Transanal Endoscopic Microsurgery with or without Completion Total Mesorectal Excision for T2 and T3 Rectal Carcinoma

Abstract

Aim: Transanal endoscopic microsurgery (TEM) is used for the resection of large rectal adenomas and well or moderately differentiated T1 carcinomas. Due to difficulty in preoperative staging, final pathology may reveal a carcinoma not suitable for TEM. Although completion total mesorectal excision is considered standard of care in T2 or more invasive carcinomas, this completion surgery is not always performed. The purpose of this article is to evaluate the outcome of patients after TEM-only, when completion surgery would be indicated. Methods: In this retrospective multicenter, observational cohort study, outcome after TEM-only (n = 41) and completion surgery (n = 40) following TEM for a pT2–3 rectal adenocarcinoma was compared. Results: Median follow-up was 29 months for the TEM-only group and 31 months for the completion surgery group. Local recurrence rate was 35 and 11% for the TEM-only and completion surgery groups respectively. Distant metastasis occurred in 16% of the patients in both groups. The 3-year overall survival was 63% in the TEM-only group and 91% in the completion surgery group respectively. Three-year disease-specific survival was 91 versus 93% respectively. Conclusions: Although local recurrence after TEM-only for pT2–3 rectal cancer is worse compared to the recurrence that occurs after completion surgery, disease-specific survival is comparable between both groups. The lower unadjusted overall survival in the TEM-only group indicates that TEM-only may be a valid alternative in older and frail patients, especially when high morbidity of completion surgery is taken into consideration. Nevertheless, completion surgery should always be advised when curation is intended.

Survival after local excision for rectal cancer: a population-based overview of clinical practice and outcome

“…As in this study, a previous study from the US also showed an increase in LE as treatment for pT1 rectal cancer but also for more invasive tumors [10]. Especially in the elderly, an increase in LE was observed, which is probably due to the fact that surgical morbidity after standard TME surgery is not insignificant and a reason for exploring less extensive treatment methods [8,17].…”

“…Local excision (LE) proved to be oncologically safe in selected T1 rectal cancer and is considered standard therapy and an attractive alternative for major surgery [4][5][6][7]. However, LE for pT2 cancer may lead to unacceptable high local recurrence rates, with a significant decrease in survival compared to TME [8,9].…”

Local recurrence after local excision of early rectal cancer: a meta-analysis of completion TME, adjuvant (chemo)radiation, or no additional treatment

“…This is lower than rates reported elsewhere. In a study 96 of locally excised pT2-3 rectal cancers, distant metastases were observed in 16 per cent at 3 years of follow-up of patients who underwent NAT or transanal endoscopic microsurgery followed by cTME. In the previous review 18 , the weighted average distant recurrence rate was 9 per cent in patients treated with aCRT or cTME.…”

Comparison of Short-Term Clinical and Pathological Outcomes after Transanal versus Laparoscopic Total Mesorectal Excision for Low Anterior Rectal Resection Due to Rectal Cancer: A Systematic Review with Meta-Analysis

“…Nowadays, a trend towards extending the indications for local excision in less advanced tumors with no adverse pathological risk-factors can be observed [ 48 ]. According to some authors, local resection may be feasible for the elderly, even up to T3 tumors with good long-term outcomes [ 49 , 50 ]. There are ongoing studies on non-operative management of rectal cancer [ 51 , 52 ].…”