Local excision of rectal cancer through windowed specula: long-term results

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.

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.

Transanal endoscopic microsurgical excision of pT2 rectal cancer: results and possible indications

PURPOSE

In previous studies, local excision was predominantly established for "low-risk" pT1 rectal cancer. The results obtained with T2 tumors are unclear; recurrence rates of 0 to 67 percent were reported. This study was designed to determine the value of local excision for T2 rectal carcinomas, prognostic factors, and the need for reoperation.

METHODS

After local excision of 649 patients with rectal tumors, pT2 carcinoma was found in 44 patients. In general, immediate reoperation was recommended; however, 24 patients declined further surgery or were not reoperated because of comorbidities. The results were analyzed separately for local R0 resection of low-risk carcinomas and for prognostically unfavorable criteria (R1/RX/R < or = 1mm/G3-4/L1/V1). Reoperation was performed within four weeks. Recurrences also were divided by previous local R0 resection of low-risk tumors as well as by unfavorable results and were analyzed in a long-term, follow-up study. Patients with palliative therapy were excluded, and follow-up was obtained in 90 percent (20 transanal endoscopic microsurgical excision alone, 17 transanal endoscopic microsurgical excision and reoperation).

RESULTS

Local recurrence rates after local R0 resection alone of low-risk T2 carcinomas were 29 percent, whereas patients with unfavorable criteria developed recurrences in 50 percent. After immediate reoperation, the local recurrence risk in patients without lymph node filiae was significantly reduced to 7 percent.

CONCLUSIONS

Local R0 resection of low-risk pT2 carcinomas represents an inadequate therapy. In pT2N0M0 rectal carcinomas, the recurrence rate can be reduced through immediate reoperation to a level similar to primary radical surgery. An initial poor local resection result (R1/RX/R < or = 1 mm/G3-4/L1/V1) has no negative influence on further oncologic outcome.

The influence of histopathologic criteria on the long-term prognosis of locally excised pT1 rectal carcinomas: results of local excision (transanal endoscopic microsurgery) and immediate reoperation

PURPOSE

Local excision of early rectal cancer is a controversial issue, which is in part because of differences in the evaluation of histopathologic criteria. This prospective study was designed to determine prognostic factors for recurrences and the need for reoperation.

METHODS

In 105 of 118 patients with pT1 carcinomas and local excision, results of recurrence rates and ten-year cancer-free survival were studied separately according to different histologic criteria (R0, R1, Rx, R < or = 1 mm, high-/low-risk situation), tumor localization (anterior, posterior, lateral wall and third of rectum), size, and degree of resection (full-thickness/partial wall). Patients were grouped into local excision (n = 89) and local excision followed by reoperation (n = 21). Risk classification was performed by division into "low-risk" carcinomas after local R0-resection (Group A) and unfavorable histologic results after local resection (R1, Rx, R < or = 1 mm, high-risk situation; Group B).

RESULTS

Local recurrence rates after local R0-resection of low-risk carcinomas were 6 percent, whereas patients in Group B with local resection were 39 percent. The recurrence risk in those patients was significantly reduced to 6 percent by reoperation (P = 0.015). In addition, ten-year, cancer-free survival was 93 percent in Group B after reoperation compared with 89 percent in patients of Group A after local excision alone.

CONCLUSIONS

Local R0-resection in cases with low-risk pT1 carcinomas represents an oncologically adequate therapy, which results in similar survival rates compared with primary radical surgery of pT1N0M0 rectal carcinomas. High recurrence rates are observed in tumors with unfavorable histologic result (Group B) requiring further treatment. In these cases immediate reoperation reduces the recurrence rate to 6 percent.

[Local excision of rectal cancer for cure]

Local excision of rectal cancer is advocated for cure only in selected patients. It should be done according to specific standards and needs close follow up. The transanal technique is well defined and indicated for posterior rectal wall tumours. Otherwise, technical modifications or microsurgery can be performed. The transacral approach should be abandoned.

The role of transrectal ultrasound-guided biopsy in the postoperative follow-up of patients with rectal cancer

BACKGROUND

The value of endorectal ultrasound (EUS) in the diagnosis of recurrent rectal cancer is limited by the inability to differentiate between malignant and benign lesions. We have prospectively investigated the role of EUS with transrectal ultrasound-guided biopsy in the postoperative follow-up of rectal cancer.

METHODS

Since 1995, patients who had undergone a sphincter-saving operation for rectal cancer (n = 312) were followed-up by a standard program including rectal palpation, carcinoembryonic antigen monitoring, computed tomography, and EUS. Transrectal EUS-guided biopsy of perirectal lesions was performed in 68 patients with perirectal lesions by using a rigid endoprobe with a 10 MHZ multiplane transducer and special targeting device.

RESULTS

Overall local recurrence was observed in 36 patients. Intraluminal recurrence was diagnosed by proctoscopy in 12 patients. Transrectal EUS-guided biopsy showed pelvic recurrence in 22 of 68 patients with perirectal lesions. Biopsy specimens with benign histology were obtained from 41 patients, and the procedure failed in 5 cases (accuracy, 92%). There was a strong agreement between transrectal biopsy results and the final diagnosis (kappa = 0.84), the sensitivity and specificity being 91% and 93%, respectively. In contrast, clinical examination (kappa = 0.27), computed tomography (kappa = 0.47), or EUS (kappa = 0.42) showed only a moderate level of agreement with the histopathologic diagnosis, mainly because of the limited specificity of all 3 methods (65% vs 46% vs 57%). EUS-guided biopsy was significantly more accurate than computed tomography and EUS (P <.01). The biopsy results had a considerable impact on the management in 18 of 68 patients (26%).

CONCLUSIONS

Transrectal EUS-guided biopsy is a safe and efficient method for tissue sampling of perirectal lesions. This minimally invasive and inexpensive technique improves the accuracy of endorectal ultrasound in the diagnosis of recurrent rectal cancer.