Long-term oncological outcomes after local excision of T1 rectal cancer

BACKGROUND

A growing proportion of patients with early rectal cancer is treated by local excision only. The aim of this study was to evaluate long-term oncological outcomes and the impact of local recurrence on overall survival for surgical local excision in pT1 rectal cancer.

METHODS

Patients who only underwent local excision for pT1 rectal cancer between 1997 and 2014 in two Dutch tertiary referral hospitals were included in this retrospective cohort study. The primary outcome was the local recurrence rate. Secondary outcomes were distant recurrence, overall survival and the impact of local recurrence on overall survival.

RESULTS

A total of 150 patients (mean age 68.5 ± 10.7 years, 57.3% males) were included in the study. Median length of follow-up was 58.9 months (range 6-176 months). Local recurrence occurred in 22.7% (n = 34) of the patients, with a median time to local recurrence of 11.1 months (range 2.3-82.6 months). The vast majority of local recurrences were located in the lumen. Five-year overall survival was 82.0%, and landmark analyses showed that local recurrence significantly impacted overall survival at 6 and 36 months of follow-up (6 months, p = 0.034, 36 months, p = 0.036).

CONCLUSIONS

Local recurrence rates after local excision of early rectal cancer can be substantial and may impact overall survival. Therefore, clinical decision-making should be based on patient- and tumour characteristics and should incorporate patient preferences.

Multidisciplinary management of early rectal cancer - The role of surgical local excision in current and future clinical practice

The implementation of bowel cancer screening programs has led to a rise in the incidence of early rectal cancer. The combination of increased incidence and the growing interest in organ-sparing treatment options has led to an amplified importance of local excision techniques in treatment strategies for early rectal cancer. In addition, developments in new technologies of single-port surgery have popularized surgical techniques. Although local treatment of early rectal cancer seems promising, a multidisciplinary approach is necessary and awareness of the oncological robustness is warranted to enable shared decision-making. This review illustrates the position of surgical local excision in the treatment of early rectal cancer and reflects on its role in current and future clinical practice.

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.

Structured Reporting of Rectal Magnetic Resonance Imaging in Suspected Primary Rectal Cancer: Potential Benefits for Surgical Planning and Interdisciplinary Communication

OBJECTIVES

The aim of this study was to evaluate the effect of structured reports (SRs) in comparison to nonstructured, free-text (FT) rectal magnetic resonance imaging (MRI) reports in patients with histologically proven rectal cancer and potential effects of both types of reporting on referring surgeons' satisfaction, interdisciplinary communication, and further clinical decision making.

MATERIALS AND METHODS

The institutional review board approved this retrospective study with waiver of informed consent. Forty-nine patients with histologically proven rectal cancer were included in this study. All patients underwent rectal MRI for local rectal cancer staging before surgery. Free-text reports and SRs for local MR staging of rectal cancer were generated for all subjects by radiologists. Two experienced abdominal surgeons evaluated a questionnaire that included 9 questions regarding satisfaction with content, presence of reported key features, effort for information extraction, and report quality.

RESULTS

Structured reports achieved significantly higher satisfaction rates with report content and clarity, and included significantly more of the 13 predefined key features compared with FT reports (SRs: mean ± SD, 12.2 ± 4.6 [range, 9-13] versus FT reports: mean ± SD, 9.2 ± 10.8 [range, 5-13]) (P < 0.001). Definite further clinical decision making (surgery vs neoadjuvant radiochemotherapy) was possible in 96% of SRs and only in 60% of FT reports (P < 0.001). In case of surgery, the reported information was considered to be sufficient for surgical planning in 94% of SRs versus only 38% in FT reports (P < 0.001). Structured report received a significantly higher overall report quality rated on a Likert scale from 1 to 6 (1, insufficient; 6, excellent) with a mean of 5.8 ± 0.42 (range, 5-6) in comparison to FT reports with 3.6 ± 1.19 (range, 1-5) (P < 0.001).

CONCLUSIONS

Structured reporting of rectal MRI in patients with rectal cancer facilitates surgical planning and leads to a higher satisfaction level of referring surgeons in comparison to FT reports. Abdominal surgeons were more confident about report correctness and further clinical decision making on the basis of SRs.

Local Excision of Rectal Cancer

Local excision (LE) of early-stage rectal cancer avoids the morbidity associated with radical surgery but has historically been associated with inferior oncologic outcomes. Newer techniques, including transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS), have been developed to improve the quality of LE and extend the benefits of LE to tumors in the more proximal rectum. This article provides an overview of conventional LE, TEM, and TAMIS techniques, including indications for their use and pertinent literature on their associated outcomes for rectal cancer.