Recurrence After Transanal Excision of T1 Rectal Cancer: Should We Be Concerned?

Madbouly, Khaled; Remzi, Feza H.; Erkek, B.; Senagore, Anthony J.; Baeslach, Christen M.; Khandwala, Farah; Fazio, Victor W.; Lavery, Ian C.

doi:10.1007/s10350-004-0666-0

Cited by 160 publications

(92 citation statements)

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“…Unfortunately, the conventional transanal excision is characterized by a high incidence of remnant disease or early recurrence [8,9]. For more than 25 years, transanal endoscopic microsurgery (TEM) had revolutionized the technique and outcome of transanal surgery, becoming the standard of treatment for large rectal adenomas [10][11][12], then offering a possibly curative treatment for early rectal cancer [13,14], and, finally, generating discussion on the potential role in the treatment of more invasive cancer in combination with neoadjuvant treatments [15][16][17][18].…”

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confidence: 99%

Risk factors for recurrence after transanal endoscopic microsurgery for rectal malignant neoplasm

et al. 2011

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BackgroundIndications and results of local excision of rectal lesions are currently under debate. Transanal endoscopic microsurgery (TEM), allowing a precise, full-thickness excision, could improve oncological results in early rectal tumors. Methods A prospective database was analyzed with the intent to identify risk factors for recurrence after TEM. Results Among 355 patients subjected to TEM, 107 had an adenocarcinoma: 48 pT1, 43 pT2, and 16 pT3. Comparing pre-and postoperative data, histological discrepancy was 20% and staging discrepancy was 34%. Mortality was nil, morbidity was 9%. Mean follow-up was 54.2 months (range = 12-164), follow-up rate was 100%. The 5-year disease-free survival rate was 85.9, 78.4, and 49.4% for pT1, pT2, and pT3, respectively (p = 0.006). Recurrence rate was 0% (0/26) in pT1sm1 cancers and 22.7% (5/22) in sm2-3 (p < 0.05). A submucosal infiltration represented a significant risk factor for recurrences: 0% sm1, 16.7% sm2, and 30% sm3. Recurrence in pT2 was 0% in patients who had neoadjuvant therapy and 26% in the others. At univariate analysis, diameter, sm stage, pT stage, tumor grading, margin infiltration, and lymphovascular invasion demonstrated statistical significance. Multivariate analysis indicated sm stage, pT stage, and tumor grading as independent predictors of recurrence. Conclusions TEM represents an effective curative treatment for pT1 sm1 rectal malignancies. pT1 sm2-3 patients should be considered high-risk cases if treated only by TEM. A consistent improvement in the preoperative assessment of the risk factors identified by the present study will be a crucial development for optimal treatment of early rectal cancers. Keywords Transanal endoscopic microsurgery Malignant rectal neoplasm Recurrence Risk factors The goal of oncological surgery is to achieve the best cancer control with preservation of function and quality of life. In the field of malignant rectal neoplasms, radical resection, consisting of anterior resection with total mesorectal excision (TME) when feasible and abdominoperineal resection (APR) when mandatory, represents the best curative treatment. Nevertheless, these procedures are burdened with a consistent morbidity rate, including genitourinary and sexual dysfunction (30-40%) [1][2][3][4], anastomotic leakage (5-17%) [5], and long-term functional bowel disturbance [6]. Up to 40% of patients experience perineal wound complications and long-term discomfort following APR, while stoma and stoma appliance-related complications occur in up to 66%. There is also significant psychological morbidity associated with change in body image and depression in 30% [7].A transanal approach to rectal malignant neoplasms, if suitable, would lower risks and improve functional results. Unfortunately, the conventional transanal excision is characterized by a high incidence of remnant disease or early recurrence [8,9]. For more than 25 years, transanal endoscopic microsurgery (TEM) had revolutionized the technique and outcome of transanal surgery, becoming the ...

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Risk factors for recurrence after transanal endoscopic microsurgery for rectal malignant neoplasm

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“…However, historical data on transanal excisions showed unacceptably high local recurrence rates (LR) (0-28.8 %) [11][12][13][14][15].…”

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Transanal Endoscopic Microsurgery (TEM) for Rectal Cancer: University Hospital of North Tees Experience

et al. 2014

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Transanal endoscopic microsurgery (TEM) is a minimally invasive technique that is increasingly being used to treat early rectal cancer (T1/T2). We studied the outcomes of TEM for rectal cancer at our institution looking at the indication, recurrence rate, need for further radical surgery, 30-day and 12-month mortality and complication rate. We performed a retrospective analysis of prospectively collected data of cases between 2008 and 2012: 110 TEM procedures were performed during this period: 40 were confirmed rectal cancers and 70 were benign. We analysed the data for the 40 patients with confirmed rectal cancer. Thirty (75 %) of the subjects were male with a mean age of 71±10 years (range 49-90 years) and 19 (48 %) patients were ASA 3 and 4. Nineteen (48 %) of cancers were pT1, eighteen (45 %) were pT2, two (5 %) were pT3 and one was yPT0. Mean specimen size was 66±20 mm (range 33-120 mm) with a mean polyp size of 41±24 mm (range 18-110 mm). The mean cancer size was 24±13 mm (range 2-50 mm). Average distance from the anal verge was 70 ±37 mm (range 10-150 mm), and the mean operating time was 72±22 min (range 40-120 min), with an average blood loss of 28±15 ml (range 10-50ml). Median hospital stay was 2±1 days (range 1-7 days). Complete excision (R0) was achieved in 37 (93 %) patients. Minor post-operative complications included urinary retention in two and pyrexia in three patients. There were no 30-day or 12-month mortalities. Mean follow-up was 13±11 months, range (3-40 months) Local recurrence occurred in two (5 %) patients, both underwent redo TEM. Twelve (30 %) patients underwent laparoscopic radical resections (seven AR and five APER) post-TEM. Post-operative histology confirmed pT0N0 in 7/12 patients. Three were lymph node-positive (T0N1), one was pT3N1 and the fifth was pT3N2. TEM is associated with quicker recovery, shorter hospital stay and fewer complications than radical surgery. It is a good alternative to radical surgery in early rectal cancer, especially for high-risk patients. Recurrent tumours can be treated with redo TEM.

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“…Additionally, some of the patients require temporary diverting enterostomies. On the other hand, there are conventional, sphincterpreserving techniques, such as conventional transanal resection with Park's retractor (Parks, 1970), which are associated with an almost unacceptably high local recurrence rate of up to 29% (Madbouly et al, 2005). The primary factor limiting the effectiveness of local treatment for early rectal cancer is lymph node invasion.…”

Section: Tem For Early Rectal Cancermentioning

confidence: 99%

Transanal Endoscopic Microsurgery - State of the Art

Palma¹,

Horisberger²

2011

Therapeutic Gastrointestinal Endoscopy

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Recurrence After Transanal Excision of T1 Rectal Cancer: Should We Be Concerned?

Cited by 160 publications

References 50 publications

Risk factors for recurrence after transanal endoscopic microsurgery for rectal malignant neoplasm

Risk factors for recurrence after transanal endoscopic microsurgery for rectal malignant neoplasm

Transanal Endoscopic Microsurgery (TEM) for Rectal Cancer: University Hospital of North Tees Experience

Transanal Endoscopic Microsurgery - State of the Art

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