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

Adjuvant Radiation Survival Benefits in Patients with Stage 1B Rectal Cancer: A Population-based Study from the Surveillance Epidemiology and End Result Database (1973-2010)

Introduction

Rectal cancer remains a leading cause of cancer morbidity and mortality in the United States. Currently, total mesorectal excision (TME) is the standard therapy for patients with T2N0 (stage IB) rectal cancer. Whether adjuvant radiation therapy provides a survival benefit to these patients or exposes them to unnecessary toxicity remains controversial and unproven to date. This study examined a large cohort of Stage 1B rectal cancer patients who underwent surgical resection and received adjuvant radiation in order to determine the demographic, clinical, and pathologic factors impacting prognosis and survival.

Methods

Demographic and clinical data on 4,054 Stage 1B rectal cancer patients were abstracted from the Surveillance Epidemiology and End Result (SEER) database (1973-2010). Statistical analysis was performed with SPSS v20.0 software (IBM Corp., Armonk, NY) using the chi-square test, paired t-test, multivariate analysis, and Kaplan-Meier functions.

Results

Among 4,054 patients with stage IB rectal cancer, 2,364 (58.3%) had surgery only, 1,477 (36.4%) received combination surgery and radiation (CSR), 139 (3.4%) received radiation only, and 74 (1.8%) received no therapy. Most stage IB patients in the surgery only and CSR groups were male (65.8 and 64%) and Caucasian (78.2% and 74.2%), p<0.001. Patients receiving CSR were younger than those undergoing surgery alone (63 vs. 69 years, p<0.001). More tumors in the CSR group were 2-4 cm (53.6%), followed by > 4 cm (24%), while fewer were <cm (22.4%). Histologically, most of the tumors in the CSR group were moderately differentiated (83.5%) and adenocarcinoma NOS (95.5%), followed by poorly (9.3%) and mucinous adenocarcinoma (4.5%), well-differentiated (6.8%), and undifferentiated (0.4%). Overall survival was prolonged in the CSR group compared to the surgery-only group (5.85 years vs. 5.44 years, p<0.001), although cancer-specific survival did not differ (6.33 years vs. 6.42 years, p=0.143). Multivariate analysis identified age>60 (OR 2.4), poorly differentiated (OR 1.7) or undifferentiated grade (OR 2.6), and tumor size >2 cm (OR 1.5) as independently associated with increased mortality in the CSR group (p<0.05) while female gender conferred a survival advantage (OR 0.8), p<0.01.

Conclusions

In the current cohort, CSR was utilized most often in young male Caucasian patients presenting with less advanced disease as compared to other treatment groups. The overall survival is prolonged and overall mortality is lower in patients receiving CSR; however, increased cancer-related mortality with the use of CSR implies that survival benefits may be attributable to favorable non-tumor-related factors such as age, gender, and race. CSR should not replace surgery alone as the standard of care for all Stage IB rectal cancer patients at this time. However, all T2N0 rectal cancer patients should be enrolled in randomized control trials to allow for more defined multimodality management to optimize clinical outcomes for these patients.

Recurrence risk and prognostic parameters in stage I rectal cancers

BACKGROUND

The standard therapy for stage I rectum cancer is surgical resection. Currently, there is no strong evidence to suggest that any type of adjuvant therapy is beneficial. The risks of local relapse and distant metastasis are higher in rectal tumors. Therefore, while there is no clearly defined absolute indication for adjuvant therapy in lymph node negative colon cancers, rectum tumors that are T3N0 and higher require adjuvant treatment. Due to the more aggressive nature of rectal cancers, we explored the clinical and pathologic factors that could predict the risk of relapse in Stage I (T1-T2) disease and whether there was any progression-free survival benefit to adjuvant therapy.

MATERIALS AND METHODS

This multicenter study was carried out by the Anatolian Society of Medical Oncology. A total of 178 patients with rectal cancers who underwent curative surgery between January 1994 and August 2012 in 13 centers were included in the study. Patient demographics, including survival data and tumor characteristics were obtained from medical charts.

RESULTS

The median age was 58 years (range 26-85 years). Most tumors were well or moderately differentiated. For adjuvant treatment, 13 patients (7.3%) received radiotherapy alone, 12 patients (6.7%) received chemotherapy alone and 15 patients (8.4%) were given chemoradiotherapy. Median follow up was 29 months (3-225 months). Some 42 patients (23.6%) had relapse during follow up; 30 with local recurrence (71.4%) whereas 12 (28.6%) were distant metastases. Among the patients, 5-year DFS was 64% and OS was 82%. Mucinous histology and receiving adjuvant therapy were found to have statistically insignificant correlations with relapse and survival.

CONCLUSIONS

In our retrospective analysis, approximately one quarter of patients exhibited either local or systemic relapse. The rates of relapse were slightly higher in the patients who had no adjuvant therapy. There may thus be a role for adjuvant therapy in high-risk stage I rectal tumors.

Local excision of rectal cancer followed by radical surgery because of poor prognostic features does not compromise the long term oncologic outcome

AIM

The outcome of patients undergoing full-thickness local excision (LE) of rectal cancers may be compromised if poor prognostic features are found in the LE specimen. Our aim was to evaluate the long-term results of radical surgery performed after LE because poor prognostic factors are identified.

METHOD

Patients with biopsy-proven rectal cancer who had undergone full-thickness LE followed by radical surgery because of a positive margin, T stage ≥3, lymphovascular invasion, poor differentiation or mucinous histology were identified from a prospective database. Their records were retrospectively reviewed and follow up was updated.

RESULTS

Between 1995 and 2003, 17 patients underwent LE followed by radical surgery because of poor prognostic features. Combined chemotherapy and radiotherapy was given to 11 (65%) patients before radical surgery. Patients underwent radical surgery after a median of 14 (range: 0-40) weeks from LE. Nine underwent a low anterior resection and eight an abdominoperineal resection. At the time of radical surgery, residual disease was found in six (35%) patients (in lymph nodes in three; intramural in two; and both lymph nodes and intramural in one). Four of the patients with residual disease had undergone neoadjuvant therapy before radical surgery. The mean follow up was 110 (95% CI: 92-129) months. Recurrence-free survival at 10 years was 88%. There was no case of local recurrence, and two patients died of metastatic disease.

CONCLUSION

In this series patients who underwent early radical surgery because of poor prognostic features found at LE had good overall and cancer-specific long-term survival. Even after neoadjuvant therapy, more than a third of patients had residual disease at the time of radical surgery. We therefore recommend radical surgery with neoadjuvant therapy when poor prognostic features are found at LE.

Radiotherapy in the treatment of resectable rectal adenocarcinoma

The goal of treatment is to cure whereas maintaining sphincter function and minimizing toxicity. Although the mainstay of the treatment is surgery, radiotherapy (RT) is used in a substantial proportion of patients depending on the location and extent of the tumor. The aim of this article is to discuss the role of RT in patients with resectable rectal adenocarcinoma. This article is a review of the pertinent literature. Results show that patients with T1N0 exophytic, well to moderately differentiated, mobile tumors < or = 3 cm in diameter may be treated with either transanal excision or endocavitary RT. The probability of cure with either approach is approximately 80% to 90% and depends on selection criteria. The advantages of endocavitary RT are that it is an outpatient procedure requiring, at most, local anesthesia and is suitable for elderly, infirm patients. The disadvantage is that few of these treatment units are available. Patients who experience a local-regional recurrence may be surgically salvaged. Patients who undergo transanal excision and have unfavorable pathologic findings including equivocal or close margins, poor differentiation, invasion of the muscularis propria, and/or endothelial-lined space invasion have a high risk of local-regional recurrence after surgery alone. The addition of postoperative RT improves the likelihood of cure from 85% to 90%. Patients presenting with unfavorable tumors that are borderline resectable with a transanal excision may be downstaged with preoperative RT and rendered suitable for a wide local excision. The addition of concomitant chemotherapy probably enhances downstaging and may improve the likelihood of sphincter preservation. Patients with T3 and/or N1 rectal cancers have a relatively high probability of local-regional recurrence after surgery alone. Preoperative RT and postoperative RT combined with adjuvant chemotherapy have been shown to significantly reduce the risk of local-regional recurrence and improve survival. Whether preoperative RT alone or combined with chemotherapy is more efficacious than postoperative chemoradiation remains unclear. Endocavitary RT or transanal excision is suitable for patients with T1N0 cancers. Depending on tumor location and extent, adjuvant RT may improve the probability of local-regional control and survival for patients with locally advanced rectal adenocarcinomas.

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.

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.

A new proctoscope for transanal endoscopic operations

Transanal access is one of many currently used procedures for rectal cancer treatment. The techniques used for local excision include conventional transanal excision, posterior access, therapeutic colonoscopy and transanal endoscopic approaches. The aim of the present study was to present a new surgical proctoscope for the endoscopic transanal excision of rectal lesions. A cylindrical proctoscope with a diameter of 4 cm was devised and built. The end inserted into the anus has a bevelled aspect and rounded borders, allowing correct exposure of the anal lesion. The rectoscope is fixed to the anal border with surgical thread through perforations in the external end. A base screw holds a fibre-light which illuminates the operative field. Part of the equipment is a guide which is positioned inside the rectoscope on insertion into the anus. In operations utilizing this proctoscope, 17 adenomas, 25 adenocarcinomas, 1 carcinoid and 1 endometrioma were excised. The diameter of the lesions varied from 1 to 6 cm. The range of procedures that are possible with this new proctoscope are similar to those achieved with conventional techniques which, however, require more expensive equipment. Hence, the present study demonstrates that this newly devised low-cost proctoscope is an efficient tool for the transanal endoscopic excision of rectal lesions.

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.

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 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.

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.

Local therapy for rectal cancer: still controversial?

PURPOSE

Many considerations, such as morbidity, sexual and urinary dysfunction, or risk of definitive stoma have led to the increased popularity of local therapy in the therapeutic strategy for rectal cancer. However, its role in curative intent is still controversial with oncologic long-term results lower than those obtained by radical surgery.

METHODS

MEDLINE, EMBASE, LILACS, Abstract books, and reference lists from reviews were searched with English language publications to review the current status of evidence for local therapy in rectal cancer, looking especially at the oncologic results and patient selection. We have focused on the new strategies combining neoadjuvant and adjuvant treatment to explain their place in the management of rectal cancer.

RESULTS AND CONCLUSIONS

The key to potentially curative local treatment for rectal cancer is patient selection by identifying the best candidates with preoperative tumor staging and clinical and pathologic assessment of favorable features. Low-risk T1 is suitable for local excision alone. Limited data suggest that adjuvant chemoradiotherapy may be helpful in patients with unfavorable T1 and T2 lesions, achieving a local recurrence rate<20 percent. However, the efficacy of salvage surgery after local excision is uncertain.

Surgical Treatment of Rectal Cancer: Local Resection

Local treatment of rectal cancer aims to decrease the morbidity and the functional sequela associated with radical surgery without compromising local tumor control and long-term survival. Local excision is associated with a higher rate of local recurrence compared with radical surgery, and salvage radical surgery cannot guarantee equivalent long-term survival compared with radical surgery as the primary form of therapy. Therefore, strict criteria for patient selection are critical for local excision to be successful. Selecting the optimal therapy for an individual patient with rectal cancer is crucial and requires consideration of both tumor and patient characteristics. Endorectal ultrasonography is essential for the accurate assessment of rectal wall invasion and nodal metastasis. Only patients with well- or moderately differentiated T1 tumors without blood vessel or lymphatic vessel invasion are candidates for curative local excision as the only form of treatment. Tumors penetrating the muscularis propria should not be treated by local excision alone. These patients can be asked to participate in a trial of chemoradiation followed by local excision. Otherwise, they should undergo radical surgery. The tumor should be removed by full-thickness local excision with an adequate normal margin for pathologic evaluation. Final decisions regarding the treatment strategy should be based on the pathology of the surgical specimen. Intense, close follow-up is critical for early diagnosis of local recurrences as many of them may be surgically salvaged by radical resection. Local treatment can also be used for palliation of patients with histological unfavorable or advanced tumors, and those who are medically unfit for radical surgery.

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.

Is local excision of T2/T3 rectal cancers adequate?

In selected patients, local excision of rectal cancer may be an alternative to radical surgery such as abdominoperineal excision of the rectum or anterior resection. Local excision carries lower mortality and morbidity, without the functional disturbance or alteration in body image that can be associated with radical surgery. There are several techniques of local therapy for rectal cancer, with most experience being available in transanal excision. Transanal endoscopic microsurgery is also used but experience with this newer technique is limited. Patient selection is the most important factor in successful local excision; however, specific criteria for selecting patients have not been universally accepted. Review of the published literature is difficult because of the variation in adjuvant therapy regimes and follow-up strategies, as well as results reported in terms of local recurrence and survival rates. There is increasing evidence to suggest that local excision should be restricted to patients with T1-stage rectal cancer without high-risk factors. The place for local excision in patients with T2 or high-risk T1 tumours requires prospective, randomised multicentre trials comparing radical surgery with local excision, with or without adjuvant therapy. Local excision for T3 tumours should be restricted to the palliative setting or patients unfit for radical surgery.

Recurrence after transanal excision of T1 rectal cancer: should we be concerned?

PURPOSE

Transanal excision is an appealing treatment for low rectal cancers because of its low morbidity, mortality, and better functional results than transabdominal procedures. However, controversy exists about whether it compromises the potential for cure. Several, recent reports of high recurrence rates after local excision prompted us to review our results of transanal excision alone in patients with T1 rectal cancers.

METHODS

All patients with T1 low rectal cancer undergoing local excision alone between 1980 through 1998 were reviewed for local recurrence, distant metastasis, disease-free interval, results of salvage surgery, and overall and disease-free survival. Demographics, tumor size, distance from anal verge, and preoperative endoluminal ultrasound results also were recorded. Patients with poorly differentiated tumors, perineural or lymphovascular invasion, or with mucinous component were excluded.

RESULTS

Fifty-two patients underwent transanal excision during the study period. Five-year recurrence was estimated to be 29.38 percent (95 percent confidence interval, 15.39-43.48). For 52 patients, five-year, cancer-specific and overall survival rates were 89 and 75 percent respectively. Fourteen of 15 patients with recurrence underwent salvage treatment with 56.2 percent (95 percent confidence interval, 35.2-90) five-year survival rate. Gender, preoperative staging by endorectal ultrasound, distance from the anal verge, tumor size, location, and T1 status discovered after transanal excision of a villous adenoma did not influence local recurrence or tumor-specific survival.

CONCLUSIONS

Transanal excision for T1 rectal tumors with low-grade malignancy has a high rate of recurrence. Although overall cancer survival rates might be regarded as satisfactory, this high recurrence and low salvage rate raises the issue about the role of transanal excision alone for early rectal cancer and the possible need for adjuvant therapy or increased role of resective surgery.

Combined modality treatment for rectal cancer

Significant gains have been achieved in the integration of radiation therapy (RT) and chemotherapy with surgery in the management of patients with localized rectal cancer. Treatment combinations of RT and chemotherapy with surgery have evolved to neoadjuvant approaches of these modalities to enhance sphincter preservation, tumor control, and reduction of acute and late treatment-related morbidity. Although 5-fluorouracil (5-FU)-based chemotherapy in combination with RT remains the standard adjuvant therapy for rectal cancer, the integration of novel chemotherapeutic agents and biologic modulators is being actively investigated.

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.

Chemotherapeutic and biologic agents as radiosensitizers in rectal cancer

Over the past 25 years, important advances have been made in the management of patients with resectable rectal cancer. Clinical studies have shown the efficacy of combined chemoradiation therapy in enhancing resectability and sphincter preservation rates, decreasing local recurrence, and improving survival of patients with rectal cancer. Although 5-fluorouracil (5-FU) remains the standard chemotherapeutic agent used concurrently with radiation therapy, newer chemotherapeutic agents including capecitabine, irinotecan, and oxaliplatin have also been studied as radiosensitizers in this setting. Novel targeted biologic agents including celecoxib and bevacizumab are being explored in combination with standard chemotherapy and radiation therapy. In this review, we will discuss the mechanism of action and the key clinical studies of each agent as a radiosensitizer.

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.

Results of Long-Term Follow-Up for Transanal Excision for Rectal Cancer

Low anterior resection and abdominoperineal resection are the surgical techniques used most frequently in the treatment of rectal cancer. It is our hypothesis that selected patients with early T stage, well or moderate grade of differentiation, and small tumor size are good candidates for transanal excision in terms of minimal morbidity, low recurrence rate, and sphincter preservation. From January 1993 until August 2001 30 patients underwent transanal excision; three patients were excluded because they had histology other than adenocarcinoma. Factors analyzed included those related to the patient [age (years), gender, race, body mass index, and anal tone], tumor [size (cm), distance from the anal verge (cm), differentiation, and American Joint Committee on Cancer stage], and additional treatment. Median follow-up of the group was 40.7 months (range 0.6–99) and the primary end points were local and distant recurrence. Data are presented as mean (range). The median age of the group was 58.9 years (range 27–94); 52 per cent were female and 48 per cent were male. The mean body mass index was 25.9 (range 22.7–36.7). Preoperatively 81, 11, and 4 per cent of the patients had stage I, II, and III/IV cancer, respectively. Preoperative size of the tumor was 2.0 cm (1–3 cm), and distance from the anal verge was 5.0 cm (3–15 cm). Blood loss was 50 cm3 (5–200 cm3), and there were no operative complications. Tumor differentiation levels were well (37%) and moderate (63%). All patients had negative margins. Additional treatment consisted of radiation therapy in seven patients (six postoperative and one preoperative). Chemotherapy was given to seven patients (six postoperative and one preoperative). The local recurrence rate was 7.4 per cent (two patients), and 3.7 per cent recurred distantly (one patient). Transanal excision of low rectal cancer in selected patients is an acceptable alternative to formal resection. Important selection criteria include early T stage, well or moderate differentiation, relatively small tumor size, and negative microscopic margins. The roles of radiation and chemotherapy remain controversial.

Local excision of rectal tumors

Local excision is increasingly being used to treat rectal cancer. It appears to be an attractive option because of low morbidity and excellent functional results. Controversies remain regarding available techniques, selection criteria and results with or without adjuvant therapy. Role of salvage therapy remains uncertain. This review examines available evidence in an attempt to clarify the role of local excision in the management of rectal cancer.

Local therapy for rectal cancer

Local procedures for carefully selected distal rectal cancer offer significant advantages such as sphincter preservation and avoidance of radical surgery. However, since preoperative selection criteria including current imaging modalities are unable to definitively stage regional lymph node status, local therapies for rectal cancer have the inherent potential disadvantage of undertreating a fraction of patients due to unresected mesorectal/regional lymph node disease. Current available data suggests that the local approach may be appropriate only for carefully selected T1 tumors with favorable pathologic features. Inferior local control and survival reported for T2 tumors and T1 tumors with unfavorable features, despite the addition of chemoradiation, outweigh the advantages of the local approach. Patients with unfavorable tumors who are unable to tolerate radical resection or who refuse surgery may be treated with local excision with or without adjuvant chemoradiation. Other modalities, such as electrocoagulation and endocavitary radiation, may also be valuable in this setting, as well as preoperative chemoradiation followed by local excision. Regardless of the approach used, all patients undergoing local therapy of a rectal cancer require careful long-term follow-up, because these patients remain at significant risk for local recurrence and distant failure.

Surgery for colon and rectal cancer

Radical surgery remains the only potentially curative treatment for colorectal cancer. Major changes in the principles of rectal cancer resection have been recently described (total mesorectum excision) whereas there have been few changes in the principles of colonic cancer resection. This chapter presents surgical procedures for curative treatment of colorectal cancer in both the elective and emergency settings.

Role of radiation therapy in the treatment of resectable rectal adenocarcinoma

The purpose of this study is to review the role of radiation therapy in the treatment of resectable rectal adenocarcinoma. Selection criteria, treatment techniques, and results are discussed.

Randomized clinical trials in rectal and anal cancer

Treatment of rectal cancer has changed dramatically over the past two decades. Radical surgery alone for resectable rectal cancer has been replaced by combined modality therapy. Interest in optimizing sphincter preservation and quality of life motivated surgeons to seek less radical surgery without compromising oncologic principles.

Treatment of rectal adenocarcinoma with endocavitary and external beam radiotherapy: results for 199 patients with localized tumors

PURPOSE

Endocavitary radiation (RT) provides a conservative alternative to proctectomy. Although most suitable for small, mobile lesions, patients with less favorable tumors are often referred if they are poor surgical candidates. Knowing the extent to which radiation can control such tumors can be an important factor in making clinical decisions.

METHODS AND MATERIALS

One hundred ninety-nine patients, who received endocavitary RT with or without external beam RT (EBRT) during 1981 through 1995, were followed for disease status for a median of 70 months, including deaths from intercurrent causes. In the early years of the study, 21 patients were treated with endocavitary RT alone, the remainder of the patients received pelvic EBRT (usually 45 Gy in 25 fractions) 5-7 weeks before endocavitary RT.

RESULTS

Overall, 141 patients (71%) had local control with RT alone. Salvage surgery rendered an additional 20 patients disease free, for an ultimate local control rate of 81%. On multivariate analysis for local control (excluding surgical salvage), the most significant factors were mobility to palpation, use of EBRT, and whether pretreatment debulking of all macroscopic disease had been done (generally a piecemeal, nontransmural procedure). Of 77 cases staged by transrectal ultrasonography, the local control rate with RT alone was 100% for uT1 lesions, 85% (90% with no evidence of disease after salvage) for freely mobile uT2 lesions, and 56% (67% with no evidence of disease after salvage) for uT3 lesions and uT2 lesions that were not freely mobile.

CONCLUSIONS

Patients with small mobile tumors that are either uT1 or have only a scar after debulking achieve excellent local control with endocavitary RT. About 15% of mobile uT2 tumors fail RT; therefore, careful follow-up is critical. Small uT3 tumors are appropriate for this treatment only if substantial contraindications to proctectomy are present.

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.

Local excision and postoperative radiotherapy for distal rectal cancer

PURPOSE

To assess the outcome following local excision and postoperative radiotherapy (RT) for distal rectal carcinoma.

MATERIALS AND METHODS

Seventy-three patients received postoperative radiotherapy following local surgery for primary rectal carcinoma at Princess Margaret Hospital from 1983 to 1998. Selection factors for postoperative RT were patient preference, poor operative risks, and "elective" where conservative therapy was regarded as optimal therapy. Median distance of the primary lesion from the anal verge was 4 cm (range, 1--8 cm). There were 24 T1, 36 T2, and 8 T3 lesions. The T category could not be determined in 5. Of 55 tumor specimens in which margins could be adequately assessed, they were positive in 18. RT was delivered using multiple fields by 6- to 25-MV photons. Median tumor dose was 50 Gy (range, 38--60 Gy), and 62 patients received 50 Gy in 2.5-Gy daily fractions. The tumor volume included the primary with 3--5 cm margins. No patients received adjuvant chemotherapy. Median follow-up was 48 months (range, 10--165 months).

RESULTS

Overall 5-year survival and disease-free survival were 67% and 55%, respectively. Tumor recurrence was observed in 23 patients. There were 14 isolated local relapses; 6 patients developed local and distant disease; and 3 relapsed distantly only. For patients with T1, T2, and T3 lesions, 5-year local relapse-free rates were 61%, 75%, and 78%, respectively, and 5-year survival rates were 76%, 58%, and 33%, respectively. The 5-year local relapse-free rate was lower in the presence of lymphovascular invasion (LVI) compared to no LVI, 52% vs. 89%, p = 0.03, or where tumor fragmentation occurred during local excision compared to no fragmentation, 51% vs. 76%, p = 0.02. Eleven of 14 patients with local relapse only underwent abdominoperineal resection, 8 achieved local control, and 4 remained cancer free. The ultimate local control, including salvage surgery, was 86% at 5 and 10 years. The 5-year colostomy-free rate was 82%. There were 2 patients who experienced RTOG Grade 3 late complications, and 1 with Grade 4 complication (bowel obstruction requiring surgery).

CONCLUSION

The local relapse rate for patients with T1 disease was high compared to other series of local excision and postoperative RT. Patients with LVI or tumor fragmentation during excision have high local relapse rates and may not be good candidates for conservative surgery and postoperative RT.

Local therapy for rectal cancer

In selected patients with early rectal cancer, local therapy is an effective alternative to radical resection and offers minimal morbidity and the avoidance of a colostomy. Several techniques are described: transanal excision, dorsal approaches (York-Mason or Kraske procedures), transanal endoscopic microsurgery, endocavitary radiation, and transanal fulguration. Among these, transanal excision is favored for the low rate of complications, promising outcomes, and ability to secure tissue for pathology. Patients with T1 lesions with favorable histologic features may undergo local excision alone, while those with T2 lesions require adjuvant chemoradiation. The data currently available do not support the use of local therapy with curative intent for tumors that are advanced (T3 or T4), poorly differentiated, or have other negative pathologic characteristics. In carefully selected patients for local excision, local recurrence and survival rates are similar to traditional radical resection. Following local excision, patients require close observation for recurrence. Most patients with local recurrence can be salvaged by radical resection, though the long-term outcome is unknown.

Radiation therapy in the management of rectal cancer

Substantial advances have been made in the adjuvant management of patients with resectable rectal cancer. Increasing interest in patient quality of life has promoted the use of radiation therapy to enhance sphincter-preserving surgical approaches as an alternative to the standard abdominoperineal resection. Because of the suggestion of enhanced sphincter preservation with preoperative therapy and the potential advantage of decreased acute morbidity, randomized trials comparing preoperative and postoperative adjuvant combined modality therapy are ongoing. Recent progress in adjuvant postoperative treatment regimens relates to the integration of systemic therapy to radiation, and redefining the techniques for both modalities. The incorporation of improved radiation planning may reduce treatment-related bowel toxicity. The integration of novel chemotherapeutic agents in the adjuvant therapy of rectal cancer remains an active area of investigation.

CONSERVATIVE TREATMENT OF RECTAL ADENOCARCINOMA

Endocavitary radiotherapy and transrectal excision are highly effective treatments for properly selected patients with favorable early-stage rectal adenocarcinoma. The likelihood of local control and survival after treatment with either modality is similar, and differences among various series probably reflect selection. The parameter most predictive of local control and survival in the authors' series was tumor configuration. As has been previously observed, "selection is the silent partner of success." Suitable candidates for endocavitary radiotherapy or wide local excision are patients whose tumors are 3 cm or less in diameter, well-to-moderately differentiated, exophytic, mobile, limited to the submucosa on transrectal ultrasound, and within 10 cm of the anal verge. The advantages of endocavitary irradiation are (1) it is an outpatient procedure, (2) it does not require anesthesia, and (3) it is less expensive than transrectal excision. The advantages of transrectal excision are (1) it may be performed during one brief hospitalization (as opposed to four outpatient visits), and (2) a small subset of patients will have pathologic findings predicting an increased risk of regional lymph node involvement, revealing the need to treat the nodes with external-beam radiotherapy. A disadvantage of wide local excision is that some patients who would be suitable for a local procedure alone must be subjected to a course of external-beam radiotherapy when they are found to have equivocal or positive margins. Patients who are treated with transrectal excision and external-beam radiotherapy have less favorable lesions and are not comparable with patients who are treated with endocavitary radiotherapy or wide local excision alone. They are best compared with patients who have undergone major surgery consisting of abdominoperineal resection or low anterior resection. Because the risk of positive nodes is significantly increased with adverse pathologic findings such as poor differentiation, invasion of the muscularis propria, and endothelial-lined space invasion, a subset of these patients treated with wide local excision would have positive nodes. This subset of patients is not comparable with patients with stage pT1N0 and pT2N0 tumors treated with major surgery. The latter group of patients undergo complete surgical staging, whereas the pathologic staging for patients who undergo wide local excision and radiotherapy is limited to the extent of the primary tumor. With this caveat in mind, wide local excision and radiotherapy seem to result in locoregional control and survival rates similar to the rates obtained with major surgery for patients with pT1 and pT2 cancers (Table 5). Patients who should receive postoperative irradiation have tumors that exhibit one or more of the following characteristics: size greater than 3 cm in diameter, poorly differentiated, invasion of the muscularis propria, endothelial-lined space invasion, fragmented resection, equivocal or positive margins, or perineural invasion. Patients with gross residual disease are not suitable candidates for radiotherapy and require further surgery. The authors' policy is to treat these patients with chemoradiation followed by resection. Patients thought to have transmural invasion before treatment are probably best treated with preoperative chemoradiation combined with major surgery, although a subset of patients can be downstaged and rendered suitable for a wide local excision.

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.

Sphincter preservation in rectal cancer

Distal rectal cancer poses two challenges to the oncologist: local tumor control and sphincter preservation. The abdominoperineal resection (APR), long considered the standard treatment of tumors with a distal edge located up to 6 cm from the anal verge, provides local control in many patients but results in sphincter loss with a permanent colostomy. This is a critical limitation. Consequently, there has been significant interest in sphincter-conserving approaches, frequently combining chemoradiation with surgery. These approaches have evolved along two fronts. For patients with small rectal cancers confined to the rectal wall, local excision techniques with and without chemoradiation may offer comparable local control and survival rates as an APR and preserve sphincter function. For patients with larger and more invasive tumors of the distal rectum where local excision is inappropriate, preoperative chemoradiation promotes tumor regression and may facilitate a resection sparing the sphincter with a coloanal anastomosis. Preliminary results from single institution studies appear promising. In both these settings (favorable and more invasive rectal cancer), chemoradiation is employed to compensate for the limitations of the sphincter-preserving surgical technique. In local excision procedures, the excision margins are invariably small, and the mesorectum (lymphatics, soft tissue) surrounding the tumor is not excised. For patients undergoing resection with coloanal anastomosis, there are narrow radial and distal surgical margins. With these approaches of chemoradiation and sphincter-sparing surgery, satisfactory local control and survival with avoidance of colostomy are possible for many patients with distal rectal cancer.

Role of endorectal ultrasound in the conservative management of rectal cancers

Endorectal ultrasonography (ERUS) extends the ability of the clinician to define the clinical features assessed on routine physical examination, and remains the best modality for accurately staging depth of penetration and presumptive nodal status in rectal cancers. The success of conservative management of rectal cancers is predicated on proper patient selection. The preoperative selection of the ideal patient for local therapies can be difficult, and the decision-making process takes into account many critical factors. Careful assessment of the T and N stages is critical in determining the success of conservative therapies, and directing treatment algorithms. Local resections with curative intent are limited to patients with T1N0 rectal cancers, and select patients with T2N0 tumors with favorable pathological criteria. Conservative management may also be extended to patients identified with significant underlying comorbid conditions staged preoperatively with unfavorable T2/T3 lesions, often combined with adjuvant therapies in a palliative setting. In addition, ERUS may have a role in the selection of those patients with more advanced lesions to neoadjuvant chemoradiation, followed by radical resection. Though not clearly defined, ERUS is evolving in its role in the postoperative follow-up of patients treated conservatively for rectal cancers, and can lead to the early detection of local recurrences. The widespread use of ERUS remains limited due to high operator variability and errors in interpretation; however, the role of ERUS in the postoperative management of rectal cancers is evolving and requires further evaluation.

Should locally excised T1 rectal cancer receive adjuvant chemoradiation?

BACKGROUND

Local excision of low-lying adenocarcinoma of the rectum is increasingly utilized, but the benefit of adjuvant treatment in T1 lesions with otherwise favorable pathology remains controversial.

METHODS

A retrospective review was performed on patients who underwent local excision of invasive rectal cancer with curative intent from 1991 to 1999.

RESULTS

Forty-eight patients were treated with local surgical excision. Twenty-seven T1 lesions were identified, 10 received postoperative chemoradiation, and no local recurrences were identified. Seventeen T1 patients did not receive adjuvant treatment and local recurrence occurred in 4 patients (24%). In all cases of local recurrence, the lesions had been excised to negative margins, none were poorly differentiated, and none exhibited vascular or lymphatic invasion.

CONCLUSION

These data suggest a trend toward improved local control with adjuvant therapy after local excision of T1 rectal cancer. This is an important consideration in patients with negative surgical margins and favorable pathology who are traditionally not treated.

Adjuvant therapy for resectable rectal adenocarcinoma

The mainstay of treatment for rectal cancer over the past 100 years has been surgical resection. However, for the majority of rectal cancers treated conventionally by resection alone, locoregional recurrence is the major mode of failure. Over the past several decades, significant progress has been made in developing effective adjuvant regimens. In the United States, postoperative chemoradiation is standard treatment for T3 or node-positive patients. However, preoperative radiation with or without chemotherapy decreases local recurrence, increases sphincter preservation, and may improve survival. The purpose of this article is to review the role of adjuvant therapy in resectable rectal cancers and to update the status of ongoing randomized trials.

Is local excision adequate therapy for early rectal cancer?

PURPOSE

Radical surgery of rectal cancer is associated with significant morbidity, and some patients with low-lying lesions must accept a permanent colostomy. Several studies have suggested satisfactory tumor control after local excision of early rectal cancer. The purpose of this study was to compare recurrence and survival rates after treating early rectal cancers with local excision and radical surgery.

METHODS

One hundred eight patients with T1 and T2 rectal adenocarcinomas treated by transanal excision were compared with 153 patients with T1N0 and T2N0 rectal adenocarcinomas treated with radical surgery. Neither group received adjuvant chemoradiation. Mean follow-up time was 4.4 years after local excision and 4.8 years after radical surgery.

RESULTS

The estimated five-year local recurrence rate was 28 percent (18 percent for T1 tumors and 47 percent for T2 tumors) after local excision and 4 percent (none for T1 tumors and 6 percent for T2 tumors) after radical surgery. Overall recurrence was also higher after local excision (21 percent for T1 tumors and 47 percent for T2 tumors) than after radical surgery (9 percent for T1 tumors and 16 percent for T2 tumors). Twenty-four of 27 patients with recurrence after local excision underwent salvage surgery. The estimated five-year overall survival rate was 69 percent after local excision (72 percent for T1 tumors and 65 percent after T2 tumors) and 82 percent after radical surgery (80 percent for T1 tumors and 81 percent for T2 tumors). Differences in survival rate between local excision and radical surgery were statistically significant in patients with T2 tumors.

CONCLUSIONS

Local excision of early rectal cancer carries a high risk of local recurrence. Salvage surgery is possible in most patients with local recurrence, but may be effective only in patients with T1 tumors. When compared with radical surgery, local excision may compromise overall survival in patients with T2 rectal cancers.

Local excision for rectal cancer

BACKGROUND AND OBJECTIVES

The aim of this retrospective study is to evaluate the results of local excision (LE) for rectal cancer for curative purposes.

METHODS

From 1969 to December 1997, a total of 456 operations were performed for surgical treatment of rectal carcinoma (262 males and 194 females, mean age 66 years). Twenty patients (4.1%) underwent LE (7 males and 13 females, median age 65 years). Patients were selected for LE if they met the following criteria during preoperative staging: tumors staged as T1-T2,N0,M0, grading G1 or G2, and accessible location. Types of LE performed were: 13 transanal excisions (Francillon's technique), 2 Mason surgeries, 2 endoscopic excisions, and 3 transanal endoscopic microsurgeries.

RESULTS

There was no in-hospital mortality among LE patients. Thirteen tumors were T1 and 7 were T2; all 20 were adenocarcinoma, 14 G1 and 6 G2. There was no specific morbidity, and aspecific morbidity was minimal (5%). There were no local recurrences, but 2 patients (10%) had secondary lesions. Five-year overall survival following LE was 87.4%. Comparing T1 and T2 tumors treated with abdominoperineal resection (APR) and SSR (17 T1 and 42 T2, all adenocarcinoma), in-hospital mortality and specific morbidity were respectively 1.7% (P = 0.55) and 28% (P = 0.007). There were 5 (8.5%) local recurrences (P = 0.17) and 6 (10.2%) metastatic lesions. Five-year overall survival was similar to LE (88.3%; P = 0.76).

CONCLUSIONS

LE for rectal carcinoma might only be successfully performed in selected patients with correct preoperative staging. In the LE cases reported five-year overall survival, local recurrence, and in-hospital mortality were similar to APR and SSR, while there was a statistically significant difference following LE in terms of specific morbidity.

Transanal excision of early rectal carcinoma-review of a personal series

Transanal excision of small rectal tumours is a relatively minor procedure that is potentially curable and can be employed in selected cases of rectal cancer. The outcome of 22 cases treated by local excision was reviewed. This represented 9% of patients treated for rectal cancer over the study period. All patients had a transanal excision with curative intent and included three patients who were medically unfit for a major procedure. Follow up was for a minimum of 5 years or until death if this was earlier. The mean age was 65.7 years with 10 males and 12 females. The 5-year recurrence rate was 27% (five of 22). The crude 5-year survival for curative resection was 77%. Of the 22 local excisions, 10 were T1 and 12 were T2. The size of tumour varied from 0.5 cm to 3.5 cm. Eight were well differentiated, 10 moderate and two poorly differentiated. Two of the earlier cases in the series were unclassified. There were six recurrences, all of which were extraluminal. Three recurrences were in less than 3 years (early recurrence) and three beyond this time. Of the recurrences, one presented with liver metastases within 2 months of surgery, one was unfit for a major procedure and subsequently died of a myocardial infarction. The remaining patients with recurrences had salvage surgery. Three are still alive and one died over 5 years after a local excision, with the presence of recurrence. All recurrences were of T2 stage, with moderate (n=5) or poor differentiation (n=1). Three of the six tumours measuring > 3 cm recurred compared with three of the 16 tumours between 0.5 cm and 3 cm. Analysis of these cases demonstrates that local resection of small rectal tumours can give good results and salvage operation is possible in the event of recurrence. Long term follow up is recommended because of risks of late recurrence. The best prognosis group appears to be with the well-differentiated T1 tumours with no involved margins.

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

OBJECTIVE

To evaluate the results of local excision alone for the treatment of rectal cancer, applying strict selection criteria.

BACKGROUND DATA

Several retrospective studies have demonstrated that tumor control in properly selected patients with rectal cancer treated locally is comparable to that observed after radical surgery. Although there is a consensus regarding the need for patient selection for local excision, the specific criteria vary among centers.

METHODS

The authors reviewed 82 patients with T1 (n = 55) and T2 (n = 27) rectal cancer treated with transanal excision only during a 10-year period. At pathologic examination, all tumors were localized to the rectal wall, had negative excision margins, were well or moderately differentiated, and had no blood or lymphatic vessel invasion, nor a mucinous component. End points were local and distant tumor recurrence and patient survival.

RESULTS

Ten of the 55 patients with T1 tumors (18%) and 10 of the 27 patients with T2 tumors (37%) had recurrence at 54 months of follow-up. Average time to recurrence was 18 months in both groups. Seventeen of the 20 patients with local recurrence underwent salvage surgery. The survival rate was 98% for patients with T1 tumors and 89% for patients with T2 tumors. Preoperative staging by endorectal ultrasound did not influence local recurrence or tumor-specific survival.

CONCLUSION

Local excision of early rectal cancer, even in the ideal candidate, is followed by a much higher recurrence rate than previously reported. Although most patients in whom local recurrence develops can be salvaged by radical resection, the long-term outcome remains unknown.

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.