Clin Colon Rectal Surg 2020; 33(06): 361-365
DOI: 10.1055/s-0040-1714240
Review Article

ISR for T1-2 Low Rectal Cancer: A Japanese Approach

Masaaki Ito
1   Department of Colorectal Surgery, National Cancer Center Hospital East, Chiba, Japan
› Author Affiliations

Abstract

The evolution over the past 20 years of anal preservation in rectal cancer surgery has been truly remarkable. Intersphincteric resection (ISR) reported by Schiessel in 1994 in Australia has been shown to enable anal preservation even for cancers quite close to the anus. In Japan, ISR via the detachment of the anal canal between the internal and external sphincters and excision of the internal sphincter first began to be practiced in the latter half of 1990. A multicenter Phase II trial of ISR in Japan suggested that 70% of the cases had relatively good function with less than 10 points of Wexner score but around 10% had severe incontinence that would not be improved for long term. The primary end point of the clinical study, 3-year local recurrence rate, was 13.2% across the overall cohort (T1, 0%; T2, 6.9%; and T3, 21.6%). When ISR is performed on T1/T2 rectal cancers, sufficient circumferential resection margin can be obtained even without preoperative chemoradiotherapy, and local recurrence rate was acceptably low. Based on these evidences, ISR is a currently important, standard treatment option among anal-preserving surgeries for T1/T2 low-lying rectal cancers. In Japan, a feasibility study (LapRC trial) of laparoscopic ISR on Stage 0 and Stage 1 low rectal cancer showed excellent outcomes. A prospective Phase II clinical trial targeting low rectal cancers within 5 cm from the anal verge (ultimate trial) is being performed and awaiting the results in near future.



Publication History

Article published online:
02 November 2020

Thieme Medical Publishers
333 Seventh Avenue, New York, NY 10001, USA.

 
  • References

  • 1 Schiessel R, Karner-Hanusch J, Herbst F, Teleky B, Wunderlich M. Intersphincteric resection for low rectal tumours. Br J Surg 1994; 81 (09) 1376-1378
  • 2 Saito N, Ono M, Sugito M. et al. Early results of intersphincteric resection for patients with very low rectal cancer: an active approach to avoid a permanent colostomy. Dis Colon Rectum 2004; 47 (04) 459-466
  • 3 Paty PB, Enker WE, Cohen AM, Lauwers GY. Treatment of rectal cancer by low anterior resection with coloanal anastomosis. Ann Surg 1994; 219 (04) 365-373
  • 4 Saito N, Moriya Y, Shirouzu K. et al. Intersphincteric resection in patients with very low rectal cancer: a review of the Japanese experience. Dis Colon Rectum 2006; 49 (10) S13-S22
  • 5 Martin ST, Heneghan HM, Winter DC. Systematic review of outcomes after intersphincteric resection for low rectal cancer. Br J Surg 2012; 99 (05) 603-612
  • 6 Ito M, Saito N, Sugito M, Kobayashi A, Nishizawa Y, Tsunoda Y. Analysis of clinical factors associated with anal function after intersphincteric resection for very low rectal cancer. Dis Colon Rectum 2009; 52 (01) 64-70
  • 7 Park JS, Huh JW, Park YA. et al. A circumferential resection margin of 1 mm is a negative prognostic factor in rectal cancer patients with and without neoadjuvant chemoradiotherapy. Dis Colon Rectum 2014; 57 (08) 933-940
  • 8 Nagtegaal ID, Marijnen CA, Kranenbarg EK, van de Velde CJ, van Krieken JH. ; Pathology Review Committee; Cooperative Clinical Investigators. Circumferential margin involvement is still an important predictor of local recurrence in rectal carcinoma: not one millimeter but two millimeters is the limit. Am J Surg Pathol 2002; 26 (03) 350-357
  • 9 Hwang MR, Park JW, Park S. et al. Prognostic impact of circumferential resection margin in rectal cancer treated with preoperative chemoradiotherapy. Ann Surg Oncol 2014; 21 (04) 1345-1351
  • 10 Fleshman J, Sargent DJ, Green E. , et al; Clinical Outcomes of Surgical Therapy Study Group. Laparoscopic colectomy for cancer is not inferior to open surgery based on 5-year data from the COST Study Group trial. Ann Surg 2007; 246 (04) 655-662 , discussion 662–664
  • 11 Jayne DG, Guillou PJ, Thorpe H. , et al; UK MRC CLASICC Trial Group. Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC Trial Group. J Clin Oncol 2007; 25 (21) 3061-3068
  • 12 Lacy AM, García-Valdecasas JC, Delgado S. et al. Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial. Lancet 2002; 359 (9325): 2224-2229
  • 13 Kitano S, Inomata M, Mizusawa J. et al. Survival outcomes following laparoscopic versus open D3 dissection for stage II or III colon cancer (JCOG0404): a phase 3, randomised controlled trial. Lancet Gastroenterol Hepatol 2017; 2 (04) 261-268
  • 14 Bonjer HJ, Deijen CL, Abis GA. , et al. COLOR II Study Group. A randomized trial of laparoscopic versus open surgery for rectal cancer. N Engl J Med 2015; 372 (14) 1324-1332
  • 15 Jeong SY, Park JW, Nam BH. et al. Open versus laparoscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): survival outcomes of an open-label, non-inferiority, randomised controlled trial. Lancet Oncol 2014; 15 (07) 767-774
  • 16 Stevenson AR, Solomon MJ, Lumley JW. , et al; ALaCaRT Investigators. Effect of laparoscopic-assisted resection vs open resection on pathological outcomes in rectal cancer: the ALaCaRT randomized clinical trial. JAMA 2015; 314 (13) 1356-1363
  • 17 Fleshman J, Branda M, Sargent DJ. et al. Effect of laparoscopic-assisted resection vs open resection of Stage II or III rectal cancer on pathologic outcomes: the ACOSOG Z6051 randomized clinical trial. JAMA 2015; 314 (13) 1346-1355
  • 18 Yamamoto S, Ito M, Okuda J. , et al; Japan Society of Laparoscopic Colorectal Surgery. Laparoscopic surgery for stage 0/I rectal carcinoma: short-term outcomes of a single-arm phase II trial. Ann Surg 2013; 258 (02) 283-288