Bentrem DJ, Okabe S, Wong WD, et al. T1 adenocarcinoma of the rectum: transanal excision or radical surgery

Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
Annals of Surgery (Impact Factor: 8.33). 11/2005; 242(4):472-7; discussion 477-9.
Source: PubMed

ABSTRACT Recent studies suggest local excision may be acceptable treatment of T1 adenocarcinoma of the rectum, but there is little comparative data with radical surgery to assess outcomes and quantify risk. We performed a retrospective evaluation of patients with T1 rectal cancers treated by either transanal excision or radical resection at our institution to assess patient selection, cancer recurrence, and survival.
All patients who underwent surgery for T1 adenocarcinomas of the rectum (0-15 cm from anal verge) by either transanal excision (TAE) or radical resection (RAD) between January 1987 and January 2004 were identified from a prospective database. Data were analyzed using Fisher exact test, Kaplan-Meier method, and log-rank test.
Three hundred nineteen consecutive patients with T1 lesions were treated by transanal excision (n = 151) or radical surgery (n = 168) over the 17-year period. RAD surgery was associated with higher tumor location in the rectum, slightly larger tumor size, a similar rate of adverse histology, and a lymph node metastasis rate of 18%. Despite these features, patients who underwent RAD surgery had fewer local recurrences, fewer distant recurrences, and significantly better recurrence-free survival (P = 0.0001). Overall and disease-specific survival was similar for RAD and TAE groups.
Despite a similar risk profile in the 2 surgical groups, patients with T1 rectal cancer treated by local excision were observed to have a 3- to 5-fold higher risk of tumor recurrence compared with patients treated by radical surgery. Local excision should be reserved for low-risk cancers in patients who will accept an increased risk of tumor recurrence, prolonged surveillance, and possible need for aggressive salvage surgery. Radical resection is the more definitive surgical treatment of T1 rectal cancers.

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Available from: David J Bentrem, Jan 09, 2015
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    • "Although preoperative locoregional staging is standard for all patients with rectal cancer, the currently accepted methods, pelvic MRI and EUS, are imperfect, particularly for lymph node staging [9-13]. Retrospective studies have demonstrated a relatively lower risk of lymph node metastasis in T1-2 rectal cancers, compared with T3 tumors [14-18]. Therefore, most patients with clinically staged T1-2 node-negative rectal cancer will undergo primary resection, and adjuvant treatment will be determined according to the pathological stage. "
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    ABSTRACT: Stage T1-2 rectal cancers are unlikely to have lymph node metastases and neoadjuvant therapy is not routinely administered. Postoperative management is controversial if lymph node metastases are detected in the resected specimen. We studied the outcomes of patients with pT1-2 node-positive rectal cancer in order to determine whether adjuvant radiotherapy was beneficial. We conducted a retrospective analysis of 284 patients with pathological T1-2 node-positive rectal cancer from a single institution. Outcomes, including local recurrence (LR), distant metastasis (DM), disease free survival (DFS) and overall survival (OS), were studied in patients with detailed TN staging and different adjuvant treatment modalities. The overall 5-year LR, DM, DFS and OS rates for all patients were 12.5%, 32.9%, 36.4% and 76.8%, respectively. Local control was inferior among patients who received no adjuvant therapy. Patients could be divided into three risk subsets: Low-risk, T1N1; Intermediate-risk, T2N1 and T1N2; and High-risk, T2N2. The 5-year LR rates were 5.3%, 9.8% and 26.4%, respectively (p = 0.005). In High-risk patients, addition of radiotherapy achieved a 5-year LR rate of 9.1%, compared 34.8% without radiotherapy. In our study, we provide the detailed outcomes and preliminary survival analysis in a relatively infrequent subset of rectal cancer. Three risk subsets could be identified based on local control for pT1-2 node positive rectal cancer. Postoperative treatment needs to be individualized for patients with pT1-2 node-positive rectal cancer.
    Radiation Oncology 12/2013; 8(1):290. DOI:10.1186/1748-717X-8-290 · 2.55 Impact Factor
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    • "Although the oncologic result of LE is significantly inferior to radical surgery in early rectal cancer, LE is still an attractive treatment tool in terms of low-morbidity, good functional outcome, and sphincter-sparing [3,5,10]. "
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    ABSTRACT: The aim of this study was to analyze oncologic outcomes after transanal local excision (LE) to ensure adequate surveillance of recurrence in order to treat with curative intent. Between January 2000 and June 2009, 102 patients who underwent transanal LE for rectal adenocarcinoma were retrospectively reviewed. Of the 102 patients, 53 (52.0%) were male. The mean age was 57 ± 11 years. Postoperative pathologic examination revealed 93 cases (91.2%) of pathologic T stage (pT)1 and 9 cases (8.8%) of pT2. Forty-eight patients (47.1%) underwent adjuvant postoperative radiotherapy. The median follow-up interval was 60 months (range, 3 to 146 months). Seven (6.9%) out of 15 patients who suffered recurrence had locoregional recurrence, three (2.9%) had systemic recurrence and five (4.9%) had both systemic and locoregional recurrence. The latter five patients and two of the three patients with systemic recurrence died because of the disease recurrence. On the other hand, only one of the seven patients with locoregional recurrence died because of disease recurrence. Systemic recurrence after transanal LE results in fatal consequences. Therefore, not only is it important to identify ideal candidates for LE, but intensive postoperative surveillance is important as well to identify curable recurrence as soon as possible.
    Journal of the Korean Surgical Society 02/2013; 84(2):94-100. DOI:10.4174/jkss.2013.84.2.94 · 0.73 Impact Factor
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    • "Unfortunately, significant morbidity risks are associated with a radical resection, including frequent defecation, voiding problems, and sexual dysfunction. Furthermore, the lifestyle and the body image of patients who undergo an abdominoperineal resection are profoundly altered [1, 39]. Patients who either refuse abdominoperineal resection to preserve the anal sphincter or have pre-existing medical co-morbidities have led some physicians to advocate for local excision in selected rectal cancer cases. "
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    ABSTRACT: Even in patients undergoing an optimal surgical technique (e.g., total mesorectal excision), radiotherapy provides a significant benefit in the local control of rectal cancer. Compared with postoperative treatment, chemoradiotherapy given preoperatively has been shown to decrease local recurrence rates and toxicity. Additionally, preoperative chemoradiotherapy permits the early identification of tumor responses to this cytotoxic treatment by surgical pathology. Pathological parameters reflecting the tumor response to chemoradiotherapy have been shown to be surrogate markers for long-term clinical outcomes. Post-chemoradiotherapy downstaging from cStage II-III to ypStage 0-I indicates a favorable prognosis, with no difference between ypStage 0 and ypStage I. Research is ongoing to develop useful tools (clinical, molecular, and radiological) for clinical determination of the pathologic chemoradiotherapeutic response before surgery, and possibly even before preoperative treatment. In the future, risk-adapted strategies, including intensification of preoperative therapy, conservative surgery, or the selective administration of postoperative chemotherapy, will be realized for locally-advanced rectal cancer patients based on their response to preoperative chemoradiotherapy.
    Journal of the Korean Society of Coloproctology 08/2012; 28(4):179-87. DOI:10.3393/jksc.2012.28.4.179
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