Local excision of T1 and T2 rectal cancer: proceed with caution

Abstract

LE of early rectal cancer is associated with higher local recurrence and decreased DFS. These disadvantages are significant for T2 lesions.

Current status of local treatment for early rectal cancer in Japan: a questionnaire survey by the 81st Congress of the Japanese Society for Cancer of the Colon and Rectum (JSCCR) in 2014

“…Therefore, the rate of recurrence was more than eight times greater than in patients with T1 RC (1.1 %) according to JSCCR guidelines [9]. On the other hand, the recurrence rate was 17-24 % in patients undergoing LE in the Western world [2,12,13,23], which was relatively higher than in our study. However, Garcia reported that CRT contributed to a decrease on LRR and improved survival [24].…”

“…Local treatment with palliative intent for elderly or poor-risk patients may be an appropriate treatment modality. Meanwhile, in the Western world, LE was widely performed for patients with T1, T2, or more advanced cancer and was associated with a high incidence of local recurrence [12][13][14]. Therefore, Nastro et al [15] suggested that large tumors (>3-4 cm) occupying >40 % of the rectal circumference or with poor prognostic factors, such as mucinous tumors, lymphovascular invasion, or ulceration, should be excluded from LE alone, and high-risk T1 tumors require prospective, randomized trials comparing radical surgery with and without adjuvant therapy.…”

Low rectal cancer: Sphincter preserving techniques-selection of patients, techniques and outcomes

“…On the other hand, the published results on the oncological outcome following TEM remain controversial, since other studies [85] reported favorable results with local recurrence rates lower than 10%, others [86] confirmed the lower local recurrence rates following TEM compared to the transanal local excision (18.5% vs 27.7%) but without statistical significance, others [87] stated alarming figures for local recurrence following TEM for T1 rectal tumors, while local recurrence rates as high as 20.5% have also been reported [88] . In an attempt to evaluate further the above findings, both Tytherleigh et al [89] in 2008, as-well-as Bach et al [90] in 2009, offered possible explanations for these unfavorable results.…”

Transanal endoscopic surgery: patient selection and perspectives

“…For patients with early stage rectal cancer, this can potentially be curative; however, this operation carries a significant morbidity (30%-68%) and mortality (0%-6.5%). 28 In a select group of patients with early rectal cancer, TES can be an option to decrease postoperative morbidity and improve quality of life as long as their oncologic outcome is not compromised. Nonetheless, not all early rectal cancers are amenable to local excision as studies have shown that patients with T1 tumors …”

“…30,31 Patients with tumors staged as T2 and above should not be considered for TES as their risk of lymph node metastasis is too high, and these patients should undergo formal TME even without any gross nodal involvement on staging workup. A study by Elmessiry et al 28 comparing local excision and TME in T1 and T2 cancers found a higher local recurrence (P=0.025) and lower disease free survival (P=0.044) for T2 lesions after local excision, suggesting that these tumors are best treated with TME. Moreover, for patients who have recurrence after local excision for early rectal cancer and recur, the outcome of salvage surgery is also affected by the initial operation.…”