Oncologic outcomes and proper surveillance after local excision of rectal cancer

Initial local excision for clinical T1 rectal cancer showed comparable overall survival despite high local recurrence rate: a propensity-matched analysis

PURPOSE

Local excision (LE) is an alternative initial treatment for clinical T1 rectal cancer, and has avoided potential morbidity. This study aimed to evaluate the clinical outcomes of LE compared with total mesorectal excision (TME) for clinical T1 rectal cancer.

METHODS

Between January 2000 and December 2011, we retrospectively reviewed from multicenter data in patients with clinically suspected T1 rectal cancer treated with either LE or TME. Of 1,071 patients, 106 were treated with LE and 965 were treated with TME. The data were analyzed using propensity score matching, with each group comprising 91 patients.

RESULTS

After propensity score matching, the median follow-up time was 60.8 months (range, 0.6-150.6 months). After adjustment for the necessary variables, patients who underwent LE showed a significantly higher local recurrence rate than did those who underwent TME; however, there were no differences in disease-free survival and overall survival. In the multivariate analysis, age (hazard ratio [HR], 9.620; 95% confidence interval [CI], 3.415-27.098; P<0.001) and angiolymphatic invasion (HR, 3.63; 95% confidence interval, 1.33-9.89; P=0.012) were independently associated with overall survival. However, LE was neither associated with overall survival nor disease-free survival.

CONCLUSION

LE for clinical T1 rectal cancer yielded a higher local recurrence rate than did TME. Nevertheless, LE provided comparable overall survival rate and can be proposed as an optional treatment in terms of organ-preserving strategies.

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.

Surveillance Intensity Comparison by Risk for T1NX Locally Excised Rectal Adenocarcinoma: a Cost-Effective Analysis

BACKGROUND

Controversy exists regarding the optimal surveillance strategy following local excision of T1NX rectal adenocarcinoma. This study aims to determine the cost-effectiveness of surveillance strategies for locally excised T1NX rectal adenocarcinoma based on histopathologic and local staging risk factors.

METHODS

A Markov model with 10-year follow-up was developed for cost-effectiveness analysis of high-, medium-, and low-intensity surveillance strategies after local excision of T1NX rectal adenocarcinoma. Literature review and expert consensus were utilized to populate state/transition probabilities and rewards. Based on this data, 87% of T1NX patients undergoing local excision were low risk. Healthcare utilization costs were based on Centers for Medicare and Medicaid Services data. The primary outcomes were costs in 2018 US dollars and effectiveness in life-years presented as net monetary benefit and incremental cost-effectiveness ratios. One-way sensitivity and probabilistic sensitivity analyses were performed.

RESULTS

Net monetary benefit for low-, medium-, and high-intensity surveillance strategies ($393,117.00, $397,978.80, and $397,290.00) shows medium-intensity surveillance to be optimal. One-way sensitivity analysis shows medium-intensity surveillance to be optimal when the cohort is 73-94% low risk. High-intensity surveillance is preferred when less than 73% of the cohort is low risk. Low-intensity surveillance is preferred when greater than 94% is low risk. Probabilistic sensitivity analysis of the base-case shows medium-intensity surveillance is the optimal strategy for 51.5% of the iterations performed.

CONCLUSIONS

Medium-intensity surveillance is the most cost-effective surveillance strategy for locally excised T1NX rectal adenocarcinoma in a clinically representative population model.

Long-term Transanal Excision Outcomes in Patients With T1 Rectal Cancer: Comparative Analysis of Radical Resection

Purpose

Transanal excision (TAE) is an alternative surgical procedure for early rectal cancer. This study compared long-term TAE outcomes, in terms of survival and local recurrence (LR), with total mesorectal excision (TME) in patients with pathologically confirmed T1 rectal cancer.

Methods

T1 rectal adenocarcinoma patients who underwent surgery from 1990 to 2011 were retrospectively reviewed. Patients that were suspected to have preoperative lymph node metastasis were excluded. Demographics, recurrence, and survival were analyzed based on TAE and TME surgery.

Results

Of 268 individuals, 61 patients (26%) underwent TAE, which was characterized by proximity to the anus, submucosal invasion depth, and lesion infiltration, compared with TME patients (P < 0.001–0.033). During a median follow-up of 10.4 years, 12 patients had systemic and/or LR. Ten-year cancer-specific survival in the TAE and TME groups was not significantly different (98% vs. 100%). However, the 10-year LR rate in the TAE group was greater than that of TME group (10% vs. 0%, P < 0.001). Although 5 of the 6 TAE patients with LR underwent salvage surgery, one of the patients eventually died. The TAE surgical procedure (hazard ratio, 19.066; P = 0.007) was the only independent risk factor for LR.

Conclusion

Although long-term survival after TAE was comparable to that after TME, TAE had a greater recurrence risk than TME. Thus, TAE should only be considered as an alternative surgical option for early rectal cancer in selected patients.

Consensus and controversies regarding follow-up after treatment with curative intent of nonmetastatic colorectal cancer: a synopsis of guidelines used in countries represented in the European Society of Coloproctology

AIM

It is common clinical practice to follow patients for a period of years after treatment with curative intent of nonmetastatic colorectal cancer, but follow-up strategies vary widely. The aim of this systematic review was to provide an overview of recommendations on this topic in guidelines from member countries of the European Society of Coloproctology, with supporting evidence.

METHOD

A systematic search of Medline, Embase and the guideline databases Trip database, BMJ Best Practice and Guidelines International Network was performed. Quality assessment included use of the AGREE-II tool. All topics with recommendations from included guidelines were identified and categorized. For each subtopic, a conclusion was made followed by the degree of consensus and the highest level of evidence.

RESULTS

Twenty-one guidelines were included. The majority recommended that structured follow-up should be offered, except for patients in whom treatment of recurrence would be inappropriate. It was generally agreed that clinical visits, measurement of carcinoembryoinc antigen and liver imaging should be part of follow-up, based on a high level of evidence, although the frequency is controversial. There was also consensus on imaging of the chest and pelvis in rectal cancer, as well as endoscopy, based on lower levels of evidence and with a level of intensity that was contradictory.

CONCLUSION

In available guidelines, multimodal follow-up after treatment with curative intent of colorectal cancer is widely recommended, but the exact content and intensity are highly controversial. International agreement on the optimal follow-up schedule is unlikely to be achieved on current evidence, and further research should refocus on individualized 'patient-driven' follow-up and new biomarkers.

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.

Cost comparison between endoscopic submucosal dissection and transanal endoscopic microsurgery for the treatment of rectal tumors

Purpose

To compare medical costs of endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) for the treatment of rectal tumors.

Methods

The records of 80 patients who underwent ESD and 32 who underwent TEM for the treatment of rectal tumors were collected. Factors compared in the two groups included patient age, sex and clinical characteristics, as well as hospital stay, procedure time, instrument use, medications, postoperative complications, and imaging and laboratory findings. Costs were analyzed based on medical insurance fees, as set publicly by the Ministry of Health & Welfare, Korea. Medical costs were also divided into patient copayments and National Health Insurance (NHI) Corporation charges.

Results

Patient characteristics, including age, sex, and comorbidities, were similar in the two groups, as were procedure time, histologic diagnosis, tumor size and distance from the anal verge, hospital stay, and complication rates. Median total hospital costs were significantly lower in the ESD than in the TEM group (1,214 United State dollars [USD] vs. 1,686 USD, P < 0.001). The costs for consumables, drugs and laboratory as well as operation fee were also significantly lower in the ESD than in the TEM group. However, patient copayments in the ESD group were significantly higher than in the TEM group (928 USD vs. 496 USD, P < 0.001), because ESD procedure for rectal tumors is not yet covered by the Korean NHI.

Conclusion

Overall direct medical costs were significantly lower for ESD than for TEM in the treatment of rectal tumors.