Long‐term Results of Patients with pT2 Rectal Cancer Treated with Radiotherapy and Transanal Endoscopic Microsurgical Excision

Abstract

Anterior resection and abdomino-perineal resection are the surgical techniques used most frequently in the treatment of rectal cancer. Local recurrence rates of 10% to 14% are described after these conventional procedures. Preoperative neoadjuvant radiotherapy reduces local failure. Because local excision techniques can be applied to treat early rectal cancer in selected patients, we evaluated the results of preoperative high-dose radiotherapy and transanal endoscopic microsurgical excision (TEM) in patients with T2 rectal cancer. All patients underwent preoperative irradiation with 5,040 cGy, divided over 5 weeks. Forty days after completion of radiotherapy, the patients underwent complete full-thickness local excision of the rectal lesion including adjacent perirectal fat by TEM. The patients were followed for up to 8 years. Thirty-five patients, with pT2 rectal cancer as determined by pathological examination of the surgical specimen were enrolled in the present study. The tumors were responsive to preoperative radiotherapy in 82.8% of cases. No intraoperative complications and no conversion to open surgery were observed. No major complications and no mortality occurred during the 60-day postoperative period. Minor postoperative complications were observed in 5 patients (14.3%). The median follow-up of the patients was 38 months (range 24 to 96 months). One local recurrence (2.85%) was noted. The probability of surviving at 96 months after completion of treatment was 83%. Local excision by TEM combined with preoperative high-dose radiotherapy can achieve results similar to those observed after conventional surgery in patients with pT2 rectal cancer.

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

“…Despite its evident limitations, it is indeed more valuable to consider EUS staging as it can provide information on wall infiltration by which to choose a local or a radical excision. It is difficult to objectively define preoperatively which lesion would better be removed by TEM instead of transabdominal surgery, or even if it would benefit from neoadjuvant therapy, which, associated with TEM, in uT2 lesions was reported to be as effective as abdominal radical surgery [15][16][17][18]. Nevertheless, it must be remembered that our series extended over 15 years and was affected by a great evolution in technology, such as the introduction of EUS 360° probes, an improvement in image definition, and the introduction of high-definition EUS 20-MHz through-the-channel miniprobes [33].…”

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

Microcirurgia endoscópica transanal no tratamento dos tumores do reto: estudo prospectivo em 50 pacientes

“…São lesões bem diferenciadas menores do que 4 cm, sem invasão angiolinfática que respondem bem à radioterapia pré-operatória. Já foi observado que, em seguimento tardio de 10 anos, não houve diferença significativa na sobrevida, quando comparados os pacientes submetidos a TEM aos com procedimento cirúrgico radical convencional (16) . Naquele caso a ultra-sonografia pré-operatória foi de pT1N0, o que demonstra que, às vezes, torna-se difícil determinar com exatidão a profundidade da invasão.…”

“…A pergunta a ser respondida é: poderia a TEM ser utilizada com sucesso em carcinomas com estádio mais avançado? A literatura já mostra resultados animadores com sua aplicação nos carcinomas pT2NO submetidos a radioterapia e quimioterapia pré-operatórias (3,16,20,28,29) .…”

Rectal Cancer and Invasion of Veins: Importance in TNM Staging 2

“…However, the question remains of how important this is, as there are only two circumstances is which the presence of lymph node metastases is relevant in clinical decision making: first, the choice of local excision in the absence of lymphadenopathy and second the present of lymph node metastases outside the end pelvic envelope makes the primary tumor locally advanced [31][32][33]. In this first situation the histological characteristics of the primary tumor are now relevant than lymph node imaging [34][35][36].…”