Transanal Endoscopic Microsurgery (TEM) Following Neoadjuvant Chemoradiation for Rectal Cancer: Outcomes of Salvage Resection for Local Recurrence

Abstract

Salvage resection for local recurrence following CRT and TEM is associated with high rates of R1 resection (CRM+) and local re-recurrence. Immediate completion of TME should be considered for patients with unfavorable pathological features after TEM.

Wait-and-see treatment strategies for rectal cancer patients with clinical complete response after neoadjuvant chemoradiotherapy: a systematic review and meta-analysis

“…The Brazil study [4] was the first to propose that nonoperation management could be used for patients with cCR. The Brazil study series [3, 4, 38, 39] also improved the process for nonoperation management, including patient selection, how and when to identify cCR, follow-up schedule, and salvage treatment. In the present study, we found that there is no difference in long-term survival, as measured by DM, DFS, and OS, in patients with cCR treated with a wait-and-see strategy compared to those with pCR who underwent radical surgery.…”

Magnetic resonance imaging following neoadjuvant chemoradiation and transanal endoscopic microsurgery for rectal cancer

“…In our previously reported oncological outcomes of TEM following nCRT, nearly all recurrences (89%) had residual cancer within the rectal wall. In fact, only 25% of patients with recurrent cancer had lymph node metastases in the resected specimen after salvage [10]. These findings are in contrast with the idea that local recurrences after local excision are exclusively within the mesorectum.…”

“…This suggests that MRI has a role not only for the diagnosis but also for surgical planning of these patients as indicated in previous studies for primary non-recurrent rectal cancer [21][22][23][24]. This is particularly relevant in a setting where R1 resections occur very frequently [10]. Ultimately, the suggestion of MRF +ve in MRI in these patients may lead surgeons to consider more extensive resections, even beyond the mesorectal plane.…”

Organ-Preserving Strategies for the Management of Near-Complete Responses in Rectal Cancer after Neoadjuvant Chemoradiation

“…Furthermore, in another report from the same group, with an expanded series of 53 patients with NCCR after CRT for LARC, the 2-year LR rate after TEM was 22% (12/53 patients); nine of the patients were LR exclusively, and eight were deemed resectable by preoperative imaging and were operated with salvage intention. 32 Of note, a disappointing positive circumferential margin was obtained in most of the cases (7/8). The authors acknowledge that TME after LE might not be the best approach and make a call for completion TME immediately after TEM in the presence of bad pathological features (ypT2-3, LVI, perineural invasion, or poor differentiation).…”

“…In fact, in the aforementioned study, 7 of 8 patients requiring a TME after LE required an abdominoperineal resection. 32 Several series have reported the results of a treatment protocol for rectal cancer patients treated according to a protocol consisting on CRT followed by LE, followed by immediate TME for patients found to have high-risk features (i.e., positive margins, LVI, perineural invasion, and poor differentiation) in the LE specimen. An Italian multicenter phase II study, including 63 patients with cT2/T3 tumor with a significant response to CRT and found to have ypT2, positive margins, tumor regression grade !…”