Surgical Salvage of Recurrent Rectal Cancer After Transanal Excision

Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.
Diseases of the Colon & Rectum (Impact Factor: 3.75). 07/2005; 48(6):1169-75. DOI: 10.1007/s10350-004-0930-3
Source: PubMed


This study examines surgical salvage of locally recurrent rectal cancer following transanal excision of early tumors.
Through retrospective review of a colorectal database we identified 50 patients who underwent attempted surgical salvage for local recurrence following initial transanal excision of T1 or T2 rectal cancer. Eight patients had resectable synchronous distant disease. Clinicopathologic variables were associated with extent of surgery required for salvage and outcome.
Salvage procedures included abdominoperineal resection (31), low anterior resection (11), total pelvic exenteration (4), and transanal excision (3). One patient had unresectable disease at exploration, requiring diverting ostomy. Of the 49 patients who underwent successful salvage, 27 (55 percent) required an extended pelvic dissection with en bloc resection of one or more of the following structures: pelvic sidewall and autonomic nerves (18); coccyx or portion of sacrum (6); prostate (5); seminal vesicle (5); bladder (4); portion of the vagina (3); ureter (2); ovary (1); and uterus (1). Complete pathologic resection (R0) was accomplished in 47 of 49 patients. Of the eight patients with distant and local recurrence, two underwent synchronous resection and six had delayed metastasectomy. With a median follow-up of 33 months, 29 patients had recurred or died of disease at the time of this analysis. Five-year disease-specific survival was 53 percent. Factors predictive of survival included evidence of any mucosal recurrence on endoscopy, low presalvage carcinoembryonic antigen, and absence of poor pathologic features (lymphovascular and perineural invasion). Patients who required an extended pelvic resection had a worse survival rate.
Pelvic recurrence following transanal excision of early rectal cancer is often locally advanced, requiring an extended pelvic dissection with en bloc resection of adjacent pelvic organs to achieve salvage. The long-term outcome in patients undergoing resection is less than expected, considering the early stage of their initial disease. When contemplating local excision for early rectal cancer, the risk of local recurrence, the extent and morbidity of surgery required for salvage, and the modest cure rate following salvage should be considered.

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    • "This result demonstrates that for strictly selected cases, local excision is more suitable for T1 patients. In addition, the recurrence rate of T2 tumors in this study was far higher than that of T1 tumors, consistent with previous studies [18,19]. Therefore, we do not recommend the application of local excision for rectal cancer patients at stage T2. "
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    ABSTRACT: Background The purpose of this research was to evaluate the therapeutic effects and prognostic factors of transanal local excision (TAE) for rectal cancer. Methods We retrospectively analyzed 116 cases that underwent TAE for rectal cancer from 1995 to 2008. A Cox regression analysis was used to analyze prognostic factors. Results The survival times for the patients were from 14 to 160.5 months (median time, 58.5 months). The 5-year and 10-year overall survival rates were 72% and 53%, respectively. In all 16 cases experienced local recurrence (13.8%). Pathological type, recurrence or metastasis, and depth of infiltration (T stage) were the prognostic factors according to the univariate analysis, and the latter two were independent factors affecting patient prognosis. For patients with T1 stage who underwent adjuvant radiotherapy, there was no local recurrence; for those in T2 stage, the local recurrence rate was 14.6%. In addition, there was no difference between the patients who received radiotherapy and those who did not (T1: P = 0.260, T2: P = 0.262 for survival rate and T1: P = 0.480, T2: P = 0.560 for recurrence). Conclusions The result of TAE for rectal cancer is satisfactory for T1 stage tumors, but it is not suitable for T2 stage tumors.
    Full-text · Article · Jul 2014 · World Journal of Surgical Oncology
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    • "Our salvage operation rate was 75% for recurrence of pT1 and 33% for pT2 while in other studies 50% to 100% of the patients with recurrence of pT1 and/or pT2 underwent salvage operation and these studies employed a variety of diverse surveillance procedures (Table 6). Weiser et al. [17] reported that overall survival after salvage operation after long term follow-up was relatively low, considering the early stage of the patients' primary tumors. However, the patients who underwent salvage operation had a more favorable prognosis than those who did not. "
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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.
    Full-text · Article · Feb 2013 · Journal of the Korean Surgical Society
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    • "Conventional full-thickness transanal excision has been recommended as the definitive treatment of early rectal cancer, but there have been growing number of concerns and contradictory results regarding the efficacy of local surgery. Many studies have now verified that recurrence after local excision of early rectal cancers is significantly higher than expected.1-4 Furthermore, recurrence after local surgery is generally characterized by advanced disease and poor long-term survival.1,5 "
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    ABSTRACT: The role of local excision in treating rectal cancer patients continues to be controversial. The aim of this study was to evaluate the long-term oncological results of local excision for early rectal adenocarcinomas and review the outcomes of salvage therapy on rectal cancer patients. Between March 1992 and September 2005, 35 consecutive patients with early-stage primary rectal adenocarcinomas were treated by local excision with curative intent. The mean tumor distance from the anal verge was 5 cm (range, 1-10 cm). The median follow-up was 66 months (range, 17-161 months). Pathological examination revealed 23 cases of T1 and 12 cases of T2. Recurrence had developed in 10 patients (6 local recurrences, 4 systemic recurrences). Purely extrapelvic recurrence was observed in only two (5.7%) patients. Of the eight recurrent patients with surgical salvage, five survived with no evidence of disease at the time of this analysis. The 5-year local recurrence-free and disease-free survival rates were 79.6% and 67.9%, respectively. Local excision alone of early-staged rectal adenocarcinomas, even in the ideal candidate, is followed by a relatively higher local recurrence rate than previously reported and may not be a valid modality. Either the use of adjuvant therapy with local excision, even in patients with T1 lesions or the use of preoperative therapy followed by local excision has good promise.
    Full-text · Article · Oct 2009 · Yonsei medical journal
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