Transanal endoscopic microsurgery for rectal lesions in a specialist regional early rectal cancer centre: the Mersey experience

Abstract

AimOrgan‐preserving local excision by transanal endoscopic microsurgery (TEM) for early rectal cancer offers significantly lower morbidity as compared to formal rectal cancer resection with acceptable outcomes. This study presents our 6‐year experience of TEM for rectal lesions referred to a specialist early rectal cancer centre in the UK.MethodData were collected for all patients referred for TEM of suspected early rectal cancer to a regional specialist early rectal cancer multidisciplinary team (MDT) over a 6‐year period.ResultsOne hundred and forty‐one patients who underwent full‐thickness TEM for suspected or confirmed early rectal cancer were included. Thirty patients were referred for TEM following incomplete endoscopic polypectomy. Final pathology was benign in 77 (54.6%) cases and malignant in 64 (45.4%). Of the 61 confirmed adenocarcinomas, TEM resections were pT0 in 17 (27.9%), pT1 in 32 (51.7%), pT2 in 11 (18.0%) and pT3 in 1 (1.6%). Thirty‐eight of 61 patients (62.3%) had one or more poor histological prognostic features and these patients were offered further treatment. Twenty‐three of 61 (37.7%) patients with rectal adenocarcinoma required no further treatment following TEM. Forty‐three cases of rectal adenocarcinoma were available for establishing recurrence rates. Two of 43 patients (4.7%) developed a recurrence at a median follow‐up of 28.7 months (12.1–66.5 months). The overall estimated 5‐year overall survival rate was 87.9% and the disease‐free survival rate was 82.9%.ConclusionAcceptable outcomes are possible for TEM surgery with appropriate patient selection, effective technique, expert histopathology, appropriate referral for adjuvant treatment and meticulous follow‐up. This can be achieved through an early rectal cancer MDT in a dedicated specialist regional centre.

Timing of recurrences of TEM resected rectal neoplasms is variable as per the surveillance practices of one tertiary care institution

“…Of those 4 patients recurred, representing a recurrence rate of 16% in this population of T1 and T2 lesions. Our recurrence rates are similar to that of many studies, which range from 4.7 to 26% depending on T stage [19][20][21][22] . Baatrup et al demonstrated a recurrence rate of 18% for patients with adenocarcinoma treated with TEM.…”

“…The focus of our study was on endoscopic surveillance practices post TEM and recurrence patterns in benign and malignant lesions, at our institution. The demographics of our patients, tumour characteristics, surgical results and outcomes are similar to other studies on TEM for benign and malignant lesions [17][18][19][20][21][22] . Although there is currently no established standardized protocol for endoscopic surveillance of patients post-TEM at our institution, the majority of the patients had their endoscopy within the timeframes of the commonly quoted surveillance recommendation from the clinic notes, namely every 6 months for 2 years.…”

“…It is possible the recurrences may have been caught too late. The average timing of recurrences quoted by numerous studies for T1 rectal cancers excised by TEM ranges between 13.0 and 28.7 months, however these same studies have shown recurrences as early as 3 months and as late as 66.5 months [19][20][21]28 . Similar to the results of our study where the earliest recurrence was caught at 7.4 and the latest was caught at 38.5 months after two previous negative endoscopic exams, this emphasizes the need for early and also continued screening.…”

Preservation of the rectum is possible in early rectal cancer with neoadjuvant radiotherapy, delay and local excision—a 12‐year single‐centre experience of the evolution of early rectal cancer treatment

“…Important considerations include the need for thorough preoperative assessment, multimodal radiological staging, multidisciplinary decision‐making and a deep appreciation of the tumour biology in order to tailor treatment towards surveillance, rescue surgery or adjuvant CXB as the individual context dictates. For this to be effective, these patients are best served in a specialist network with the appropriate expertise [46].…”

Long‐term outcomes of patients with poor prognostic factors following transanal endoscopic microsurgery for early rectal cancer

“…We maintained a prospective electronic database of all patients discussed at the regional specialist ERC (SERC) multidisciplinary team (MDT) in a tertiary care centre. The SERC MDT was set up in 2011 and serves approximately 2.5 million people of Merseyside and Cheshire [19] accepting referrals from seven regional hospitals. It comprises colorectal surgeons and endoscopists with a special interest in LE techniques, oncologists, radiologists, pathologists and colorectal nurse specialists.…”