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Clin Colon Rectal Surg 2017; 30(05): 313-323
DOI: 10.1055/s-0037-1606108
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Local Excision and Endoscopic Resections for Early Rectal Cancer

Guilherme Pagin São Julião
1   Angelita & Joaquim Gama Institute, São Paulo, São Paulo, Brazil
,
Juan Pablo Celentano
1   Angelita & Joaquim Gama Institute, São Paulo, São Paulo, Brazil
,
Flavia Andrea Alexandre
1   Angelita & Joaquim Gama Institute, São Paulo, São Paulo, Brazil
,
Bruna Borba Vailati
1   Angelita & Joaquim Gama Institute, São Paulo, São Paulo, Brazil
› Author Affiliations
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Publication History

Publication Date:
27 November 2017 (online)

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Abstract

Radical surgery is considered as the standard treatment for rectal cancer. Transanal local excision has been considered an interesting alternative for the management of selected patients with rectal cancers for many decades. Different approaches had been considered for local excision, from endoscopic submucosal dissection to resections using platforms, such as transanal endoscopic microsurgery or transanal minimally invasive surgery. Identifying the ideal candidate for this approach is crucial, as a local failure after local excision is associated with poor outcomes, even for an initial early rectal tumor. In this article, the diagnostic tools and criteria to select patients for local excision, the different modalities used, and the outcomes are discussed.

Keywords

rectal cancer - local excision - endoscopic resection - transanal endoscopic microsurgery - transanal endoscopic operation
 

  • References

  • 1 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 (12) 1286-1295
    CrossrefPubMedGoogle Scholar
  • 2 Maeda K, Koide Y, Katsuno H. When is local excision appropriate for “early” rectal cancer?. Surg Today 2014; 44 (11) 2000-2014
    CrossrefPubMedGoogle Scholar
  • 3 Chang HC, Huang SC, Chen JS. , et al. Risk factors for lymph node metastasis in pT1 and pT2 rectal cancer: a single-institute experience in 943 patients and literature review. Ann Surg Oncol 2012; 19 (08) 2477-2484
    CrossrefPubMedGoogle Scholar
  • 4 Kudo S, Hirota S, Nakajima T. , et al. Colorectal tumours and pit pattern. J Clin Pathol 1994; 47 (10) 880-885
    CrossrefPubMedGoogle Scholar
  • 5 Nascimbeni R, Burgart LJ, Nivatvongs S, Larson DR. Risk of lymph node metastasis in T1 carcinoma of the colon and rectum. Dis Colon Rectum 2002; 45 (02) 200-206
    CrossrefPubMedGoogle Scholar
  • 6 Nastro P, Beral D, Hartley J, Monson JR. Local excision of rectal cancer: review of literature. Dig Surg 2005; 22 (1-2): 6-15
    CrossrefPubMedGoogle Scholar
  • 7 Bipat S, Glas AS, Slors FJ, Zwinderman AH, Bossuyt PM, Stoker J. Rectal cancer: local staging and assessment of lymph node involvement with endoluminal US, CT, and MR imaging–a meta-analysis. Radiology 2004; 232 (03) 773-783
    CrossrefPubMedGoogle Scholar
  • 8 Santoro GA, Gizzi G, Pellegrini L, Battistella G, Di Falco G. The value of high-resolution three-dimensional endorectal ultrasonography in the management of submucosal invasive rectal tumors. Dis Colon Rectum 2009; 52 (11) 1837-1843
    CrossrefPubMedGoogle Scholar
  • 9 Landmann RG, Wong WD, Hoepfl J. , et al. Limitations of early rectal cancer nodal staging may explain failure after local excision. Dis Colon Rectum 2007; 50 (10) 1520-1525
    CrossrefPubMedGoogle Scholar
  • 10 Hompes R, Cunningham C. Extending the role of transanal endoscopic microsurgery (TEM) in rectal cancer. Colorectal Dis 2011; 13 (Suppl. 07) 32-36
    CrossrefPubMedGoogle Scholar
  • 11 Saraste D, Gunnarsson U, Janson M. Local excision in early rectal cancer-outcome worse than expected: a population based study. Eur J Surg Oncol 2013; 39 (06) 634-639
    CrossrefPubMedGoogle Scholar
  • 12 Kobayashi H, Mochizuki H, Kato T. , et al. Is total mesorectal excision always necessary for T1-T2 lower rectal cancer?. Ann Surg Oncol 2010; 17 (04) 973-980
    CrossrefPubMedGoogle Scholar
  • 13 Gagliardi G, Newton TR, Bailey HR. Local excision of rectal cancer followed by radical surgery because of poor prognostic features does not compromise the long term oncologic outcome. Colorectal Dis 2013; 15 (11) e659-e664
    CrossrefPubMedGoogle Scholar
  • 14 Peng J, Chen W, Venook AP. , et al. Long-term outcome of early-stage rectal cancer undergoing standard resection and local excision. Clin Colorectal Cancer 2011; 10 (01) 37-41
    CrossrefPubMedGoogle Scholar
  • 15 Borschitz T, Heintz A, Junginger T. The influence of histopathologic criteria on the long-term prognosis of locally excised pT1 rectal carcinomas: results of local excision (transanal endoscopic microsurgery) and immediate reoperation. Dis Colon Rectum 2006; 49 (10) 1492-1506 , discussion 1500–1505
    CrossrefPubMedGoogle Scholar
  • 16 Buess G, Kipfmüller K, Hack D, Grüssner R, Heintz A, Junginger T. Technique of transanal endoscopic microsurgery. Surg Endosc 1988; 2 (02) 71-75
    CrossrefPubMedGoogle Scholar
  • 17 Albert MR, Atallah SB, deBeche-Adams TC, Izfar S, Larach SW. Transanal minimally invasive surgery (TAMIS) for local excision of benign neoplasms and early-stage rectal cancer: efficacy and outcomes in the first 50 patients. Dis Colon Rectum 2013; 56 (03) 301-307
    CrossrefPubMedGoogle Scholar
  • 18 Moore JS, Cataldo PA, Osler T, Hyman NH. Transanal endoscopic microsurgery is more effective than traditional transanal excision for resection of rectal masses. Dis Colon Rectum 2008; 51 (07) 1026-1030 , discussion 1030–1031
    CrossrefPubMedGoogle Scholar
  • 19 Clancy C, Burke JP, Albert MR, O'Connell PR, Winter DC. Transanal endoscopic microsurgery versus standard transanal excision for the removal of rectal neoplasms: a systematic review and meta-analysis. Dis Colon Rectum 2015; 58 (02) 254-261
    CrossrefPubMedGoogle Scholar
  • 20 Maslekar S, Pillinger SH, Sharma A, Taylor A, Monson JR. Cost analysis of transanal endoscopic microsurgery for rectal tumours. Colorectal Dis 2007; 9 (03) 229-234
    CrossrefPubMedGoogle Scholar
  • 21 Kraske on cancer of the rectum. Ann Surg 1897; 26 (03) 371-381
    PubMedGoogle Scholar
  • 22 Onaitis M, Ludwig K, Perez-Tamayo A. , et al. The Kraske procedure: a critical analysis of a surgical approach for mid-rectal lesions. J Surg Oncol 2006; 94 (03) 194-202
    CrossrefPubMedGoogle Scholar
  • 23 Middleton PF, Sutherland LM, Maddern GJ. Transanal endoscopic microsurgery: a systematic review. Dis Colon Rectum 2005; 48 (02) 270-284
    CrossrefPubMedGoogle Scholar
  • 24 Bach SP, Hill J, Monson JR. , et al; Association of Coloproctology of Great Britain and Ireland Transanal Endoscopic Microsurgery (TEM) Collaboration. A predictive model for local recurrence after transanal endoscopic microsurgery for rectal cancer. Br J Surg 2009; 96 (03) 280-290
    CrossrefPubMedGoogle Scholar
  • 25 Stone HB, Coleman CN, Anscher MS, McBride WH. Effects of radiation on normal tissue: consequences and mechanisms. Lancet Oncol 2003; 4 (09) 529-536
    CrossrefPubMedGoogle Scholar
  • 26 Matthiessen P, Hallböök O, Rutegård J, Simert G, Sjödahl R. Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg 2007; 246 (02) 207-214
    CrossrefPubMedGoogle Scholar
  • 27 Marks JH, Valsdottir EB, DeNittis A. , et al. Transanal endoscopic microsurgery for the treatment of rectal cancer: comparison of wound complication rates with and without neoadjuvant radiation therapy. Surg Endosc 2009; 23 (05) 1081-1087
    CrossrefPubMedGoogle Scholar
  • 28 Perez RO, Habr-Gama A, São Julião GP, Proscurshim I, Scanavini Neto A, Gama-Rodrigues J. Transanal endoscopic microsurgery for residual rectal cancer after neoadjuvant chemoradiation therapy is associated with significant immediate pain and hospital readmission rates. Dis Colon Rectum 2011; 54 (05) 545-551
    CrossrefPubMedGoogle Scholar
  • 29 Arezzo A, Arolfo S, Allaix ME. , et al. Results of neoadjuvant short-course radiation therapy followed by transanal endoscopic microsurgery for t1-t2 n0 extraperitoneal rectal cancer. Int J Radiat Oncol Biol Phys 2015; 92 (02) 299-306
    CrossrefPubMedGoogle Scholar
  • 30 Nash GM, Weiser MR, Guillem JG. , et al. Long-term survival after transanal excision of T1 rectal cancer. Dis Colon Rectum 2009; 52 (04) 577-582
    CrossrefPubMedGoogle Scholar
  • 31 Peng J, Chen W, Sheng W. , et al. Oncological outcome of T1 rectal cancer undergoing standard resection and local excision. Colorectal Dis 2011; 13 (02) e14-e19
    CrossrefPubMedGoogle Scholar
  • 32 Greenberg JA, Shibata D, Herndon II JE, Steele Jr GD, Mayer R, Bleday R. Local excision of distal rectal cancer: an update of cancer and leukemia group B 8984. Dis Colon Rectum 2008; 51 (08) 1185-1191 , discussion 1191–1194
    CrossrefPubMedGoogle Scholar
  • 33 Tsai BM, Finne CO, Nordenstam JF, Christoforidis D, Madoff RD, Mellgren A. Transanal endoscopic microsurgery resection of rectal tumors: outcomes and recommendations. Dis Colon Rectum 2010; 53 (01) 16-23
    CrossrefPubMedGoogle Scholar
  • 34 Doornebosch PG, Ferenschild FT, de Wilt JH, Dawson I, Tetteroo GW, de Graaf EJ. Treatment of recurrence after transanal endoscopic microsurgery (TEM) for T1 rectal cancer. Dis Colon Rectum 2010; 53 (09) 1234-1239
    CrossrefPubMedGoogle Scholar
  • 35 Hahnloser D, Wolff BG, Larson DW, Ping J, Nivatvongs S. Immediate radical resection after local excision of rectal cancer: an oncologic compromise?. Dis Colon Rectum 2005; 48 (03) 429-437
    CrossrefPubMedGoogle Scholar
  • 36 Hompes R, McDonald R, Buskens C. , et al; Association of Coloproctology of Great Britain and Ireland Transanal Endoscopic Microsurgery Collaboration. Completion surgery following transanal endoscopic microsurgery: assessment of quality and short- and long-term outcome. Colorectal Dis 2013; 15 (10) e576-e581
    CrossrefPubMedGoogle Scholar
  • 37 Morino M, Allaix ME, Arolfo S, Arezzo A. Previous transanal endoscopic microsurgery for rectal cancer represents a risk factor for an increased abdominoperineal resection rate. Surg Endosc 2013; 27 (09) 3315-3321
    CrossrefPubMedGoogle Scholar
  • 38 Park SU, Min YW, Shin JU. , et al. Endoscopic submucosal dissection or transanal endoscopic microsurgery for nonpolypoid rectal high grade dysplasia and submucosa-invading rectal cancer. Endoscopy 2012; 44 (11) 1031-1036
    Article in Thieme ConnectPubMedGoogle Scholar
  • 39 Arezzo A, Passera R, Saito Y. , et al. Systematic review and meta-analysis of endoscopic submucosal dissection versus transanal endoscopic microsurgery for large noninvasive rectal lesions. Surg Endosc 2014; 28 (02) 427-438
    CrossrefPubMedGoogle Scholar
  • 40 Russell AH, Harris J, Rosenberg PJ. , 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 (02) 313-322
    CrossrefPubMedGoogle Scholar
  • 41 Chakravarti A, Compton CC, Shellito PC. , et al. Long-term follow-up of patients with rectal cancer managed by local excision with and without adjuvant irradiation. Ann Surg 1999; 230 (01) 49-54
    CrossrefPubMedGoogle Scholar
  • 42 Balyasnikova S, Read J, Tait D. , et al. The results of local excision with or without postoperative adjuvant chemoradiotherapy for early rectal cancer among patients choosing to avoid radical surgery. Colorectal Dis 2017; 19 (02) 139-147
    CrossrefPubMedGoogle Scholar
  • 43 Sauer R, Becker H, Hohenberger W. , et al; German Rectal Cancer Study Group. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 2004; 351 (17) 1731-1740
    CrossrefPubMedGoogle Scholar
  • 44 Sebag-Montefiore D, Stephens RJ, Steele R. , et al. Preoperative radiotherapy versus selective postoperative chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCIC-CTG C016): a multicentre, randomised trial. Lancet 2009; 373 (9666): 811-820
    CrossrefPubMedGoogle Scholar
  • 45 Kapiteijn E, Marijnen CA, Nagtegaal ID. , et al; Dutch Colorectal Cancer Group. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 2001; 345 (09) 638-646
    CrossrefPubMedGoogle Scholar
  • 46 Bosset JF, Calais G, Mineur L. , et al. Enhanced tumorocidal effect of chemotherapy with preoperative radiotherapy for rectal cancer: preliminary results--EORTC 22921. J Clin Oncol 2005; 23 (24) 5620-5627
    CrossrefPubMedGoogle Scholar
  • 47 Das P, Skibber JM, Rodriguez-Bigas MA. , et al. Predictors of tumor response and downstaging in patients who receive preoperative chemoradiation for rectal cancer. Cancer 2007; 109 (09) 1750-1755
    CrossrefPubMedGoogle Scholar
  • 48 Vecchio FM, Valentini V, Minsky BD. , et al. The relationship of pathologic tumor regression grade (TRG) and outcomes after preoperative therapy in rectal cancer. Int J Radiat Oncol Biol Phys 2005; 62 (03) 752-760
    CrossrefPubMedGoogle Scholar
  • 49 Bujko K, Kolodziejczyk M, Nasierowska-Guttmejer A. , et al; Polish Colorectal Cancer Group. Tumour regression grading in patients with residual rectal cancer after preoperative chemoradiation. Radiother Oncol 2010; 95 (03) 298-302
    CrossrefPubMedGoogle Scholar
  • 50 Francois Y, Nemoz CJ, Baulieux J. , et al. Influence of the interval between preoperative radiation therapy and surgery on downstaging and on the rate of sphincter-sparing surgery for rectal cancer: the Lyon R90-01 randomized trial. J Clin Oncol 1999; 17 (08) 2396
    CrossrefPubMedGoogle Scholar
  • 51 Tulchinsky H, Shmueli E, Figer A, Klausner JM, Rabau M. An interval >7 weeks between neoadjuvant therapy and surgery improves pathologic complete response and disease-free survival in patients with locally advanced rectal cancer. Ann Surg Oncol 2008; 15 (10) 2661-2667
    CrossrefPubMedGoogle Scholar
  • 52 Kalady MF, de Campos-Lobato LF, Stocchi L. , et al. Predictive factors of pathologic complete response after neoadjuvant chemoradiation for rectal cancer. Ann Surg 2009; 250 (04) 582-589
    CrossrefPubMedGoogle Scholar
  • 53 Bujko K, Nowacki MP, Nasierowska-Guttmejer A. , et al; Polish Colorectal Study Group. Prediction of mesorectal nodal metastases after chemoradiation for rectal cancer: results of a randomised trial: implication for subsequent local excision. Radiother Oncol 2005; 76 (03) 234-240
    CrossrefPubMedGoogle Scholar
  • 54 Mignanelli ED, de Campos-Lobato LF, Stocchi L, Lavery IC, Dietz DW. Downstaging after chemoradiotherapy for locally advanced rectal cancer: is there more (tumor) than meets the eye?. Dis Colon Rectum 2010; 53 (03) 251-256
    CrossrefPubMedGoogle Scholar
  • 55 Park IJ, You YN, Skibber JM. , et al. Comparative analysis of lymph node metastases in patients with ypT0-2 rectal cancers after neoadjuvant chemoradiotherapy. Dis Colon Rectum 2013; 56 (02) 135-141
    CrossrefPubMedGoogle Scholar
  • 56 Kim DW, Kim DY, Kim TH. , et al. Is T classification still correlated with lymph node status after preoperative chemoradiotherapy for rectal cancer?. Cancer 2006; 106 (08) 1694-1700
    CrossrefPubMedGoogle Scholar
  • 57 Perez RO, Habr-Gama A, Proscurshim I. , et al. Local excision for ypT2 rectal cancer--much ado about something. J Gastrointest Surg 2007; 11 (11) 1431-1438 , discussion 1438–1440
    CrossrefPubMedGoogle Scholar
  • 58 Engelen SM, Beets-Tan RG, Lahaye MJ. , et al. MRI after chemoradiotherapy of rectal cancer: a useful tool to select patients for local excision. Dis Colon Rectum 2010; 53 (07) 979-986
    CrossrefPubMedGoogle Scholar
  • 59 Callender GG, Das P, Rodriguez-Bigas MA. , et al. Local excision after preoperative chemoradiation results in an equivalent outcome to total mesorectal excision in selected patients with T3 rectal cancer. Ann Surg Oncol 2010; 17 (02) 441-447
    CrossrefPubMedGoogle Scholar
  • 60 Bonnen M, Crane C, Vauthey JN. , et al. Long-term results using local excision after preoperative chemoradiation among selected T3 rectal cancer patients. Int J Radiat Oncol Biol Phys 2004; 60 (04) 1098-1105
    CrossrefPubMedGoogle Scholar
  • 61 Perez RO, Habr-Gama A, Lynn PB. , et al. Transanal endoscopic microsurgery for residual rectal cancer (ypT0-2) following neoadjuvant chemoradiation therapy: another word of caution. Dis Colon Rectum 2013; 56 (01) 6-13
    CrossrefPubMedGoogle Scholar
  • 62 Pucciarelli S, De Paoli A, Guerrieri M. , et al. Local excision after preoperative chemoradiotherapy for rectal cancer: results of a multicenter phase II clinical trial. Dis Colon Rectum 2013; 56 (12) 1349-1356
    CrossrefPubMedGoogle Scholar
  • 63 Verseveld M, de Graaf EJ, Verhoef C. , et al; CARTS Study Group. Chemoradiation therapy for rectal cancer in the distal rectum followed by organ-sparing transanal endoscopic microsurgery (CARTS study). Br J Surg 2015; 102 (07) 853-860
    CrossrefPubMedGoogle Scholar
  • 64 Garcia-Aguilar J. Transanal endoscopic microsurgery following neoadjuvant chemoradiation therapy in rectal cancer: a word of caution about patient selection?. Dis Colon Rectum 2013; 56 (01) 1-3
    CrossrefPubMedGoogle Scholar
  • 65 Lezoche G, Baldarelli M, Guerrieri M. , et al. A prospective randomized study with a 5-year minimum follow-up evaluation of transanal endoscopic microsurgery versus laparoscopic total mesorectal excision after neoadjuvant therapy. Surg Endosc 2008; 22 (02) 352-358
    CrossrefPubMedGoogle Scholar
  • 66 Lezoche E, Baldarelli M, Lezoche G, Paganini AM, Gesuita R, Guerrieri M. Randomized clinical trial of endoluminal locoregional resection versus laparoscopic total mesorectal excision for T2 rectal cancer after neoadjuvant therapy. Br J Surg 2012; 99 (09) 1211-1218
    CrossrefPubMedGoogle Scholar
  • 67 Garcia-Aguilar J, Shi Q, Thomas Jr CR. , et al. A phase II trial of neoadjuvant chemoradiation and local excision for T2N0 rectal cancer: preliminary results of the ACOSOG Z6041 trial. Ann Surg Oncol 2012; 19 (02) 384-391
    CrossrefPubMedGoogle Scholar
  • 68 Habr-Gama A, São Julião GP, Perez RO. Pitfalls of transanal endoscopic microsurgery for rectal cancer following neoadjuvant chemoradiation therapy. Minim Invasive Ther Allied Technol 2014; 23 (02) 63-69
    CrossrefPubMedGoogle Scholar
  • 69 Hayden DM, Jakate S, Pinzon MC. , et al. Tumor scatter after neoadjuvant therapy for rectal cancer: are we dealing with an invisible margin?. Dis Colon Rectum 2012; 55 (12) 1206-1212
    CrossrefPubMedGoogle Scholar
  • 70 Habr-Gama A, Perez RO, Wynn G, Marks J, Kessler H, Gama-Rodrigues J. Complete clinical response after neoadjuvant chemoradiation therapy for distal rectal cancer: characterization of clinical and endoscopic findings for standardization. Dis Colon Rectum 2010; 53 (12) 1692-1698
    CrossrefPubMedGoogle Scholar
  • 71 Habr-Gama A, Perez RO, Nadalin W. , et al. Operative versus nonoperative treatment for stage 0 distal rectal cancer following chemoradiation therapy: long-term results. Ann Surg 2004; 240 (04) 711-717 , discussion 717–718
    PubMedGoogle Scholar
  • 72 Lambregts DM, Maas M, Bakers FC. , et al. Long-term follow-up features on rectal MRI during a wait-and-see approach after a clinical complete response in patients with rectal cancer treated with chemoradiotherapy. Dis Colon Rectum 2011; 54 (12) 1521-1528
    CrossrefPubMedGoogle Scholar
  • 73 Lambregts DM, Vandecaveye V, Barbaro B. , et al. Diffusion-weighted MRI for selection of complete responders after chemoradiation for locally advanced rectal cancer: a multicenter study. Ann Surg Oncol 2011; 18 (08) 2224-2231
    CrossrefPubMedGoogle Scholar
  • 74 Perez RO, Habr-Gama A, Gama-Rodrigues J. , et al. Accuracy of positron emission tomography/computed tomography and clinical assessment in the detection of complete rectal tumor regression after neoadjuvant chemoradiation: long-term results of a prospective trial (National Clinical Trial 00254683). Cancer 2012; 118 (14) 3501-3511
    CrossrefPubMedGoogle Scholar
  • 75 Smith FM, Chang KH, Sheahan K, Hyland J, O'Connell PR, Winter DC. The surgical significance of residual mucosal abnormalities in rectal cancer following neoadjuvant chemoradiotherapy. Br J Surg 2012; 99 (07) 993-1001
    CrossrefPubMedGoogle Scholar