Conservative management of extensive low-lying rectal carcinomas with transanal local excision and combined preoperative and postoperative radiation therapy. A report of a phase I-II trial

Evidence and research in rectal cancer

The main evidences of epidemiology, diagnostic imaging, pathology, surgery, radiotherapy, chemotherapy and follow-up are reviewed to optimize the routine treatment of rectal cancer according to a multidisciplinary approach. This paper reports on the knowledge shared between different specialists involved in the design and management of the multidisciplinary ESTRO Teaching Course on Rectal Cancer. The scenario of ongoing research is also addressed. In this time of changing treatments, it clearly appears that a common standard for large heterogeneous patient groups have to be substituted by more individualised therapies based on clinical-pathological features and very soon on molecular and genetic markers. Only trained multidisciplinary teams can face this new challenge and tailor the treatments according to the best scientific evidence for each patient.

Current options for the management of rectal cancer

Patients diagnosed with rectal cancer should undergo locoregional staging with transrectal endoscopic ultrasound (EUS) or surface coil array MRI of the pelvis if that technique is available. Patients thought to have more than very early stage (T1 or T2) disease should undergo abdominal imaging as well by CT or MRI, and chest imaging with either CXR or preferably CT. The care of rectal cancer patients should be coordinated amongst an experienced multidisciplinary team to maximize the chance of cure and to minimize both local recurrence and complications of therapy. For patients with very early stage disease (T1N0 or T2N0), local resection with or without chemoradiation may be adequate therapy, but these patients must be selected carefully and should be without any poor prognostic factors. For the majority of patients with T3N0 or greater rectal cancer, standard therapy consists of neoadjuvant continuous 5-FU and radiation followed by surgery and further chemotherapy (either with 5-FU, capecitabine, or FOLFOX). The use of capecitabine, irinotecan, and oxaliplatin during radiotherapy shows promise, but remains investigational pending results of phase III studies. Neoadjuvant therapy is preferred because it decreases local recurrence and appears to result in improved postoperative bowel function in comparison with postoperative therapy. Select patients with high (>10 cm from the anal verge) uT3N0 tumors may be at sufficiently low risk of local recurrence to justify omission of radiotherapy. Patients who experience pathologic complete response to radiotherapy should still receive postoperative adjuvant chemotherapy to reduce systemic recurrence risk until data demonstrate that this is not necessary. Patients with stage IV rectal cancer may still require local therapy with radiation, surgery, or both; however, care should be taken in these patients that chemotherapy is not excessively delayed as this is the one modality in this case that can result in improved survival.

Imaging and management of rectal cancer

Local staging and management of rectal cancer has evolved during the past decade. Imaging modalities used for staging rectal cancer include CT, endoscopic ultrasound, pelvic phased-array coil MRI, endorectal MRI, and PET. Each modality has its strengths and limitations. Evidence supports the use of both endoscopic ultrasound and CT in staging rectal cancer. MRI is the only reliable tool for determining the status of the circumferential resection margin, which is important for the assessment of the risk of local recurrence.

Transanal endoscopic microsurgery

TEM has been used effectively to treat large rectal polyps and early rectal malignancy for more than 20 years in Europe. Until recently, only a few specialized centers offered TEM in the United States, where it is now gaining popularity. Many hospitals have purchased equipment and are offering TEM; however, the equipment is expensive and the learning curve is steep. Therefore, it is essential that anyone performing TEM have an adequate number of cases to develop and maintain expertise in this technique. That being said, TEM remains unique when compared with laparoscopy and other minimally invasive techniques that incorporate less invasive methods of performing old operations. TEM allows surgeons to perform operations that were impossible before the development and acceptance of this technique.

Tumor budding and evidence-based treatment of T2 rectal carcinomas

BACKGROUND

The validity of the histological criteria in deciding additional bowel resection after local excision of T2 rectal carcinomas is questioned.

METHODOLOGY

In 72 T2 colorectal carcinomas resected by major surgery, the associations between lymph node metastasis (LNM) and clinicopathologic parameters were examined statistically, a prediction formula for LNM was constructed and decision analysis was attempted.

RESULTS

Multivariate analysis showed that female gender and a greater number of tumor budding were significantly associated with LNM. The probability of LNM can be calculated as follows; Z = 0.037 x (budding number) + 2.08 x (SEX; male, 1; female, 2) - 5.736; Probability = 1/1 + e(-Z). When a 75-year-old patient has pulmonary complications, the operative risk is assumed to be over 2%. If a number of tumor budding is 0, the risk of LNM is calculated as 2.4% in a male and 17.1% in a female patient. On the assumption that the risk of liver metastasis is half of that of LNM, and the salvageabilities after LNM and liver metastasis are 20% and 50%, respectively, observation policy is justified for a male patient, whereas additional surgery should be undertaken for a female patient.

CONCLUSIONS

A number of tumor budding may be useful for determining the individualized treatment of T2 rectal carcinomas.

Transanal endoscopic microsurgery: a prospective evaluation of functional results

PURPOSE

Local excision is a commonly used technique for many benign and selected malignant rectal lesions. Compared with radical resection, it is associated with decreased morbidity and mortality and improved functional results. Transanal endoscopic microsurgery is gaining popularity because of its ability to access the upper rectum and its precise excision techniques. However, the functional consequences have not been extensively studied.

METHODS

All patients subject to transanal endoscopic microsurgery prospectively completed preoperative and postoperative (6 weeks) surveys including Fecal Incontinence Severity Index, Fecal Incontinence Quality of Life, number of bowel movements per 24 hours, and ability to defer defecation. All data were collected by an independent research coordinator. Demographics, operative details, and complications were also collected prospectively.

RESULTS

Forty-one patients successfully underwent transanal endoscopic microsurgery. Fourteen patients had malignant lesions and 27 had benign lesions. Two patients required abdominoperineal resection based on postoperative diagnosis. Thirty-nine patients have completed follow-up and were available for review. Mean length of surgery was 64 minutes and length of stay was 0.9 day. Average distance from the anal verge to the proximal tumor margin was 11.4 cm and mean tumor size was 8.75 cm. Twenty-three patients had full-thickness excision with primary closure, ten had full-thickness excision without closure, five had partial-thickness excision, one had an excision of a mass in the anovaginal septum, and one had resection of an anastomotic stricture. Each patient served as his own control. Preoperative and postoperative number of bowel movements per 24 hours were 2.0 and 2.0, respectively. Preoperative vs. postoperative urgency (ability to defer defecation less than ten minutes) was unchanged. Mean preoperative and postoperative Fecal Incontinence Severity Index scores were 2.4 (range, 0-43) and 2.4 (range, 0-17), respectively (higher scores indicate worse function). In addition, the four parameters measured by the Fecal Incontinence Quality of Life survey were unchanged when preoperative and postoperative data were compared.

CONCLUSIONS

Transanal endoscopic microsurgery allows precise excision of tumors throughout the rectum. However, it involves inserting a 40-mm-diameter operating proctoscope and significant operating times. Despite this, as measured by ability to defer defecation, number of bowel movements per 24 hours, Fecal Incontinence Severity Index, and Fecal Incontinence Quality of Life survey, transanal endoscopic microsurgery has no detrimental affect on fecal continence.

A current perspective on local excision of rectal cancer

Local excision of rectal cancer is appealing because of its technical ease and excellent functional results, but concern over inadequate pathologic staging and inferior treatment outcomes when compared with radical surgery remain a major hurdle for its widespread use. Local failure rates in modern series for local excision are 4%-18% for T1 rectal cancers and 22%-67% for T2 cancers, and cancer cure rates are only 70%-80%. In addition, data from the past decade suggest that preoperative staging with endorectal ultrasound, use of postoperative adjuvant chemotherapy/radiation therapy, and aggressive salvage surgery have not been reliable methods of limiting local tumor recurrence or improving long-term cure rates. At present, highly stringent criteria for patient selection are recommended, yet such stringency decreases the utility of the procedure. What are needed are new approaches to an old problem. Novel strategies under evaluation include enhanced imaging modalities for lymph node metastases, neoadjuvant chemotherapy/radiation therapy, and more liberal use of immediate salvage resection for high-risk pathologic features. Molecular profiling of tumors with genetic markers and better integration of traditional and gene-targeted systemic therapy are promising approaches for the future. This review of the literature evaluates the recent successes and failures of local excision of rectal cancer and provides a current perspective on the expanded use of local excision without compromising care.

Endocavitary Radiation Therapy for Rectal Adenocarcinoma

Local control, survival, and toxicity in patients treated with endocavitary radiation therapy for rectal cancer were evaluated. Thirty-five patients received a total of 20 to 155 Gy in 1 to 5 fractions with 50 kV x-rays through a treatment proctoscope. Twenty-nine of the 35 patients were treated with curative intent. Median follow-up was 102 months. Local control was achieved in 23 of the 29 patients treated curatively and in 3 of the 6 treated palliatively. Local control for patients treated curatively was 76% at 10 years. No local failures occurred after 21 months. For patients treated curatively, survival was 65% at 5 years and 42% at 10 years. Toxicity within 90 days after treatment was observed in 77% of the patients. Toxicity occurring more than 90 days after treatment was observed in 80%, but only 1 patient needed a colostomy, which was for a perforation after the biopsy of a benign ulcer. In conclusion, radiation therapy resulted in a local control rate of 76% at 10 years in curatively treated patients. Although most patients experience toxicity from this treatment, loss of sphincter function is rare.

Local excision of rectal cancer: what is the evidence?

PURPOSE

Although local excision of rectal cancers is a less morbid alternative to radical resection, its role as a curative procedure is unclear. The role of adjuvant therapy after local excision is also controversial. This review aims to examine current evidence on local excision of rectal cancers and how it fits into the management algorithm for rectal cancer.

METHODS

A literature review was undertaken through the MEDLINE database and by cross-referencing previous publications, thus identifying 41 studies on curative local excision of rectal cancer published in English. Details of preoperative staging, surgical procedures, adjuvant therapy, follow-up, and outcome measures, including complications, survival data, recurrences, and salvage were examined.

RESULTS

Preoperative staging of rectal cancers is variable. Digital rectal examination and computerized tomography are used in most studies. Endorectal ultrasound is used in some patients in 9 of 41 studies. Local excision preserves anorectal function, and seems to have limited morbidity (0-22 percent). Local excision alone is associated with local recurrences in 9.7 (range, 0-24) percent of T1, 25 (range, 0-67) percent of T2 and 38 (range, 0-100) percent of T3 cancers. The addition of adjuvant chemoradiotherapy after local excision yields local recurrence rates of 9.5 (range, 0-50) percent for T1, 13.6 (range, 0-24) percent for T2, and 13.8 (range, 0-50) percent for T3 cancers. Data on local excision after preoperative chemoradiotherapy for tumor down staging are limited. Factors other than T-stage that lead to higher local recurrence rates after local excision include poor histologic grade, the presence of lymphovascular invasion, and positive margins. Local recurrences after local excision can be surgically salvaged (84 of 114 patients in 15 studies), with a disease-free survival rates between 40 and 100 percent at a follow-up of 0.1 to 13.5 years.

CONCLUSIONS

Local excision for rectal cancers is associated with a low morbidity and provides satisfactory local control and disease-free survival rates for T1 rectal cancers. There is, however, a need for a randomized, controlled trial for T2 cancers, comparing local excision with adjuvant chemoradiotherapy to radical resection.

Preoperative chemoradiotherapy and radical surgery for locally advanced distal rectal adenocarcinoma: pathologic findings and clinical implications

PURPOSE

Preoperative chemoradiotherapy followed by radical surgical resection has been the preferred treatment for patients presenting with locally advanced distal rectal carcinoma at our institutions. We postulated that chemoradiotherapy-induced pathologic response of the primary tumor would identify which patients would be candidates for local excision as definitive surgical therapy.

METHODS

A retrospective analysis of 60 patients with palpable, locally advanced, distal rectal adenocarcinomas treated from 1995 to 2000 was performed. All patients received preoperative chemoradiotherapy consisting of 5-fluorouracil (325 mg/m(2)) and leucovorin (20 mg/m(2)) by bolus infusion on Days 1 through 5 and 29 through 33 delivered concurrently with at least 45.0 to 50.4 Gy of pelvic radiation, followed six to eight weeks later by radical surgery and then adjuvant chemotherapy.

RESULTS

Among 60 patients (20 females) there was a mean age of 58.7 (28-84) years. Clinical staging was as follows: Stage II, 14 patients (23 percent); Stage III, 35 patients (58 percent); and Stage IV, 11 patients (18 percent). Pathologic examination revealed that negative margins were obtained in 58 patients (97 percent). Downstaging to T0-2N0 was achieved in 17 patients (28 percent), with five (8 percent) achieving a pathologically complete response. Lymph nodes were positive in 24 patients (40 percent) despite chemoradiotherapy. Pathologic node positivity was found in 0 of 5 pT0 patients, 9 (41 percent) of 22 pT1 or pT2, and 15 (45 percent) of 33 pT3. Clinical stage, tumor size, pathologic stage, and adverse histologic features could not reliably predict pN0 status, except pT0 (5 patients only).

CONCLUSIONS

Preoperative chemoradiotherapy often downsizes and downstages locally advanced rectal carcinoma. Neither pretreatment clinical characteristics, response to preoperative chemoradiotherapy, or pathologic features reliably predict pN0 status. Therefore, local excision is not recommended as an alternative to radical surgery for locally advanced adenocarcinoma of the distal rectum regardless of the response of the primary tumor to preoperative chemoradiotherapy.

The indication of local excision for T2 rectal carcinomas

BACKGROUND

Several researchers reported that local excision with or without postoperative chemo-radiation therapy is an alternative approach for sphincter preservation in patients with locally invasive rectal carcinoma. However, indications and long-term results have not yet been determined.

METHODS

Seventy-two patients with T2 colorectal carcinomas underwent bowel resection with regional lymph node dissection. The associations between lymph node metastasis (LNM) and clinicopathologic factors were examined with special reference to the presence or absence of moderate to severe degree of focal dedifferentiation or mucinous component at the invasive margin (unfavorable histology).

RESULTS

Multivariate logistic regression analysis revealed that both sex and unfavorable histology were significantly associated with LNM (P = 0.0102, 0.0226, respectively). However, the associations between LNM and lymphatic invasion or tumor location were not statistically significant (P = 0.0947, 0.1738).

CONCLUSIONS

When locally resected T2 rectal carcinoma specimens have unfavorable histology at the invasive margin, additional bowel resection with lymph node dissection should be recommended.

Anal sphincter conservation for patients with adenocarcinoma of the distal rectum: long-term results of radiation therapy oncology group protocol 89-02

PURPOSE

To assess the outcome of a multi-institutional, national cooperative group study attempting functional preservation of the anorectum for patients with limited, distal rectal cancer.

METHODS AND MATERIALS

Between September 21, 1989 and November 1, 1992, a Phase II trial of sphincter-sparing therapy was conducted for patients with clinically mobile rectal cancers located below the pelvic peritoneal reflection. Protocol treatment was designed for patients who were, in the judgement of their attending surgeon, unsuitable for anal sphincter conservation in the context of anterior resection, and would have required abdominoperineal resection (APR) as conventional surgical therapy. Primary cancers were estimated to be 4 cm or less in largest clinical diameter, and occupied 40% or less of the rectal circumference. Chest radiography and computerized axial tomography (CT) of the abdomen and pelvis excluded patients with overt lymphatic or hematogenous metastases. Protocol surgery was intended to remove the primary cancer by en-bloc, transmural excision of an ellipse of rectal wall by transanal, transcoccygeal, or trans-sacral technique, while conserving the anal sphincter. Based on tumor size, T classification, grade, and adequacy of surgical margins, patients were allocated to one of three treatment assignments: observation, or adjuvant treatment with 5-fluorouracil (5-FU) and one of two different dose levels of local-regional radiation. After completion of protocol therapy, patients were observed with follow-up that included periodic general physical and rectal examination, determinations of CEA, abdominopelvic CT, chest radiography, and surveillance endoscopy. Sixty-five eligible and analyzable patients were registered.

RESULTS

With minimum follow-up of 5 years and median follow-up of 6.1 years, 11 patients have failed: 3 patients recurred local-regionally only, 3 patients had distant failure alone, and 5 patients manifested local-regional and distant failure. Eight patients died of intercurrent illness. Local-regional failure correlated with T-category revealed: T1 1/27 (4%), T2 4/25 (16%), and T3 3/13 (23%). Local-regional failure escalated with percentage involvement of the rectal circumference: 2/31 (6%) among patients with cancers involving 20% or less of the rectal circumference, and 6/34 (18%) among patients with cancers involving 21-40% of the circumference. Distant dissemination rose with T-category with 1/27 (4%) T1, 3/25 (12%) T2, and 4/13 (31%) T3 patients manifesting hematogenous spread. Eight patients (12%) required temporary or permanent colostomy. Five of 8 patients with local-regional recurrence achieved local-regional control with management including surgery, although 4 of these patients subsequently developed distant dissemination. Three patients (5%) had persistent, uncontrolled, local disease. Actuarial freedom from pelvic relapse at 5 years is 88% based on the entire study population, and 86% for the less favorable patients treated with adjuvant radiation and 5-FU.

CONCLUSION

Conservative, sphincter-sparing therapy is a feasible alternative treatment for selected patients with limited cancer involving the middle and lower rectum. Risk of both local and distant failure appears to escalate with increasing T-category (depth of invasion). Results achieved in the multi-institutional, cooperative group setting approximate results reported from single institutions.

Local Excision and Chemoradiation for Low Rectal T1 and T2 Cancers Is an Effective Treatment

Lesions located in the distal third of the rectum are usually treated with abdominoperineal resection or a low anterior resection with a coloanal anastomosis. However, in a select group of patients with favorable histology and a low probability of lymphatic spread, sphincter-sparing procedures will afford long-term disease-free survival and cure without the need for extensive, complicated surgery. We performed a 10-year retrospective review, including pathologic examination of specimens by a single pathologist, in an attempt to identify factors associated with a decreased disease-free survival. Thirty-five patients (median age, 71 years; range, 48–88) with low rectal carcinomas were treated with full-thickness disc excision (with or without chemoradiation), with curative intent Median follow-up was 46 months (range, 8–120). There were 15 T1, 16 T2, and 4 T3 lesions. Tumors with poor histologic factors or greater than T1 received adjuvant radiation (with or without 5-fluorouracil). Four patients developed a local failure at a median of 21.5 months (range, 9–30) and were salvaged with abdominoperineal resection. The 5-year cancer-specific survival was 91 per cent. Negative margins approached statistical significance (P < 0.07) in influencing local control. We conclude that, when combined with chemoradiation for lesions deeper than submucosa or with adverse histologic factors, local resection of rectal cancer is an effective treatment in selected patients.

Long-term follow-up of patients with rectal cancer managed by local excision with and without adjuvant irradiation

OBJECTIVE

The long-term outcomes of patients undergoing local excision with or without pelvic irradiation were examined to define the role of adjuvant irradiation after local excision of T1 and T2 rectal cancers.

METHODS

Ninety-nine patients with T1 or T2 rectal cancers underwent local excision with or without adjuvant irradiation at Massachusetts General Hospital and Emory University Hospital between January 1966 and January 1997. Of these, 52 patients were treated by local excision alone and 47 patients by local excision plus adjuvant irradiation. Twenty-six of these 47 patients were treated by irradiation in combination with 5-fluorouracil chemotherapy. The outcomes of these groups were compared.

RESULTS

The 5-year actuarial local control and recurrence-free survival rates were 72% and 66%, respectively, for the local excision alone group and 90% and 74%, respectively, for the adjuvant irradiation group. This improvement in outcome was evident despite the presence of a higher-risk patient population in the adjuvant irradiation group. Adverse pathologic features such as poorly differentiated histology and lymphatic or blood vessel invasion decreased local control and recurrence-free survival rates in the local excision only group. Adjuvant irradiation significantly improved 5-year outcomes in patients with high-risk pathologic features. Four cases of late local recurrence were seen at 64, 72, 86, and 91 months in the adjuvant irradiation group.

CONCLUSIONS

The authors recommend adjuvant chemoradiation for all patients undergoing local excision for T2 tumors, and for T1 tumors with high-risk pathologic features. The four cases of late local failures beyond 5 years in the adjuvant irradiation group underscores the need for careful long-term follow-up in these patients.

Outcome of local excision for locally invasive rectal carcinomas with special reference to histological features at the invasive margin

BACKGROUND

Several researchers reported promising results that local excision with or without postoperative chemo-radiation therapy is an alternative approach for sphincter preservation in patients with locally invasive rectal carcinomas. However, indications and long-term results have not yet been determined.

METHODS

Demographic and pathological characteristics of eight patients with locally invasive tumors undergoing initially local excision were reviewed with reference to histological features at the invasive margin.

RESULTS

All the tumors were well differentiated adenocarcinomas. In all but two tumors, the invasion was limited within the proper muscle layer. Radiation therapy was given preoperatively in one patient and postoperatively in two patients. Additional bowel resection was not attempted in these three cases. Among the remaining five patients, two received additional bowel resection with lymph node dissection. No lymph node metastasis was observed in these two patients. During the average follow-up period of 55 months, three patients had regional lymph node metastases at 7, 36 and 72 months, respectively. Another patient had regional lymph node and distant metastases at 5 months. Three out of five patients with moderate to severe grade of dedifferentiated histology at the invasive margin (H-inv) had regional lymph node metastases. On the other hand, one out of three patients with mild H-inv had lymph node metastases.

CONCLUSIONS

H-inv may be useful as a clinical predictor of lymph node metastasis. However, more experience is needed to confirm the usefulness of H-inv in selecting invasive rectal cancer patients in whom local excision is safe and appropriate.

Transanal treatment of rectal cancer: ablative methods and open resection

Conservative surgical techniques are an alternative to radical surgery for selected patients with rectal carcinoma. The goals of conservative management are to select patients with low risk for nodal metastases and achieve local tumor control while preserving anal sphincter function. Patient selection is critical to achieve this outcome because properly selected patients can obtain results comparable to radical surgery. Selection is based on preoperative histologic characteristics and endorectal ultrasonography. Predictors of pelvic lymph node metastasis risk include tumor grade, depth of penetration, mucinous features, and vascular and lymphatic invasion. Endorectal ultrasound (ERUS) is important in accurately staging the lesion by identifying both depth of invasion and presumptive nodal status. The options for local therapy reviewed include techniques of full-thickness local excision and ablative procedures including endocavitary irradiation, electrocoagulation, and laser therapy. The techniques of full-thickness transanal excision and endocavitary irradiation are described with results from the University of Minnesota experience.

Results of local excision followed by postoperative radiation therapy for rectal cancer

There is increasing interest in the use of local excision and postoperative radiation therapy (RT) as a sphincter-sparing approach for selected rectal cancers. The data suggest that this treatment approach should be limited to patients with either T1 tumors with adverse pathologic factors or T2 tumors. Transmural (T3) tumors have a 25% local recurrence rate with this technique and are treated more effectively with standard surgery and pre- or postoperative therapy. The results of local excision and postoperative RT are encouraging, however, more experience is needed to determine if this approach will have similar local control and survival rates as standard surgery.

Prospective evaluation of local excision for small rectal cancers

OBJECTIVE

Most data on local excisions for rectal cancer are based on retrospective studies. We review the results of a prospective registry of patients eligible for local excision of rectal cancer using a transanal, transsphincteric, or transcoccygeal technique combined with multimodality therapy for lesions penetrating the muscularis propria (T2) or perirectal fat (T3).

METHODS

Patients with lesions less than 4 cm in diameter and less than 10 cm from the dentate line, with no evidence of distant metastases or invasion into the perirectal fat, were eligible for local excision. Patients with invasion into the muscularis propria (T2) or greater (T3) received adjuvant chemoradiation therapy.

RESULTS

Forty-eight patients have been followed prospectively. Average age is 63 years. Thirty-three patients underwent a transanal excision. Fifteen patients underwent either a transsphincteric or technique excision. There was no perioperative mortality. Pathology revealed 1 Tis, 21 T1, 21 T2, and 5 T3 cancers. Mean follow-up is 40.5 months. Cancer-related overall mortality was 4 percent. Overall local or distant recurrence rate was 8 percent (4/48). Recurrence appeared to be related to presence of a positive margin or aggressive histology (lymphatic invasion). Local recurrences were treated with salvage therapy.

CONCLUSION

Local excision can be used selectively for small rectal cancers, with minimum morbidity. Recurrence rates are low (8 percent). Patients with either a positive margin or lymphatic invasion need to be considered for further therapy, including abdominoperineal resection, even with T1 lesions. Adjuvant chemoradiation appears to be a benefit for all T2 or T3 cancers.

Preservation of the anus in the therapy of distal rectal cancers

Using the gold standard of APR as a measure of cancer control, sphincter-sparing procedures appear to provide similar rates of local control and survival. Specifically, for T1, T2, and T3 lesions, local excision alone, local excision plus adjuvant therapy, and low anterior resection with coloanal anastomoses, respectively, have proven to be acceptable forms of therapy. However, questions remain as to the significance of certain prognostic factors, such as lymphatic invasion with regard to the treatment plan for patients with low rectal cancers. Lastly, quantitative studies addressing the issue of the function of the spared anal sphincters after surgery with or without adjuvant therapy, and how this relates to the patient's quality of life, need to be performed.

Local excision and external beam radiotherapy in early rectal cancer

PURPOSE

To assess the local control and survival of local excision and postoperative radiation in patients with early stage rectal cancer.

METHODS AND MATERIALS

From 1980 to 1992, 21 patients with clinical stage T1-2NxM0 adenocarcinoma of the middle and lower rectum were treated with transanal excision and postoperative external beam radiotherapy (44.6 Gy). The pathologic T stages were: 9 T1 (43%) and 12 T2 (57%). One patient had unassessable resection margins. The median follow-up was 54 months (range: 18-128 months).

RESULTS

The actuarial local recurrence-free survival at 5 years was 85.2%, and the overall survival at 5 years was 80.6%. One patient developed a local recurrence and distant metastases at 22 months, and two patients had local recurrence at 11 and 15 months, respectively; both had abdomino-perineal resection (APR) and one remained free of disease 16 months after APR. The incidence of Grade 3 diarrhea was 5%. Sphincter function was good to excellent in the 18 patients with local control. No patients developed clinical evidence of pelvic lymph node recurrence.

CONCLUSION

These results are similar to other published series and suggest that this approach is feasible in selected patients with T1-2NxM0 rectal cancer and results in good long-term control of the disease.

Endocavitary irradiation for early rectal carcinomas T1 (T2). A series of 101 patients treated with the Papillon's technique

PURPOSE

This work is a retrospective analysis of a series of patients treated with endocavitary irradiation stressing the role of transrectal ultrasound (TRUS), which has been used routinely in the staging since 1987.

METHODS AND MATERIALS

Between 1977 and 1993, 101 patients with infiltrating adenocarcinomas were treated. Clinical staging was 65 T1 N0 and 36 T2 N0. TRUS used in 36 patients showed: 22 UT1 N0, 10 UT2 N0, and 3 UT2 N1. Contact x-ray was delivered with a 50 kV radiotherapy unit. The median dose was 92 Gy (60-125) in five fractions, 55 days. In 28 patients a boost was given with 192Ir implant delivering a median dose of 25 Gy/21 h.

RESULTS

Complete response was observed in all patients at the completion of treatment. Loco-regional failures were seen in 14 patients (local in 7 patients, nodal pararectal in 6 patients, and local + nodal in 1 patient). A curative salvage treatment was attempted in 13 patients and resulted in an ultimate pelvic control rate of 99 patients. Rectal preservation was possible in 92 patients. Overall and specific 5-year survival was 83.3% and 94.4%. No serious complication was observed. TRUS was more sensitive than digital rectal examination to detect involvement of pararectal metastatic nodes (N1). No loco- regional relapse was observed out of 22 UT1 N0.

CONCLUSION

Endocavitary irradiation can cure early adenocarcinoma of the rectum without complication. TRUS appears as a significant improvement in the selection of patients amenable to this treatment. If restricted to UT1 N0 tumors, endocavitary irradiation should control locally more than 90% of these patients. Any UN1 is a contraindication for endocavitary irradiation alone.

Combined curative radiation therapy alone in (T1) T2-3 rectal adenocarcinoma: a pilot study of 29 patients

AIM

Analysis of a pilot study including 29 consecutive patients with high surgical risk or refusal of colostomy treated with radiation therapy alone with curative intent.

PATIENTS

Between 1986 and 1992, 29 patients were treated for infiltrating adenocarcinoma of the rectum. Median age was 72 years. Transrectal ultrasound staging was used in 24 patients (T1, 2; T2, 14; T3, 13; N0, 23; N1, 6). In 20 patients the lower border of the tumor was at 5 cm or less from the anal verge and in 19 patients the diameter exceeded 3 cm. CEA was elevated in seven cases.

TREATMENT

Contact X-ray (50 kV) was given first (70 Gy/3 fractions). External beam radiation therapy used a three-field technique in the prone position. Accelerated schedule (39 Gy/13 fractions/17 days) with a concomitant boost "field within the field' (4 Gy/4 fractions). Six weeks later an iridium-192 implant was performed in 21 (20 Gy/22 h).

RESULTS

Median follow-up time was 46 months. Overall and specific survival at 5 years was 68% (SE = 0.09) and 76% (SE = 0.08). Local control was obtained in 21/29 patients (72%). There was one grade 2 rectal bleeding and five grade 2 rectal necroses. The overall tolerance was good in these frail patients.

DISCUSSION

For T2. T3 or T1 > 3 cm diameter rectal adenocarcinoma, where contact X-ray alone is not recommended, a combined treatment with radiation therapy alone is able to give good local control with acceptable toxicity. This treatment should be restricted to inoperable patients.

Long-term follow-up of local excision and radiation therapy for invasive rectal cancer

PURPOSE

Little is known regarding the long-term outcome of patients with rectal cancer treated by local excision and radiation therapy. We updated our institutional experience with this approach.

METHODS

From January 1986 to December 1991, 23 patients (median age, 64 (range, 30-80) years) with mobile, moderately differentiated adenocarcinoma of the rectum were offered transanal excision. Two patients with large T3 tumors, who were judged intraoperatively to be unsuited for a local procedure, received radical resection and were excluded from analysis. Twenty-one patients underwent transanal excision en bloc (14) or piece-meal (7) through a resectoscope. Seven patients (74 percent) had either extensive medical problems or refused a colostomy. Patients received a median of 5,040 cGy postoperatively, and 15 also received 500 cGy preoperatively on protocol. Two patients received concomitant chemotherapy. Median follow-up is 56 months for all patients and 67 months for survivors (range, 27-92 months).

RESULTS

There were 2 T1, 15 T2, and 4 T3 tumors. The distance from the anal verge was a median of 4 (range, 1-7) cm. The median tumor size was 3 (range, 2-7) cm. Sixteen patients had more than one-third of the wall involved. Four patients (19 percent) developed a local recurrence at 26, 30, 33, and 48 (median, 31.5) months. Three were salvaged (abdominoperineal resection = 2; low anterior resection = 1) and remain disease-free 18, 36, and 37 months postoperatively. Four patients (19 percent) developed metastases (lung = 3; liver = 1) at 3, 22, 25 and 44 months after initial treatment (median, 23.5 months). The actuarial five-year overall, disease-free and recurrence-free survival are 77, 75, and 58 percent, respectively. Twelve patients (57 percent) have no evidence of disease while retaining their rectum. There was one postoperative death.

CONCLUSIONS

Long-term follow-up confirms that local excision and radiation therapy is of value in patients with mobile tumors of the rectum. It suggests that this treatment can be offered to those patients who refuse a colostomy or are medically compromised and may be an acceptable option for selected patients with T2 or T3, mobile adenocarcinomas of the rectum.

Conservative treatment of rectal cancer with local excision and postoperative radiation therapy

The conventional surgical treatment for patients with potentially curable transmural and/or node positive rectal cancer is a low anterior resection or abdominoperineal resection. Recently, there has been increasing interest in the use of local excision and postoperative radiation therapy as primary therapy for selected rectal cancers. The limited data suggest that the approach of local excision and postoperative radiation therapy should be limited to patients with either T1 tumours with adverse pathological factors or T2 tumours. Transmural tumours, which have a 24% local failure rate, are treated more effectively with standard surgery and pre- or postoperative therapy. The results of local excision and postoperative radiation therapy are encouraging, but more experience is needed to determine if this approach ultimately has similar local control and survival rates as standard surgery.

Variables related to risk of recurrence in rectal cancer without lymph node metastasis

BACKGROUND

There has been recent interest in the use of local excision for rectal cancer under consideration of patient's quality of life. However, local excision of the primary tumor does not remove the areas of lymphatic spread. Therefore, the decision to use this procedure must be considered carefully.

METHODS

The authors retrospectively analyzed 142 patients who underwent radical resection of rectal cancer without lymph node metastasis in order to define the risk factors for recurrence. The macroscopic and microscopic pathological characteristics, immunohistochemical staining for p53, and DNA ploidy pattern of the primary tumor were examined as potential predictors of recurrence.

RESULTS

The rates for 5-year disease-free survival, local control, freedom from distant metastasis, and overall survival in these 142 patients were 87%, 93%, 93%, and 91%, respectively. Factors related to recurrence and prognosis included the depth of tumor invasion, vascular/lymphatic involvement, tumor differentiation, and tumor size. However, p53 staining and DNA ploidy pattern were not useful indicators.

CONCLUSIONS

Our findings suggest that adjunctive radiotherapy and chemotherapy should be considered for patients who have rectal cancer without lymph node metastasis in the following situations: tumor invasion of the serosa, vascular/lymphatic involvement, moderately differentiated adenocarcinoma, and lesions > 2 cm in diameter. Local excision should not be used in these situations, even if there are no lymph node metastases.

Rectal cancer

Preview When in rectal cancer surgery can the anal sphincter be spared? For which patients is iliac lymphadenectomy advisable? Should radiation therapy and chemotherapy be given before surgery rather than after? Drs Sexe and Miedema address these and other questions in this discussion of recent advances and future trends in therapy for rectal cancer.

Clinical experience with local excision and postoperative radiation therapy for rectal cancer

The standard surgical treatment for patients with potentially curable transmural and/or node-positive rectal cancer is a low anterior resection or abdominoperineal resection. There is increasing interest in the use of local excision and postoperative radiation therapy as primary therapy for selected rectal cancers. The limited data suggest that the approach of local excision and postoperative radiation therapy should be limited to patients with either T1 tumors with adverse pathologic factors or T2 tumors. Transmural tumors have a 24 percent local failure rate and are treated more effectively with standard surgery and preoperative or postoperative therapy. The results of local excision and postoperative radiation therapy are encouraging; however, more experience is needed to determine whether this approach ultimately has local control and survival rates similar to standard surgery.

Local excision and post-operative radiation therapy for rectal carcinoma

PURPOSE

To assess the patterns of failure and outcome following conservative surgery and post-operative radiation therapy for rectal cancer.

METHODS AND MATERIALS

Twenty-five patients underwent post-operative radiation therapy (50 Gy in 20 fractions over 4 weeks) following local excision or electrocoagulation for carcinoma of the rectum. None of the patients had palpable residual disease following surgery. Selection factors for post-operative radiation therapy were refusal of a permanent colostomy, excessive operative risk of an abdominal perineal resection and concern regarding local control with conservative surgery alone.

RESULTS

Six of 25 patients developed failure at the primary site. There was no lymph node failure. All five patients with primary failure alone underwent abdominal perineal resection and 2 remained free of recurrence. With a median follow-up of 6 years, 20 of 25 patients remained alive and free of disease. There was no apparent influence of age, sex, type of surgery, tumor size, distance of tumor from anal verge, tumor configuration, resection margins, integrity of the resected tissue, depth of invasion, differentiation, presence of lymphatic or vascular channel invasion, radiation dose or field size on local control and survival. One of 15 patients failed locally when the overall treatment time was 30 days or less, whereas 5 of 10 patients developed local failure when the overall treatment time exceeded 30 days. Sixteen of 20 patients in whom cancer did not recur retained normal anorectal function. All four patients with grade 3 early morbidity and the only patient with Grade 3 late morbidity were amongst the group of 13 patients treated with large AP-PA fields (mean: 15 x 19 cm2).

CONCLUSION

In selected patients who are at high risk of local recurrence following local excision alone, and who refuse a colostomy or are at high operative risk from radical surgery, post-operative radiation therapy is an alternative to radical surgery.

Radiation therapy for colorectal cancer

The role of radiation therapy in the management of colorectal cancer has become more clearly defined as the number of clinical studies has grown. It is now evident that radiation is capable of sterilizing subclinical deposits of cancer at doses tolerable by adjacent normal tissues, and to a lesser extent, these doses can control more bulky cancers. The integration of radiation and chemotherapy has already led to some improvement in survival rates in the adjuvant treatment of rectal cancer. The further development of such combinations seems likely to improve tumor control and survival rates in many stages of cancer. In the next decade, it is also likely that there will be refinement of the use of radiation through better understanding of the biology of colorectal cancer, perhaps supplemented by the development of predictive assays that can guide both the selection of patients for treatment and the choice of the most effective radiation schedule.

Conservative management of rectal carcinoma: the efficacy of a multimodality approach

The goals of the conservative management of adenocarcinoma of the distal rectum are to preserve rectal sphincter function and achieve excellent local tumor control. Multimodality therapy for more advanced disease suggests that these goals will be met by conservative surgery combined with radiation therapy and chemotherapy. Over 100 patients with T0-3 N0-1 lesions have been treated in prospective single institution trials with either local excision or anterior resection with coloanal anastomosis, usually combined with chemotherapy and radiotherapy. The typical criteria for local excision have been for lesions to be 4.0 cm or less, mobile, and not poorly differentiated or mucinous. Patients with larger or more advanced lesions may undergo anterior resection with coloanal anastomosis. Following resection, radiotherapy is delivered to the pelvis and tumor bed often with concomitant chemotherapy. The overall rate of local failure in the trials in which local excision is performed with postoperative chemoradiotherapy is 3% for T1 lesions, 5% for T2 lesions, and 30% for T3 lesions with a median follow-up of at least 25 months. Local failure in patients with a coloanal anastomosis is 9% overall. Salvage was successful in about half of the patients who failed locally. Importantly, nearly all patients remained continent. These institutional studies show that sphincter preservation can be used in patients who are objectively selected for this procedure. However, before this multimodality approach may be considered standard therapy the rate of local control must be confirmed in a large, Phase II, multicenter, prospective trial such as that now underway in many of the cooperative groups.