Reference Citation Analysis: Find an Article, Find a Category, Find a Journal, Find a Scholar

For: Greenberg JA, Shibata D, Herndon JE 2nd, Steele GD Jr, Mayer R, Bleday R. Local excision of distal rectal cancer: an update of cancer and leukemia group B 8984. Dis Colon Rectum 2008;51:1185-91; discussion 1191-4. [PMID: 18536973 DOI: 10.1007/s10350-008-9231-6] [Citation(s) in RCA: 112] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2007] [Revised: 06/15/2007] [Accepted: 08/05/2007] [Indexed: 02/08/2023]

For:	Greenberg JA, Shibata D, Herndon JE 2nd, Steele GD Jr, Mayer R, Bleday R. Local excision of distal rectal cancer: an update of cancer and leukemia group B 8984. Dis Colon Rectum 2008;51:1185-91; discussion 1191-4. [PMID: 18536973 DOI: 10.1007/s10350-008-9231-6] [Citation(s) in RCA: 112] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2007] [Revised: 06/15/2007] [Accepted: 08/05/2007] [Indexed: 02/08/2023]

Number

Cited by Other Article(s)

Chen N, Li CL, Wang L, Yao YF, Peng YF, Zhan TC, Zhao J, Wu AW. Local excision for middle-low rectal cancer after neoadjuvant chemoradiation: A retrospective study from a single tertiary center. World J Gastrointest Oncol 2024;16:4614-4624. [PMID: 39678786 PMCID: PMC11577377 DOI: 10.4251/wjgo.v16.i12.4614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Revised: 08/13/2024] [Accepted: 09/05/2024] [Indexed: 11/12/2024] Open

Abstract

BACKGROUND

Rectal cancer has become one of the leading malignancies threatening people's health. For locally advanced rectal cancer (LARC), the comprehensive strategy combining neoadjuvant chemoradiotherapy (NCRT), total mesorectal excision (TME), and adjuvant chemotherapy has emerged as a standard treatment regimen, leading to favorable local control and long-term survival. However, in recent years, an increasing attention has been paid on the exploration of organ preservation strategies, aiming to enhance quality of life while maintaining optimal oncological treatment outcomes. Local excision (LE), compared with low anterior resection (LAR) or abdominal-perineal resection (APR) was introduced dating back to 1970's. LE has historically been linked to a heightened risk of recurrence compared to TME, potentially due to occult lymph node metastasis and intraluminal recurrence. Recent evidence has demonstrated that LE might be an alternative approach, instead of LAR or APR, in cases with favorable tumor regression after NCRT with potentially better quality of life. Therefore, a retrospective analysis of clinicopathological data from mid-low LARC patients who underwent LE after NCRT was conducted, aiming to evaluate the treatment's efficacy, safety, and oncologic prognosis.

AIM

To explore the safety, efficacy, and long-term prognosis of LE in patients with mid-low rectal cancer who had a good response to NCRT.

METHODS

Patients with LE between 2012 to 2021 were retrospectively collected from the rectal cancer database from Gastro-intestinal Ward III in Peking University Cancer Hospital. The clinicopathological features, postoperative complications, and long-term prognosis of these patients were analyzed. The Kaplan-Meier method was used to create cancer-specific survival curve, and the log-rank test was used to compare the differences regarding outcomes.

RESULTS

A total of 33 patients were included in this study. The median interval between NCRT and surgery was 25.4 (range: 8.7-164.4) weeks. The median operation time was 57 (20.0-137.0) minutes. The initial clinical T staging (cT): 9 (27.3%) patients were cT2, 19 (57.6%) patients were cT3, and 5 (15.2%) patients were cT4; The initial N staging (cN): 8 patients (24.2%) were cN negative, 25 patients (75.8%) were cN positive; The initial M stage (cM): 2 patients (6.1%) had distant metastasis (ycM1), 31 (93.9%) patients had no distant metastasis (cM0). The pathological results: 18 (54.5%) patients were pathological T0 stage (ypT0), 6 (18.2%) patients were ypT1, 7 (21.2%) patients were ypT2, and 2 (6.1%) patients were ypT3. For 9 cT2 patients, 5 (5/9, 55.6%) had a postoperative pathological result of ypT0. For 19 cT3 patients, 11 (57.9%) patients were ypT0, and 2 (40%) were ypT0 in 5 cT4 patients. The most common complication was chronic perineal pain (71.4%, 5/7), followed by bleeding (43%, 3/7), stenosis (14.3%, 1/7), and fecal incontinence (14.3%, 1/7). The median follow-up time was 42.0 (4.0-93.5) months. For 31 patients with cM0, the 5-year disease-free survival (DFS) rate, 5-year local recurrence-free survival (LRFS) rate, and 5-year overall survival (OS) rate were 88.4%, 96.7%, and 92.9%, respectively. There were significant differences between the ycT groups concerning either DFS (P = 0.042) or OS (P = 0.002) in the Kaplan-Meier analysis. The LRFS curve of ycT ≤ T1 patients was better than that of ycT ≥ T2 patients, and the P value was very close to 0.05 (P = 0.070). The DFS curve of patients with ypT ≤ T1 was better than that of patients with ypT ≥ T2, but the P value was not statistically significant (P = 0.560). There was a significant difference between the ypT groups concerning OS (P = 0.014) in the Kaplan-Meier analysis. The LRFS curve of ypT ≤ T1 patients was better than that of ypT ≥ T2 patients, and the P value was very close to 0.05 (P = 0.070). Two patients with initial cM1 were alive at the last follow-up.

CONCLUSION

LE for rectal cancer with significant tumor regression after NCRT can obtain better safety, efficiency, and oncological outcome. Minimally invasive or nonsurgical treatment with patient participation in decision-making can be performed for highly selected patients. Further investigation from multiple centers will bring better understanding of potential advantages regarding local resection.

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Donohue K, Rossi A, Deek MP, Feingold D, Patel NM, Jabbour SK. Local Excision for Early-Stage Rectal Adenocarcinomas. Cancer J 2024;30:245-250. [PMID: 39042775 DOI: 10.1097/ppo.0000000000000734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]

Fadel MG, Ahmed M, Shaw A, Fehervari M, Kontovounisios C, Brown G. Oncological outcomes of local excision versus radical surgery for early rectal cancer in the context of staging and surveillance: A systematic review and meta-analysis. Cancer Treat Rev 2024;128:102753. [PMID: 38761791 DOI: 10.1016/j.ctrv.2024.102753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 05/09/2024] [Accepted: 05/11/2024] [Indexed: 05/20/2024]

Abstract

BACKGROUND

Local resection (LR) methods for rectal cancer are generally considered in the palliative setting or for patients deemed a high anaesthetic risk. This systematic review and meta-analysis aimed to compare oncological outcomes of LR and radical resection (RR) for early rectal cancer in the context of staging and surveillance assessment.

METHODS

A literature search of MEDLINE, Embase and Emcare databases was performed for studies that reported data on clinical outcomes for both LR and RR for early rectal cancer from January 1995 to April 2023. Meta-analysis was performed using random-effect models and between-study heterogeneity was assessed. The quality of assessment was assessed using the Newcastle-Ottawa Scale for observational studies and the Cochrane Risk of Bias 2.0 tool for randomised controlled trials.

RESULTS

Twenty studies with 12,022 patients were included: 6,476 patients had LR and 5,546 patients underwent RR. RR led to an improvement in 5-year overall survival (OR 1.84; 95 % CI 1.54-2.20; p < 0.0001; I2 20 %) and local recurrence (OR 3.06; 95 % CI 2.02-4.64; p < 0.0001; I2 39 %) when compared to LR. However, when staging and surveillance methods were clearly adopted in LR cases, there was an improvement in R0 rates (96.7 % vs 85.6 %), 5-year disease-free survival (93.0 % vs 77.9 %) and overall survival (81.6 % vs 79.0 %) compared to when staging and surveillance was not reported/performed.

CONCLUSIONS

LR may be appropriate for selected patients without poor prognostic factors in early rectal cancer. This study also highlights that there is currently no single standardised staging or surveillance approach being adopted in the management of early rectal cancer. A more specified and standardised preoperative staging for patient selection as well as clinical and image-based surveillance protocols is needed.

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Dekkers N, Dang H, van der Kraan J, le Cessie S, Oldenburg PP, Schoones JW, Langers AMJ, van Leerdam ME, van Hooft JE, Backes Y, Levic K, Meining A, Saracco GM, Holman FA, Peeters KCMJ, Moons LMG, Doornebosch PG, Hardwick JCH, Boonstra JJ. Risk of recurrence after local resection of T1 rectal cancer: a meta-analysis with meta-regression. Surg Endosc 2022;36:9156-9168. [PMID: 35773606 PMCID: PMC9652303 DOI: 10.1007/s00464-022-09396-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 06/06/2022] [Indexed: 01/06/2023]

Abstract

BACKGROUND

T1 rectal cancer (RC) patients are increasingly being treated by local resection alone but uniform surveillance strategies thereafter are lacking. To determine whether different local resection techniques influence the risk of recurrence and cancer-related mortality, a meta-analysis was performed.

METHODS

A systematic search was conducted for T1RC patients treated with local surgical resection. The primary outcome was the risk of RC recurrence and RC-related mortality. Pooled estimates were calculated using mixed-effect logistic regression. We also systematically searched and evaluated endoscopically treated T1RC patients in a similar manner.

RESULTS

In 2585 unique T1RC patients (86 studies) undergoing local surgical resection, the overall pooled cumulative incidence of recurrence was 9.1% (302 events, 95% CI 7.3-11.4%; I2 = 68.3%). In meta-regression, the recurrence risk was associated with histological risk status (p < 0.005; low-risk 6.6%, 95% CI 4.4-9.7% vs. high-risk 28.2%, 95% CI 19-39.7%) and local surgical resection technique (p < 0.005; TEM/TAMIS 7.7%, 95% CI 5.3-11.0% vs. other local surgical excisions 10.8%, 95% CI 6.7-16.8%). In 641 unique T1RC patients treated with flexible endoscopic excision (16 studies), the risk of recurrence (7.7%, 95% CI 5.2-11.2%), cancer-related mortality (2.3%, 95% CI 1.1-4.9), and cancer-related mortality among patients with recurrence (30.0%, 95% CI 14.7-49.4%) were comparable to outcomes after TEM/TAMIS (risk of recurrence 7.7%, 95% CI 5.3-11.0%, cancer-related mortality 2.8%, 95% CI 1.2-6.2% and among patients with recurrence 35.6%, 95% CI 21.9-51.2%).

CONCLUSIONS

Patients with T1 rectal cancer may have a significantly lower recurrence risk after TEM/TAMIS compared to other local surgical resection techniques. After TEM/TAMIS and endoscopic resection the recurrence risk, cancer-related mortality and cancer-related mortality among patients with recurrence were comparable. Recurrence was mainly dependent on histological risk status.

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Affiliation(s)

Nik Dekkers Department of Gastroenterology and Hepatology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
Hao Dang Department of Gastroenterology and Hepatology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
Jolein van der Kraan Department of Gastroenterology and Hepatology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
Saskia le Cessie Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
Philip P Oldenburg Department of Gastroenterology and Hepatology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
Jan W Schoones Directorate of Research Policy (Formerly: Walaeus Library), Leiden University Medical Center, Leiden, The Netherlands
Alexandra M J Langers Department of Gastroenterology and Hepatology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
Monique E van Leerdam Department of Gastroenterology and Hepatology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
Jeanin E van Hooft Department of Gastroenterology and Hepatology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
Yara Backes Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
Katarina Levic Gastrounit-Surgical Division, Center for Surgical Research, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
Alexander Meining Department of Gastroenterology, University Hospital of Würzburg, Würzburg, Germany
Giorgio M Saracco Division of Gastroenterology, Department of Medical Sciences, Molinette Hospital, University of Turin, Turin, Italy
Fabian A Holman Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
Koen C M J Peeters Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
Leon M G Moons Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
Pascal G Doornebosch Department of Surgery, IJsselland Hospital, Capelle Aan Den IJssel, The Netherlands
James C H Hardwick Department of Gastroenterology and Hepatology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
Jurjen J Boonstra Department of Gastroenterology and Hepatology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands

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Peltrini R, Imperatore N, Di Nuzzo MM, Pellino G. Towards personalized treatment of T2N0 rectal cancer: A systematic review of long-term oncological outcomes of neoadjuvant therapy followed by local excision. J Gastroenterol Hepatol 2022;37:1426-1433. [PMID: 35614027 PMCID: PMC9545053 DOI: 10.1111/jgh.15898] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 05/17/2022] [Accepted: 05/19/2022] [Indexed: 12/20/2022]

Abstract

BACKGROUND AND AIM

Total mesorectal excision (TME) remains the treatment of choice in T2N0 tumors. However, evidence suggest that one-size-fits-all approach is not always beneficial for this group of patients. The aim of this study is to synthesize data on long-term outcomes after neoadjuvant therapy (NAT) followed by local excision (LE) in T2N0 rectal cancer patients in the perspective of a rectal-preserving strategy.

METHODS

A systematic search of PubMed/MEDLINE, SCOPUS, and Web of Science databases was conducted until October 2021 to identify studies comparing LE after NAT and TME or reporting oncologic outcomes after conservative approach. A pooled analysis was conducted using a fixed-effect model in the case of non-significant heterogeneity (P > 0.1), and a random effect model (DerSimonian-Laird method) when significant heterogeneity was present (P < 0.1) CRD42022300344.

RESULTS

Nine studies were included in the analysis. Three of them were comparative studies. The pooled 3-year DFS, 5-year DFS, 3-year OS, 5-year OS, local and distant recurrence rates were 92.8% (95% CI 81.6-99.5%), 91.3% (95% CI 88.3-94.3%), 96.1% (95% CI 90.5-100%), 72.6% (95% CI 57.5-87.7%), 4% (95% CI 18-63%), and 4.9% (95% CI 2-7.8%), respectively, in subjects treated with NAT followed by LE. No heterogeneity was found for all these analyses, except for the 5-year OS sub-analysis (I2 95.5%, P < 0.001). Complete pathological response (ypT0) rate after NAT and LE ranges from 26.7% to 59%.

CONCLUSION

LE following neoadjuvant CRT may provide comparable survival benefit to radical surgery for patients with clinical stage T2N0 in selected patients although the evidence is still limited to provide solid recommendations. A personalized therapeutic approach taking into account tumor and patient-related factors should be considered.

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When is transanal endoscopic surgery appropriate? Surg Oncol 2022;43:101773. [DOI: 10.1016/j.suronc.2022.101773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 04/07/2022] [Indexed: 11/23/2022]

Perez RO, Julião GPS, Vailati BB. Transanal Local Excision of Rectal Cancer after Neoadjuvant Chemoradiation: Is There a Place for It or Should Be Avoided at All Costs? Clin Colon Rectal Surg 2022;35:122-128. [PMID: 35237107 PMCID: PMC8885162 DOI: 10.1055/s-0041-1742112] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]

Coffman AR, Tao R, Cohan JN, Huang LC, Pickron TB, Torgeson AM, Lloyd S. Factors associated with the refusal of surgery and the associated impact on survival in patients with rectal cancer using the National Cancer Database. J Gastrointest Oncol 2021;12:1482-1497. [PMID: 34532104 DOI: 10.21037/jgo-20-437] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 06/08/2021] [Indexed: 11/06/2022] Open

Abstract

Background

Surgical resection is an integral component of the curative-intent treatment for most patients with non-metastatic rectal cancer. However, some patients refuse surgery for a number of reasons. Utilizing the National Cancer Database (NCDB), we investigated the sociodemographic and clinical factors associated with patients who were coded as having been offered but refused surgery, and the factors affecting overall survival (OS) in these patients.

Methods

Adult patients with adenocarcinoma of the rectum (excluding T1N0M0 and M1 disease) diagnosed from 2004 to 2015 were analyzed in this retrospective cohort study. Logistic regression was performed to identify factors associated with refusal of surgery. OS of patients refusing surgery was compared using Kaplan-Meier estimate, log-rank test, propensity score matching, and proportional hazards regression.

Results

A total of 55,704 patients were identified: 54,266 received definitive surgery (97.4%) and 1,438 refused (2.6%). Of patients refusing surgery, 135 (9.4%) were stage I, 709 (49.3%) were stage II, and 594 (41.3%) were stage III. Patients were more likely to refuse surgery as the study period progressed (P<0.01). Factors associated with refusal of surgery on multivariate analysis include: age ≥70 years, Black race, non-private insurance, and tumor size greater than 2 cm (all values P≤0.01). The 5-year OS was 61.6% for the surgery cohort and 35.7% for the refusal cohort. In the propensity matched groups, median survival was 84.2 months in patients who received definitive surgery compared to 43.7 months in patients who refused surgery. As an index for comparison, patients who refused surgery but received both radiotherapy and chemotherapy had a median survival of 48.5 months. Among patients that refused surgery, those that received radiotherapy alone, chemotherapy alone, or radiotherapy and chemotherapy (compared to no treatment) experienced a survival benefit (all values P≤0.01).

Conclusions

In patients with non-metastatic adenocarcinoma of the rectum reported in the NCDB, age, race, and insurance status were associated with refusal of surgery. Refusal of surgery was more common in the later years of the study. Survival is poor in patients who refused surgical resection.

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Fields AC, Lu P, Hu F, Hirji S, Irani J, Bleday R, Melnitchouk N, Goldberg JE. Lymph Node Positivity in T1/T2 Rectal Cancer: a Word of Caution in an Era of Increased Incidence and Changing Biology for Rectal Cancer. J Gastrointest Surg 2021;25:1029-1035. [PMID: 32246393 DOI: 10.1007/s11605-020-04580-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 03/23/2020] [Indexed: 01/31/2023]

Zhao S, Chen X, Wen D, Zhang C, Wang X. Oncologic Nomogram for Stage I Rectal Cancer to Assist Patient Selection for Adjuvant (Chemo)Radiotherapy Following Local Excision. Front Oncol 2021;11:632085. [PMID: 33816269 PMCID: PMC8017267 DOI: 10.3389/fonc.2021.632085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 02/08/2021] [Indexed: 12/16/2022] Open

van Oostendorp SE, Smits LJH, Vroom Y, Detering R, Heymans MW, Moons LMG, Tanis PJ, de Graaf EJR, Cunningham C, Denost Q, Kusters M, Tuynman JB. Local recurrence after local excision of early rectal cancer: a meta-analysis of completion TME, adjuvant (chemo)radiation, or no additional treatment. Br J Surg 2020;107:1719-1730. [PMID: 32936943 PMCID: PMC7692925 DOI: 10.1002/bjs.12040] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 07/13/2020] [Accepted: 08/10/2020] [Indexed: 12/12/2022]

Franke AJ, Skelton WP, George TJ, Iqbal A. A Comprehensive Review of Randomized Clinical Trials Shaping the Landscape of Rectal Cancer Therapy. Clin Colorectal Cancer 2020;20:1-19. [PMID: 32863179 DOI: 10.1016/j.clcc.2020.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 07/18/2020] [Accepted: 07/20/2020] [Indexed: 12/31/2022]

Ushigome H, Ohue M, Kitamura M, Nakatsuka S, Haraguchi N, Nishimura J, Yasui M, Wada H, Takahashi H, Omori T, Miyata H, Yano M, Takiguchi S. Evaluation of risk factors for lymph node metastasis in T2 lower rectal cancer to perform chemoradiotherapy after local resection. Mol Clin Oncol 2020;12:390-394. [PMID: 32190324 DOI: 10.3892/mco.2020.1993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 01/16/2020] [Indexed: 11/05/2022] Open

Sevak S, Gregoir T, Wolthuis A, Albert M. How can we utilize local excision to help, not harm, geriatric patients with rectal cancer? Eur J Surg Oncol 2020;46:344-348. [PMID: 31983488 DOI: 10.1016/j.ejso.2019.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 09/12/2019] [Accepted: 12/13/2019] [Indexed: 01/24/2023] Open

Melnitchouk N, Fields AC, Lu P, Scully RE, Powell AC, Maldonado L, Goldberg JE, Bleday R. Local versus Radical Excision of Early Distal Rectal Cancers: A National Cancer Database Analysis. Ann Surg Oncol 2020;27:2169-2176. [PMID: 31898098 DOI: 10.1245/s10434-019-08155-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Indexed: 01/04/2023]

Russo S, Anker CJ, Abdel-Wahab M, Azad N, Das P, Dragovic J, Goodman KA, Herman JM, Jones W, Kennedy T, Konski A, Kumar R, Lee P, Patel NM, Sharma N, Small W, Suh WW, Jabbour SK. Executive Summary of the American Radium Society Appropriate Use Criteria for Local Excision in Rectal Cancer. Int J Radiat Oncol Biol Phys 2019;105:977-993. [PMID: 31445109 PMCID: PMC11101014 DOI: 10.1016/j.ijrobp.2019.08.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 08/02/2019] [Accepted: 08/11/2019] [Indexed: 02/07/2023]

Tseng M, Soon YY, Vellayappan B, Ho F, Tey J. Radiation therapy for rectal cancer. J Gastrointest Oncol 2019;10:1238-1250. [PMID: 31949945 DOI: 10.21037/jgo.2018.12.04] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open

Rouleau-Fournier F, Brown CJ. Can less be more? Organ preservation strategies in the management of rectal cancer. ACTA ACUST UNITED AC 2019;26:S16-S23. [PMID: 31819706 DOI: 10.3747/co.26.5841] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]

Ortega CD, Perez RO. Role of magnetic resonance imaging in organ-preserving strategies for the management of patients with rectal cancer. Insights Imaging 2019;10:59. [PMID: 31147789 PMCID: PMC6542937 DOI: 10.1186/s13244-019-0742-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 04/05/2019] [Indexed: 02/06/2023] Open

Robotic Transanal Minimally Invasive Surgery for the Excision of Rectal Neoplasia: Clinical Experience With 58 Consecutive Patients. Dis Colon Rectum 2019;62:279-285. [PMID: 30451744 DOI: 10.1097/dcr.0000000000001223] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]

Abstract

BACKGROUND

Given the significant perioperative risks and costs of total mesorectal excision, minimally invasive transanal surgical approaches have grown in popularity for early rectal cancer and rectal polyps. This article discusses a transanal robotic surgery technique to perform full-thickness resections of benign and malignant rectal neoplasms.

OBJECTIVE

The purpose of this study was to describe an initial experience with robotic transanal minimally invasive surgery.

DESIGN

This was a retrospective cohort study of consecutive patients who underwent robotic transanal minimally invasive surgery.

SETTINGS

The study was conducted at a high-volume colorectal surgery practice with a large health maintenance organization.

PATIENTS

Patients at Southern California Kaiser Permanente with early rectal cancer and rectal polyps amenable to transanal excision were included.

INTERVENTIONS

Transanal resection of rectal tumors were removed using robotic transanal minimally invasive surgery.

MAIN OUTCOME MEASURES

Local recurrence of rectal pathology was measured.

RESULTS

A total of 58 patients underwent robotic transanal minimally invasive surgery with full-thickness rectal resection by 4 surgeons for the following indications: rectal cancer (n = 28), rectal polyp (n = 18), rectal carcinoid (n = 11), and rectal GI stromal tumor (n = 1). Mean operative time was 66.2 minutes (range, 17-180 min). The mean tumor height from the anal verge was 8.8 cm (range, 4-14 cm), and the mean specimen size was 3.3 cm (range, 1.3-8.2 cm). A total of 57 (98.3%) of 58 specimens were intact, and 55 (94.8%) of 58 specimens had negative surgical margins. At a mean follow-up of 11.5 months (range, 0.3-33.3 mo), 3 patients (5.5%) developed local recurrences, and all underwent successful salvage surgery.

LIMITATIONS

The study was limited by being a retrospective, nonrandomized trial with short follow-up.

CONCLUSIONS

Robotic transanal minimally invasive surgery is a safe, oncologically effective surgical approach for rectal polyps and early rectal cancers. It offers the oncologic benefits and perioperative complication profile of other transanal minimally invasive surgical approaches but also enhances surgeon ergonomics and provides an efficient transanal rectal platform. See Video Abstract at http://links.lww.com/DCR/A759.

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Current Surgical Strategies in the Management of Rectal Cancer. CURRENT COLORECTAL CANCER REPORTS 2019. [DOI: 10.1007/s11888-019-00428-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]

Cutting JE, Hallam SE, Thomas MG, Messenger DE. A systematic review of local excision followed by adjuvant therapy in early rectal cancer: are pT1 tumours the limit? Colorectal Dis 2018;20:854-863. [PMID: 29992729 DOI: 10.1111/codi.14340] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 07/02/2018] [Indexed: 12/14/2022]

Suzuki T, Sadahiro S, Tanaka A, Okada K, Saito G, Miyakita H, Akiba T, Yamamuro H. Outcomes of Local Excision plus Chemoradiotherapy in Patients with T1 Rectal Cancer. Oncology 2018;95:246-250. [PMID: 29909419 DOI: 10.1159/000489930] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 05/08/2018] [Indexed: 01/03/2023]

Letarte F, Raval M, Karimuddin A, Phang PT, Brown CJ. Salvage TME following TEM: a possible indication for TaTME. Tech Coloproctol 2018;22:355-361. [PMID: 29725785 DOI: 10.1007/s10151-018-1784-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 12/07/2017] [Indexed: 01/16/2023]

Read J, Tekkis P, Rullier E, Nicholls J, Mortensen N, Marks J, Steele RJC, Brown G. Session 3: Many ways to organ preserve the rectum but which is correct? Colorectal Dis 2018;20 Suppl 1:82-87. [PMID: 29878680 DOI: 10.1111/codi.14085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]

São Julião GP, Celentano JP, Alexandre FA, Vailati BB. Local Excision and Endoscopic Resections for Early Rectal Cancer. Clin Colon Rectal Surg 2017;30:313-323. [PMID: 29184466 DOI: 10.1055/s-0037-1606108] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]

Postoperative Chemoradiotherapy After Local Resection for High-Risk T1 to T2 Low Rectal Cancer: Results of a Single-Arm, Multi-Institutional, Phase II Clinical Trial. Dis Colon Rectum 2017;60:914-921. [PMID: 28796729 PMCID: PMC5553237 DOI: 10.1097/dcr.0000000000000870] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]

Abstract

BACKGROUND

After treatment with local excision for TNM stage I low rectal cancer, the risk of local recurrence is not only high for T2 lesions but also for T1 lesions with features of massive invasion to the submucosal layer and/or lymphovascular invasion.

OBJECTIVE

The purpose of this study was to determine the efficacy of chemoradiotherapy combined with local excision in the treatment of T1 to T2 low rectal cancer.

DESIGN

We conducted a prospective, single-arm, phase II trial.

SETTINGS

This was a multicenter study.

PATIENTS

From April 2003 to October 2010, 57 patients were treated with local excision after additional external beam irradiation (45 Gy) plus continuous 5-week intravenous injection of 5-fluorouracil (250 mg/m per day) at 10 domestic hospitals. Fifty-three patients had clinical T1N0 lesions, and 4 had T2N0 lesions in the low rectum, located below the peritoneal reflection.

MAIN OUTCOMES MEASURES

The primary end point was disease-free survival at 5 years.

RESULTS

The completion rate for full-dose chemoradiotherapy was 86% (49/57). Serious, nontransient treatment-related complications were not reported. With a median follow-up of 7.3 years after local excision, the 5-year disease-free survival rate was 94% for the 53 patients with T1 lesions and 75% for the 4 patients with T2 lesions. There were 2 local recurrences during the entire observation period. Anal function after local excision and chemoradiation were kept at almost the same levels as observed before treatment.

LIMITATIONS

The study was limited by the small number of registered T2 rectal cancers, retrospective evaluations of quality of life, and the exclusion of poorly differentiated adenocarcinoma (a high-risk feature of T1 lesions).

CONCLUSIONS

The addition of chemoradiotherapy to local excision of T1 rectal adenocarcinomas with poor prognostic features including deep submucosal invasion and lymphovascular invasion could improve on less favorable historic oncologic outcomes of local excision alone in this high-risk group for lymph node metastasis. See Video Abstract at http://links.lww.com/DCR/A421.

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Gollins S, Moran B, Adams R, Cunningham C, Bach S, Myint AS, Renehan A, Karandikar S, Goh V, Prezzi D, Langman G, Ahmedzai S, Geh I. Association of Coloproctology of Great Britain & Ireland (ACPGBI): Guidelines for the Management of Cancer of the Colon, Rectum and Anus (2017) - Multidisciplinary Management. Colorectal Dis 2017;19 Suppl 1:37-66. [PMID: 28632307 DOI: 10.1111/codi.13705] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]

Shin YS, Yu CS, Park JH, Kim JC, Lim SB, Park IJ, Kim TW, Hong YS, Kim KP, Yoon SM, Joo JH, Kim JH. Total Mesorectal Excision Versus Local Excision After Favorable Response to Preoperative Chemoradiotherapy in "Early" Clinical T3 Rectal Cancer: A Propensity Score Analysis. Int J Radiat Oncol Biol Phys 2017;99:136-144. [PMID: 28816139 DOI: 10.1016/j.ijrobp.2017.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 05/02/2017] [Accepted: 05/08/2017] [Indexed: 01/29/2023]

Balyasnikova S, Read J, Tait D, Wotherspoon A, Swift I, Cunningham D, Tekkis P, Brown G. The results of local excision with or without postoperative adjuvant chemoradiotherapy for early rectal cancer among patients choosing to avoid radical surgery. Colorectal Dis 2017;19:139-147. [PMID: 27474876 DOI: 10.1111/codi.13477] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 04/17/2016] [Indexed: 01/28/2023]

Riansuwan W, Lohsiriwat V. Local Excision Versus Total Mesorectal Excision for Clinical Stage I (cT1–cT2) Rectal Cancer. CURRENT COLORECTAL CANCER REPORTS 2017. [DOI: 10.1007/s11888-017-0350-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]

Transanal Endoscopic Microsurgery for Early Rectal Cancer: A Single-Center Experience. Dis Colon Rectum 2017;60:152-160. [PMID: 28059911 DOI: 10.1097/dcr.0000000000000764] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]

Abstract

BACKGROUND

There is debate regarding the appropriate use of transanal endoscopic microsurgery for rectal cancer.

OBJECTIVE

This study analyzed our single-center experience with transanal endoscopic microsurgery for early rectal cancer.

DESIGN

Medical charts of patients who underwent transanal endoscopic microsurgery were reviewed to determine lesion characteristics, as well as operative and treatment characteristics. Complications and recurrences were recorded.

SETTINGS

The study was conducted at a single academic medical center.

PATIENTS

Patients with early stage cancer (T1 or T2, N0, and M0) of the rectum were included.

MAIN OUTCOME MEASURES

Local and overall recurrence and disease-specific survival were measured.

RESULTS

A total of 92 patients were analyzed. Median follow-up was 4.6 years. Negative margins were obtained in 98.9%. Length of stay was 1 day for 95.4% of patients. The complication rate was 10.9% (n = 10), including urinary retention at 4.3% (n = 4) and postoperative bleeding at 4.3% (n = 4). Preoperative staging included 54 at T1 (58.7%) and 38 at T2 (41.3%). Adjuvant therapy was recommended for all of the T2 and select T1 lesions with adverse features on histology. The final pathologic stages of tumors were ypT0 at 8.7% (n = 8), pT1 at 58.7% (n = 54), pT2 at 23.9% (n = 22), and ypT2 at 8.7% (n = 8). The 3-year local recurrence risk was 2.4% (SE = 1.7), and overall recurrence was 6.7% (SE = 2.9). There were no recurrences among patients with complete pathologic response to neoadjuvant therapy. Mean time to recurrence was 2.5 years (SD = 1.43). A total of 89.2% of patients with very low tumors underwent curative resection without a permanent stoma (33/37). The 3-year disease-specific survival rate was 98.6% (95% CI, 90.4%-99.8%), and overall survival rate was 89.4% (95% CI, 79.9%-94.6%).

LIMITATIONS

The study was limited by its single-center retrospective experience.

CONCLUSIONS

Transanal endoscopic microsurgery provides comparable oncologic outcomes to radical resection in properly selected patients with early rectal cancer. Sphincter preservation rates approach 90% even in patients with very distal rectal cancer.

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Combined Modality Therapy for Rectal Cancer. Cancer J 2017;22:211-7. [PMID: 27341601 DOI: 10.1097/ppo.0000000000000193] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]

Current Controversies in Transanal Surgery for Rectal Cancer. Surg Laparosc Endosc Percutan Tech 2016;26:431-438. [DOI: 10.1097/sle.0000000000000357] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]

A Systematic Review of Local Excision After Neoadjuvant Therapy for Rectal Cancer: Are ypT0 Tumors the Limit? Dis Colon Rectum 2016;59:984-97. [PMID: 27602930 DOI: 10.1097/dcr.0000000000000613] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]

Abstract

BACKGROUND

Neoadjuvant therapy reduces local recurrence after radical surgery for rectal cancer with complete pathological response in 15% to 25% of patients. Radical surgery is associated with significant morbidity that may be avoided by local excision in selected cases.

OBJECTIVE

This systematic review aimed to determine the oncological outcomes and morbidity of local excision after neoadjuvant therapy.

DATA SOURCES

Data sources included MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials databases.

STUDY SELECTION

A systematic search of the databases using validated terms for rectal cancer, neoadjuvant therapy, and local excision was conducted.

INTERVENTIONS

Neoadjuvant therapy and local excision were the included interventions.

MAIN OUTCOME MEASURES

Pooled local recurrence, median survival, and pooled morbidity were measured.

RESULTS

Twenty unique studies were included (14 cohort, 5 comparative cohort, and 1 randomized controlled trial), describing 1068 patients. Patient choice, prohibitive comorbidity, good clinical response, and early stage disease were the most frequent indications for local excision. Pretreatment T2 and T3 tumors accounted for 46.4% and 30.7% of cases. Long-course treatment was administered in all of the studies, except to a cohort of 64 patients who received short-course radiotherapy. Pooled complete clinical response was 45.8% (95% CI, 31.4%-60.5%), and pooled complete pathological response was 44.2% (95% CI, 36.4%-52.0%). Median follow-up was 54 months (range, 12-81 months). ypT0 tumors had a pooled local recurrence rate of 4.0% (95% CI, 1.9%-6.9%) and a median disease-free survival rate of 95.0% (95% CI, 87.4%-100%). Pooled local recurrence and median disease-free survival rates for ypT1 tumors or higher were 21.9% (95% CI, 15.9%-28.5%) and 68.0% (58.3%-69.0%). Pooled incidence of complications was 23.2% (95% CI, 15.7%-31.7%), with suture-line dehiscence reported in 9.9% (95% CI, 4.8%-16.7%).

LIMITATIONS

Limitations included study quality, high risk of selection bias and detection bias in study designs, and limited sample sizes.

CONCLUSIONS

Local excision after neoadjuvant therapy should only be considered a curative treatment if complete pathological response is obtained. Given the high rate of local recurrence among incomplete responders, future studies should focus on predicting patients who will achieve complete pathological response.

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Novel Radiation Approaches for the Treatment of Rectal Cancer: Where Are We Now? CURRENT COLORECTAL CANCER REPORTS 2016. [DOI: 10.1007/s11888-016-0337-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]

Jeong JU, Nam TK, Kim HR, Shim HJ, Kim YH, Yoon MS, Song JY, Ahn SJ, Chung WK. Adjuvant chemoradiotherapy instead of revision radical resection after local excision for high-risk early rectal cancer. Radiat Oncol 2016;11:114. [PMID: 27595767 PMCID: PMC5011790 DOI: 10.1186/s13014-016-0692-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Accepted: 08/31/2016] [Indexed: 01/30/2023] Open

Abstract

BACKGROUND

After local excision of early rectal cancer, revision radical resection is recommended for patients with high-risk pathologic stage T1 (pT1) or pT2 cancer, but the revision procedure has high morbidity rates. We evaluated the efficacy of adjuvant concurrent chemoradiotherapy (CCRT) for reducing recurrence after local excision in these patients.

METHODS

Eighty-three patients with high-risk pT1 or pT2 rectal cancer underwent postoperative adjuvant CCRT after local excision. We defined high-risk features as pT1 having tumor size ≤3 cm, and/or resection margin (RM) ≤3 mm, and/or lymphovascular invasion (LVI), and/or non-full thickness excision such as endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD), or unknown records regarding those features, or pT2 cancer. Radiotherapy was administered with a median dose of 50.4 Gy in 1.8 Gy fraction size over 5-7 weeks. Concurrent 5-fluorouracil and leucovorin were administered for 4 days in the first and fifth weeks of radiotherapy.

RESULTS

The median interval between local excision and radiotherapy was 34 (range, 11-104) days. Fifteen patients (18.1 %) had stage pT2 tumors, 22 (26.5 %) had RM of ≥3 mm, and 21 (25.3 %) had tumors of ≥3 cm in size. Thirteen patients (15.7 %) had LVI. Transanal excision was performed in 58 patients (69.9 %) and 25 patients (30.1 %) underwent EMR or ESD. The median follow-up was 61 months. The 5-year overall survival (OS), locoregional relapse-free survival (LRFS), and disease-free survival (DFS) rates for all patients were 94.9, 91.0, and 89.8 %, respectively. Multivariate analysis did not identify any significant factors for OS or LRFS, but the only significant factor affecting DFS was the pT stage (p = 0.027).

CONCLUSIONS

In patients with high-risk pT1 rectal cancer, adjuvant CCRT after local excision could be an effective alternative treatment instead of revision radical resection. However, patients with pT2 stage showed inferior DFS compared to pT1.

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Hunter C, Brown G. Pre-operative staging of rectal cancer: a review of imaging techniques. Expert Rev Gastroenterol Hepatol 2016;10:1011-25. [PMID: 27152870 DOI: 10.1080/17474124.2016.1179577] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]

Borstlap WAA, Tanis PJ, Koedam TWA, Marijnen CAM, Cunningham C, Dekker E, van Leerdam ME, Meijer G, van Grieken N, Nagtegaal ID, Punt CJA, Dijkgraaf MGW, De Wilt JH, Beets G, de Graaf EJ, van Geloven AAW, Gerhards MF, van Westreenen HL, van de Ven AWH, van Duijvendijk P, de Hingh IHJT, Leijtens JWA, Sietses C, Spillenaar-Bilgen EJ, Vuylsteke RJCLM, Hoff C, Burger JWA, van Grevenstein WMU, Pronk A, Bosker RJI, Prins H, Smits AB, Bruin S, Zimmerman DD, Stassen LPS, Dunker MS, Westerterp M, Coene PP, Stoot J, Bemelman WA, Tuynman JB. A multi-centred randomised trial of radical surgery versus adjuvant chemoradiotherapy after local excision for early rectal cancer. BMC Cancer 2016;16:513. [PMID: 27439975 PMCID: PMC4955121 DOI: 10.1186/s12885-016-2557-x] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 07/13/2016] [Indexed: 12/13/2022] Open

Abstract

Background

Rectal cancer surgery is accompanied with high morbidity and poor long term functional outcome. Screening programs have shown a shift towards more early staged cancers. Patients with early rectal cancer can potentially benefit significantly from rectal preserving therapy. For the earliest stage cancers, local excision is sufficient when the risk of lymph node disease and subsequent recurrence is below 5 %. However, the majority of early cancers are associated with an intermediate risk of lymph node involvement (5–20 %) suggesting that local excision alone is not sufficient, while completion radical surgery, which is currently standard of care, could be a substantial overtreatment for this group of patients.

Methods/Study design

In this multicentre randomised trial, patients with an intermediate risk T1-2 rectal cancer, that has been locally excised using an endoluminal technique, will be randomized between adjuvant chemo-radiotherapylimited to the mesorectum and standard completion total mesorectal excision (TME). To strictly monitor the risk of locoregional recurrence in the experimental arm and enable early salvage surgery, there will be additional follow up with frequent MRI and endoscopy. The primary outcome of the study is three-year local recurrence rate. Secondary outcomes are morbidity, disease free and overall survival, stoma rate, functional outcomes, health related quality of life and costs. The design is a non inferiority study with a total sample size of 302 patients.

Discussion

The results of the TESAR trial will potentially demonstrate that adjuvant chemoradiotherapy is an oncological safe treatment option in patients who are confronted with the difficult clinical dilemma of a radically removed intermediate risk early rectal cancer by polypectomy or transanal surgery that is conventionally treated with subsequent radical surgery. Preserving the rectum using adjuvant radiotherapy is expected to significantly improve morbidity, function and quality of life if compared to completion TME surgery.

Trial registration

NCT02371304, registration date: February 2015

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Affiliation(s)

W A A Borstlap Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
P J Tanis Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
T W A Koedam Department of Surgery, VU University Medical Center, De Boelelaan 1117, 1081 HZ, Amsterdam, The Netherlands
C A M Marijnen Department of Radiotherapy, Leiden University Medical Center, Leiden, The Netherlands
C Cunningham Department of Surgery, Oxford University Hospital, Oxford, UK
E Dekker Department of Gastroenterology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
M E van Leerdam Department of Gastroenterology, Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
G Meijer Department of Pathology, Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
N van Grieken Department of Pathology, VU University Medical Center, Amsterdam, The Netherlands
I D Nagtegaal Department of Pathology, RadboudUMC, Nijmegen, The Netherlands
C J A Punt Department of Medical Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
M G W Dijkgraaf Clinical Research Unit, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
J H De Wilt Department of Surgery, RadboudUMC, Nijmegen, The Netherlands
G Beets Department of Surgery, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
E J de Graaf Department of Surgery, IJselland Hospital, Capelle aan de Ijssel, The Netherlands
A A W van Geloven Department of surgery, Tergooi Hospital, Hilversum, The Netherlands
M F Gerhards Department of surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
H L van Westreenen Department of surgery, Isala Hospital, Zwolle, The Netherlands
A W H van de Ven Department of surgery, Flevo Hospital, Almere, The Netherlands
P van Duijvendijk Department of surgery, Gelre Hospital, Apeldoorn, The Netherlands
I H J T de Hingh Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
J W A Leijtens Department of Surgery, Laurentius Hospital, Roermond, The Netherlands
C Sietses Department of Surgery, Gelderse Vallei Hospital, Ede, The Netherlands
E J Spillenaar-Bilgen Department of Surgery, Rijnstate Hospital, Arnhem, The Netherlands
R J C L M Vuylsteke Department of Surgery, Spaarne Gasthuis, Haarlem, The Netherlands
C Hoff Department of Surgery, Medisch Centrum Leewarden, Leeuwarden, The Netherlands
J W A Burger Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
W M U van Grevenstein Department of Surgery, University Medical Center, Utrecht, The Netherlands
A Pronk Department of Surgery, Diaconessenziekehuis, Utrecht, The Netherlands
R J I Bosker Department of Surgery, Deventer Hospital, Deventer, The Netherlands
H Prins Department of Surgery, Jeroen Bosch Hospital, Den Bosch, The Netherlands
A B Smits Department of Surgery, Sint. Antonius Hospital, Nieuwegein, The Netherlands
S Bruin Department of Surgery, Slotervaart Hospital, Amsterdam, The Netherlands
D D Zimmerman Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
L P S Stassen Department of Surgery, MUMC, Maastricht, The Netherlands
M S Dunker Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
M Westerterp Department of Surgery, Medical Center Haaglanden, The Hague, The Netherlands
P P Coene Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands
J Stoot Department of Surgery, Zuyderland Hospital, Sittard, The Netherlands
W A Bemelman Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
J B Tuynman Department of Surgery, VU University Medical Center, De Boelelaan 1117, 1081 HZ, Amsterdam, The Netherlands.

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Borstlap WAA, Coeymans TJ, Tanis PJ, Marijnen CAM, Cunningham C, Bemelman WA, Tuynman JB. Meta-analysis of oncological outcomes after local excision of pT1-2 rectal cancer requiring adjuvant (chemo)radiotherapy or completion surgery. Br J Surg 2016;103:1105-16. [PMID: 27302385 DOI: 10.1002/bjs.10163] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 02/16/2016] [Accepted: 02/17/2016] [Indexed: 01/29/2023]

Abstract

BACKGROUND

Completion total mesorectal excision (TME) is advised for high-risk early (pT1/pT2) rectal cancer following transanal removal. The main objective of this meta-analysis was to determine oncological outcomes of adjuvant (chemo)radiotherapy as a rectum-preserving alternative to completion TME.

METHODS

A literature search using PubMed, Embase and the Cochrane Library was performed in February 2015. Studies had to include at least ten patients with pT1/pT2 adenocarcinomas that were removed transanally and followed by either adjuvant chemoradiotherapy or completion surgery. A weighted average of the logit proportions was determined for the pooled analyses of subgroups according to treatment modality and pT category.

RESULTS

In total, 14 studies comprising 405 patients treated with adjuvant (chemo)radiotherapy and seven studies comprising 130 patients treated with completion TME were included. Owing to heterogeneity it was not possible to compare the two strategies directly. However, the weighted average local recurrence rate for locally excised pT1/pT2 rectal cancer treated with adjuvant (chemo)radiotherapy was 14 (95 per cent c.i. 11 to 18) per cent, and 7 (4 to 14) per cent following completion TME. The weighted averages for distance recurrence were 9 (6 to 14) and 9 (5 to 16) per cent respectively. Weighted averages for local recurrence rate after adjuvant chemo(radiotherapy) and completion TME for pT1 were 10 (4 to 21) and 6 (3 to 15) per cent respectively. Corresponding averages for pT2 were 15 (11 to 21) and 10 (4 to 22) per cent respectively.

CONCLUSION

A higher recurrence rate after transanal excision and adjuvant (chemo)radiotherapy must be balanced against the morbidity and mortality associated with mesorectal excision. A reasonable approach is close follow-up and salvage mesorectal surgery as needed.

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Brunner W, Widmann B, Marti L, Tarantino I, Schmied BM, Warschkow R. Predictors for regional lymph node metastasis in T1 rectal cancer: a population-based SEER analysis. Surg Endosc 2016;30:4405-15. [PMID: 26895892 DOI: 10.1007/s00464-016-4759-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 01/11/2016] [Indexed: 02/06/2023]

Lee GC, Sylla P. Shifting Paradigms in Minimally Invasive Surgery: Applications of Transanal Natural Orifice Transluminal Endoscopic Surgery in Colorectal Surgery. Clin Colon Rectal Surg 2015;28:181-93. [PMID: 26491411 DOI: 10.1055/s-0035-1555009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]

Abstract

Since the advent of laparoscopy, minimally invasive techniques such as single port laparoscopy, robotics, endoscopically assisted laparoscopy, and transanal endoscopic surgery continue to revolutionize the field of colorectal surgery. Transanal natural orifice transluminal endoscopic surgery (NOTES) represents a further paradigm shift by combining the advantages of these earlier techniques to reduce the size and number of abdominal incisions and potentially optimize rectal dissection, especially with respect to performance of an oncologically adequate total mesorectal excision (TME) for rectal cancer. Since the first experimental report of transanal rectosigmoid resection in 2007, the potential impact of transanal NOTES in colorectal surgery has been extensively investigated in experimental models and recently transitioned to clinical application. There have been 14 clinical trials of transanal TME (taTME) for rectal cancer that have demonstrated the feasibility and preliminary oncologic safety of this approach in carefully selected patients, with results comparable to outcomes after laparoscopic and open TME, including cumulative intraoperative and postoperative complication rates of 5.5 and 35.5%, respectively, 97.3% rate of complete or near-complete specimens, and 93.6% rate of negative margins. Transanal NOTES has also been safely applied to proctectomy and colectomy for benign indications. The consensus among published series suggests that taTME is most safely performed with transabdominal assistance by surgeons experienced with laparoscopic TME, transanal endoscopic surgery, and sphincter-preserving techniques including intersphincteric resection. Future applications of transanal NOTES may include evolution to a pure endoscopic transanal approach for TME, colectomy, and sentinel lymph node biopsy for rectal cancer, with a potential role for robotic assistance.

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