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Wetterholm E, Rönnow CF, Thorlacius H. Risk of recurrence following transanal endoscopic microsurgery without neoadjuvant or adjuvant treatment in T2 rectal cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2025; 51:109974. [PMID: 40139119 DOI: 10.1016/j.ejso.2025.109974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2024] [Revised: 02/15/2025] [Accepted: 03/12/2025] [Indexed: 03/29/2025]
Abstract
BACKGROUND Transanal endoscopic microsurgery (TEM) is only curative treatment for T1 rectal cancer with low-risk features. In T2 cancer, TEM is not recommended but could be used as a palliative procedure and/or in patients unfit for surgery. Few studies exist investigating recurrence after TEM for T2 rectal cancer. METHOD Retrospective, population-based study using the Swedish Colorectal Cancer Registry. Included patients had T2 rectal adenocarcinoma treated with TEM or surgery without neoadjuvant or adjuvant therapy between 2009 and 2021. Patients lost to follow-up, with syn/metachronous tumours or unknown recurrence status were excluded. Patient characteristics, perioperative morbidity, local and distant recurrence were compared. RESULTS 63 patients treated with TEM and 894 with surgery. Median age was 81 and 70 (p < 0.01). 59 % and 23 % respectively were ASA III-IV (p < 0.01). TEM tumours were more distal, 37 % vs 16 % in the lower third of the rectum (p < 0.01). There were no severe complications after TEM compared to 6 % following surgery (p = 0.04). 5-year local recurrence was 33 % after TEM and 2 % after surgery (HR = 25.58, (p < 0.01). 5-year distant recurrence rate was 9 % after TEM and 7 % after surgery (HR = 0.49, (p = 0.27). Mean time to local recurrence was 16 months after TEM, 34 months after surgery, time to distant recurrence 22 months after both. CONCLUSION TEM for T2 rectal cancer has high risk of local recurrence and cannot be recommended when intent is curative. TEM could be an option for patients unfit for surgery.
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Affiliation(s)
- Erik Wetterholm
- Department of Clinical Sciences, Malmö, Division of Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Carl-Fredrik Rönnow
- Department of Clinical Sciences, Malmö, Division of Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Henrik Thorlacius
- Department of Clinical Sciences, Malmö, Division of Surgery, Skåne University Hospital, Lund University, Malmö, Sweden.
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Woo JS, Cho MJ, Park IK, Im YC, Kim GY, Park DJ, Yang S. Initial case series experience with robotic-assisted transanal minimally invasive surgery performed with da Vinci single-port system for the excision of rectal cancer. Surg Endosc 2024; 38:6762-6770. [PMID: 39160313 DOI: 10.1007/s00464-024-11142-w] [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: 04/20/2024] [Accepted: 08/01/2024] [Indexed: 08/21/2024]
Abstract
BACKGROUND Transanal minimally invasive surgery (TAMIS) is widely used for rectal lesion excision. Robot-assisted TA TAMIS (R-TAMIS) may improve surgical ergonomics. The introduction of the da Vinci Single-Port (SP) robot, designed for endoluminal surgery, has brought new possibilities. Our primary objective herein was to assess the technical and oncological feasibility and efficacy of Single-port robotic TAMIS (SPR-TAMIS) in rectal cancer excision. The secondary objective was to analyze the perioperative outcomes. MATERIALS AND METHODS We included 14 consecutive patients with rectal cancer who underwent SPR-TAMIS between April 2021 and February 2023. Patient data, surgical details, and clinical outcome data were collected to assess the safety and feasibility of SPR-TAMIS. RESULTS The median participant age was 72 years, and full-thickness excision was performed without specimen fragmentation in all cases. The median tumor diameter was 2.7 cm, positioned between 10 cm proximally and 7 cm distally from the anal verge. Negative margins were achieved in 93% of cases, with one case requiring further resection. The median operative time was 175 min, and the median hospital stay was 5 days. No intraoperative conversion from SPR-TAMIS to laparoscopic or conventional transanal excision was required. No mortalities or major postoperative complications occurred; however, one patient (7.1%) experienced minor morbidity manifesting as wound dehiscence (Clavien-Dindo grade I). No recurrence was observed during the 24-month follow-up. CONCLUSIONS In our early experience, SPR-TAMIS is a safe and feasible surgery for selected early stage rectal cancers, offering enhanced visualization and stable maneuverability transanally. This platform may have potential advantages for the excision of larger or more proximal lesions.
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Affiliation(s)
- Ji Su Woo
- Department of Surgery, University of Ulsan College of Medicine, Ulsan University Hospital, 15, Daehakbyeongwon-ro, Dong-gu, Ulsan, South Korea
| | - Min Jeng Cho
- Department of Surgery, University of Ulsan College of Medicine, Ulsan University Hospital, 15, Daehakbyeongwon-ro, Dong-gu, Ulsan, South Korea
| | - In Kyu Park
- Department of Surgery, University of Ulsan College of Medicine, Ulsan University Hospital, 15, Daehakbyeongwon-ro, Dong-gu, Ulsan, South Korea
| | - Yeong Cheol Im
- Department of Surgery, University of Ulsan College of Medicine, Ulsan University Hospital, 15, Daehakbyeongwon-ro, Dong-gu, Ulsan, South Korea
| | - Gyu Yeol Kim
- Department of Surgery, University of Ulsan College of Medicine, Ulsan University Hospital, 15, Daehakbyeongwon-ro, Dong-gu, Ulsan, South Korea
| | - Dong Jin Park
- Department of Surgery, University of Ulsan College of Medicine, Ulsan University Hospital, 15, Daehakbyeongwon-ro, Dong-gu, Ulsan, South Korea
| | - Songsoo Yang
- Department of Surgery, University of Ulsan College of Medicine, Ulsan University Hospital, 15, Daehakbyeongwon-ro, Dong-gu, Ulsan, South Korea.
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Farid A, Tutton M, Thambi P, Gill TS, Khan J. Local excision of early rectal cancer: A multi-centre experience of transanal endoscopic microsurgery from the United Kingdom. World J Gastrointest Surg 2024; 16:3114-3122. [PMID: 39575271 PMCID: PMC11577408 DOI: 10.4240/wjgs.v16.i10.3114] [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: 06/09/2024] [Revised: 07/25/2024] [Accepted: 09/03/2024] [Indexed: 09/27/2024] Open
Abstract
BACKGROUND Total mesorectal excision remains the gold standard for the management of rectal cancer however local excision of early rectal cancer is gaining popularity due to lower morbidity and higher acceptance by the elderly and frail patients. AIM To investigate the results of local excision of rectal cancer by transanal endoscopic microsurgery (TEMS) approach carried out at three large cancer centers in the United Kingdom. METHODS TEMS database was retrospectively reviewed to assess demographics, operative findings and post operative clinical and oncological outcomes. This is a retrospective review of the prospective databases, which included all patients operated with TEMS approach, for early rectal cancer (Node-negative T1-T2), selected T3 in unfit/frail patients. RESULTS Two hundred and twenty-two patients underwent TEMS surgery. This included 144 males (64.9%) and 78 females (35.1%), Median age was 71 years. The median distance of the tumours from the anal verge 4.5 cm. Median tumour size was 2.6 cm. The most frequent operative position of the patient was lithotomy (32.3%), Full-thickness rectal wall excision was done in 204 patients. Median operating time was 90 minutes. Average blood loss was minimal. There were two 90-day mortalities. Complete excision of the tumour with free microscopic margins by > 1mm were accomplished in 171 patients (76.7%). Salvage total mesorectal excision was performed in 42 patients (19.8%). Median disease-free survival was 65 months (range: 3-146 months) (82.8%), and median overall survival was 59 months (0-146 months). CONCLUSION TEMS provides a promising option for early rectal cancers (Large adenomas-cT1/cT2N0), and selected therapy-responding cancers. Full-thickness complete excision of the tumour is mandatory to avoid jeopardising the oncological outcomes.
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Affiliation(s)
- Ahmed Farid
- Department of General Surgery, Oncology Center Mansoura University, Cairo 11432, Egypt
| | - Matthew Tutton
- Department of Colorectal Surgery, East Suffolk and North Essex NHS Trust, Colchester CO1 1AA, Essex, United Kingdom
| | - Prem Thambi
- Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth PO6 3LY, Hampshire, United Kingdom
| | - TS Gill
- Department of Surgery, University Hospital of North Tees, Stockton on Tees TS18-TS21, Darlington, United Kingdom
| | - Jim Khan
- Department of General Surgery, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth PO6 3LY, Hampshire, United Kingdom
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4
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Read M, Felder S. Transanal Approaches to Rectal Neoplasia. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Berger NF, Sylla P. The Role of Transanal Endoscopic Surgery for Early Rectal Cancer. Clin Colon Rectal Surg 2022; 35:113-121. [PMID: 35237106 PMCID: PMC8885158 DOI: 10.1055/s-0041-1742111] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Transanal endoscopic surgery (TES), which is performed through a variety of transanal endoluminal multitasking surgical platforms, was developed to facilitate endoscopic en bloc excision of rectal lesions as a minimally invasive alternative to radical proctectomy. Although the oncologic safety of TES in the treatment of malignant rectal tumors has been an area of vigorous controversy over the past two decades, TES is currently accepted as an oncologically safe approach for the treatment of carefully selected early and superficial rectal cancers. TES can also serve as both a diagnostic and potentially curative treatment of partially resected unsuspected malignant polyps. In this article, indications and contraindications for transanal endoscopic excision of early rectal cancer lesions are reviewed, as well as selection criteria for the most appropriate transanal excisional approach. Preoperative preparation and surgical technique for complications of TES will be reviewed, as well as recommended surveillance and management of upstaged tumors.
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Affiliation(s)
| | - Patricia Sylla
- Icahn School of Medicine at Mount Sinai, New York, New York,Division of Colon and Rectal Surgery, Department of Surgery, Mount Sinai Hospital, New York, New York,Address for correspondence Patricia Sylla, MD, FACS, FASCRS Division of Colon and Rectal Surgery, Department of Surgery, Mount Sinai Hospital5 East 98th Street, Box 1259, New York, NY 10029
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Haak HE, Beets GL, Peeters K, Nelemans PJ, Valentini V, Rödel C, Kuo L, Calvo FA, Garcia-Aguilar J, Glynne-Jones R, Pucciarelli S, Suarez J, Theodoropoulos G, Biondo S, Lambregts DMJ, Beets-Tan RGH, Maas M. Prevalence of nodal involvement in rectal cancer after chemoradiotherapy. Br J Surg 2021; 108:1251-1258. [PMID: 34240110 PMCID: PMC8604154 DOI: 10.1093/bjs/znab194] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 04/28/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND The purpose of this study was to investigate the prevalence of ypN+ status according to ypT category in patients with locally advanced rectal cancer treated with chemoradiotherapy and total mesorectal excision, and to assess the impact of ypN+ on disease recurrence and survival by pooled analysis of individual-patient data. METHODS Individual-patient data from 10 studies of chemoradiotherapy for rectal cancer were included. Pooled rates of ypN+ disease were calculated with 95 per cent confidence interval for each ypT category. Kaplan-Meier and Cox regression analyses were undertaken to assess influence of ypN status on 5-year disease-free survival (DFS) and overall survival (OS). RESULTS Data on 1898 patients were included in the study. Median follow-up was 50 (range 0-219) months. The pooled rate of ypN+ disease was 7 per cent for ypT0, 12 per cent for ypT1, 17 per cent for ypT2, 40 per cent for ypT3, and 46 per cent for ypT4 tumours. Patients with ypN+ disease had lower 5-year DFS and OS (46.2 and 63.4 per cent respectively) than patients with ypN0 tumours (74.5 and 83.2 per cent) (P < 0.001). Cox regression analyses showed ypN+ status to be an independent predictor of recurrence and death. CONCLUSION Risk of nodal metastases (ypN+) after chemoradiotherapy increases with advancing ypT category and needs to be considered if an organ-preserving strategy is contemplated.
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Affiliation(s)
- H E Haak
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
| | - G L Beets
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
| | - K Peeters
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - P J Nelemans
- Department of Epidemiology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - V Valentini
- Department of Radiation Oncology, Universita Cattolica del Sacro Cuore, Rome, Italy
| | - C Rödel
- Department of Radiation Oncology, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - L Kuo
- Department of Colorectal Surgery, Taipei Medical University Hospital, Taipei, Taiwan
| | - F A Calvo
- Department of Oncology, General University Hospital Gregorio Marañón, Madrid, Spain
| | - J Garcia-Aguilar
- Department of Surgery, Memorial Sloan Kettering Cancer Centre, New York, USA
| | - R Glynne-Jones
- Department of Clinical Oncology, Mount Vernon Hospital, London, UK
| | - S Pucciarelli
- Department of Surgical, Oncological and Gastroenterological Sciences, First Surgical Clinic, University of Padua, Padua, Italy
| | - J Suarez
- Department of Surgery, Hospital de Navarra, Pamplona, Spain
| | - G Theodoropoulos
- First Department of Propaedeutic Surgery, Athens Medical School, Hippocration General Hospital, Athens, Greece
| | - S Biondo
- Department of Surgery, Bellvitge University Hospital, Barcelona, Spain
- IDIBELL, University of Barcelona, Barcelona, Spain
| | - D M J Lambregts
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - R G H Beets-Tan
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - M Maas
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
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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]
Abstract
BACKGROUND The evaluation of lymph nodes in rectal cancer dictates treatment. The goals of this study are to characterize the contemporary rate of lymph node metastasis in early stage rectal cancer and to re-investigate histologic factors that predict positive lymph nodes. MATERIALS AND METHODS Using the National Cancer Database, we identified patients with clinical stage I rectal adenocarcinoma. Multivariable logistic regression was used to determine risk factors for lymph node positivity. RESULTS 12.2% of patients with T1 tumors and 18.0% of patients with T2 tumors had positive lymph nodes. For T1 tumors, positive lymph nodes were present in 9.3% with neither poor differentiation nor lymphovascular invasion (LVI), 17.3% with poor differentiation alone, 34.7% with LVI alone, and 45.0% with both poor differentiation and LVI. For T2 tumors, positive lymph nodes were present in 11.7% with neither poor differentiation nor LVI, 25.3% with poor differentiation alone, 47.3% with LVI alone, and 41.5% with both poor differentiation and LVI. LVI was an independent predictor of positive lymph nodes (OR;4.75,95%CI;3.17-7.11,p < 0.001) for T1 and (OR;6.20,95%CI;4.53-8.51,p < 0.001) T2 tumors. CONCLUSIONS T1/T2 tumors have higher rates of positive lymph nodes when poor differentiation and LVI are present. These results should be taken into consideration prior to surgical treatment.
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Affiliation(s)
- Adam C Fields
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
| | - Pamela Lu
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Frances Hu
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Sameer Hirji
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Jennifer Irani
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Ronald Bleday
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Nelya Melnitchouk
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Joel E Goldberg
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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Feasibility and Advantages of Transanal Minimally Invasive Surgery (TAMIS) for Various Lesions in the Rectum. ACTA ACUST UNITED AC 2020; 23:36-42. [PMID: 35600726 PMCID: PMC8985647 DOI: 10.7602/jmis.2020.23.1.36] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/11/2019] [Accepted: 10/21/2019] [Indexed: 12/14/2022]
Abstract
Purpose We report our experience in the use of transanal minimally invasive surgery (TAMIS) and the feasibility and safety of this surgical technique in operating for various rectal diseases that require a transanal approach. Methods Between 2013 and 2019, 30 patients underwent TAMIS for a rectal lesion at Seoul National University Boramae Medical Center. The clinical data including age, gender, body mass index, tumour size, distance from the anal verge, diagnosis, operation time, postoperative complications, duration of hospital stay, and post-operative margin status were obtained retrospectively from the electronic medical records. Results The mean operation time was 52.1±33.5 and the mean duration of hospital stay after surgery was 4.3±4.2 days. Most of the patients had undergone TAMIS for neuroendocrine tumor (NET) (60%) followed by an adenoma (16.7%) and rectal cancer (13.3%). 4 patients (13.3%) had minor complications after TAMIS. 2 patients (50%) had complained of diarrhea, 1 patient (25%) complained of fecal incontinence and 1 patient (25%) been diagnosed fluid in the operation bed. Conclusion TAMIS is a useful method for local excision of rectal lesion located in mid to upper rectum as well as other rectal pathologies that require a transanal approach.
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Yoshida N, Nakanishi M, Inoue K, Yasuda R, Hirose R, Naito Y, Itoh Y, Arita T, Murayama Y, Kuriu Y, Otsuji E, Yanagisawa A, Ogiso K, Murakami T, Morinaga Y, Konishi E, Inada Y, Kishimoto M. Pure Well-Differentiated Adenocarcinoma Is a Safe Factor for Lymph Node Metastasis in T1 and T2 Colorectal Cancer: A Pilot Study. Gastroenterol Res Pract 2018; 2018:8798405. [PMID: 30581465 PMCID: PMC6276412 DOI: 10.1155/2018/8798405] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 09/07/2018] [Accepted: 09/25/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND AIMS Various risk factors for lymph node metastasis (LNM) have been reported in colorectal T1 cancers. However, the factors available are insufficient for predicting LNM. We therefore investigated the utility of the new histological factor "pure well-differentiated adenocarcinoma" (PWDA) as a safe factor for predicting LNM in T1 and T2 cancers. MATERIALS AND METHODS We reviewed 115 T2 cancers and 202 T1 cancers in patients who underwent surgical resection in our center. We investigated the rates of LNM among various clinicopathological factors, including PWDA. PWDA was defined as a lesion comprising only well-differentiated adenocarcinoma. The consistency of the diagnosis of PWDA was evaluated among two pathologists. In addition, 72 T1 cancers with LNM from 8 related hospitals over 10 years (2008-2017) were also analyzed. RESULTS The rates of LNM and PWDA were 23.5% and 20.0%, respectively, in T2 cancers. Significant differences were noted between patients with and without LNM regarding lymphatic invasion (81.5% vs. 36.4%, p < 0.001), poor histology (51.9% vs. 19.3%, p = 0.008), and PWDA (3.7% vs. 25.0%, p = 0.015). The rates of LNM and PWDA were 8.4% and 36.1%, respectively, in T1 cancers. Regarding the 73 PWDA cases and 129 non-PWDA cases, the rates of LNM were 0.0% and 13.2%, respectively (p < 0.001). Among the 97 cases with lymphatic or venous invasion, the rates of LNM in 29 PWDA cases and 68 non-PWDA were 0% and 14.7%, respectively (p = 0.029). The agreement of the two pathologists for the diagnosis of PWDA was acceptable (kappa value > 0.5). A multicenter review showed no cases of PWDA among 72 T1 cancers with LNM. CONCLUSIONS PWDA is considered to be a safe factor for LNM in T1 cancer.
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Affiliation(s)
- Naohisa Yoshida
- Department of Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Masayoshi Nakanishi
- Department of Surgery, Division of Digestive Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Ken Inoue
- Department of Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Ritsu Yasuda
- Department of Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Ryohei Hirose
- Department of Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Yuji Naito
- Department of Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Yoshito Itoh
- Department of Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Tomohiro Arita
- Department of Surgery, Division of Digestive Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yasutoshi Murayama
- Department of Surgery, Division of Digestive Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoshiaki Kuriu
- Department of Surgery, Division of Digestive Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Eigo Otsuji
- Department of Surgery, Division of Digestive Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Akio Yanagisawa
- Department of Pathology, Kyoto First Red Cross Hospital, Kyoto, Japan
| | - Kiyoshi Ogiso
- Department of Gastroenterology, JR Osaka railway Hospital, Osaka, Japan
| | - Takaaki Murakami
- Department of Gastroenterology, JCHO Kyoto Kuramaguchi Medical Center, Kyoto, Japan
| | - Yukiko Morinaga
- Department of Surgical Pathology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Eiichi Konishi
- Department of Surgical Pathology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Yutaka Inada
- Department of Gastroenterology, Fukuchiyama City Hospital, Kyoto, Japan
| | - Mitsuo Kishimoto
- Department of Surgical Pathology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
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Han J, Hur H, Min BS, Lee KY, Kim NK. Predictive Factors for Lymph Node Metastasis in Submucosal Invasive Colorectal Carcinoma: A New Proposal of Depth of Invasion for Radical Surgery. World J Surg 2018; 42:2635-2641. [PMID: 29352338 DOI: 10.1007/s00268-018-4482-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Patients with lymph node metastasis (LNM) in submucosal invasive colorectal carcinoma (SM cancer) require additional surgical treatment after endoscopic dissection. However, because additional radical resection after endoscopic local resection may be unnecessary for cases without LNM, more specific criteria are required in order to diminish the incidence of further radical resection after endoscopic dissection. METHODS A total of 492 patients with biopsy-proven SM cancer who underwent curative surgery between January 2008 and December 2012 were collected and were divided into LNM group and no LNM group. The cutoff value for the depth of submucosal invasion was analyzed by a receiver operating characteristic (ROC) curve. In this retrospective study, the association between LNM and clinicopathologic factors was analyzed by logistic regression analysis. RESULTS The depth of submucosal invasion of 1900 μm was determined as the cutoff value by ROC curve. Significant, independent predictive factors for LNM included the depth of submucosal invasion >1900 μm (odds ratio [OR] 7.5; 95% confidence interval [CI] 3.1-18.3; p < 0.001), venous invasion (OR 2.4; 95% CI 1.1-5.5; p = 0.03), and poorly differentiated/mucinous adenocarcinoma (OR 6.3; 95% CI 1.3-30.8; p = 0.02). CONCLUSIONS Our study demonstrates that the depth of submucosal invasion (>1900 μm), vascular invasion and poorly differentiated/mucinous carcinoma were predictive factors of LNM in patients with SM cancer. These predictors may help to reduce the incidence of unnecessary surgery after endoscopic resection.
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Affiliation(s)
- Jeonghee Han
- Department of Surgery, Hallym University College of Medicine, Chuncheon, Korea
| | - Hyuk Hur
- Division of Colon and Rectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Korea
| | - Byung Soh Min
- Division of Colon and Rectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Korea
| | - Kang Young Lee
- Division of Colon and Rectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Korea
| | - Nam Kyu Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Korea.
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11
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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]
Abstract
OBJECTIVE The National Comprehensive Cancer Network (NCCN) guidelines recommend local excision and observation as standard treatment for selected patients with clinical T1N0M0 rectal cancer. In patients with pathological T1 (pT1) rectal cancer who received local excision, the local recurrence rate is at least 10%. We studied oncological outcomes in patients with pT1 rectal cancer who received chemoradiotherapy (CRT) after local excision. METHODS Local excision was performed in 65 patients with clinical T1N0M0 rectal cancer (≤8 cm from the anal verge, tumor size < 30 mm, well or moderately differentiated adenocarcinoma). The patients received CRT (40 or 45 Gy in 1.8-2.0 fractions with concurrent oral UFT [tegafur/uracil] or S-1 [tegafur/gimeracil/ote-racil]) after confirmation of pT1 and negative margins. RESULTS Patients who had pT2 cancer or who did not provide informed consent were excluded. The remaining 50 patients additionally received CRT. The CRT was completed in 48 patients (96%). The median follow-up period was 71 months. Local recurrence occurred in 1 patient (2%). Distant metastases occurred in 3 patients (6%). The 5-year disease-free survival rate was 86%, and the 5-year overall survival rate was 92%. CONCLUSIONS Our study suggested that multidisciplinary treatment with local excision plus CRT can be used as a treatment option in selected patients with clinical T1N0M0 rectal cancer.
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Affiliation(s)
- Toshiyuki Suzuki
- Department of Surgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Sotaro Sadahiro
- Department of Surgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Akira Tanaka
- Department of Surgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Kazutake Okada
- Department of Surgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Gota Saito
- Department of Surgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Hiroshi Miyakita
- Department of Surgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Takeshi Akiba
- Department of Radiology, Tokai University School of Medicine, Kanagawa, Japan
| | - Hiroshi Yamamuro
- Department of Radiology, Tokai University School of Medicine, Kanagawa, Japan
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12
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Abstract
Local excision (LE) of early-stage rectal cancer avoids the morbidity associated with radical surgery but has historically been associated with inferior oncologic outcomes. Newer techniques, including transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS), have been developed to improve the quality of LE and extend the benefits of LE to tumors in the more proximal rectum. This article provides an overview of conventional LE, TEM, and TAMIS techniques, including indications for their use and pertinent literature on their associated outcomes for rectal cancer.
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Affiliation(s)
- Daniel Owen Young
- Colorectal Surgery Program, Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, 1100 9th Avenue Seattle, WA 98101, USA
| | - Anjali S Kumar
- Colorectal Surgery Program, Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, 1100 9th Avenue Seattle, WA 98101, USA.
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13
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Riansuwan W, Lohsiriwat V. Local Excision Versus Total Mesorectal Excision for Clinical Stage I (cT1–cT2) Rectal Cancer. CURRENT COLORECTAL CANCER REPORTS 2017; 13:54-60. [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]
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14
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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]
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15
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Moreno CC, Sullivan PS, Kalb BT, Tipton RG, Hanley KZ, Kitajima HD, Dixon WT, Votaw JR, Oshinski JN, Mittal PK. Magnetic resonance imaging of rectal cancer: staging and restaging evaluation. ACTA ACUST UNITED AC 2016; 40:2613-29. [PMID: 25759246 DOI: 10.1007/s00261-015-0394-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Magnetic resonance imaging is used to non-invasively stage and restage rectal adenocarcinomas. Accurate staging is important as the depth of tumor extension and the presence or absence of lymph node metastases determines if an individual will undergo preoperative neoadjuvant chemoradiation. Accurate description of tumor location is important for presurgical planning. The relationship of the tumor to the anal sphincter in addition to the depth of local invasion determines the surgical approach used for resection. High-resolution T2-weighted imaging is the primary sequence used for initial staging. The addition of diffusion-weighted imaging improves accuracy in the assessment of treatment response on restaging scans. Approximately 10%-30% of individuals will experience a complete pathologic response following chemoradiation with no residual viable tumor found in the resected specimen at histopathologic assessment. In some centers, individuals with no residual tumor visible on restaging MR who are thought to be at high operative risk are monitored with serial imaging and a "watch and wait" approach in lieu of resection. Normal rectal anatomy, MR technique utilized for staging and restaging scans, and TMN staging are reviewed. An overview of surgical techniques used for resection including newer, minimally invasive endoluminal techniques is included.
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Affiliation(s)
- Courtney C Moreno
- Department of Radiology & Imaging Sciences, Emory University School of Medicine, Atlanta, GA, 30322, USA.
| | - Patrick S Sullivan
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Bobby T Kalb
- Department of Medical Imaging, The University of Arizona School of Medicine, Tucson, AZ, 85724, USA
| | - Russell G Tipton
- Department of Pathology, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Krisztina Z Hanley
- Department of Pathology, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Hiroumi D Kitajima
- Department of Radiology & Imaging Sciences, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - W Thomas Dixon
- Department of Radiology & Imaging Sciences, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - John R Votaw
- Department of Radiology & Imaging Sciences, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - John N Oshinski
- Department of Radiology & Imaging Sciences, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Pardeep K Mittal
- Department of Radiology & Imaging Sciences, Emory University School of Medicine, Atlanta, GA, 30322, USA
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16
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Keller DS, Haas EM. Transanal Minimally Invasive Surgery: State of the Art. J Gastrointest Surg 2016; 20:463-9. [PMID: 26608195 DOI: 10.1007/s11605-015-3036-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 11/17/2015] [Indexed: 01/31/2023]
Abstract
The treatment for rectal cancer and benign rectal lesions continues to progress in the arena of minimally invasive surgery. While surgical excision of the primary mass remains essential for eradication of disease, there has been a paradigm shift towards less invasive resection methods. Local excision is increasing in popularity for its low morbidity and excellent functional results in select patients. Transanal minimally invasive surgery (TAMIS) is a new technology developed to elevate the practice of local excision to state-of-the-art resection. The goal of this article is to evaluate the history, short-term outcomes, and evolution of the TAMIS technique for excision of benign and malignant rectal neoplasia.
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Affiliation(s)
- D S Keller
- Colorectal Surgical Associates, Houston, TX, USA
- Division of Colon and Rectal Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - E M Haas
- Colorectal Surgical Associates, Houston, TX, USA.
- Division of Minimally Invasive Colorectal Surgery, Department of Surgery, University of Texas Medical School at Houston, 7900 Fannin, Suite 2700, Houston, TX, 77054, USA.
- Division of Colon and Rectal Surgery, Houston Methodist Hospital, Houston, TX, USA.
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17
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Local Failure After Conservative Treatment of Rectal Cancer. Updates Surg 2016. [DOI: 10.1007/978-88-470-5767-8_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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18
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Park IJ, Lee JL, Yoon YS, Kim CW, Lim SB, Lee JS, Park SH, Park JH, Kim JH, Yu CS, Kim JC. Influence of Preoperative Chemoradiotherapy on the Surgical Strategy According to the Clinical T Stage of Patients With Rectal Cancer. Medicine (Baltimore) 2015; 94:e2377. [PMID: 26717384 PMCID: PMC5291625 DOI: 10.1097/md.0000000000002377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 11/23/2015] [Accepted: 12/04/2015] [Indexed: 11/25/2022] Open
Abstract
The aim of this study was to evaluate the pathologic responses and changes to surgical strategies following preoperative chemoradiotherapy (PCRT) in rectal cancer patients according to their clinical T stage (cT).The use of PCRT has recently been extended to less advanced disease.The authors enrolled 650 patients with cT2 to 4 mid and low rectal cancer who received both PCRT and surgical resection. The rate of total regression and the proportion of local excision were compared according to the cT category. The 3-year recurrence-free survival (RFS) rate was compared using the log-rank test according to patient cT category, pathologic stage, and type of surgical treatment.Patients with cT2 were older (P = 0.001), predominately female (P = 0.028), and had low-lying rectal cancer (P = 0.008). Pathologic total regression was achieved most frequently in cT2 patients (54% of cT2 versus 17.6% of cT3 versus 8.2% of cT4; P < 0.001). Local excision was performed on 42 cT2 (42%) and 24 cT3 (5.2%) patients (P < 0.001). The 3-year RFS rates differed according to both cT (P < 0.001) and ypT stage (P < 0.001). Among patients with ypT0 to 1 disease, the 3-year RFS did not differ according to the type of surgical treatment received (P = 0.5).Total regression of the primary tumor and a change in the surgical strategy after PCRT are most commonly seen in cT2 disease. Although PCRT is not generally indicated for cT2 rectal cancer, optimal surgical treatment may be achieved with the tailored use of PCRT.
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Affiliation(s)
- In Ja Park
- From the Department of Colon and Rectal Surgery (IJP, JLL, YSY, CWK, S-BL, JCK); Department of Radiology (JSL, SHP); and Department of Radiation Oncology (JHP, JHK), University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea
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19
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Use of Preoperative MRI to Select Candidates for Local Excision of MRI-Staged T1 and T2 Rectal Cancer: Can MRI Select Patients With N0 Tumors? Dis Colon Rectum 2015; 58:923-30. [PMID: 26347963 DOI: 10.1097/dcr.0000000000000437] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND To minimize the recurrence rate after local excision of rectal cancer, the false-negative rate of nodal staging should be minimized. OBJECTIVE The purpose of this study was to develop a set of criteria using preoperative MRI that would minimize the false-negative rate for the diagnosis of regional lymph node metastasis. DESIGN A prospectively maintained colorectal cancer database and MRI images were retrospectively reviewed. SETTINGS This study was conducted at a multidisciplinary tertiary center. PATIENTS A total of 246 consecutive patients who underwent MRI and curative-intent surgery for MRI-staged T1/T2 rectal cancer from January 2008 to July 2012 were included. MAIN OUTCOME MEASURES MRI features significantly associated with lymph node metastasis were identified using a χ test. Five diagnostic criteria for lymph node metastasis were created based on these predictive MRI features, and their false-negative rates were compared using the generalized estimating equation method. RESULTS Small size/homogeneity of lymph nodes and no visible tumor/partially involved muscular layer were significantly associated with lower risks of lymph node metastasis. When tumor invasion depth was not considered, the false-negative rate did not decrease below 10%, even when the strictest criterion for morphologic evaluation of lymph nodes (not visible or <3 mm) was used. Adding invasion depth to the diagnostic criteria significantly decreased the false-negative rate as low as 1.8%. LIMITATIONS This study is limited by its small sample size and retrospective nature. CONCLUSIONS Assessing both the depth of tumor invasion and lymph node morphology may reduce the false-negative rate and can be helpful to better identify candidates suitable for local excision of early stage rectal cancer. However, strict MRI criteria for oncologic safety might result in considerable false-positive cases and limit the application of local excision.
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20
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Ferko A, Orhalmi J, Dusek T, Chobola M, Hovorkova E, Hadzi Nikolov D, Dolejs J. Small carcinomas involving less than one-quarter of the rectal circumference: local excision is still associated with a high risk of nodal positivity. Colorectal Dis 2015; 17:876-81. [PMID: 25808035 DOI: 10.1111/codi.12953] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 01/30/2015] [Indexed: 02/08/2023]
Abstract
AIM A study was carried out to determine the relationship between mesorectal lymph nodal involvement and T stage in a group of patients with a rectal cancer involving less than one-quarter of the rectal circumference, such as might be selected for local excision. METHOD The data of patients having rectal resection between 2010 and 2014 were prospectively entered in a rectal carcinoma registry. A model for describing tumours involving less than one quadrant of the rectal circumference was created to facilitate the evaluation process. RESULTS In all, 304 patients were included in the study. In 68 (22.4%) a small tumour (< 1 quadrant involved) was found. Of these, 26.5% had positive mesorectal lymph nodes (N+). In lesions of Stage ypT0 cancer 12.5% patients were node positive, in Stage Tis and T1 tumours there was no case of node positivity, but in Stage T2 and Stage T3 cancers the incidence of node positivity was 27.5% and 64%. CONCLUSION The study demonstrated that, even for small tumours involving only one rectal quadrant, the risk of lymph nodal involvement was about 25%. Had the patients undergone local excision the treatment would have been incomplete.
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Affiliation(s)
- A Ferko
- Department of Surgery, Faculty of Medicine in Hradec Králové, Charles University in Prague, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - J Orhalmi
- Department of Surgery, Faculty of Medicine in Hradec Králové, Charles University in Prague, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - T Dusek
- Department of Surgery, Faculty of Medicine in Hradec Králové, Charles University in Prague, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - M Chobola
- Department of Surgery, Faculty of Medicine in Hradec Králové, Charles University in Prague, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - E Hovorkova
- Fingerland Department of Pathology, Faculty of Medicine Hradec Králové, Charles University in Prague, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - D Hadzi Nikolov
- Fingerland Department of Pathology, Faculty of Medicine Hradec Králové, Charles University in Prague, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - J Dolejs
- Department of Informatics and Quantitative Methods, Faculty of Informatics and Management, University of Hradec Králové, Hradec Králové, Czech Republic
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21
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Cihan S, Kucukoner M, Ozdemir N, Dane F, Sendur MAN, Yazilitas D, Urakci Z, Durnali A, Yuksel S, Aksoy S, Colak D, Seker MM, Taskoylu BY, Oguz A, Isikdogan A, Zengin N. Recurrence risk and prognostic parameters in stage I rectal cancers. Asian Pac J Cancer Prev 2015; 15:5337-41. [PMID: 25040998 DOI: 10.7314/apjcp.2014.15.13.5337] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The standard therapy for stage I rectum cancer is surgical resection. Currently, there is no strong evidence to suggest that any type of adjuvant therapy is beneficial. The risks of local relapse and distant metastasis are higher in rectal tumors. Therefore, while there is no clearly defined absolute indication for adjuvant therapy in lymph node negative colon cancers, rectum tumors that are T3N0 and higher require adjuvant treatment. Due to the more aggressive nature of rectal cancers, we explored the clinical and pathologic factors that could predict the risk of relapse in Stage I (T1-T2) disease and whether there was any progression-free survival benefit to adjuvant therapy. MATERIALS AND METHODS This multicenter study was carried out by the Anatolian Society of Medical Oncology. A total of 178 patients with rectal cancers who underwent curative surgery between January 1994 and August 2012 in 13 centers were included in the study. Patient demographics, including survival data and tumor characteristics were obtained from medical charts. RESULTS The median age was 58 years (range 26-85 years). Most tumors were well or moderately differentiated. For adjuvant treatment, 13 patients (7.3%) received radiotherapy alone, 12 patients (6.7%) received chemotherapy alone and 15 patients (8.4%) were given chemoradiotherapy. Median follow up was 29 months (3-225 months). Some 42 patients (23.6%) had relapse during follow up; 30 with local recurrence (71.4%) whereas 12 (28.6%) were distant metastases. Among the patients, 5-year DFS was 64% and OS was 82%. Mucinous histology and receiving adjuvant therapy were found to have statistically insignificant correlations with relapse and survival. CONCLUSIONS In our retrospective analysis, approximately one quarter of patients exhibited either local or systemic relapse. The rates of relapse were slightly higher in the patients who had no adjuvant therapy. There may thus be a role for adjuvant therapy in high-risk stage I rectal tumors.
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Affiliation(s)
- Sener Cihan
- Department of Medical Oncology, Okmeydani Education and Research Hospital, Istanbul, Turkey E-mail :
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22
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Frenkel JL, Marks JH. Predicting the risk of lymph node metastasis in early rectal cancer. SEMINARS IN COLON AND RECTAL SURGERY 2015. [DOI: 10.1053/j.scrs.2014.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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23
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High frequency of CD8 positive lymphocyte infiltration correlates with lack of lymph node involvement in early rectal cancer. DISEASE MARKERS 2014; 2014:792183. [PMID: 25609852 PMCID: PMC4293805 DOI: 10.1155/2014/792183] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 12/11/2014] [Indexed: 12/18/2022]
Abstract
AIMS A trend towards local excision of early rectal cancers has prompted us to investigate if immunoprofiling might help in predicting lymph node involvement in this subgroup. METHODS A tissue microarray of 126 biopsies of early rectal cancer (T1 and T2) was stained for several immunomarkers of the innate and the adaptive immune response. Patients' survival and nodal status were analyzed and correlated with infiltration of the different immune cells. RESULTS Of all tested markers, only CD8 (P = 0.005) and TIA-1 (P = 0.05) were significantly more frequently detectable in early rectal cancer biopsies of node negative as compared to node positive patients. Although these two immunomarkers did not display prognostic effect "per se," CD8+ and, marginally, TIA-1 T cell infiltration could predict nodal involvement in univariate logistic regression analysis (OR 0.994; 95% CI 0.992-0.996; P = 0.009 and OR 0.988; 95% CI 0.984-0.994; P = 0.05, resp.). An algorithm significantly predicting the nodal status in early rectal cancer based on CD8 together with vascular invasion and tumor border configuration could be calculated (P < 0.00001). CONCLUSION Our data indicate that in early rectal cancers absence of CD8+ T-cell infiltration helps in predicting patients' nodal involvement.
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24
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Chand M, Heald RJ, West N, Swift RI, Tekkis P, Brown G. The evolution in the detection of extramural venous invasion in rectal cancer: implications for modern-day practice. COLORECTAL CANCER 2014. [DOI: 10.2217/crc.14.36] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
SUMMARY Venous invasion has been considered a poor prognostic factor in rectal cancer for over half a century. This term has evolved in recent years and now applies specifically to tumor invasion into extramural veins – extramural venous invasion. This distinction from intramural venous invasion is important as it is more clinically relevant. Extramural venous invasion can be identified by histopathology and MRI but until recently there has been a lack of consistency in definitions and detection techniques. This paper reviews the historical evidence for the prognostic importance and detection of venous invasion in rectal cancer.
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Affiliation(s)
- Manish Chand
- Royal Marsden Hospital, Downs Road, Sutton, SM2 5PT, UK
- Department of Surgery & Cancer, Imperial College London, London, UK
| | - Richard J Heald
- North Hampshire & Basingstoke Hospital, Aldermaston Road, Basingstoke, RG24 9NA, UK
| | - Nick West
- Pathology & Tumor Biology, Leeds Institute of Cancer & Pathology, University of Leeds, Leeds, UK
| | - R Ian Swift
- Croydon University Hospital, London, CR7 7YE, UK
| | - Paris Tekkis
- Department of Surgery & Cancer, Imperial College London, London, UK
| | - Gina Brown
- Royal Marsden Hospital, Downs Road, Sutton, SM2 5PT, UK
- Department of Surgery & Cancer, Imperial College London, London, UK
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Kulu Y, Müller-Stich BP, Bruckner T, Gehrig T, Büchler MW, Bergmann F, Ulrich A. Radical Surgery with Total Mesorectal Excision in Patients with T1 Rectal Cancer. Ann Surg Oncol 2014; 22:2051-8. [DOI: 10.1245/s10434-014-4179-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Indexed: 01/03/2023]
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Heafner TA, Glasgow SC. A critical review of the role of local excision in the treatment of early (T1 and T2) rectal tumors. J Gastrointest Oncol 2014. [PMID: 25276407 DOI: 10.3978/j.issn.2078-6891.2014.066jgo-05-05-345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The optimal treatment of early (T1 and T2) rectal adenocarcinomas remains controversial. Local excision and radical resection with total mesorectal excision are the two surgical techniques for excising early rectal cancer. Each has their respective benefits, with local excision allowing for decreased operative morbidity and mortality while radical resection provides an oncologically complete treatment through lymphadenectomy. Local excision can be accomplished via transanal endoscopic microsurgery or transanal excision. There is no significant difference in the recurrence rates (21% vs. 33%) or overall survival (80% vs. 66%) between the two local excision modalities; however, transanal endoscopic microsurgery does allow for a higher rate of R0 resection. Current selection criteria for local excision include well to moderately differentiated tumors without high-risk features such as lymphovascular invasion, perineural invasion, or mucinous components. In addition, tumors should ideally be <3 cm in size, excised with a clear margin, occupy less than 1/3 of the circumference of the bowel and be mobile/nonfixed. Despite these stringent inclusion criteria, local excision continues to be plagued with a high recurrence rate in both T1 and T2 tumors due to a significant rate of occult locoregional metastases (20% to 33%). For both tumor groups, the recurrence rate in the local excision group is more than double compared to radical resection. However, the overall survival is not significantly different between those with and without metastases. With intense postoperative surveillance, these recurrences can be identified early while they are confined to the pelvis allowing for salvage surgical options. Recently, neoadjuvant therapy followed by local excision has shown favorable short and long-term oncological outcomes to radical resection in the treatment of T2 rectal cancer. Ultimately, the management of early rectal cancer must be individualized to each patient's expectations of quality and quantity of life. With informed consent, patients may be willing to accept a higher failure rate and an increased post-operative surveillance regimen to preserve a perceived increased quality of life.
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Affiliation(s)
- Thomas A Heafner
- 1 Department of Surgery, San Antonio Military Medical Center, Ft. Sam Houston, TX, USA ; 2 Department of Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Sean C Glasgow
- 1 Department of Surgery, San Antonio Military Medical Center, Ft. Sam Houston, TX, USA ; 2 Department of Surgery, Washington University in St. Louis, St. Louis, MO, USA
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Heafner TA, Glasgow SC. A critical review of the role of local excision in the treatment of early (T1 and T2) rectal tumors. J Gastrointest Oncol 2014; 5:345-352. [PMID: 25337275 PMCID: PMC4173049 DOI: 10.3978/j.issn.2078-6891.2014.066] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 08/12/2014] [Indexed: 12/16/2022] Open
Abstract
The optimal treatment of early (T1 and T2) rectal adenocarcinomas remains controversial. Local excision and radical resection with total mesorectal excision are the two surgical techniques for excising early rectal cancer. Each has their respective benefits, with local excision allowing for decreased operative morbidity and mortality while radical resection provides an oncologically complete treatment through lymphadenectomy. Local excision can be accomplished via transanal endoscopic microsurgery or transanal excision. There is no significant difference in the recurrence rates (21% vs. 33%) or overall survival (80% vs. 66%) between the two local excision modalities; however, transanal endoscopic microsurgery does allow for a higher rate of R0 resection. Current selection criteria for local excision include well to moderately differentiated tumors without high-risk features such as lymphovascular invasion, perineural invasion, or mucinous components. In addition, tumors should ideally be <3 cm in size, excised with a clear margin, occupy less than 1/3 of the circumference of the bowel and be mobile/nonfixed. Despite these stringent inclusion criteria, local excision continues to be plagued with a high recurrence rate in both T1 and T2 tumors due to a significant rate of occult locoregional metastases (20% to 33%). For both tumor groups, the recurrence rate in the local excision group is more than double compared to radical resection. However, the overall survival is not significantly different between those with and without metastases. With intense postoperative surveillance, these recurrences can be identified early while they are confined to the pelvis allowing for salvage surgical options. Recently, neoadjuvant therapy followed by local excision has shown favorable short and long-term oncological outcomes to radical resection in the treatment of T2 rectal cancer. Ultimately, the management of early rectal cancer must be individualized to each patient's expectations of quality and quantity of life. With informed consent, patients may be willing to accept a higher failure rate and an increased post-operative surveillance regimen to preserve a perceived increased quality of life.
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Ung L, Chua TC, Engel AF. A systematic review of local excision combined with chemoradiotherapy for early rectal cancer. Colorectal Dis 2014; 16:502-15. [PMID: 24605870 DOI: 10.1111/codi.12611] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 01/12/2014] [Indexed: 02/08/2023]
Abstract
AIM Local excision of early rectal cancer is a less morbid alternative to major abdominal surgery. This review evaluates the role of local excision with neoadjuvant or adjuvant chemoradiotherapy to identify a select group of patients where local excision is appropriate without significantly compromising the oncological outcome. METHOD MEDLINE, PubMed and the Cochrane Central Register of Controlled Trials databases were searched to identify relevant articles investigating the role of local excision with adjuvant or neoadjuvant chemoradiotherapy in patients with T1/T2N0M0 disease. Eleven studies comprising 455 patients were selected. Oncological end-points included overall survival, disease-free and disease-specific survival, recurrence rates as well as perioperative morbidity and mortality. RESULTS At a range of 30.5-115.2 months, median overall survival, disease-specific and disease-free survival were 75% (66-80.6%), 89% (75-93.3%) and 74% (64-85.2%), respectively. Median local, distant and overall recurrence rates were 10% (4.8-25%), 4.7% (4-11.8%) and 13.1% (10.7-23.5%), respectively. Mortality was 0% in all studies except one (2.9%). Most reported complications were minor and were treated conservatively. CONCLUSION This systematic review provides data suggesting that selected patients with T1/T2N0M0 rectal cancer may undergo local excision without compromising the oncological outcome otherwise conferred by total mesorectal excision. It may be a particularly useful option in patients in whom radical surgery is contraindicated. Randomized trials comparing both management strategies to consolidate this finding may lead to a paradigm change in the management of early rectal cancer.
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Affiliation(s)
- L Ung
- Northern Sydney Colorectal Clinic, Department of Gastrointestinal Surgery, Royal North Shore Hospital, University of Sydney, Sydney, Australia
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Ablative therapies for colorectal polyps and malignancy. BIOMED RESEARCH INTERNATIONAL 2014; 2014:986352. [PMID: 25089281 PMCID: PMC4095981 DOI: 10.1155/2014/986352] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 05/23/2014] [Accepted: 06/09/2014] [Indexed: 12/23/2022]
Abstract
Endoscopic techniques are gaining popularity in the management of colorectal polyps and occasionally superficial cancers. While their use is in many times palliative, they have proven to be curative in carefully selected patients with polyps or malignancies, with less morbidity than radical resection. However, one should note that data supporting local and ablative therapies for colorectal cancer is scarce and may be subject to publication bias. Therefore, for curative intent, these techniques should only be considered in highly select cases as higher rates of local recurrences have also been reported. The aim of this review is to explain the different modalities of local and ablative therapies specific to colorectal neoplasia and explain the indications and circumstances where they have been most successful.
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Emhoff IA, Lee GC, Sylla P. Future directions in surgery for colorectal cancer: the evolving role of transanal endoscopic surgery. COLORECTAL CANCER 2014. [DOI: 10.2217/crc.14.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
SUMMARY The morbidity associated with radical surgery for rectal cancer has launched a revolution in increasingly less-invasive methods of resection, including a recent resurgence in transanal endoscopic surgical approaches. The next evolution in transanal surgery for rectal cancer is natural orifice translumenal endoscopic surgery (NOTES). To date, 14 series of transanal NOTES total mesorectal excision (TME) for rectal cancer have been published (n = 76). Overall, the intraoperative and postoperative complication rates of 8 and 28%, respectively, compare favorably to those expected from laparoscopic and open TME. Short-term follow-up after NOTES TME has yielded no cancer recurrence in average-risk patients. High-risk patients have cancer recurrence rates similar to those after laparoscopic TME. Overall, these early data support transanal NOTES TME as a safe and viable alternative to conventional TME. Advances in instrumentation, surgical expertise and neoadjuvant treatment may expand current indications for NOTES even further.
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Affiliation(s)
- Isha Ann Emhoff
- Department of Surgery, Division of Gastrointestinal Surgery, Massachusetts General Hospital, 15 Parkman Street, Wang 460, Boston, MA 02114, USA
| | - Grace Clara Lee
- Department of Surgery, Division of Gastrointestinal Surgery, Massachusetts General Hospital, 15 Parkman Street, Wang 460, Boston, MA 02114, USA
| | - Patricia Sylla
- Department of Surgery, Division of Gastrointestinal Surgery, Massachusetts General Hospital, 15 Parkman Street, Wang 460, Boston, MA 02114, USA
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Emhoff IA, Lee GC, Sylla P. Transanal colorectal resection using natural orifice translumenal endoscopic surgery (NOTES). Dig Endosc 2014; 26 Suppl 1:29-42. [PMID: 24033375 DOI: 10.1111/den.12157] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Accepted: 07/08/2013] [Indexed: 02/08/2023]
Abstract
The surgical management of rectal cancer has evolved over the past century, with total mesorectal excision (TME) emerging as standard of care. As a result of the morbidity associated with open TME, minimally invasive techniques have become popular. Natural orifice translumenal endoscopic surgery (NOTES) has been held as the next revolution in surgical techniques, offering the possibility of 'incisionless' TME. Early clinical series of transanal TME with laparoscopic assistance (n = 72) are promising, with overall intraoperative and postoperative complication rates of 8.3% and 27.8%, respectively, similar to laparoscopic TME. The mesorectal specimen was intact in all patients, and 94.4% had negative margins. There was no oncological recurrence in average-risk patients at short-term follow up, and 2-year survival rates in high-risk patients were comparable to that after laparoscopic TME. These preliminary studies demonstrate transanal NOTES TME with laparoscopic assistance to be clinically feasible and safe given careful patient selection, surgical expertise, and appropriate procedural training. We are hopeful that with optimization of transanal instruments and surgical techniques, pure transanal NOTES TME will become a viable alternative to open and laparoscopic TME in the future.
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Affiliation(s)
- Isha Ann Emhoff
- Department of Surgery, Division of Gastrointestinal Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
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Survival outcome of local excision versus radical resection of colon or rectal carcinoma: a Surveillance, Epidemiology, and End Results (SEER) population-based study. Ann Surg 2013; 258:563-9; discussion 569-71. [PMID: 23979270 DOI: 10.1097/sla.0b013e3182a4e85a] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To compare cancer-specific results of local excision with major resection. BACKGROUND Technological advances have enabled endoscopic and local excision techniques to be applied in the treatment of early colorectal cancer in preference to radical surgery. METHOD Patients with stage 0 (carcinoma in situ) or stage I (T1/2N0M0) adenocarcinoma of the colon or rectum undergoing surgery between 1998 and 2009 were included from the SEER (Surveillance, Epidemiology, and End Results) database. Local excision (endoscopic or surgical) was compared with major surgical resection using adjusted hazard ratios (HRs) for 5-year cancer-specific survival (CSS). RESULTS This study included 7378 local excisions and 36,116 major resections. There were 3553 patients with carcinoma in situ and 39,941 with clinical stage I cancer. Local tumor excision for carcinoma in situ was associated with equivalent CSS compared to major resection (HRs = 1.06, P = 0.814, for colon and 0.78, P = 0.494, for rectum). Local excision of T1 and T2 colon cancer was associated with reduced CSS (HR = 1.31, P = 0.020, and 2.89, P < 0.001, respectively). Local excision of T1 rectal cancer did not affect CSS (HR = 1.16, P = 0.236), but it significantly reduced CSS for T2 cancer (HR = 1.71, P < 0.001). Subgroup analysis of T1 and T2 rectal cancer after neoadjuvant therapy and local excision showed oncological equivalence to major resection (HR = 1.12, P = 0.802, and 1.23, P = 0.802). CONCLUSIONS Local excision for early colorectal cancer was oncologically equivalent to major surgery for carcinoma in situ and T1 rectal cancer, but inferior for T1-2 colon and T2 rectal cancer. Exploratory data suggest local excision of T1-2 rectal cancer after neoadjuvant therapy may be safe.
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Madoff RD. Total mesorectal neglect in the age of total mesorectal excision. J Clin Oncol 2013; 31:4273-5. [PMID: 24166519 DOI: 10.1200/jco.2013.52.6434] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
Rectal resection with total mesorectal excision is the standard treatment for rectal cancers. Local excision represents an alternative with less post-operative mortality and morbidity and preservation of intestinal and bladder function. However, local excision cannot provide adequate nodal staging. Presently, endorectal ultrasound and magnetic resonance imaging are used to select the appropriate patients for local excision, those with limited T1 rectal tumors. There is general agreement that the ideal tumors for local excision are less or equal to 3 cm in diameter, superficial (usTis and/or usT1N0), infra-peritoneal, located below the middle rectal valve, and involving no more than 40% of the rectal circumference. Transanal tumor excision is suitable for distal tumors and transanal endoscopic microsurgery for mid and upper lesions. The principles of adequate resection margin, non-fragmentation, and full-thickness excision are similar to those for any cancer resection. Unfavorable pathologic criteria, as assessed on the fixed rectal specimen, include depth of tumor invasion (submucosal [T1sm3] or muscular [T2]), positive resection margins, vascular and/or lymphatic invasion, and poor differentiation. Further radical surgery is required in case of unfavorable criteria. Simple surveillance may be advised for superficial tumors (T1sm1) without any unfavorable criteria. Management of T1sm2 tumors without any unfavorable criteria should be discussed on a case-by-case basis.
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Affiliation(s)
- C Lartigau
- Service de chirurgie digestive, CHU de Caen, avenue de la Côte-de-Nacre, 14033 Caen cedex, France
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Dieguez A. Rectal cancer staging: focus on the prognostic significance of the findings described by high-resolution magnetic resonance imaging. Cancer Imaging 2013; 13:277-97. [PMID: 23876415 PMCID: PMC3719056 DOI: 10.1102/1470-7330.2013.0028] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2013] [Indexed: 12/14/2022] Open
Abstract
High-resolution (HR) magnetic resonance imaging (MRI) has become an indispensable tool for multidisciplinary teams (MDTs) addressing rectal cancer. It provides anatomic information for surgical planning and allows patients to be stratified into different groups according to the risk of local and distant recurrence. One of the objectives of the MDT is the preoperative identification of high-risk patients who will benefit from neoadjuvant treatment. For this reason, the correct evaluation of the circumferential resection margin (CRM), the depth of tumor spread beyond the muscularis propria, extramural vascular invasion and nodal status is of the utmost importance. Low rectal tumors represent a special challenge for the MDT, because decisions seek a balance between oncologic safety, in the pursuit of free resection margins, and the patient's quality of life, in order to preserve sphincter function. At present, the exchange of information between the different specialties involved in dealing with patients with rectal cancer can rank the contribution of colleagues, auditing their work and incorporating knowledge that will lead to a better understanding of the pathology. Thus, beyond the anatomic description of the images, the radiologist's role in the MDT makes it necessary to know the prognostic value of the findings that we describe, in terms of recurrence and survival, because these findings affect decision making and, therefore, the patients' life. In this review, the usefulness of HR MRI in the initial staging of rectal cancer and in the evaluation of neoadjuvant treatment, with a focus on the prognostic value of the findings, is described as well as the contribution of HR MRI in assessing patients with suspected or confirmed recurrence of rectal cancer.
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Affiliation(s)
- Adriana Dieguez
- Diagnóstico Médico, Junín 1023 (C1113AAE), Ciudad Autónoma de Buenos Aires, Argentina.
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Saraste D, Gunnarsson U, Janson M. Predicting lymph node metastases in early rectal cancer. Eur J Cancer 2013; 49:1104-8. [DOI: 10.1016/j.ejca.2012.10.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Revised: 09/30/2012] [Accepted: 10/03/2012] [Indexed: 02/08/2023]
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Analysis of risk factors for lymph nodal involvement in early stages of rectal cancer: when can local excision be considered an appropriate treatment? Systematic review and meta-analysis of the literature. Int J Surg Oncol 2012; 2012:438450. [PMID: 22778940 PMCID: PMC3388331 DOI: 10.1155/2012/438450] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Revised: 04/15/2012] [Accepted: 04/17/2012] [Indexed: 02/08/2023] Open
Abstract
Background. Over the past ten years oncological outcomes achieved by local excision techniques (LETs) as the sole treatment for early stages of rectal cancer (ESRC) have been often disappointing. The reasons for these poor results lie mostly in the high risk of the disease's diffusion to local-regional lymph nodes even in ESRC. Aims. This study aims to find the correct indications for LET in ESRC taking into consideration clinical-pathological features of tumours that may reduce the risk of lymph node metastasis to zero. Methods. Systematic literature review and meta-analysis of casistics of ESRC treated with total mesorectal excision with the aim of identifying risk factors for nodal involvement. Results. The risk of lymph node metastasis is higher in G ≥ 2 and T ≥ 2 tumours with lymphatic and/or vascular invasion. Other features which have not yet been sufficiently investigated include female gender, TSM stage >1, presence of tumour budding and/or perineural invasion. Conclusions. Results comparable to radical surgery can be achieved by LET only in patients with T(1) N(0) G(1) tumours with low-risk histological features, whereas deeper or more aggressive tumours should be addressed by radical surgery (RS).
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Glasgow SC, Bleier JIS, Burgart LJ, Finne CO, Lowry AC. Meta-analysis of histopathological features of primary colorectal cancers that predict lymph node metastases. J Gastrointest Surg 2012; 16:1019-28. [PMID: 22258880 DOI: 10.1007/s11605-012-1827-4] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Accepted: 01/05/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Treatment decisions for colorectal cancer vary based on lymph node status. While some histopathological features of the primary tumor correlate with lymph node spread, the relative influences of these risk factors are not well quantified. OBJECTIVE This study aims to systematically review published studies relating histopathological features of primary colorectal cancer to the presence of lymph node metastases and to determine how reliable certain factors might be at predicting nodal metastasis when only the primary lesion is available for study. DATA SOURCES Inclusive literature search using EMBASE and Ovid MEDLINE databases plus manual reference checks of all articles correlating lymphatic spread with colorectal cancer (any T stage) from 1984 to mid-2008 was performed. STUDY SELECTION This search generated two levels of screening utilized on 602 citations, yielding 123 articles for full review. Data reported from 76 articles were chosen. MAIN OUTCOME MEASURES The relative influence of each histopathological feature on the likelihood of lymphatic metastases was determined. Fixed-effects meta-analysis was performed, and results were reported as Mantel-Haenszel odds ratios (OR). RESULTS Of 42 histopathological features analyzed, only 40.4% were reported in >2 articles. The positive predictive values for the top quartile of most frequently reported risk factors were 25.5-86.4%. Among the commonly reported histopathological findings, lymphatic invasion (OR, 8.62) significantly outperformed tumor depth (T2 vs. T1; OR, 2.62) and overall differentiation (OR, 2.38) in predicting nodal spread. For the rectal cancer subset, risk factors differed from the overall colorectal group in predictive ability; poor differentiation at the invasive front (OR, 6.08) and tumor budding (OR, 5.82) were the most predictive. LIMITATIONS This literature search is limited by the small number of studies examining only rectal cancers and the potential changes in histological and/or surgical techniques over the study period. CONCLUSIONS No single histopathological feature of colorectal cancer reliably predicted lymph node metastases. Several risk factors that correlate highly with nodal disease are not routine components of standard pathology reports. Until further research establishes histopathological or molecular patterns for predicting lymph node spread, caution should be exercised when basing treatment decisions solely on these factors.
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Affiliation(s)
- Sean C Glasgow
- Department of Surgery, San Antonio Military Medical Center, 3551 Roger Brooke Drive, Ft. Sam Houston, San Antonio, TX 78234-6200, USA.
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Wu ZY, Zhao G, Chen Z, Du JL, Wan J, Lin F, Peng L. Oncological outcomes of transanal local excision for high risk T 1 rectal cancers. World J Gastrointest Oncol 2012; 4:84-8. [PMID: 22532882 PMCID: PMC3334385 DOI: 10.4251/wjgo.v4.i4.84] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2011] [Revised: 03/04/2012] [Accepted: 03/10/2012] [Indexed: 02/05/2023] Open
Abstract
AIM: To evaluate the oncological outcomes of transanal local excision and the need for immediate conventional reoperation in the treatment of patients with high risk T1 rectal cancers.
METHODS: Twenty five high risk T1 rectal cancers treated by transanal local excision at the Guangdong General Hospital were analyzed retrospectively. Twelve patients received transanal local excision and 13 patients underwent subsequent immediate surgical rescue after transanal local excision within 4 wk. Differences in the local recurrence rates and 5-year overall survival rates between the two groups were analyzed. The prognostic value of immediate conventional reoperation for high risk T1 rectal cancers was also evaluated.
RESULTS: The median follow-up period was 62 mo. The local recurrence rates after transanal local excision for high risk T1 rectal cancer were 50%. By immediate conventional reoperation, the local recurrence rates were significantly reduced to 7.7%. The difference between these two groups was statistically significant (P = 0.030). Kaplan-Meier survival analysis showed a trend for decreased 5-year overall survival rates for patients treated by transanal local excision compared with immediate conventional reoperation (63% vs 89%).
CONCLUSION: Transanal local excision cannot be considered sufficient treatment for patients with high risk T1 rectal cancers. Immediate conventional reoperation should be performed if the pathology of the local excision is high risk.
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Affiliation(s)
- Ze-Yu Wu
- Ze-Yu Wu, Gang Zhao, Zhe Chen, Jia-Lin Du, Jin Wan, Feng Lin, Lin Peng, Department of General Surgery, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong Province, China
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40
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Chang HC, Huang SC, Chen JS, Tang R, Changchien CR, Chiang JM, Yeh CY, Hsieh PS, Tsai WS, Hung HY, You JF. Risk factors for lymph node metastasis in pT1 and pT2 rectal cancer: a single-institute experience in 943 patients and literature review. Ann Surg Oncol 2012; 19:2477-84. [PMID: 22396007 DOI: 10.1245/s10434-012-2303-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Indexed: 01/22/2023]
Abstract
BACKGROUND Local excision has become an alternative for radical resection in rectal cancer for selected patients. The purpose of this study was to assess the clinicopathologic factors determining lymph node metastasis (LNM) in patients with T1-2 rectal cancer. METHODS Between January 1995 and December 2009, a total of 943 patients with pT1 or pT2 rectal adenocarcinoma received radical resection at a single institution. Clinicopathologic factors were evaluated by univariate and multivariate analyses to identify risk factors for LNM. RESULTS A total of 943 patients (544 men and 399 women) treated for T1-2 rectal cancer were included in this study. LNM was found in 188 patients (19.9%). In multivariate analysis, lymphovascular invasion (LVI; P < 0.001, hazard ratio 11.472), poor differentiation (PD; P = 0.007, hazard ratio 3.218), and depth of invasion (presence of pT2; P = 0.032, hazard ratio 1.694) were significantly related to nodal involvement. The incidence for LNM lesions in the presence of LVI, PD, and pT2 was 68.8, 50.0, and 23.1%, respectively, while that for pT1 carcinomas with no LVI or PD was 7.5%. CONCLUSIONS LVI, PD, and pT2 are independent risk factors predicting LNM in pT1-2 rectal carcinoma.
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Affiliation(s)
- Hao-Cheng Chang
- Department of Surgery, Colorectal Section, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
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Abstract
Local excision (LE) was historically developed to palliate patients with rectal adenocarcinoma who either are medically unfit or have adamantly refused to undergo transabdominal standard resection (SR) procedures. Over the years, the tradeoffs between the oncologic benefit and adverse functional sequelae associated with SR procedures have been increasingly recognized. In parallel, there has been growing interest in considering LE as an alternative to SR in select patients with early-stage disease. However, concerns regarding its oncologic adequacy remain. These concerns relate to the adequacy of tumor resection, the removal of mesorectal disease, the accuracy of preoperative selection, and the use of adjunctive treatment modalities. Evolving strategies that aim at improving the oncologic outcomes of LE for stage I T1/T2 rectal cancers include adoption of transanal endoscopic microsurgery and the addition of non-surgical modalities. Current evidence surrounding these approaches is examined to provide a basis for an informed discussion with patients. Key factors to be considered in formulating the treatment plan for an individual patient with T1/T2 rectal cancer are summarized.
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Affiliation(s)
- Y Nancy You
- Department of Surgical Oncology, University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA.
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Steinhagen E, Chang G, Guillem JG. Initial experience with transanal endoscopic microsurgery: the need for understanding the limitations. J Gastrointest Surg 2011; 15:958-62. [PMID: 21479673 DOI: 10.1007/s11605-011-1496-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Accepted: 03/22/2011] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Transanal endoscopic microsurgery is an alternative to transanal excision or radical surgery for benign and carefully selected malignant rectal tumors. Advantages over transanal excision include better visualization, access to more proximal lesions, higher likelihood of negative margins, and lower recurrence rates. Compared to radical resection, patients experience lower rates of morbidity and mortality but may have higher rates of local recurrence. METHODS A review of a prospectively maintained database of patients scheduled for transanal endoscopic microsurgery was performed. RESULTS Ninety-three patients underwent 96 procedures for 13 carcinoid tumors, 1 submucosal mass, 46 adenomas, 12 in situ adenocarcinomas, and 21 invasive adenocarcinomas. Of these cases, 81.2% was successfully completed. There were nine complications (11.5%). Final pathology demonstrated 33 in situ and invasive adenocarcinomas. The mean follow-up was 25.9 months. The four recurrences (12.1%) occurred in: one tubulovillous adenoma, two in situ carcinomas, and one T2 lesion. CONCLUSIONS Transanal endoscopic microsurgery is appropriate for benign lesions such as carcinoid tumors and adenomas and can also be curative in carefully selected patients with early-stage invasive rectal cancer. In cases of invasive adenocarcinoma, it should be reserved for low-risk cancers in patients who accept the possible increased risk of recurrence.
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Affiliation(s)
- Emily Steinhagen
- Department of Surgery, Colorectal Service, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, C-1077, New York, NY 10065, USA
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Nasseri Y, Kohanzadeh S, Murrell Z, Berel D, Melmed G, Fleshner P. Phantom publications among applicants to a colorectal surgery residency program. Dis Colon Rectum 2011; 54:220-5. [PMID: 21228672 DOI: 10.1007/dcr.0b013e3181fb0e7a] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Previous studies have reported that as many as one third of applicants misrepresent their publication record on residency or fellowship applications. OBJECTIVE To determine the incidence of potentially fraudulent (or "phantom") research publications among applicants to a colorectal surgery residency program. DESIGN Electronic Residency Application Services applications were reviewed. All listed publications were tabulated and checked whether they were published using various search engines. SETTING Cedars-Sinai Medical Center. PATIENTS Applicants from 2006 to 2008. MAIN OUTCOME MEASURES We searched for phantom publications, defined as peer review journal citations that could not be verified. Demographics and other academic factors were compared between applicants with phantom publications and applicants with verifiable publications. RESULTS Of the 133 study group applicants, there were 91 (68%) males and 58 (44%) whites. Median age of the study cohort was 32 years (range, 27-48 y). Eight-seven of 130 applicants (65%) listed a total of 392 publications. Thirty-six (9%) of these 392 citations could not be verified and were considered to be phantom publications. The 36 phantom publications were identified in 21 applicants, representing 16% (21/133) of all applicants and 24% (21/87) of all applicants who cited publications. We found no significant difference in any demographic or other studied variable between applicants with phantom publications and those with verifiable publications. When comparing applicants with 3 or more phantom publications with applicants with verifiable publications, the former group had a significantly higher rate of individuals over age 35 (50% vs 24%; P = .02), foreign medical school graduates (75% vs 20%; P = .03), and individuals with 5 or more publications (100% vs 30%; P = .01). LIMITATIONS Publications may simply have been missed in our search. We specifically may have failed to find publications in foreign journals. CONCLUSION The significance of professionalism and ethical behavior must be emphasized in surgery training programs.
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Affiliation(s)
- Yosef Nasseri
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Quirke P, Risio M, Lambert R, von Karsa L, Vieth M. Quality assurance in pathology in colorectal cancer screening and diagnosis—European recommendations. Virchows Arch 2011; 458:1-19. [PMID: 21061133 PMCID: PMC3016207 DOI: 10.1007/s00428-010-0977-6] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Revised: 08/29/2010] [Accepted: 09/05/2010] [Indexed: 02/08/2023]
Abstract
In Europe, colorectal cancer is the most common newly diagnosed cancer and the second most common cause of cancer deaths, accounting for approximately 436,000 incident cases and 212,000 deaths in 2008. The potential of high-quality screening to improve control of the disease has been recognized by the Council of the European Union who issued a recommendation on cancer screening in 2003. Multidisciplinary, evidence-based European Guidelines for quality assurance in colorectal cancer screening and diagnosis have recently been developed by experts in a pan-European project coordinated by the International Agency for Research on Cancer. The full guideline document consists of ten chapters and an extensive evidence base. The content of the chapter dealing with pathology in colorectal cancer screening and diagnosis is presented here in order to promote international discussion and collaboration leading to improvements in colorectal cancer screening and diagnosis by making the principles and standards recommended in the new EU Guidelines known to a wider scientific community.
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Affiliation(s)
- Phil Quirke
- Pathology and Tumour Biology, Leeds Institute of Molecular Medicine, University of Leeds, Leeds, UK
| | - Mauro Risio
- Pathology Department, Institute for Cancer Research and Treatment, Turin, Italy
| | - René Lambert
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, Lyon, France
| | - Lawrence von Karsa
- Quality Assurance Group, Early Detection and Prevention Section, International Agency for Research on Cancer, Lyon, France
| | - Michael Vieth
- Institute of Pathology, Klinikum Bayreuth, Preuschwitzerstr. 101, 95445 Bayreuth, Germany
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Kajiwara Y, Ueno H, Hashiguchi Y, Mochizuki H, Hase K. Risk factors of nodal involvement in T2 colorectal cancer. Dis Colon Rectum 2010; 53:1393-9. [PMID: 20847621 DOI: 10.1007/dcr.0b013e3181ec5f66] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE Because of the adverse consequences of radical resection of T2 colorectal cancer, criteria are needed for selection of patients who can safely undergo local excision without requiring additional radical surgery. We therefore conducted a retrospective study of patients with T2 colorectal cancer to identify risk factors for nodal involvement that might be used in selecting patients for local excision. METHODS We reviewed records from consecutive patients who had undergone curative resection of T2 colorectal cancer at the Department of Surgery, National Defense Medical College, Saitama, Japan, between 1985 and 2005. Data on conventional clinicopathologic variables were retrieved from pathology reports at the time of surgery, and archived slides were evaluated regarding potential risk factors such as extent of poorly differentiated component (grade I-III), myxoid cancer stroma, tumor budding, and growth pattern and invasion depth in the muscularis propria. RESULTS A total of 244 patients (139 men and 105 women) treated for T2 colorectal cancer were included. Nodal involvement was found in 7 (8.4%) of 83 patients classified as grade I on the poorly differentiated component vs. 47 (29.2%) of 161 patients classified as grade II or III (P < .001). Of 148 patients negative for myxoid cancer stroma, 30 (16.9%) had nodal involvement vs. 24 (36.4%) of 42 patients who were positive for myxoid cancer stroma (P = .0011). According to multiple variable logistic analysis, significant independent risk factors for nodal involvement included poorly differentiated component (P = .002), myxoid cancer stroma (P = .032), and lymphovascular invasion (P = .022). CONCLUSIONS Poorly differentiated component, myxoid cancer stroma, and lymphovascular invasion are significant independent risk factors for nodal involvement in T2 colorectal cancer. We need further study to validate these results on another data set, especially in patients with rectal cancer, and to confirm whether local resection of T2 rectal cancer is able to predict the nodal involvement before laparotomy.
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Affiliation(s)
- Yoshiki Kajiwara
- Department of Surgery, National Defense Medical College, Saitama, Japan.
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46
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47
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48
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Abstract
The treatment of rectal cancer includes both radical resection and local therapy. Radical resection remains the standard treatment, but is associated with increased morbidity and mortality, as well as the potential need for a temporary and occasionally, a permanent ostomy. The benefits of local treatment include a less invasive procedure with maintenance of bowel function and avoidance of a stoma. However, the efficacy of local treatment is now being challenged as the rates of recurrence after local excision alone appear to be much higher than previously thought. Although the primary goal of an oncologic resection is disease eradication, each case must be individualized to determine an optimal care plan.
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Affiliation(s)
- Daniel P Geisler
- Department of Colorectal Surgery, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
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Derwinger K, Kodeda K, Bexe-Lindskog E, Taflin H. Tumour differentiation grade is associated with TNM staging and the risk of node metastasis in colorectal cancer. Acta Oncol 2010; 49:57-62. [PMID: 20001500 DOI: 10.3109/02841860903334411] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
AIM The tumour differentiation grade has been shown by numerous multivariate analyses to be a stage-independent prognostic factor in colorectal cancer. The aim of this study was to explore the importance of differentiation grading for the staging of colorectal cancer and how it relates to the components of the TNM system. MATERIAL AND METHODS The study was a retrospective single-centre analysis of all patients undergoing surgical resection for colorectal cancer during the period 2002-2007 (n = 1239). The clinical parameters and pathology data of overall stage, differentiation grade, local tumour (T)-stage and metastasis status (M-stage) were included as well as the lymph node count of both assessed and metastatic nodes. The differentiation grade was correlated with demography, overall stage and each component of the TNM staging system. The correlation between differentiation grade and N-stage was also explored for the separate T-stages. RESULTS The tumour differentiation grade correlated significantly with the overall TNM stage (p < 0.0001). The grade significantly correlated with the T-stage and the risk of having lymph node metastasis (p < 0.0001). A high grade was associated with a higher positive lymph node count in stage III disease (p < 0.0002). For the T-stages, the risk of node metastasis was significantly linked to the tumour grade. A low grade (G1) T2 had a 17% risk of lymph node metastasis compared to a 44% risk for a high grade (G4) T2. CONCLUSION Tumour differentiation is an important prognostic factor. It correlates significantly with the overall stage of the TNM system and also to each of its components. The risk of having lymph node metastasis for each T-stage also correlates with the tumour grade. The findings can be of importance in postoperative risk assessment or when considering local resection procedures like TEM.
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Abstract
A variety of lesions comprise tumors of the anal canal, with carcinoma in situ and epidermoid cancers being the most common. Less common anal neoplasms include adenocarcinoma, melanoma, gastrointestinal stromal cell tumors, neuroendocrine tumors, and Buschke-Lowenstein tumors. Treatment strategies are based on anatomic location and histopathology. In this article different tumors and management of each, including a brief review of local excision for rectal cancer, are discussed in turn.
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Affiliation(s)
- Kelly Garrett
- Department of Colorectal Surgery, Digestive Disease Institute, 9500 Euclid Avenue, A30 Cleveland Clinic, Cleveland, OH 44195, USA
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