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

Abstract

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

Systematic review and meta-analysis of endoscopic submucosal dissection versus transanal endoscopic microsurgery for large noninvasive rectal lesions

“…One of the most important risk factors for recurrence of rectal lesions is an R1 resection [2,31,32], which is obviously less probable when an en bloc resection is attempted. A recent systematic review by Barendse et al [33] reported a recurrence rate of 11.2 % at 3 months after piecemeal EMR for colorectal lesions, which dropped to 1.5 % at 3 months after further endoscopic treatment.…”

Recurrence after transanal endoscopic microsurgery for large rectal adenomas

“…In fact, transanal surgery with retractors is associated with a consistent incidence of recurrence, especially for tumors of the upper and midrectum [12,13]. TEM combines a less invasive transanal approach with the benefits of better postoperative functional outcome and quality of life [17] and low recurrence rates for adenomas and selected early rectal cancers, thanks to enhanced visualization of the surgical field which allows more precise dissection [25]. No studies as of yet have compared piecemeal endoscopic techniques with TEM for large rectal adenomas.…”

Early rectal cancer: the European Association for Endoscopic Surgery (EAES) clinical consensus conference

“…LE has also been proposed in frail patients or in those refusing major surgery to remove more invasive rectal cancers (T1 sm2-3 and T2). However, the risk of recurrence is significantly higher, and therefore LE alone should be considered only as a compromise procedure [89][90][91][92]. The use of neoadjuvant (chemo)radiation therapy followed by full thickness LE of more advanced T1 and T2…”