Local Management of Rectal Neoplasia

ABSTRACT

The treatment of rectal neoplasia, whether benign or malignant, challenges the surgeon. The challenge in treating rectal cancer is selecting the proper approach for the appropriate patient. In a small number of rectal cancer patients local excision may be the best approach. In an attempt to achieve two goals—cure of disease with a low rate of local failure and maintenance of function and quality of life—multiple approaches can be utilized. The key to obtaining a good outcome for any one patient is balancing the competing factors that impact on these goals. Any effective treatment aimed at controlling rectal cancer in the pelvis must take into account the disease in the bowel wall itself and the disease, or potential disease, in the mesorectum. The major downside of local excision techniques is the potential of leaving untreated disease in the mesorectum. Local management techniques avoid the potential morbidity, mortality, and functional consequences of a major abdominal radical resection and are thus quite effective in achieving the maintenance of function and quality of life goal. The issue for the transanal techniques is how they fare in achieving the first goal—cure of the cancer while keeping local recurrence rates to an absolute minimum. Without removing both the rectum and the mesorectum there is no completely accurate way to determine whether a rectal cancer has moved outside the bowel wall, so any decision on local management of a rectal neoplasm is a calculated risk. For benign neoplasia, the challenge is removing the lesion without having to resort to a major abdominal procedure.

Cancer - rectum - neoplasms - transanal - villous adenoma

REFERENCES

• 1 Endreseth B H, Myrvold H E, Romunstad P et al.. Transanal excision versus major surgery for T1 rectal cancer.  Dis Colon Rectum. 2005;  48 1380-1388
• 2 Habr-Gama A, Perez R O, Nadalin W et al.. Operative versus nonoperative treatment for stage O distal rectal cancer following chemoradiation therapy: long term results.  Ann Surg. 2004;  240 711-718
• 3 Saclarides T J, Bhattacharyya A K, Britton-Kuzel C, Szeluga D, Economou S G. Predicting lymph node metastases in rectal cancer.  Dis Colon Rectum. 1994;  37 52-57
• 4 Brodsky J T, Richard G K, Cohen A M et al.. Variables correlated with the risk of lymph node metastasis in early rectal cancer.  Cancer. 1992;  69 322-326
• 5 Blumberg D, Paty P B, Guillem J G et al.. All patients with small intramural rectal cancers are at risk for lymph node metastasis.  Dis Colon Rectum. 1999;  42 881-885
• 6 Sitzler P J, Seow-Choen F, Ho Y H, Leong A P. Lymph node involvement and tumor depth in rectal cancers: an analysis of 805 patients.  Dis Colon Rectum. 1997;  40 1472-1476
• 7 Kauer W KH, Prantl L, Dittler H J, Siewart J R. The value of endosonographic rectal carcinoma staging in routine diagnostics.  Surg Endosc. 2004;  18 1075-1078
• 8 Knaebel H-P, Koch M, Feise T, Benner A, Kienle P. Diagnostics of rectal cancer: endorectal ultrasound.  Recent Results Cancer Res. 2005;  165 46-57
• 9 Harewood G C. Assessment of publication bias in the reporting EUS performance in staging rectal cancer.  Am J Gastroenterol. 2005;  100 808-816
• 10 Ptok H, Marusch F, Meyer F et al.. Feasibility and accuracy of TRUS in the pre-treatment staging for rectal carcinoma in general practice.  Eur J Surg Oncol. 2006;  32 420-425
• 11 Kwok H, Bisset I, Hill G L. Preoperative staging of rectal cancer.  Int J Colorectal Dis. 2000;  15 9-20
• 12 Kim N K, Kim M J, Yun S H et al.. Comparative study of transrectal ultrasonography, pelvic computerized tomography, and magnetic resonance imaging in preoperative staging of rectal cancer.  Dis Colon Rectum. 1999;  42 770-775
• 13 Dworak O. Number and size of lymph node metastases in rectal carcinomas.  Surg Endosc. 1989;  3 96-99
• 14 Herzog U, von Flue M, Tondelli P et al.. How accurate is endorectal ultrasound in the preoperative staging of rectal cancer?.  Dis Colon Rectum. 1993;  36 127-134
• 15 Graham R A, Garnsey L, Jessup J M. Local excision of rectal cancer.  Am J Surg. 1990;  160 306-312
• 16 Cohen A M, Wood W C, Gunderson L L, Shinnar M. Pathologic studies in rectal cancer.  Cancer. 1980;  45 2965-2968
• 17 Nascimbeni R, Burgart L J, Nivatvongs S et al.. Risk of lymph node metastasis in T1 carcinoma of the colon and rectum.  Dis Colon Rectum. 2002;  45 200-206
• 18 Brodsky J T, Richard G K, Cohen A M et al.. Variables correlated with the risk of lymph node metastasis in early rectal cancer.  Cancer. 1992;  69 322-326
• 19 Decosse J J, Wong R J, Quan S JQ et al.. Conservative treatment of distal rectal cancer by local excision.  Cancer. 1989;  63 219-223
• 20 Minsky B D. Clinical experience with local excision and postoperative radiation therapy for rectal cancer.  Dis Colon Rectum. 1993;  36 405-409
• 21 Greaney M G, Irvin T T. Criteria for the selection of rectal cancer for local treatment.  Dis Colon Rectum. 1977;  20 463-466
• 22 Chambers W M, Khan U, Gagliano A et al.. Tumour morphology as a predictor of outcome after local excision of rectal cancer.  Br J Surg. 2004;  91 457-459
• 23 Whiteway J, Nicholls R J, Morson B C. The role of surgical local excision in the treatment of rectal cancer.  Br J Surg. 1985;  72 694-697
• 24 Sitzler P J, Seow-Choen F, Ho Y et al.. Lymph node involvement and tumor depth in rectal cancers: an analysis of 805 patients.  Dis Colon Rectum. 1997;  40 1472-1476
• 25 Nascimbeni R, Burgart L J, Nivatvongs S et al.. Risk of lymph node metastasis in T1 carcinoma of the colon and rectum.  Dis Colon Rectum. 2002;  45 200-206
• 26 Kikuchi R, Takano M, Takagi K et al.. Management of early invasive colorectal cancer. Risk of recurrence and clinical guidelines.  Dis Colon Rectum. 1995;  38 1286-1295
• 27 Buess G, Kipfmuller K, Ibald R et al.. Clinical results of transanal endoscopic microsurgery.  Surg Endosc. 1988;  2 245-250
• 28 Buess G, Mentges B, Manncke K et al.. Technique and results of transanal endoscopic microsurgery in early rectal cancer.  Am J Surg. 1992;  163 63-70
• 29 Smith L E, Ko S T, Saclarides T et al.. Transanal endoscopic microsurgery-USA registry results.  Dis Colon Rectum. 1995;  38 33-34
• 30 Onaitis M, Ludwig K A, Perez-Tamayo A et al.. The Kraske procedure: a critical analysis of a surgical approach for mid-rectal lesions.  J Surg Oncol. 2006;  94 194-202
• 31 Mason A Y. Transsphincteric approach to rectal lesion.  Surg Annu. 1977;  9 171-194
• 32 Thompson B W, Tucker W E. Transsphincteric approach to lesions of the rectum.  South Med J. 1987;  80 41-43
• 33 Mellgren A, Sirivongs P, Rothenberger D A, Madoff R D, Garcia-Aguilar J. Is local excision adequate therapy for early rectal cancer?.  Dis Colon Rectum. 2000;  43(8) 1064-1074
• 34 Goldberg J, Parker S C, Rothenberger D A et al.. Long-term outcome of local excision for early rectal cancer.  Dis Colon Rectum. 2005;  48 611A
• 35 Paty P B, Nash G M, Baron P et al.. Long-term results of local excision for rectal cancer.  Ann Surg. 2002;  236 522-529
• 36 Madbouly K M, Remzi F H, Erkek B A et al.. Recurrence after transanal excision of T1 rectal cancer: Should we be concerned?.  Dis Colon Rectum. 2005;  48 711-721
• 37 You Yn, Baxter N N, Stewart A, Nelson H. Is the increasing rate of local excision for Stage I rectal cancer in the United States justified?.  Ann Surg. 2007;  245 726-733
• 38 Middleton P F, Sutherland L M, Maddern G J. Transanal endoscopic microsurgery: a systematic review.  Dis Colon Rectum. 2005;  48 270-284
• 39 Steele Jr G D, Herndon J E, Bleday R et al.. Sphincter sparing treatment for distal rectal adenocarcinoma.  Ann Surg Oncol. 1999;  6 433-441
• 40 Winde G, Nottberg H, Keller R et al.. Surgical cure for early rectal carcinomas (T1).  Dis Colon Rectum. 1996;  39 969-976
• 41 Floyd N D, Saclarides T J. Transanal endoscopic microsurgical resection of pT1 rectal tumors.  Dis Colon Rectum. 2006;  49 164-168
• 42 Lezoche E, Guerrieri M, Paganini A M et al.. Long-term results of patients with pT2 rectal cancer treated with radiotherapy and transanal endoscopic microsurgical excision.  World J Surg. 2002;  26 1170-1174
• 43 Lee W, Lee D, Choi S, Chun H. Transanal endoscopic microsurgery and radical surgery for T1 and T2 rectal cancer.  Surg Endosc. 2003;  17 1283-1287
• 44 Baron P L, Enker W E, Zakowski M F et al.. Immediate versus salvage resection after local treatment for early rectal cancer.  Dis Colon Rectum. 1995;  38 177-181
• 45 Weiser M R, Landmann R G, Wong W D et al.. Surgical salvage of recurrent rectal cancer after transanal excision.  Dis Colon Rectum. 2005;  48 1169-1175
• 46 Russell A H, Harris J, Rosenberg P J et al.. Anal sphincter conservation for patients with adenocarcinoma of the distal rectum: long-term results of radiation therapy oncology group protocol 89–02.  Int J Radiat Oncol Biol Phys. 2000;  46 313-322
• 47 Bleday R, Breen E, Jessup J M, Burgess A, Sentovich S M, Steele Jr G D. Prospective evaluation of local excision for small rectal cancers.  Dis Colon Rectum. 1997;  40 388-392
• 48 Ota D M, Nelson H. Local excision of rectal cancer revisited: ACSOG protocol Z6041.  Ann Surg Oncol. 2006;  14 271
• 49 Marks G, Mohiuddin M M, Masoni L et al.. High-dose preoperative radiation and full-thickness local excision. A new option for patients with select cancers of the rectum.  Dis Colon Rectum. 1990;  33 735-739
• 50 Galandiak S, Fazio V W, Jagelman D G et al.. Villous and tubulovillous adenomas of the colon and rectum: a retrospective review.  Am J Surg. 1987;  153 41-47
• 51 Nivatvongs S, Nicholson J D, Rothenberger D A et al.. Villous adenomas of the rectum: the accuracy of clinical assessment.  Surgery. 1980;  87 549-551
• 52 Adams W, Wong W D. Endorectal ultrasonic detection of malignancy within rectal villous lesions.  Dis Colon Rectum. 1995;  38 1093-1096
• 53 Keck J O, Schoetz Jr D J, Roberts P L et al.. Rectal mucosectomy in the treatment of giant rectal villous tumors.  Dis Colon Rectum. 1995;  38 233-238
• 54 Thompson J P. Treatment of sessile villous and tubulovillous adenomas of the rectum: experience of St. Mark's Hospital 1963–1972.  Dis Colon Rectum. 1977;  20 467-472