T2). Much of the apparent discrepancy is due to patient selection, which is far more rigid in prospective trials. Conflicting data also exist as to how this outcome affects overall survival, although surgical salvage averages approximately 50% with close follow-up. The following topics will be discussed in this article: the surgical evolution of rectal cancer, best patient selection criteria for transanal excision versus more radical operation, utility and effect of adjuvant therapy in early-stage rectal cancer, current trends in the treatment of early-stage rectal cancer, and current early-stage rectal cancer trials.

Complete clinical response after preoperative chemoradiation in rectal cancer: is a "wait and see" policy justified?

PURPOSE

A proportion of patients, who receive preoperative chemoradiation for locally advanced (T3, T4, NX) rectal cancer achieve a complete clinical response and a pathologic complete response in the region of 15 to 30 percent. Support is growing in the United Kingdom for the concept of "waiting to see" and not proceeding to radical surgery when a complete clinical response is observed. The purpose of this review was to use a literature search to assess how often complete clinical response is achieved after neoadjuvant chemoradiation, the concordance of this finding with pathologic complete response, and to determine whether it is feasible to observe patients who achieve complete clinical response rather than proceed to surgery.

RESULTS

In total, 218 Phase I/II or retrospective studies and 28 Phase III trials of preoperative radiotherapy or chemoradiation were identified: 96 percent of trials documented the pathologic complete response, but only 38 trials presented data on the achievement of a complete clinical response/partial clinical response. Only five studies were found in which patients with clinically staged T2/T3 tumors were treated with radiotherapy/chemoradiation and did not routinely proceed to surgery and also reported on the long-term outcome of a "wait and see" policy.

DISCUSSION

It remains uncertain whether the degree of response to chemoradiation in terms of complete clinical response or pathologic complete response is a useful clinical end point. Studies that include T3 rectal cancer are associated with high local recurrence rates after nonsurgical treatment. Few studies report long-term outcome after achievement of a complete clinical response.

CONCLUSIONS

The end point of complete clinical response is inconsistently defined and seems insufficiently robust with only partial concordance with pathologic complete response. The rationale of a "wait and see" policy when complete clinical response status is achieved relies on retrospective observations, which are currently insufficient to support this policy except in patients who are recognized to be unfit for or refuse radical surgery.

Population-based study of local surgery for rectal cancer

BACKGROUND

The aim was to determine long-term survival and recurrence rates after local excision of rectal cancer from a prospectively registered population-based database.

METHODS

Swedish Rectal Cancer Registry data from 1995 to 2001, including 10 181 patients of whom 643 (6.3 per cent) had a local excision, were analysed. Complete 5-year follow-up data from 1995 to 1998 were available. Cumulative relative and cancer-specific survival rates, and rates of local recurrence and distant metastases, were calculated by actuarial methods.

RESULTS

The 5-year cancer-specific survival rate for 256 patients with stage I disease who had local excision was 95.3 (95 per cent confidence interval 91.5 to 99.1) per cent. The 5-year local recurrence rate was 7.2 per cent. After adjustment for age, sex, tumour stage and preoperative radiotherapy, the relative risk of death from cancer was the same as that after major resection.

CONCLUSION

Population-based results after local excision of rectal cancer are the same as those reported in controlled series for early-stage tumours after abdominal resection. A low relative survival and a high median age indicate the use of local excision in patients with a high level of co-morbidity. To achieve acceptable long-term results, optimal preoperative and postoperative staging is needed.

Transanal local excision for preoperative concurrent chemoradiation therapy for distal rectal cancer in selected patients

PURPOSE

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).

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Local excision for ypT2 rectal cancer--much ado about something

BACKGROUND

The role of local excision for pT2 distal rectal cancer has been challenged because of the observation of high rates of lymph node metastases and local failure. However, neoadjuvant chemoradiation therapy (CRT) has led to increased local disease control and significant tumor downstaging, possibly decreasing rates of lymph node metastases. In this setting, a possible role for local excision of ypT2 has been suggested.

METHODS

A total of 401 patients with distal rectal cancer underwent neoadjuvant CRT. Tumor response assessment was performed after at least 8 weeks from CRT completion. One hundred and twelve patients with complete clinical response were not immediately operated on and were excluded from the study, and 289 patients with incomplete clinical response were managed by radical surgery. Patients with final pathological stage ypT2 were analyzed to determine the risk of unfavorable pathological features that could represent unacceptable risk for local failure after local excision.

RESULTS

Eighty-eight (30%) patients had ypT2 rectal cancer. Final ypT status was not associated with pretreatment radiological staging (p = 0.62). ypT status was significantly associated with the risk of lymph node metastases, risk of perineural and vascular invasion, and recurrence (p = 0.001). Lymph node metastases were present in 19% of patients with ypT2 rectal cancer. The risk of lymph node metastases in ypT2 was associated with the presence of perineural invasion (47% vs 4%; p = <0.001), vascular invasion (59% vs 6%; p < 0.001), and decreased mean interval CRT surgery (12 vs 18 weeks; p < 0.001), but not with mean tumor size (3.2 vs 3.1 cm; p = 0.8). Disease-free and overall survival rates were significantly better for patients with ypT2N0 (p = 0.02 and 0.006, respectively). Fifty-five (63%) patients with ypT2 had at least one unfavorable pathological feature for local excision (lymph node metastases, vascular or perineural invasion, mucinous type or tumor size >3 cm).

CONCLUSION

Lymph node metastases were present in 19% of patients with ypT2 and were significantly associated with poor overall and disease-free survival rates. The risk of lymph node metastases could not be predicted by radiological staging or tumor size. Radical surgery should be considered the standard treatment option for ypT2 rectal cancer after CRT.

Long-term oncologic results of patients with distal rectal cancer treated by local excision with or without adjuvant treatment

AIM

The aim of this study is to review long-term oncologic results of local excision (LE) and to investigate the validity and feasibility of LE as a treatment option for distal rectal cancer.

MATERIALS AND METHODS

Seventy-six patients who underwent LE for distal rectal adenocarcinoma with curative intent from 1991 to 2000 at Severance Hospital Yonsei University Medical Center, Seoul, Korea were enrolled in this study.

RESULTS

Preoperative transrectal ultrasonography revealed 3 cases of uT0, 55 cases of uT1 and 18 cases of uT2. Postoperative pathologic examination revealed 10 cases of pT0 (where no residual cancer cells remained), 11 cases of pTis, 37 cases of pT1, 16 cases of pT2, and 2 cases of pT3. Eleven out of 37 patients with pT1 tumors received adjuvant radiation therapy. Among 16 patients with pT2 tumor, 7 undertook salvage operation and 8 received adjuvant therapy. The median follow-up period was 84.9 months. Local recurrence was observed in six patients. The 5-year local recurrence-free survival rate (LFS) was 89.4% in the pT1 group and 75.0% in the pT2 group (p = 0.012). Among the patients with pT1 cancer, those who received adjuvant radiation therapy demonstrated a 5-year LFS of 100%, compared to those who did not, 76.0% (p = 0.038).

CONCLUSION

Our results imply a potential role of LE and adjuvant radiation as an option for the treatment of distal rectal cancer, and that even for pT1 carcinoma, LE alone might not be a valid modality.

Transanal endoscopic microsurgery for rectal tumors: the St. Mary's experience

BACKGROUND

The aim of this study is to describe a single institution's experience in the use of transanal endoscopic microsurgery for rectal tumors.

METHODS

Between 1996 and 2005, transanal endoscopic microsurgery was performed in 76 patients. The histologic diagnosis was adenoma in 48 and adenocarcinoma in 28 patients.

RESULTS

Clear resection margins were achieved in 71 of 74 patients (95.9%). Overall morbidity was 18.9% because 14 patients developed minor (10 patients) or major complications (4 patients). During the follow-up, benign tumor recurrence was detected in 3 patients (6.3%). The recurrence rates among patients with T1, T2, and T3 malignant tumors were 7.1%, 42.8%, and 66.6%, respectively.

COMMENTS

Transanal endoscopic microsurgery is a safe and feasible technique with low incomplete excision rates and may be the preferred method in patients with benign rectal tumors. Its role in the management of malignant tumors should be limited to selected patients with T1 lesions.

Preoperative chemoradiation followed by transanal excision for rectal cancer

BACKGROUND

This study was conducted to assess the efficacy of preoperative chemoradiation followed by transanal excision among patients with locally advanced lower rectal cancer.

METHODS

Between May 1994 and June 2005, 73 patients with locally advanced lower rectal cancer were treated with curative intent by preoperative chemoradiation followed by surgical resection. Transanal excision was performed in 9 patients due to either the absolute refusal of a permanent stoma by the patient (n = 8) or medical comorbidity (n = 1). Sixty-four patients were treated by radical proctectomy. Preoperative 5-fluorouracil-based chemotherapy and pelvic radiation (4500 to 5040 cGy) were followed by surgery 6 wk after treatment, and all patients except one with transanal excision received postoperative 5-fluorouracil-based chemotherapy during the first year after surgery.

RESULTS

The mean follow-up period was 91 mo (range, 50 to 127 mo); median follow-up was 94 mo. One local recurrence occurred at 30 mo after transanal excision (11.1%); 5 in 64 patients who received radical proctectomy (7.8%) experienced local recurrences. The disease-free survival rate at 10 y was 77.8% in transanal excision group compared with a rate of 62.7% among radical proctectomy patients (P = 0.335). The overall survival rate at 10 y was 88.9% in transanal excision group compared with 74.2% among radical proctectomy patients (P = 0.424).

CONCLUSIONS

Transanal excision after preoperative chemoradiation in highly-selected patients with locally advanced lower rectal cancer could probably be an acceptable alternative to conventional radical surgery. However, this approach should be prospectively validated, and strict patient selection criteria should be used.

Conservative alternatives to extirpative surgery for rectal cancer

Selected cases of favourable rectal cancer can be treated with less than radical surgery. Published studies show that excellent local control can be achieved using either local excision or carefully confined high-dose radiation to treat the primary tumour site. For many patients treated conservatively there is also a role for external beam radiation to the pelvis -- this treats subclinical disease in regional nodes and around the tumour bed. The locoregional control for T1 lesions is excellent. There are recent data that indicate that the overall no evidence of disease survival may exceed 95% for T1 lesions treated with external and endocavitary radiotherapy combined with a limited local excision. For T2 lesions, about 25% of patients can experience recurrence after conservative treatment. This risk may be substantially less if external beam radiation, local excision and endocavitary radiation are combined. Close follow-up of these patients is important, as local failures after conservative treatment are more amenable to salvage surgery than failures after standard radical surgery. Careful selection of cases, combining physical findings with endorectal ultrasound or magnetic resonance imaging is important.

Are we undertreating rectal cancer in the elderly? An epidemiologic study

OBJECTIVE

To better understand the reasons for decreased survival rates in elderly patients with rectal cancer by performing an epidemiologic evaluation of age-related differences in treatment and survival.

SUMMARY BACKGROUND DATA

The incidence of rectal cancer increases with older age, and localized disease can be curatively treated with stage-appropriate radical surgery. However, older patients have been noted to experience decreased survival.

METHODS

Patients with localized rectal adenocarcinoma were identified in the Surveillance, Epidemiology, and End Results database (1991-2002). Cancer-specific survival by age, sex, surgery type, tumor grade, lymph node status, and use of radiation therapy was evaluated using univariate and multivariate regression analysis.

RESULTS

We identified 21,390 patients who met the selection criteria. The median age was 68 years. Each half-decade increase in age > or =70 years was associated with a 37% increase in the relative risk (RR) for cancer-related mortality (RR = 1.37; 95% confidence interval [CI], 1.33-1.42); decreased receipt of cancer-directed surgery (odds ratio [OR] = 0.56; 95% CI, 0.36-0.63); more local excision and less radical surgery (OR = 0.76; 95% CI, 0.72-0.81); less radiotherapy (OR = 0.64; 95% CI, 0.61-0.67); and greater likelihood of N0 pathologic stage classification (OR = 1.10; 95% CI, 1.05-1.15) (P < 0.0001 for each factor). The effect of age on cancer-specific mortality persisted in multivariate analysis with each half-decade increase in age > or =70 years resulting in a 31% increase in cancer-specific mortality (RR = 1.31; 95% CI, 1.25-1.36; P < 0.0001).

CONCLUSIONS

In elderly patients, rectal cancer is characterized by decreased cancer-related survival rates that are associated with less aggressive treatment overall and decreased disease stages at presentation. Investigation into the reasons for these treatment differences may help to define interventions to improve cancer outcomes.

Surgical management of rectal cancer

Rectal cancer affects more than 40,000 people in the United States annually. Despite recent advances in radiation and chemotherapy, surgical resection remains an integral part of curative therapy for this disease. Although rectal cancer is thought to be biologically similar to colon cancer, the anatomic complexity of the pelvis makes therapy for this disease considerably more complicated. Local recurrence is also a greater concern in rectal cancer than in colon cancer. The choice of surgical therapy depends on the location of the tumor, depth of rectal wall invasion, and clinical stage. Surgical options include local excision (transanal excision and transanal endoscopic microsurgery) and radical resection (low anterior resection, extended low anterior resection with coloanal anastomosis, abdominoperineal resection [APR], and pelvic exenteration). Technical advances such as transanal endoscopic microsurgery and laparoscopy also are changing the surgical approach to rectal tumors. Finally, chemotherapy and radiation are now frequently recommended in conjunction with surgical therapy. This article reviews the current surgical approach to treating patients with rectal cancer.