Outcome of transanal endoscopic microsurgery and adjuvant radiotherapy in patients with T2 rectal cancer

[Transanal endoscopic rectal resection: immediate and long-term results]

OBJECTIVE

To analyze the results of transanal endoscopic microsurgery in patients with rectal tumors.

MATERIAL AND METHODS

We analyzed 87 transanal endoscopic resections of rectal benign tumors (35 patients) and rectal cancer cT1N0M0 (52 patients) for the period since 2012.

RESULTS

There were 2 (3.8%) intraoperative intestinal wall perforations into abdominal cavity and 2 (3.8%) postoperative bleedings among patients with rectal cancer. Four (7.7%) patients developed recurrent rectal cancer (pT1N0M0 - 1 patient, pT2N0M0 - 3 patients; by tumor grades: G1 - 2 patients, G2 - 2 patients) within 1.6-5.2 years. All recurrent tumors were located on anterior rectal wall. In patients with rectal cancer, cumulative relapse-free survival was 0.923 (standard error 0.037), cumulative overall survival - 0.926 (standard error 0.043). There was 1 (4.3%) intraoperative intestinal wall perforation among patients with benign rectal tumors. Postoperative anastomotic leakage occurred in 1 (4.3%) patient. Recurrent benign tumors occurred in 2 (8.7%) patients with villous rectal tumors. No relapses were observed in patients with rectal adenomas (p=1.0).

CONCLUSION

Transanal endoscopic rectal resection is effective for benign rectal tumors and rectal cancer pT1N0M0 with high relapse-free and overall survival and low complication rate. Risk factors of recurrence are tumor stage pT2N0M0, tumor location on anterior wall and distance from the anus over 10 cm.

Short- and long-term outcomes of local excision with adjuvant radiotherapy in high-risk T1 rectal cancer patients

Purpose

Methods

Results

Conclusion

Local recurrence after local excision of early rectal cancer: a meta-analysis of completion TME, adjuvant (chemo)radiation, or no additional treatment

BACKGROUND

The risks of local recurrence and treatment-related morbidity need to be balanced after local excision of early rectal cancer. The aim of this meta-analysis was to determine oncological outcomes after local excision of pT1-2 rectal cancer followed by no additional treatment (NAT), completion total mesorectal excision (cTME) or adjuvant (chemo)radiotherapy (aCRT).

METHODS

A systematic search was conducted in PubMed, Embase and the Cochrane Library. The primary outcome was local recurrence. Statistical analysis included calculation of the weighted average of proportions.

RESULTS

Some 73 studies comprising 4674 patients were included in the analysis. Sixty-two evaluated NAT, 13 cTME and 28 aCRT. The local recurrence rate for NAT among low-risk pT1 tumours was 6·7 (95 per cent c.i. 4·8 to 9·3) per cent. There were no local recurrences of low-risk pT1 tumours after cTME or aCRT. The local recurrence rate for high-risk pT1 tumours was 13·6 (8·0 to 22·0) per cent for local excision only, 4·1 (1·7 to 9·4) per cent for cTME and 3·9 (2·0 to 7·5) per cent for aCRT. Local recurrence rates for pT2 tumours were 28·9 (22·3 to 36·4) per cent with NAT, 4 (1 to 13) per cent after cTME and 14·7 (11·2 to 19·0) per cent after aCRT.

CONCLUSION

There is a substantial risk of local recurrence in patients who receive no additional treatment after local excision, especially those with high-risk pT1 and pT2 rectal cancer. The lowest recurrence risk is provided by cTME; aCRT has outcomes comparable to those of cTME for high-risk pT1 tumours, but shows a higher risk for pT2 tumours.

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.

Transanal endoscopic microsurgery for rectal villous tumours: Can we rely solely on preoperative biopsies and the surgeon’s experience?

Background

Transanal endoscopic microsurgery has become the standard of treatment for rectal villous adenomas. However, the role of preoperative imaging for these lesions is not clear. The aim of this study was to compare the value of preoperative imaging and surgeon clinical staging in the preoperative evaluation of patients with rectal villous adenomas having transanal endoscopic microsurgery resection.

Methods

We conducted a single-centre comparative retrospective cohort study of patients who underwent transanal endoscopic microsurgery surgery for rectal villous adenomas from 2011 to 2013. The intervention was preoperative imaging versus surgeon clinical staging. The primary outcome was the accuracy of clinical staging by preoperative imaging and surgeon clinical staging according to the histopathologic staging.

Results

A total of 146 patients underwent transanal endoscopic microsurgery surgery for rectal villous adenomas. One hundred and twelve (76.7%) of those patients had no preoperative imaging while 34 patients (23.3%) had either endorectal ultrasound (22 patients) or magnetic resonance imaging (12 patients). Surgeon staging was accurate in 89.3% of cases whereas staging by endorectal ultrasound was accurate in 40.9% cases and magnetic resonance imaging was accurate in 0% of cases. In the imaging group, inaccurate staging would have led to unnecessary radical surgery in 44.0% of patients.

Conclusion

This study was subject to selection bias because of its retrospective nature and the limited number of patients with imaging. Patients with rectal villous tumours without invasive carcinoma on biopsies and without malignant characteristics on appearance in the judgment of an experienced colorectal surgeon might not benefit from preoperative imaging before undergoing transanal endoscopic microsurgery procedures.

Transanal endoscopic microsurgery for rectal lesions in a specialist regional early rectal cancer centre: the Mersey experience

AIM

Organ-preserving local excision by transanal endoscopic microsurgery (TEM) for early rectal cancer offers significantly lower morbidity as compared to formal rectal cancer resection with acceptable outcomes. This study presents our 6-year experience of TEM for rectal lesions referred to a specialist early rectal cancer centre in the UK.

METHOD

Data were collected for all patients referred for TEM of suspected early rectal cancer to a regional specialist early rectal cancer multidisciplinary team (MDT) over a 6-year period.

RESULTS

One hundred and forty-one patients who underwent full-thickness TEM for suspected or confirmed early rectal cancer were included. Thirty patients were referred for TEM following incomplete endoscopic polypectomy. Final pathology was benign in 77 (54.6%) cases and malignant in 64 (45.4%). Of the 61 confirmed adenocarcinomas, TEM resections were pT0 in 17 (27.9%), pT1 in 32 (51.7%), pT2 in 11 (18.0%) and pT3 in 1 (1.6%). Thirty-eight of 61 patients (62.3%) had one or more poor histological prognostic features and these patients were offered further treatment. Twenty-three of 61 (37.7%) patients with rectal adenocarcinoma required no further treatment following TEM. Forty-three cases of rectal adenocarcinoma were available for establishing recurrence rates. Two of 43 patients (4.7%) developed a recurrence at a median follow-up of 28.7 months (12.1-66.5 months). The overall estimated 5-year overall survival rate was 87.9% and the disease-free survival rate was 82.9%.

CONCLUSION

Acceptable outcomes are possible for TEM surgery with appropriate patient selection, effective technique, expert histopathology, appropriate referral for adjuvant treatment and meticulous follow-up. This can be achieved through an early rectal cancer MDT in a dedicated specialist regional centre.

Radiotherapy after local excision of rectal cancer may offer reduced local recurrence rates

AIM

Early rectal cancer can be managed effectively with local excision, which is now the standard of care for many T1 lesions. However, the presence of unexpected adverse histopathological factors may indicate an increased risk of local recurrence, prompting consideration of completion radical surgery. Many patients are unfit or prefer to avoid radical surgery, relying instead on surveillance and early detection of recurrent disease. Recently, radiotherapy has shown promise as an adjuvant therapy in this group. This study assesses local recurrence rates after local excision with adjuvant radiotherapy at a single centre.

METHOD

This was a retrospective review of a prospective database of all patients undergoing transanal endoscopic microsurgery (TEM) in a single institution. Data covering a 10-year period were analysed.

RESULTS

Of 197 patients undergoing TEM for rectal cancer, 33 (17%) had adjuvant radiotherapy because of adverse histopathological features. At 3.2 years' median follow-up, there were three instances of local recurrence (9.1%). Estimated local recurrence at 1 and 3 years was 0% and 6.9%, compared to 16.8% and 21.2% in a propensity-score-matched group who were followed by surveillance alone. Local recurrence was diagnosed at a median of 23 months post-TEM in the radiotherapy group, compared to 8 months in the matched group.

CONCLUSION

Radiotherapy after TEM is associated with a trend towards a reduced rate of local recurrence, even for high-risk disease. Radiotherapy would appear to offer a viable alternative to radical completion surgery in the presence of unforeseen adverse histopathological features, as long as a meticulous surveillance programme is in place.

Adjuvant radiotherapy after local excision of rectal cancer

BACKGROUND

Local excision is now accepted as a standard treatment option for certain patients with early rectal cancer. However, there is a higher risk of local recurrence than after radical surgery with total mesorectal excision. Adjuvant radiotherapy after local excision may reduce this excess risk, and yet retain the benefits of local excision, with rectal preservation.

METHODS

A review of the literature pertaining to the use of adjuvant radiotherapy after local excision of rectal cancer and a discussion of current practice.

RESULTS

We first considered local excision as a treatment option for early rectal cancer, looking at technical developments and the risks and benefits of organ preservation, in particular, the advantages for quality of life and the risk of leaving residual disease which may result in local recurrence. We then looked at reported outcomes for studies using adjuvant radiotherapy after local excision. Few of the studies routinely used modern endoscopic methods of local excision and only the recent used chemoradiation. Local recurrence rates after adjuvant radiotherapy have improved over time, with rates of around 3.5% in the recent studies. Adverse effects of adjuvant radiotherapy are not commonly described, but generally, they are relatively mild when described. We then discussed current practice regarding adjuvant radiotherapy, including pathological criteria, discussion of local recurrence risk with the patient and the importance of a surveillance regime to detect any recurrence at an early stage.

CONCLUSION

We conclude that the current state of knowledge regarding adjuvant radiotherapy after local excision suggests a potential role in decreasing the risk of local recurrence but further studies are required to better define this effect, clarify which patients will gain the most benefit from this pathway, and identify those who should avoid exposure to the risks of radiotherapy.

A systematic review of local excision followed by adjuvant therapy in early rectal cancer: are pT1 tumours the limit?

AIM

Total mesorectal excision remains the cornerstone of treatment for rectal cancer. Significant morbidity means local excision may be more appropriate in selected patients. Adjuvant therapy reduces local recurrence and improves survival; however, there is a paucity of data on its impact following local excision, which this systematic review aims to address.

METHODS

A systematic search of the MEDLINE, Embase and Cochrane databases using validated terms for rectal cancer, adjuvant therapy and local excision was performed. Included studies focused on local excision with adjuvant therapy for adenocarcinoma of the rectum. Primary outcome measures were local recurrence, survival and morbidity. Studies providing neoadjuvant therapy or local excision alone were excluded.

RESULTS

Twenty-two studies described 804 patients. Indications for local excision included favourable histology, patient choice and comorbidities. T1, T2 and T3 tumours accounted for 35.1%, 58.0% and 6.9% of cases, respectively. The most frequent local excision technique was transanal excision (77.7%). Adjuvant therapy included long-course chemoradiation or radiotherapy. Median follow-up was 51 months (range 1-165). The pooled local recurrence was 5.8% (95% CI 3.0-9.5) for pT1, 13.8% (95% CI 10.1-17.9) for pT2 and 33.7% (95% CI 19.2-50.1) for pT3 tumours. The overall median disease-free survival was 88% (range 50%-100%) with a pooled overall morbidity of 15.1% (95% CI 11.0-18.7).

CONCLUSIONS

This area remains highly relevant to modern clinical practice. The data suggest that local excision followed by adjuvant therapy can achieve acceptable long-term outcomes in high-risk pT1 tumours, but not in T2 tumours and above in whom radical surgery should be offered.

Survival outcome of adjuvant radiotherapy after local excision for T2 early rectal cancer: An analysis based on the surveillance, epidemiology, and end result registry database

BACKGROUND

Major resection (MR) is recommended for cases with T2 finding after local excision (LE) of early rectal cancer, but the revision procedure is accompanied with high morbidity. We evaluated the oncological safety of LE followed by adjuvant radiotherapy as a rectum-preserving alternative to MR for T2 early rectal cancer.

METHODS

A total of 3786 patients with T2N0M0 rectal adenocarcinoma between 1998 and 2013 were included from the SEER database. Survival rates were compared using the Kaplan-Meier method with a log-rank test, and multivariate analyses were performed using Cox proportional regression models.

RESULTS

Of these patients included, 429 (11.3%) treated with LE alone (LE group), 3067 (81.0%) treated with MR (MR group), and 290 (7.7%) treated with LE followed by adjuvant radiotherapy (LE + adjuvant RT group). The 5-year cancer specific survival (CSS) rate and 5-year overall survival (OS) rate were significantly lower in LE patients group than those in MR patients group (70.5% vs. 81.8%, P < 0.001; 57.3% vs. 72.3%, P < 0.001). The 5-year CSS rate and 5-year OS rate were similar between LE + adjuvant RT and MR groups (78.4% vs. 81.8%, P = 0.975, and 70.7% vs. 72.3%, P = 0.311, respectively). Multivariate Cox regression revealed that treatment strategies, age and CEA status were independently associated with CSS and OS. After age adjustment, LE was associated with reduced CSS (using MR as a reference, HR, 1.784; P < 0.001) and reduced OS (HR, 1.739; P < 0.001). However, CSS and OS related to LE + adjuvant RT of T2 rectal cancer group weren't be affected (HR, 0.994; P = 0.962 and HR, 0.904; P = 0.302, respectively).

CONCLUSIONS

When MR is inappropriate for T2 early rectal cancer patients because of patients refusal or co-morbidities, LE + adjuvant RT can provide acceptable levels of long-term survival.

Laparoscopic Total Mesorectal Excision Following Transanal Endoscopic Microsurgery for Rectal Cancer

BACKGROUND

Patients' selection for transanal endoscopic microsurgery (TEM) depends on diagnostic modalities; however, there are still some limitations in the preoperative diagnosis of rectal lesions, and in some reports, up to third of the adenomas resected by TEM were found to be adenocarcinoma; therefore, salvage radical resection (RR) remains necessary for achieving oncological resection. Salvage RR may encounter some technical problems as the violation of the mesorectum and the scar formation. In this study, we aimed to report the outcome in patients undergoing salvage RR in terms of morbidity and oncological results.

MATERIALS AND METHODS

Demographic and clinical data pertaining to patients undergoing RR following TEM between 2004 and 2014 were retrospectively collected.

RESULTS

One hundred forty one TEM were performed in the study period, 53 (38%) for malignant rectal lesions. Indication for TEM: 15 (28%) benign adenoma, 25 (47%) early rectal cancer, and 13 (25%) had clinical complete response after neoadjuvant radiochemotherapy. Ten (19%) patients had no residual tumor in TEM specimen, 15 (28%) had T1, and 2 of them underwent salvage low anterior resection (LAR). Ten (19%) had T2, 4 had LAR, and 1 had abdominoperineal resection (APR). Five (9%) had a T3, 3 underwent LAR, and 2 had APR. Among the 13 (25%) after chemo-radiotherapy (CRT), 4 had salvage AR. The time from TEM to RR was 47 days (range32-70). Of 16 salvage surgeries, 8 (50%) were laparoscopic. The median operative time was 210 minutes (range165-360). Five patients had protective ileostomy. Rectal perforation occurred in 2 (12%) patients; both had a posterior location, one after CRT. Two (12%) postoperative small-bowl obstruction and three wound infections occurred. There was no perioperative mortality in any of the patients who underwent RR. The final pathology was no residual disease in 9, T3N1 in 1, T3N0 in 3, T2N1 in 1, and T2N0 in 2 patients. Eight (50%) had adjuvant chemotherapy.

CONCLUSION

Laparoscopic total mesorectal excision following TEM seems to be safe, and with no negative impact of the completeness of the resection. The concern of intraoperative specimen perforation is real, and should be dealt with meticulous technique and careful dissection, particularly after CRT.

The outcome of transanal endoscopic microsurgery in obese patients

BACKGROUND

The prevalence of obesity is as high as one-third of the adult population in the ultrasound. Obese patients operated for rectal cancer are less likely to undergo sphincter-preserving surgery, and have an increased morbidity and mortality. We aim to report the outcomes of transanal-endoscopic-microsurgery (TEM) in obese patients with benign and malignant neoplasms.

MATERIALS AND METHODS

An analysis was carried out of all patients undergoing TEM at a single institution between 2004 and 2015. Clinical, demographic, and pathologic data were analyzed in respect to BMI; a dichotomous variable was created categorizing the patients in this retrospective case series as either obese (BMI≥30) or nonobese (BMI<30).

RESULTS

Of the 158 patients who underwent TEM during the study period, 51 (32%) were obese and 107 (68%) were nonobese. No significant differences were found in terms of patients' demographics and tumor characteristics. There were no significant differences in operative time [105 min (range: 75-170) and 98 (range: 56-170), respectively, P=0.2], hospital length of stay [3 days (range: 2-6) and 4 (range: 2-12), respectively, P=0.48], or complication rates (20 and 23%, respectively, P=0.68).

CONCLUSION

TEM is a safe procedure for rectal neoplasms in the obese population. We found no difference in surgical time and completeness of specimen resection, and no increase in complications or length of stay in the hospital in obese versus nonobese patients. As for selected high risk patients, the TEM may be of benefit in obese patients with T1/T2N0M0 rectal cancer.

Outcomes following completion and salvage surgery for early rectal cancer: A systematic review

OBJECTIVES

To establish outcomes after completion and salvage surgery following local excision in literature published since 2005, to inform decision-making when offering local excision.

BACKGROUND

Local excision of early rectal cancer aims to offer cure while maintaining quality of life through organ preservation. However, some patients will require radical surgery, prompted by unexpected poor pathology or local recurrence. Consistent definition and reporting of these scenarios is poor. We propose the term "salvage surgery" for recurrence after local excision and "completion surgery" for poor pathology.

METHODS

Electronic databases were searched in February 2016. Studies since 2005 describing outcomes for radical surgery following local excision of rectal cancer were included. Pooled and average values were obtained.

RESULTS

A total of 23 studies included 262 completion and 165 salvage operations. Most completion operations were done within 4 weeks; local recurrence rate was 5% and overall disease recurrence rate was 14%. The majority of salvage operations for local recurrence were within 15 months of local excision, often following adjuvant treatment. Re-do local excision was used in 15%; APR was the most common radical procedure. Further local recurrence was uncommon (3%) but overall disease recurrence rate was 13%. Estimated 5-year survival was in the order of 50%. Heterogeneity was high among the studies.

CONCLUSIONS

Patients undergoing local excision must be informed of risks and expected outcomes, but better data on completion and salvage surgery are required to achieve this.

SYSTEMATIC REVIEW REGISTRATION NUMBER

CRD42014014758.

A multi-centred randomised trial of radical surgery versus adjuvant chemoradiotherapy after local excision for early rectal cancer

Background

Rectal cancer surgery is accompanied with high morbidity and poor long term functional outcome. Screening programs have shown a shift towards more early staged cancers. Patients with early rectal cancer can potentially benefit significantly from rectal preserving therapy. For the earliest stage cancers, local excision is sufficient when the risk of lymph node disease and subsequent recurrence is below 5 %. However, the majority of early cancers are associated with an intermediate risk of lymph node involvement (5–20 %) suggesting that local excision alone is not sufficient, while completion radical surgery, which is currently standard of care, could be a substantial overtreatment for this group of patients.

Methods/Study design

In this multicentre randomised trial, patients with an intermediate risk T1-2 rectal cancer, that has been locally excised using an endoluminal technique, will be randomized between adjuvant chemo-radiotherapylimited to the mesorectum and standard completion total mesorectal excision (TME). To strictly monitor the risk of locoregional recurrence in the experimental arm and enable early salvage surgery, there will be additional follow up with frequent MRI and endoscopy. The primary outcome of the study is three-year local recurrence rate. Secondary outcomes are morbidity, disease free and overall survival, stoma rate, functional outcomes, health related quality of life and costs. The design is a non inferiority study with a total sample size of 302 patients.

Discussion

The results of the TESAR trial will potentially demonstrate that adjuvant chemoradiotherapy is an oncological safe treatment option in patients who are confronted with the difficult clinical dilemma of a radically removed intermediate risk early rectal cancer by polypectomy or transanal surgery that is conventionally treated with subsequent radical surgery. Preserving the rectum using adjuvant radiotherapy is expected to significantly improve morbidity, function and quality of life if compared to completion TME surgery.

Trial registration

NCT02371304, registration date: February 2015

Meta-analysis of oncological outcomes after local excision of pT1-2 rectal cancer requiring adjuvant (chemo)radiotherapy or completion surgery

BACKGROUND

Completion total mesorectal excision (TME) is advised for high-risk early (pT1/pT2) rectal cancer following transanal removal. The main objective of this meta-analysis was to determine oncological outcomes of adjuvant (chemo)radiotherapy as a rectum-preserving alternative to completion TME.

METHODS

A literature search using PubMed, Embase and the Cochrane Library was performed in February 2015. Studies had to include at least ten patients with pT1/pT2 adenocarcinomas that were removed transanally and followed by either adjuvant chemoradiotherapy or completion surgery. A weighted average of the logit proportions was determined for the pooled analyses of subgroups according to treatment modality and pT category.

RESULTS

In total, 14 studies comprising 405 patients treated with adjuvant (chemo)radiotherapy and seven studies comprising 130 patients treated with completion TME were included. Owing to heterogeneity it was not possible to compare the two strategies directly. However, the weighted average local recurrence rate for locally excised pT1/pT2 rectal cancer treated with adjuvant (chemo)radiotherapy was 14 (95 per cent c.i. 11 to 18) per cent, and 7 (4 to 14) per cent following completion TME. The weighted averages for distance recurrence were 9 (6 to 14) and 9 (5 to 16) per cent respectively. Weighted averages for local recurrence rate after adjuvant chemo(radiotherapy) and completion TME for pT1 were 10 (4 to 21) and 6 (3 to 15) per cent respectively. Corresponding averages for pT2 were 15 (11 to 21) and 10 (4 to 22) per cent respectively.

CONCLUSION

A higher recurrence rate after transanal excision and adjuvant (chemo)radiotherapy must be balanced against the morbidity and mortality associated with mesorectal excision. A reasonable approach is close follow-up and salvage mesorectal surgery as needed.

Clinical practice guidelines for the surgical treatment of rectal cancer: a consensus statement of the Hellenic Society of Medical Oncologists (HeSMO)

In rectal cancer management, accurate staging by magnetic resonance imaging, neo-adjuvant treatment with the use of radiotherapy, and total mesorectal excision have resulted in remarkable improvement in the oncological outcomes. However, there is substantial discrepancy in the therapeutic approach and failure to adhere to international guidelines among different Greek-Cypriot hospitals. The present guidelines aim to aid the multidisciplinary management of rectal cancer, considering both the local special characteristics of our healthcare system and the international relevant agreements (ESMO, EURECCA). Following background discussion and online communication sessions for feedback among the members of an executive team, a consensus rectal cancer management was obtained. Statements were subjected to the Delphi methodology voting system on two rounds to achieve further consensus by invited multidisciplinary international experts on colorectal cancer. Statements were considered of high, moderate or low consensus if they were voted by ≥80%, 60-80%, or <60%, respectively; those obtaining a low consensus level after both voting rounds were rejected. One hundred and two statements were developed and voted by 100 experts. The mean rate of abstention per statement was 12.5% (range: 2-45%). In the end of the process, all statements achieved a high consensus. Guidelines and algorithms of diagnosis and treatment were proposed. The importance of centralization, care by a multidisciplinary team, adherence to guidelines, and personalization is emphasized.

Transanal Endoscopic Microsurgery

Transanal endoscopic microsurgery (TEM) was developed by Professor Gerhard Buess 30 years ago at the dawn of minimally invasive surgery. TEM utilizes a closed proctoscopic system whereby endoluminal surgery is accomplished with high-definition magnification, constant CO2 insufflation, and long-shafted instruments. The end result is a more precise excision and closure compared to conventional instrumentation. Virtually any benign lesion can be addressed with this technology; however, proper patient selection is paramount when using it for cancer.

Local excision by transanal endoscopic surgery

Transanal endoscopic surgery (TES) consists of a series of anorectal surgical procedures using different devices that are introduced into the anal canal. TES has been developed significantly since it was first used in the 1980s. The key point for the success of these techniques is how accurately patients are selected. The main indication was the resection of endoscopically unresectable adenomas. In recent years, these techniques have become more widespread which has allowed them to be applied in conservative rectal procedures for both benign diseases and selected cases of rectal cancer. For more advanced rectal cancers it should be considered palliative or, in some controlled trials, experimental. The role of newer endoscopic techniques available has not yet been defined. TES may allow for new strategies in the treatment of rectal pathology, like transanal natural orifice transluminal endoscopic surgery or total mesorectal excision.

Transanal Endoscopic Microsurgery After Neoadjuvant Chemoradiotherapy for Rectal Cancer

BACKGROUND

Radical rectal resection following neoadjuvant chemoradiation therapy (CRT) for locally advanced rectal cancer is accompanied by relatively high morbidity. Local excision of rectal cancer may be more appropriate for some frail patients with severe comorbidities. Transanal endoscopic microsurgery (TEM), consisting of local excision of selected rectal cancers, has been associated with low rates of postoperative complications. Because neoadjuvant CRT for rectal cancer may be associated with increased complications, the suitability of TEM following CRT is still unclear. In this study we aimed to assess the clinical outcomes of patients undergoing TEM following neoadjuvant CRT.

PATIENTS AND METHODS

This study retrospectively analyzed all patients undergoing TEM for malignant rectal tumor in our institution between 2004 and 2010. They were divided into those who received CRT (CRT group) and those without CRT (non-CRT group). Demographics and clinical data were compared.

RESULTS

Forty-four of 97 patients who underwent TEM were included: 13 CRT and 31 non-CRT. Age, comorbidities, and the duration of the procedure were similar for both groups. There were no significant group differences in tumor diameter (2.1 cm [range, 0.5-3.5 cm] and 2.9 cm [range, 0.5-4.2 cm], respectively; P=.125) or distance of the lower part of the tumor from the anal verge (6.7 cm [range, 5-10 cm] and 7.7 cm [range, 5-15 cm], respectively; P=.285). Two non-CRT patients had peritoneal entry, and 1 of them underwent protective ileostomy because of insecure rectal defect closure. One non-CRT patient underwent a re-operation for postoperative bleeding. The other perioperative complications were minor and included urinary retention requiring catheter placement (2 patients in each group), pulmonary edema (1 non-CRT patient), and pneumonia (1 non-CRT patient). All complications were managed conservatively. There was no wound disruption, major complication, or mortality in either group.

CONCLUSIONS

With proper patient selection, TEM can be performed safely following CRT, without major complication or increased postoperative morbidity.

How useful is endorectal ultrasound in the management of early rectal carcinoma?

INTRODUCTION

Endorectal ultrasonography (EUS) is used to T stage early rectal tumours and select patients to whom transanal endoscopic microsurgery (TEM) could be offered. Published papers have shown that EUS can have good accuracy, but there is little literature on how EUS influences patient management. The study aim is to ascertain the value of EUS in the management of early rectal tumours.

METHODS

Patients with adenomas/early rectal carcinoma being considered for TEM were prospectively studied. Each patient underwent EUS. The surgeon recorded the expected T stage, confidence level of the T stage and management plan for each patient on a proforma before and after the ultrasound result was revealed. Comparison was made between the ultrasound stage and final pathological stage where available.

RESULTS

Ninety-six patients were referred over 2 years. Nine were out of reach of the rigid probe and were excluded. Proformas were completed on 53/87 patients (age range 28-87 years, mean age 66 years, 30 males/23 females). Forty-eight patients had a pathological report to compare with the EUS T stage. Ultrasound agreed with the pathological T staging in 43 patients (90%). Patient management was changed in five patients. In 30% of (16/53) patients, EUS increased the confidence level for T staging.

CONCLUSION

Although EUS has a high accuracy in predicting the T stage of early rectal cancers, it never changes the management plan for lesions thought to be benign. It seldom changes the pre-operative selection process when clinical examination is considered with other imaging modalities (MRI/CT). EUS should be reserved for answering specific questions in difficult cases rather than for all patients.

A systematic review of local excision combined with chemoradiotherapy for early rectal cancer

AIM

Local excision of early rectal cancer is a less morbid alternative to major abdominal surgery. This review evaluates the role of local excision with neoadjuvant or adjuvant chemoradiotherapy to identify a select group of patients where local excision is appropriate without significantly compromising the oncological outcome.

METHOD

MEDLINE, PubMed and the Cochrane Central Register of Controlled Trials databases were searched to identify relevant articles investigating the role of local excision with adjuvant or neoadjuvant chemoradiotherapy in patients with T1/T2N0M0 disease. Eleven studies comprising 455 patients were selected. Oncological end-points included overall survival, disease-free and disease-specific survival, recurrence rates as well as perioperative morbidity and mortality.

RESULTS

At a range of 30.5-115.2 months, median overall survival, disease-specific and disease-free survival were 75% (66-80.6%), 89% (75-93.3%) and 74% (64-85.2%), respectively. Median local, distant and overall recurrence rates were 10% (4.8-25%), 4.7% (4-11.8%) and 13.1% (10.7-23.5%), respectively. Mortality was 0% in all studies except one (2.9%). Most reported complications were minor and were treated conservatively.

CONCLUSION

This systematic review provides data suggesting that selected patients with T1/T2N0M0 rectal cancer may undergo local excision without compromising the oncological outcome otherwise conferred by total mesorectal excision. It may be a particularly useful option in patients in whom radical surgery is contraindicated. Randomized trials comparing both management strategies to consolidate this finding may lead to a paradigm change in the management of early rectal cancer.

Transanal endoscopic microsurgery: a review

Rectal adenomas and cancers occur frequently. Small adenomas can be removed colonoscopically, whereas larger polyps are removed via conventional transanal excision. Owing to technical difficulties, adenomas of the mid- and upper rectum require radical resection. Transanal endoscopic microsurgery (TEM) was first designed as an alternative treatment for these lesions. However, since its development TEM has been also used for a variety of rectal lesions, including carcinoids, rectal prolapse and diverticula, early stage carcinomas and palliative resection of rectal cancers. The objective of this review is to describe the current status of TEM in the treatment of rectal lesions. Since the 1980s, TEM has advanced substantially. With low recurrence rates, it is the method of choice for resection of endoscopically unresectable adenomas. Some studies have shown benefits to its use in treating early T1 rectal cancers compared with radical surgery in select patients. However, for more advanced rectal cancers TEM should be considered palliative or experimental. This technique has also been shown to be safe for the treatment of other uncommon rectal tumours, such as carcinoids. Transanal endoscopic microsurgery may allow for new strategies in the treatment of rectal pathology where technical limitations of transanal techniques have limited endoluminal surgical innovations.

Transanal endoscopic microsurgery

Transanal endoscopic microsurgery (TEMS) is a well established method of accurate resection of specimens from the rectum under binocular vision. This review examines its role in the treatment of benign conditions of the rectum and the evidence to support its use and compliment existing endoscopic treatments. The evolution of TEMS in early rectal cancer and the concepts and outcomes of how it has been utilised to treat patients so far are presented. The bespoke nature of early rectal cancer treatment is changing the standard algorithms of rectal cancer care. The future of TEMS in the organ preserving treatment of early rectal cancer is discussed and how as clinicians we are able to select the correct patients for neoadjuvant or radical treatments accurately. The role of radiotherapy and outcomes from combination treatment using TEMS are presented with suggestions for areas of future research.

Transanal endoscopic microsurgery

There is increasing interest in organ-preserving options in the management of rectal cancer. Excision of small, early stage cancers by transanal endoscopic microsurgery (TEM) is an important part of this approach. Carefully selected cancers can be treated successfully by TEM with acceptably low risk of recurrent disease and overall cancer outcomes similar to radical surgery. The impact of recurrence can be mitigated by early detection of luminal or nodal disease for which a robust surveillance programme is essential. However, patients with high risk features on post-TEM pathology should be offered completion radical surgery which is associated with good oncological results. There may be an opportunity to expand the population of patients who can be offered rectal preservation with the use of radiotherapy in either adjuvant or neo-adjuvant context. Full thickness excision by TEM may be particularly valuable in those demonstrating a clinical complete response to radiotherapy, where diagnosis of complete pathological response can be confirmed. The use of TEM in managing more advanced rectal cancers is exciting, but must be tested within formal clinical trials before being adopted as routine practice.

Transanal endoscopic microsurgery for rectal neoplasms. How I do it

INTRODUCTION

Transanal endoscopic microsurgery (TEM) has revolutionized the technique and outcomes of transanal surgery, becoming the standard of treatment for large sessile rectal adenomas, and may represent a possible treatment modality for early rectal cancer.

METHODS

A full-thickness excision is made on the rectal wall down to the perirectal fatty tissue. The specimen is retrieved transanally. After the parietal defect is disinfected, the wound is closed with one or more running sutures secured with silver clips.

RESULTS

Peritoneal perforation during TEM is not associated with adverse short-term or oncologic outcomes. The postoperative morbidity rate ranges between 2 % and 15 %, and in most cases, complications can be conservatively managed. The local recurrence rate of large adenomas is about 6 %, and most recurrences can be safely re-resected by TEM. TEM represents an effective treatment for pT1 sm1 rectal malignancies, while pT1 sm2-3 and pT2 should be considered at high risk of recurrence if treated by TEM alone. Finally, TEM does not influence anorectal function or quality of life.

CONCLUSION

TEM is a safe procedure and provides excellent functional and oncologic outcomes in the treatment of large sessile benign rectal lesions and selected early rectal cancers.

Transanal endoscopic microsurgery

The aim of oncologic surgery is radical cancer treatment with preservation of function and quality of life. Almost 30 years ago, transanal endoscopic microsurgery (TEM) revolutionised the technique and outcomes of transanal surgery, first becoming the standard of treatment for large rectal adenomas, then offering a possibly curative treatment for early rectal cancer, and finally generating discussion on its potential role in combination with neoadjuvant therapies for the treatment of more invasive cancer. TEM afforded the advantage of combining a less invasive transanal approach with low recurrence rates thanks to enhanced visualization of the surgical field, which allows more precise dissection. We describe the current indications, the preoperative work-up, the surgical technique (with the aid of a video), postoperative management and results obtained in an over 20-year-long experience. Designed as an accurate means to allow excision of benign rectal neoplasms with a very low morbidity rate, TEM today is indicated as a curative treatment of malignant neoplasms that are histologically confirmed as pT1 sm1 carcinomas. T1 sm2-3 and T2 lesions should at present be included in prospective trials. Accurate preoperative staging is essential for optimal selection of patients. Patients with clear indication for TEM should be referred to specialized medical centres experienced with the technique.

Transanal endoscopic microsurgery vs. laparoscopic total mesorectal excision for T2N0 rectal cancer

OBJECTIVE

The aim was to compare transanal endoscopic microsurgery (TEM) and laparoscopic resection (LR) in terms of short-term and oncologic outcomes in patients with a preoperatively diagnosed T2N0 extraperitoneal rectal cancer.

METHODS

We conducted a retrospective analysis of a prospective database. All patients with a preoperatively staged T2N0 extraperitoneal rectal adenocarcinoma were considered for LR. Patients refusing LR or medically unfit for LR were considered for TEM, which was associated with neoadjuvant RT in the last cases. Only patients with a minimum follow-up of 36 months were included.

RESULTS

Seventy-eight patients were included. TEM was indicated or preferred in 43 patients; of these, 11 underwent neoadjuvant RT. Morbidity was significantly lower after TEM (p < 0.001). The median follow-up was 70 (36-140) months. A higher local recurrence rate was noted after TEM (26 %), compared to neoadjuvant RT + TEM (0 %) and LR (9 %) (p = 0.070). Overall, 5-year survival rate was 76 % after TEM, 77.8 % after RT + TEM, and 96 % after LR, respectively (p = 0.134).

CONCLUSIONS

While TEM alone may only be considered a palliative treatment, it might allow similar oncologic results to abdominal resection in responders to neoadjuvant RT. Large prospective randomized trials are awaited to confirm these findings.

Transanal endoscopic microsurgery for rectal tumors: a review

Since its introduction in 1983, transanal endoscopic microsurgery (TEM) has emerged as a safe and effective method to treat rectal lesions including benign tumors, early rectal cancer, and rectal fistulas and strictures. This minimally invasive technique offers the advantages of superior visualization of the lesion and greater access to proximal lesions with lower margin positivity and specimen fragmentation and lower long-term recurrence rates over traditional transanal excision. In addition, over two decades of scientific data support the use of TEM as a viable alternative to radical excision of the rectum with less morbidity, faster recovery, and greater potential cost savings when performed at specialized centers.

Previous transanal full-thickness excision increases the morbidity of radical resection for rectal cancer

AIM

The aim of the study was to determine the impact of primary full-thickness transanal excision (TAE) on the morbidity rate following radical rectal resection for cancer.

METHOD

Fourteen consecutive patients underwent radical resection for lower third rectal cancer following full-thickness TAE without closure of the defect. They were compared with 25 matched patients from a prospective database of 275 rectal resections who had undergone radical resection without previous TAE for lower third rectal cancer (control group). The confounding factors were: age, sex, body mass index (BMI), classification according to the American Society of Anaesthesiologists, administration of neoadjuvant radiotherapy before rectal resection, tumour stage and type of surgical procedure.

RESULTS

There were no deaths. Overall morbidity was 64.3% in the TAE group and 32% in the control group (P = 0.112). Surgical complications were significantly more frequent in the former (57.1%vs 20%; P = 0.048). The frequency of specific surgical site complications, including anastomotic complications and pelvic abscess formation requiring surgical drainage, was significantly higher in the TAE group than in the control group (42.8%vs 8%; P = 0.032). In univariate analysis, the only factors associated with specific surgical site complications were BMI > 27 and TAE before rectal resection.

CONCLUSION

This case-matched study suggests that previous full-thickness TAE increases the risk of surgical complications after radical resection for lower third rectal cancer, including anastomotic dehiscence and pelvic sepsis.

Extending the role of Transanal Endoscopic Microsurgery (TEM) in rectal cancer

Increasingly it is becoming clear that there is a role for local excision of early rectal cancer by Transanal Endoscopic Microsurgery (TEM) as part of an organ-preservation strategy. This role is based on careful preoperative assessment, thorough postoperative histopathological examination and standardized follow up, with recourse to completion or salvage radical surgery in the face of poor prognostic factors, or early concerns over recurrent disease. Additionally, TEM is also proposed in selected circumstances after neoadjuvant treatment for rectal cancer. This latter topic is even more controversial with clinical evidence still evolving, but specialist centres report impressive results that cannot be ignored in the modern management of rectal cancer.

Incidence, treatment and outcome of rectal stenosis following transanal endoscopic microsurgery

BACKGROUND

As an alternative to more radical abdominal surgery, transanal endoscopic microsurgery (TEM) offers a minimally invasive solution for the excision of certain rectal polyps and early-stage rectal tumours. The patient benefits of TEM as compared to radical abdominal surgery are clear; nevertheless, some drawback is possible. The aim of our study was to determine the risk factors, treatment and outcomes of rectal stenosis following TEM.

METHODS

We analysed a series of 354 consecutive patients who underwent TEM for benign or malignant rectal tumours between 1997 and 2009. We recorded the maximum histological diameter of the lesion, and whether the lesion was circumferential. Rectal stenosis was defined as a rectal narrowing not allowing passage of a 12 mm sigmoidoscope.

RESULTS

Histological results with a measured specimen diameter were available in 304 of the 354 cases. There were 11 stenoses in total (3.6%), 7 stenoses due to 9 circumferential lesions (78%) and 4 due to lesions with a maximum diameter ≥ 5 cm (3.2%). Two patients presented as emergencies, and the other 9 patients reported symptoms of increased stool frequency at follow-up. Three of the stenoses were associated with recurrent disease. All stenoses were treated by a combination of endoscopic/radiological balloon dilatation or surgically with Hegar's dilators. A median of two procedures were required to treat stenoses until resolution of symptoms.

CONCLUSIONS

Rectal stenosis following TEM excision is rare. It is predictable in patients with circumferential lesions but is rare in patients with non-circumferential lesions with a maximum diameter ≥ 5 cm. It is effectively treated with surgical or balloon dilatation. Most patients require repeated treatments.

Risk factors for recurrence after transanal endoscopic microsurgery for rectal malignant neoplasm

BACKGROUND

Indications and results of local excision of rectal lesions are currently under debate. Transanal endoscopic microsurgery (TEM), allowing a precise, full-thickness excision, could improve oncological results in early rectal tumors.

METHODS

A prospective database was analyzed with the intent to identify risk factors for recurrence after TEM.

RESULTS

Among 355 patients subjected to TEM, 107 had an adenocarcinoma: 48 pT1, 43 pT2, and 16 pT3. Comparing pre- and postoperative data, histological discrepancy was 20% and staging discrepancy was 34%. Mortality was nil, morbidity was 9%. Mean follow-up was 54.2 months (range = 12-164), follow-up rate was 100%. The 5-year disease-free survival rate was 85.9, 78.4, and 49.4% for pT1, pT2, and pT3, respectively (p = 0.006). Recurrence rate was 0% (0/26) in pT1sm1 cancers and 22.7% (5/22) in sm2-3 (p < 0.05). A submucosal infiltration represented a significant risk factor for recurrences: 0% sm1, 16.7% sm2, and 30% sm3. Recurrence in pT2 was 0% in patients who had neoadjuvant therapy and 26% in the others. At univariate analysis, diameter, sm stage, pT stage, tumor grading, margin infiltration, and lymphovascular invasion demonstrated statistical significance. Multivariate analysis indicated sm stage, pT stage, and tumor grading as independent predictors of recurrence.

CONCLUSIONS

TEM represents an effective curative treatment for pT1 sm1 rectal malignancies. pT1 sm2-3 patients should be considered high-risk cases if treated only by TEM. A consistent improvement in the preoperative assessment of the risk factors identified by the present study will be a crucial development for optimal treatment of early rectal cancers.

Risk factors of nodal involvement in T2 colorectal cancer

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Treatment of recurrence after transanal endoscopic microsurgery (TEM) for T1 rectal cancer

PURPOSE

The aim of this study was to evaluate the management and outcome of local recurrences after transanal endoscopic microsurgery for T1 rectal cancer.

METHODS

Consecutive patients who underwent transanal endoscopic microsurgery for pT1 rectal cancer at a Dutch referral center (IJsselland Hospital) were registered in a prospective database. Follow-up was according to Dutch guidelines on rectal cancer, with additional rigid rectoscopy and endorectal ultrasound examinations every 3 months for the first 2 years, and every 6 months thereafter. Annual MRI of the lesser pelvis was added during the last 2 years of the study. Patients with local recurrence during follow-up were selected for individual analysis of outcome.

RESULTS

Of a total of 88 patients who underwent transanal endoscopic microsurgery for pT1 rectal cancer, 18 patients (20.5%) had a local recurrence. Median time to local recurrence was 10 (range, 4-50) months. Median age at diagnosis of recurrence was 74 (range, 56-84) years. Of the 18 patients, 2 did not undergo further surgery because of concomitant metastatic disease, and 16 underwent salvage surgery, without need for multivisceral resections. No postoperative mortality was observed. In 15 patients (94%), a microscopically negative excision margin was obtained; in 1 patient, the excision margin was microscopically positive. Median follow-up after salvage surgery was 20 (range, 2-112) months. One patient had a local renewal of recurrence, and 7 patients (39%) had distant metastases. At 3 years, overall survival was 31%; cancer-related survival was 58%.

CONCLUSIONS

Recurrent disease after transanal endoscopic microsurgery for T1 rectal cancer is a major problem. Although salvage surgery for achieving local control is feasible in most patients, survival is limited, mainly because of distant metastases. Tailoring selection of T1 rectal cancers and exploring possible adjuvant treatment strategies following salvage procedures should be the next steps toward improving survival.

Transanal endoscopic microsurgery resection of rectal tumors: outcomes and recommendations

PURPOSE

Transanal endoscopic microsurgery provides a minimally invasive alternative to radical surgery for excision of benign and malignant rectal tumors. The purpose of this study was to review our experience with transanal endoscopic microsurgery to clarify its role in the treatment of different types of rectal pathology.

METHODS

A prospective database documented all patients undergoing transanal endoscopic microsurgery from October 1996 through June 2008. We analyzed patient and operative factors, complications, and tumor recurrence. For recurrence analysis, we excluded patients with fewer than 6 months of follow-up, previous excisions, known metastases at initial presentation, and those who underwent immediate radical resection following transanal endoscopic microsurgery.

RESULTS

Two hundred sixty-nine patients underwent transanal endoscopic microsurgery for benign (n = 158) and malignant (n = 111) tumors. Procedure-related complications (21%) included urinary retention (10.8%), fecal incontinence (4.1%), fever (3.8%), suture line dehiscence (1.5%), and bleeding (1.5%). Local recurrence rates for 121 benign and 83 malignant tumors were 5% for adenomas, 9.8% for T1 adenocarcinoma, 23.5% for T2 adenocarcinoma, 100% for T3 adenocarcinoma, and 0% for carcinoid tumors. All 6 (100%) recurrent adenomas were retreated with endoscopic techniques, and 8 of 17 (47%) recurrent adenocarcinomas underwent salvage procedures with curative intent.

CONCLUSIONS

Transanal endoscopic microsurgery is a safe and effective method for excision of benign and malignant rectal tumors. Transanal endoscopic microsurgery can be offered for (1) curative resection of benign tumors, carcinoid tumors, and select T1 adenocarcinomas, (2) histopathologic staging in indeterminate cases, and (3) palliative resection in patients medically unfit or unwilling to undergo radical resection.

Transanal endoscopic microsurgery for rectal neoplasms: experience of 300 consecutive cases

PURPOSE

Abdominal resection for rectal neoplasms is associated with significant morbidity. Local excision with retractors can be proposed only for distal rectal lesions. With this retrospective review of our prospective series of transanal endoscopic microsurgery procedures, we wanted to verify the advantages of local treatment in terms of disease recurrence and complication rates.

METHODS

Indications for transanal endoscopic microsurgery were adenoma, early carcinoma, rectal ulcers, carcinoid tumors, gastrointestinal stromal tumors, and leiomyosarcoma apparently located in the extraperitoneal rectum. We analyzed operating time, morbidity and mortality rates, length of hospital stay, staging discrepancy, recurrence rate, and oncological outcome.

RESULTS

From January 1993 to January 2007, 300 patients underwent transanal endoscopic microsurgery at our institution. The mean operating time was 66 minutes. The peritoneum was inadvertently opened in 13 cases. The overall morbidity rate was 7.7%. The mean hospital stay was five days. Histology demonstrated cancer in 90 patients. At a mean follow-up of 60 months, the recurrence rate was zero in pT1, 24% in pT2, and 50% in pT3. The overall estimated five-year survival rate was 87%, and the disease-free survival rate was 82%.

CONCLUSIONS

Transanal endoscopic microsurgery is safe and effective in the treatment of adenoma and pT1 carcinoma; it carries a lower morbidity than conventional surgery and a recurrence rate comparable to that of conventional surgery.

Lymph node size in rectal cancer following neoadjuvant chemoradiation--can we rely on radiologic nodal staging after chemoradiation?

OBJECTIVES

Local excision is currently being considered as an alternative strategy for ypT0-2 rectal cancer. However, patient selection is crucial to rule out nodal disease and is performed by radiologic studies that consider size as a surrogate marker for positive nodes. The purpose of this study was to determine the difference in size between metastatic and nonmetastatic nodes and the critical lymph node size after neoadjuvant chemoradiation therapy.

METHODS

The 201 lymph nodes available from 31 patients with ypT0-2 rectal cancer were reviewed and measured. Lymph nodes were compared according to the presence of metastases and size.

RESULTS

There was a mean of 6.5 lymph nodes per patient and 12 positive nodes of the 201 recovered (6%). Ninety-five percent of all lymph nodes were <5 mm, whereas 50% of positive lymph nodes were <3 mm. Metastatic lymph nodes were significantly greater in size (5.0 vs. 2.5mm; P = 0.02). Lymph nodes >4.5 mm had a greater risk of harboring metastases (P = 0.009).

CONCLUSIONS

Patients with ypT0-2 rectal cancer following neoadjuvant chemoradiation have very small perirectal nodes. Individual metastatic lymph nodes are significantly larger. However, a significant number of lymph nodes after neoadjuvant chemoradiation (negative and positive) are <3 mm. Individual lymph node size is not a good predictor of nodal metastases and may lead to inaccurate radiologic staging.

Transanal endoscopic microsurgery

Transanal endoscopic microsurgery (TEM) is a minimally invasive surgical technique that was developed more than two decades ago to manage distal colorectal neoplasias. The aim of the current study was to present a prospective review of 7 years of experience in using this equipment. All patients undergoing TEM between 1999 and 2007 were prospectively evaluated. Patients underwent regular endoscopic follow up. Cumulative incidence probability analysis was used to calculate rates of recurrence. The study involved 232 patients, median age 68 years (interquartile range (IQR), 37-90). The median neoplasia area was 12 cm(2) (IQR, 6-25 cm(2)) and the median height above the anal verge was 9 cm (IQR, 3-17 cm). Histology indicated 128 adenomas, 52 carcinomas in situ, and 52 adenocarcinomas. The median postoperative stay was 1 day (IQR, 1-3 days). There was one (0.5%) unplanned return to theatre and no postoperative deaths. Sixteen patients (6.9%) underwent more radical surgical procedures following the identification of carcinoma in the resected specimen. During a median follow up of 4.2 years (IQR, 2.6-6.2 years), the 5-year cumulative incidence for local recurrence for benign pathology was 3.1% (95% confidence interval (CI): 1.2-6.7%, n = 180) and for cancers managed primarily by TEM excision it was 8.5% (95%CI: 1.4-23.9%, n = 36). TEM is an excellent treatment modality for benign rectal neoplasias of any size, and in any location. TEM is an oncologically inferior treatment for rectal cancer, however, when compared to more radical treatments. Its principal advantage in this setting is that it is associated with relatively minimal morbidity and mortality.

Transanal endoscopic microsurgery: indications, results and controversies

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

Transanal endoscopic microsurgery for the treatment of rectal cancer: comparison of wound complication rates with and without neoadjuvant radiation therapy

BACKGROUND

Neoadjuvant therapy for rectal cancer has led to improved tumor downstaging and higher complete pathologic response rates. At the same time, the introduction of transanal endoscopic microsurgery (TEM) technique has renewed interest in local excision of rectal cancer. There has been concern that radiation may make the more radical local excision with TEM unsuitable. Our study compared morbidity rates and wound complication rates for patients undergoing TEM and local excision with and without neoadjuvant radiation to determine whether this could be accomplished safely.

METHODS

Data for all patients undergoing TEM are prospectively entered into a database. This database was queried for patients with rectal cancer undergoing TEM from November 1997 to June 2007. Of 64 patients identified, 2 were excluded because of previous radiation to the pelvis.

RESULTS

The study enrolled 62 patients with a final pathologic diagnosis of rectal cancer: 43 treated using neoadjuvant therapy with radiation (XRT) and 19 patients treated with TEM alone. The patients in the XRT group were 67 years of age (range, 29-86 years) and included 13 women. The patients in the non-XRT group were 66 years of age (range, 40-89 years) and included 8 women. Neither group had any mortalities. The overall morbidity rate was 33% for the XRT group and 5.3% for the non-XRT group, and this difference was statistically significant (p < 0.05). The wound complication rates were 25.6% for the XRT group (11 patients) and 0% for the non-XRT group (p = 0.015). Nine patients in the XRT group (82%) had minor wound separations, and two patients (18%) had major wound separation. Ten patients with wound separations were treated as outpatients and administered long-term oral antibiotics. One patient required additional surgery (diverting stoma).

CONCLUSIONS

Not unexpectedly, the wound complication rate was higher in the XRT group. However, 82% of those wounds were minor, and 91% were treated without any additional surgery or intervention. Although a significant concern, wound complications do not prohibit TEM treatment after neoadjuvant treatment.