Clinical Research
Copyright ©The Author(s) 2003. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Apr 15, 2003; 9(4): 871-873
Published online Apr 15, 2003. doi: 10.3748/wjg.v9.i4.871
Local excision carcinoma in early stage
Ji-Dong Gao, Yong-Fu Shao, Jian-Jun Bi, Su-Sheng Shi, Jun Liang, Yu-Hua Hu
Ji-Dong Gao, Yong-Fu Shao, Jian-Jun Bi, Department of General Surgical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
Su-Sheng Shi, Department of Pathology, Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
Jun Liang, Yu-Hua Hu, Department of Radiotherapy Oncology, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China
Author contributions: All authors contributed equally to the work.
Correspondence to: Ji-Dong Gao, Department of General Surgical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China. ab168@vip.sina.com
Telephone: +86-10-87708308
Received: December 22, 2002
Revised: January 9, 2003
Accepted: January 16, 2003
Published online: April 15, 2003

Abstract

AIM: To assess the validity of local excision for the early stage low rectal cancer as an effective treatment alternative to radical resection.

METHODS: A retrospective medical chart review was done in 47 patients with early stage low rectal carcinoma who underwent local excision from November 1980 through November 1999 at Cancer Hospital of Chinese Academy of Medical Sciences (CAMS). The patients were treated by either transanal (40 cases), trans-sacral (5 cases), or trans-vaginal (2 cases) excision of tumors and no death was related to surgery. Sixteen patients received postoperative radiotherapy.

RESULTS: T1 and T2 lesion was found in 36 (76.6%) and 11 patients (23.4%) respectively. The overall local tumor recurrence rate was 14.9% (7/47), with an average recurrence time of 21 months. Among these 7 recurrent patients, there were 4 T1 and 3 T2 lesions. Microscopically, the surgical incisal margin was negative in 45 (95.7%) and positive in 2 patients (4.3%); Both of the later had developed local recurrence. The overall 5-year survival rate was 91.7%, in which there were 94.4% for T1 and 83.3% for T2 tumors. T stage, intravessel tumor thrombosis, lymphocytic infiltration and histological grade were not found to be significant by related to the local recurrence and survival (P > 0.05).

CONCLUSION: Local tumor excision was a safe procedure for the treatment of early stage low rectal carcinoma with minimal morbidity and mortality, which might serves as one of the primary surgical treatment methods for the disease of this kind.



Citation: Gao JD, Shao YF, Bi JJ, Shi SS, Liang J, Hu YH. Local excision carcinoma in early stage. World J Gastroenterol 2003; 9(4): 871-873
INTRODUCTION

Abdominoperineal resection (APR) has traditionally been use to treat the Adenocarcinoma of the low rectum[1-2]. In which a permanent colostomy has to be performed, leading to the risk of complications, inconvenience of patients and even death[3,4]. More recently, local excision has been performed with the curative intent to remove the well-differentiated lesions that are less than 3 cm in diameter and limited to the mucosa or submucosa[5-7], which offers these patients fewer operative complications and long-term survival outcome[8-13]. The increasing evidence based on the local tumor recurrence and survival rates supports the use of local excision as a primary treatment modality in the selected patients[14-18].

The aim of the present study was to review our experience in the local excision of the early rectal cancers and to assess the validity of this therapeutic strategy as an effective treatment alternative to radical resection.

MATERIALS AND METHODS
Materials

Forty-seven 47 patients with early stage low rectal carcinomas were treated by local excision from November 1980 to November 1999 at the Department of General Surgical Oncology, Cancer Hospital of Chinese Academy of Medical Sciences (CAMS). They were 23 male and 24 female and with an average age 57 years (ranging from 31 to 80 years). The rectal carcinomas were located 3 to 8 cm from the anal verge (Table 1).

Table 1 Patient and treatment characteristics (n = 47).
CharacteristicNo. patients
Sex
Male23
Female24
Surgical margin
Negative45
Positive2
Radiotherapy
No31
Yes16
T stage
T136
T211
Grade
Well differentiated22
Moderately differentiated23
Poorly differentiated2
Surgical Procedure
Transanal excision40
Trans-sacral excision5
Trans-vaginal excision2
Treatment

Patients were treated by either transanal (40 cases), trans-sacral (5 cases), or trans-vaginal (2 cases) excision of tumors, in which 16 patients received postoperative radiotherapy.

Pathological diagnosis

All available pathohistological sections were reviewed by a single pathologist to assessed the depth and extent of tumor invasion, the lymphocytic infiltration, mucinous status, and the degree of tumor differentiation. The tumor was staged according to the American Joint Committee on Cancer Staging System (AJCC1996).

Statistical analysis

The end points of this study were local and distant tumor recurrence and patient survival. Obtained data were analyzed using the Statistical Package for the Social Sciences (Release 11.0, SPSS, Inc). Survival curves were estimated using the Kaplan-Meier method and were compared using the log-rank test. Significance was defined as P < 0.05.

RESULTS

There was no death related to surgery. The most severe complication was the fistula formation, which was necessitated to perform a temporary diverting colostomy in two patients treated with trans-sacral excision. Other complications included bleeding in 2 patients and anal stricture in one patient (Table 1).

The median tumor diameter was 2.0 cm (ranging form 0.4 to 3 cm). Thirty-six patients (76.6%) had T1 and 11 patients (23.4%) had T2 lesion. The resected tumors in most cases were well or moderately differentiated, poorly differentiated were only seen in two patients. For those pathological sections were available, intravessel tumor thrombosis was identified in 10 patients (21.3%) and lymphocytic infiltration in 8 patients (17.0%). Tumor cells appeared on the surgical incisal margin were negative in 45 patients (95.7%) and positive in 2 cases (4.3%).

The average time for follow-up survey was 53 months. The overall local tumor recurrence rate was 14.9% (7 patients) with the median recurrence time of 21 months (ranging from 12 to 48 months) postoperation. Among those with local recurrence, T1 and T2 tumors were found in 4 and 3 cases respectively. Five patients had immediate reoperation (APR or anterior resection). Both of the two patients with tumor cell positive incisal margin developed local recurrence. The overall 5-year survival rate was 91.7%, in which there were 94.4% for T1 and 83.3% for T2 tumors.

T stage, intravessel tumor thrombosis, lymphocytic infiltration, histological grade and mucinous differentiation were not found to be significant predictors for local tumor recurrence and survival (P > 0.05).

DISCUSSION

Abdominoperineal resection, the mainstay of treatment for rectal cancer nowadays, has been reported bearing a death rate of 2.3% to 3.2% and 30% to 46% postoperative complications in the patient. permanent colostomy, urinary and sexual dysfunction are common sequelae of radical proctectomy that impair seriously affecting the patient’s quality of life[1-4]. In the past, local excision was performed only if the patient was in poor medical condition or refused to have a colostomy. Recent data suggest that the combination of local excision and postoperative chemo-radiation therapy may be an option for some patients with early stage rectal cancer. Encouraging results of local treatment of early rectal cancer and the development of new diagnostic technology providing accurate preoperative staging have greatly increased the interest of surgical oncology in this therapeuticstrategy[14-19].

However, broad acceptance of local excision as the primary treatment rectal cancer has been limited by the high local tumor recurrence that was difficult to be interpreted because the literature was dominated by retrospective analyses of heterogeneous groups of patients. Included the patients with the tumors undifferentiated and penetrating the perirectal fat, with questionable or even positive tumor cell incisal margins, or with different surgical approaches, even palliative surgery[20,21]. Besides specific reference was not always made to the lymphatic and blood vessel invasion, and the role of salvage surgery after failed local excision has also not been clearly stated[22-26]. Therefore, There is an almost uniform agreement at present that only the well- or moderately differentiated T1 and T2 tumors, without blood vessel or lymphatic invasion or mucinous components could be treated by local excision with curative intent.

The present study there was no death related to the surgery, postoperative mortality. Complications occurring more and with a minimal in patients treated with trans-sacral excision was the fistula that was necessitated to perform a temporary diverting colostomy in two patients. Transanal excision was associated with less morbidity than any other local excision procedures.

Our data suggested that longer follow-up was necessary to identify those who would have a relapse, as shown by the fact that the median time for the local tumor recurrence in our study was about 21 months, with a range of 12 to 48 months postoperation. Recurrence rates were 11.1% and 27.3% in T1 and T2 tumors, respectively, which suggested that T stage was an important factor affecting recurrence.

The fact that both of the 2 patients with tumor cell positive incisal margin developed local recurrence suggested that tumor-free incisal margin and completely tumor excision was crucial for the prevention of local tumor recurrence, which was difficult to achieve for T3 lesion because the tumor had invaded the perirectal fat or anal sphincter. Therefore, if a tumor cell negative incisal margin could not be achieved in the operation, the patient was not considered as a good candidate for the local excision[27,28]. Statistical analysis showed that intravessel tumor thrombosis, lymphocytic infiltration, histologic grade and mucinous differentiation were not found to be the significant predictors for the local tumor recurrence and survival (P > 0.05).

In summary, on the basis of our retrospective data, the sphincter-preserving local excision can be used as one of the primary surgical treatment methods for the early-stage low rectal cancer with minimal morbidity and mortality.

Footnotes

Edited by Zhu L

References
1.  Nissan A, Guillem JG, Paty PB, Douglas Wong W, Minsky B, Saltz L, Cohen AM. Abdominoperineal resection for rectal cancer at a specialty center. Dis Colon Rectum. 2001;44:27-35; discussion 35-36.  [PubMed]  [DOI]
2.  Zheng S, Liu XY, Ding KF, Wang LB, Qiu PL, Ding XF, Shen YZ, Shen GF, Sun QR, Li WD. Reduction of the incidence and mortality of rectal cancer by polypectomy: a prospective cohort study in Haining County. World J Gastroenterol. 2002;8:488-492.  [PubMed]  [DOI]
3.  Luna-Pérez P, Rodríguez-Ramírez S, Vega J, Sandoval E, Labastida S. Morbidity and mortality following abdominoperineal resection for low rectal adenocarcinoma. Rev Invest Clin. 2001;53:388-395.  [PubMed]  [DOI]
4.  McLeod RS. Comparison of quality of life in patients undergoing abdominoperineal extirpation or anterior resection for rectal cancer. Ann Surg. 2001;233:157-158.  [PubMed]  [DOI]
5.  Sengupta S, Tjandra JJ. Local excision of rectal cancer: what is the evidence. Dis Colon Rectum. 2001;44:1345-1361.  [PubMed]  [DOI]
6.  Masaki T, Sugiyama M, Atomi Y, Matsuoka H, Abe N, Watanabe T, Nagawa H, Muto T. The indication of local excision for T2 rectal carcinomas. Am J Surg. 2001;181:133-137.  [PubMed]  [DOI]
7.  Taylor RH, Hay JH, Larsson SN. Transanal local excision of selected low rectal cancers. Am J Surg. 1998;175:360-363.  [PubMed]  [DOI]
8.  Bleday R, Steele G. Current protocols and outcomes of local therapy for rectal cancer. Surg Oncol Clin N Am. 2000;9:751-758; discussion 751-758.  [PubMed]  [DOI]
9.  Rothenberger DA, Garcia-Aguilar J. Role of local excision in the treatment of rectal cancer. Semin Surg Oncol. 2000;19:367-375.  [PubMed]  [DOI]
10.  Chorost MI, Petrelli NJ, McKenna M, Kraybill WG, Rodriguez-Bigas MA. Local excision of rectal carcinoma. Am Surg. 2001;67:774-779.  [PubMed]  [DOI]
11.  Blair S, Ellenhorn JD. Transanal excision for low rectal cancers is curative in early-stage disease with favorable histology. Am Surg. 2000;66:817-820.  [PubMed]  [DOI]
12.  Hall NR, Finan PJ, al-Jaberi T, Tsang CS, Brown SR, Dixon MF, Quirke P. Circumferential margin involvement after mesorectal excision of rectal cancer with curative intent. Predictor of survival but not local recurrence. Dis Colon Rectum. 1998;41:979-983.  [PubMed]  [DOI]
13.  Chakravarti A, Compton CC, Shellito PC, Wood WC, Landry J, Machuta SR, Kaufman D, Ancukiewicz M, Willett CG. Long-term follow-up of patients with rectal cancer managed by local excision with and without adjuvant irradiation. Ann Surg. 1999;230:49-54.  [PubMed]  [DOI]
14.  Wagman RT, Minsky BD. Conservative management of rectal cancer with local excision and adjuvant therapy. Oncology (Williston Park). 2001;15:513-519, 524; discussion 513-519.  [PubMed]  [DOI]
15.  Daniels IR, Simson JN. Local excision and chemoradiation for low rectal T1 and T2 cancers is an effective treatment. Am Surg. 2000;66:512.  [PubMed]  [DOI]
16.  Medich D, McGinty J, Parda D, Karlovits S, Davis C, Caushaj P, Lembersky B. Preoperative chemoradiotherapy and radical sur-gery for locally advanced distal rectal adenocarcinoma: patho-logic findings and clinical implications. Dis Colon Rectum. 2001;44:1123-1128.  [PubMed]  [DOI]
17.  Benson R, Wong CS, Cummings BJ, Brierley J, Catton P, Ringash J, Abdolell M. Local excision and postoperative radiotherapy for distal rectal cancer. Int J Radiat Oncol Biol Phys. 2001;50:1309-1316.  [PubMed]  [DOI]
18.  Varma MG, Rogers SJ, Schrock TR, Welton ML. Local excision of rectal carcinoma. Arch Surg. 1999;134:863-867; discussion 863-867.  [PubMed]  [DOI]
19.  Akasu T, Kondo H, Moriya Y, Sugihara K, Gotoda T, Fujita S, Muto T, Kakizoe T. Endorectal ultrasonography and treatment of early stage rectal cancer. World J Surg. 2000;24:1061-1068.  [PubMed]  [DOI]
20.  Weber TK, Petrelli NJ. Local excision for rectal cancer: an uncertain future. Oncology (Williston Park). 1998;12:933-943; discussion 944, 947.  [PubMed]  [DOI]
21.  Bouvet M, Milas M, Giacco GG, Cleary KR, Janjan NA, Skibber JM. Predictors of recurrence after local excision and postoperative chemoradiation therapy of adenocarcinoma of the rectum. Ann Surg Oncol. 1999;6:26-32.  [PubMed]  [DOI]
22.  Graham RA, Hackford AW, Wazer DE. Local excision of rectal carcinoma: a safe alternative for more advanced tumors. J Surg Oncol. 1999;70:235-238.  [PubMed]  [DOI]
23.  Benoist S, Panis Y, Martella L, Nemeth J, Hautefeuille P, Valleur P. Local excision of rectal cancer for cure: should we always regard rigid pathologic criteria. Hepatogastroenterology. 1998;45:1546-1551.  [PubMed]  [DOI]
24.  Mellgren A, Sirivongs P, Rothenberger DA, Madoff RD, García-Aguilar J. Is local excision adequate therapy for early rectal cancer. Dis Colon Rectum. 2000;43:1064-1071; discussion 1064-1071.  [PubMed]  [DOI]
25.  Wexner SD, Rotholtz NA. Surgeon influenced variables in resectional rectal cancer surgery. Dis Colon Rectum. 2000;43:1606-1627.  [PubMed]  [DOI]
26.  Lopez-Kostner F, Fazio VW, Vignali A, Rybicki LA, Lavery IC. Locally recurrent rectal cancer: predictors and success of salvage surgery. Dis Colon Rectum. 2001;44:173-178.  [PubMed]  [DOI]
27.  Kim CJ, Yeatman TJ, Coppola D, Trotti A, Williams B, Barthel JS, Dinwoodie W, Karl RC, Marcet J. Local excision of T2 and T3 rectal cancers after downstaging chemoradiation. Ann Surg. 2001;234:352-358; discussion 352-358.  [PubMed]  [DOI]
28.  Beart RW Jr. Predictors of recurrence after local excision. Ann Surg Oncol. 1999;6:26-32.  [PubMed]  [DOI]