Skip to main content

Advertisement

SpringerLink
Log in

Radical Surgery with Total Mesorectal Excision in Patients with T1 Rectal Cancer

  • Colorectal Cancer
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Radical resection with total mesorectal excision (TME) is the accepted standard of care for most rectal cancers. However, T1 rectal cancers may be at low risk for metastases and are therefore treatable with local resection. The aim of our study was to investigate whether the identification of these patients is possible through existing selection criteria.

Methods

Between 2001 and 2012, radical resection with TME was performed in 68 patients with a histologically confirmed T1 adenocarcinoma of the rectum. Each patient was staged preoperatively as lymph node negative. Patients at low risk to metastasize were defined as proposed by Hermanek and Gall (Int J Colorectal Dis 1(2):79–84, 1986), Kikuchi et al. (Dis Colon Rectum 38(12):1286–1295, 1995) and Hase et al. (Dis Colon Rectum 38(1):19–26, 1995) Postoperative morbidity, mortality, and oncological outcome were analyzed.

Results

Despite nodal negative staging, 9 of 68 patients (13 %) were node positive. Following the proposal of Hermanek and Gall, Kikuchi et al., and Hase et al., 14 % (5/37), 12 % (3/26), and 16 % (6/38) of patients, respectively, with low-risk tumors had lymph node metastases. In the univariate analysis, none of the investigated parameters could predict lymph node metastases. Following radical resection, none of the patients, regardless of nodal involvement, developed a recurrence.

Conclusions

Preoperative diagnostics regarding lymphatic tumor propagation and histomorphological assessment of tumor samples as predictors of lymph node metastasis are unreliable. Following radical resection with TME, the oncological outcome of node-positive patients with T1 rectal adenocarcinoma is comparable with that of lymph node-negative patients. Considering the lymph node metastases rate, a local excision should always be complemented with additional therapy.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Heald RJ, Ryall RD. Recurrence and survival after total mesorectal excision for rectal cancer. Lancet. 1986;1(8496):1479–82.

    Article  CAS  PubMed  Google Scholar 

  2. Rahbari NN, Ulrich AB, Bruckner T, et al. Surgery for locally recurrent rectal cancer in the era of total mesorectal excision: is there still a chance for cure? Ann Surg. 2011;253(3):522–33.

    Article  PubMed  Google Scholar 

  3. Contin P, Kulu Y, Bruckner T, et al. Comparative analysis of late functional outcome following preoperative radiation therapy or chemoradiotherapy and surgery or surgery alone in rectal cancer. Int J Colorectal Dis. 2014;29(2):165–75.

    Article  PubMed  Google Scholar 

  4. Khoo CK, Vickery CJ, Forsyth N, Vinall NS, Eyre-Brook IA. A prospective randomized controlled trial of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer. Ann Surg. 2007;245(6):867–72.

    Article  PubMed Central  PubMed  Google Scholar 

  5. Chuwa EW, Seow-Choen F. Outcomes for abdominoperineal resections are not worse than those of anterior resections. Dis Colon Rectum. 2006;49(1):41–9.

    Article  PubMed  Google Scholar 

  6. Bentrem DJ, Okabe S, Wong WD, et al. T1 adenocarcinoma of the rectum: transanal excision or radical surgery? Ann Surg. 2005;242(4):472–7; discussion 477–9.

    PubMed Central  PubMed  Google Scholar 

  7. Bhangu A, Brown G, Nicholls RJ, Wong J, Darzi A, Tekkis P. Survival outcome of local excision versus radical resection of colon or rectal carcinoma: a surveillance, epidemiology, and end results (SEER) population-based study. Ann Surg. 2013;258(4):563–9; discussion 569–71.

    PubMed  Google Scholar 

  8. Chang AJ, Nahas CS, Araujo SE, Nahas SC, Marques CF, Kiss DR, et al. Early rectal cancer: local excision or radical surgery? J Surg Educ. 2008;65(1):67–72.

    Article  PubMed  Google Scholar 

  9. Peng J, Chen W, Sheng W, Xu Y, Cai G, Huang D, et al. Oncological outcome of T1 rectal cancer undergoing standard resection and local excision. Colorectal Dis. 2011;13(2):e14–9.

    Article  CAS  PubMed  Google Scholar 

  10. Tytherleigh MG, Warren BF, Mortensen NJ. Management of early rectal cancer. Br J Surg. 2008;95(4):409–23.

    Article  CAS  PubMed  Google Scholar 

  11. Madbouly KM, Remzi FH, Erkek BA, et al. Recurrence after transanal excision of T1 rectal cancer: should we be concerned? Dis Colon Rectum. 2005;48(4):711-9; discussion 719–21.

    Article  PubMed  Google Scholar 

  12. You YN, Baxter NN, Stewart A, Nelson H. Is the increasing rate of local excision for stage I rectal cancer in the United States justified?: a nationwide cohort study from the National Cancer Database. Ann Surg. 2007;245(5):726–33.

    Article  PubMed Central  PubMed  Google Scholar 

  13. Paty PB, Nash GM, Baron P, et al. Long-term results of local excision for rectal cancer. Ann Surg. 2002;236(4):522–29; discussion 529–30.

    Article  PubMed Central  PubMed  Google Scholar 

  14. 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):1520–5.

    Article  PubMed  Google Scholar 

  15. Muthusamy VR, Chang KJ. Optimal methods for staging rectal cancer. Clin Cancer Res. 2007;13(22 Pt 2):6877s–84s.

    Article  PubMed  Google Scholar 

  16. Hermanek P, Merkel S, Fietkau R, Rodel C, Hohenberger W. Regional lymph node metastasis and locoregional recurrence of rectal carcinoma in the era of TME [corrected] surgery. Implications for treatment decisions. Int J Colorectal Dis. 2010;25(3):359–68.

    Article  PubMed  Google Scholar 

  17. Kosinski L, Habr-Gama A, Ludwig K, Perez R. Shifting concepts in rectal cancer management: a review of contemporary primary rectal cancer treatment strategies. CA Cancer J Clin. 2012;62(3):173–202.

    Article  PubMed  Google Scholar 

  18. Park JS, Jang YJ, Choi GS, Park SY, Kim HJ, Kang H, et al. Accuracy of preoperative MRI in predicting pathology stage in rectal cancers: node-for-node matched histopathology validation of MRI features. Dis Colon Rectum. 2014;57(1):32–8.

    Article  PubMed  Google Scholar 

  19. Hase K, Shatney CH, Mochizuki H, Johnson DL, Tamakuma S, Vierra M, et al. Long-term results of curative resection of “minimally invasive” colorectal cancer. Dis Colon Rectum. 1995;38(1):19–26.

    Article  CAS  PubMed  Google Scholar 

  20. Hermanek P, Gall FP. Early (microinvasive) colorectal carcinoma. Pathology, diagnosis, surgical treatment. Int J Colorectal Dis. 1986;1(2):79–84.

    Article  CAS  PubMed  Google Scholar 

  21. Kikuchi R, Takano M, Takagi K, Fujimoto N, Nozaki R, Fujiyoshi T, et al. Management of early invasive colorectal cancer. Risk of recurrence and clinical guidelines. Dis Colon Rectum. 1995;38(12):1286–95.

    Article  CAS  PubMed  Google Scholar 

  22. Kitajima K, Fujimori T, Fujii S, et al. Correlations between lymph node metastasis and depth of submucosal invasion in submucosal invasive colorectal carcinoma: a Japanese collaborative study. J Gastroenterol. 2004;39(6):534–43.

    Article  PubMed  Google Scholar 

  23. Shimomura T, Ishiguro S, Konishi H, et al. New indication for endoscopic treatment of colorectal carcinoma with submucosal invasion. J Gastroenterol Hepatol. 2004;19(1):48–55.

    Article  PubMed  Google Scholar 

  24. Hase K, Shatney C, Johnson D, Trollope M, Vierra M. Prognostic value of tumor “budding” in patients with colorectal cancer. Dis Colon Rectum. 1993;36(7):627–35.

    Article  CAS  PubMed  Google Scholar 

  25. Masaki T, Matsuoka H, Sugiyama M, et al. Budding as a useful determinant of the optimal treatment for T1 rectal carcinomas. Hepatogastroenterology. 2003;50(50):388–91.

    PubMed  Google Scholar 

  26. Morson BC, Whiteway JE, Jones EA, Macrae FA, Williams CB. Histopathology and prognosis of malignant colorectal polyps treated by endoscopic polypectomy. Gut. 1984;25(5):437–44.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  27. Wilcox GM, Anderson PB, Colacchio TA. Early invasive carcinoma in colonic polyps. A review of the literature with emphasis on the assessment of the risk of metastasis. Cancer. 1986;57(1):160–71.

    Article  CAS  PubMed  Google Scholar 

  28. Pollack J, Holm T, Cedermark B, Altman D, Holmstrom B, Glimelius B, et al. Late adverse effects of short-course preoperative radiotherapy in rectal cancer. Br J Surg. 2006;93(12):1519–25.

    Article  CAS  PubMed  Google Scholar 

  29. Brodsky JT, Richard GK, Cohen AM, Minsky BD. Variables correlated with the risk of lymph node metastasis in early rectal cancer. Cancer. 1992;69(2):322–6.

    Article  CAS  PubMed  Google Scholar 

  30. Blumberg D, Paty PB, Guillem JG, Picon AI, Minsky BD, Wong WD, et al. All patients with small intramural rectal cancers are at risk for lymph node metastasis. Dis Colon Rectum. 1999;42(7):881–5.

    Article  CAS  PubMed  Google Scholar 

  31. Goldstein NS, Hart J. Histologic features associated with lymph node metastasis in stage T1 and superficial T2 rectal adenocarcinomas in abdominoperineal resection specimens. Identifying a subset of patients for whom treatment with adjuvant therapy or completion abdominoperineal resection should be considered after local excision. Am J Clin Pathol. 1999;111(1):51–8.

    CAS  PubMed  Google Scholar 

  32. Ptok H, Marusch F, Meyer F, et al. Oncological outcome of local vs radical resection of low-risk pT1 rectal cancer. Arch Surg. 2007;142(7):649–55; discussion 656.

    Article  PubMed  Google Scholar 

  33. Winde G, Nottberg H, Keller R, Schmid KW, Bunte H. Surgical cure for early rectal carcinomas (T1). Transanal endoscopic microsurgery vs. anterior resection. Dis Colon Rectum. 1996;39(9):969–76.

    Article  CAS  PubMed  Google Scholar 

  34. Palma P, Freudenberg S, Samel S, Post S. Transanal endoscopic microsurgery: indications and results after 100 cases. Colorectal Dis. 2004;6(5):350–5.

    Article  CAS  PubMed  Google Scholar 

  35. Tarantino I, Hetzer FH, Warschkow R, Zund M, Stein HJ, Zerz A. Local excision and endoscopic posterior mesorectal resection versus low anterior resection in T1 rectal cancer. Br J Surg. 2008; 95(3):375–80.

    Article  CAS  PubMed  Google Scholar 

  36. Okabe S, Kanenobu M, Matsumoto A, Murase N, Yabata E, Takemura K, et al. Controversy on therapeutic modality to early colorectal carcinomas from the viewpoint of histopathological features (in Japanese). Nihon Geka Gakkai Zasshi. 1992;93(9):1079–82.

    CAS  PubMed  Google Scholar 

  37. Kulu Y, Ulrich A, Bruckner T, et al. Validation of the International Study Group of Rectal Cancer definition and severity grading of anastomotic leakage. Surgery. 2013;153(6):753–61.

    Article  PubMed  Google Scholar 

  38. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205–13.

    Article  PubMed Central  PubMed  Google Scholar 

  39. S3-Leitlinie Kolorektales Karzinom, Langversion 1.0, AWMF Registrierungsnummer: 021-007OL [Leitlinienprogramm Onkologie (Deutsche Krebsgesellschaft, Deutsche Krebshilfe, AWMF) web site]. http://leitlinienprogramm-onkologie.de/Leitlinien.7.0.html.

  40. Rahbari NN, Weitz J, Hohenberger W, et al. Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer. Surgery. 2010;147(3):339–51.

    Article  PubMed  Google Scholar 

  41. Chok KS, Law WL. Prognostic factors affecting survival and recurrence of patients with pT1 and pT2 colorectal cancer. World J Surg. 2007;31(7):1485–90.

    Article  PubMed  Google Scholar 

  42. Sitzler PJ, Seow-Choen F, Ho YH, Leong AP. Lymph node involvement and tumor depth in rectal cancers: an analysis of 805 patients. Dis Colon Rectum. 1997;40(12):1472–6.

    Article  CAS  PubMed  Google Scholar 

  43. Haggitt RC, Glotzbach RE, Soffer EE, Wruble LD. Prognostic factors in colorectal carcinomas arising in adenomas: implications for lesions removed by endoscopic polypectomy. Gastroenterology. 1985;89(2):328–36.

    CAS  PubMed  Google Scholar 

  44. Sticca RP, Rodriguez-Bigas M, Penetrante RB, Petrelli NJ. Curative resection for stage I rectal cancer: natural history, prognostic factors, and recurrence patterns. Cancer Invest. 1996;14(5):491–7.

    Article  CAS  PubMed  Google Scholar 

  45. Pollard CW, Nivatvongs S, Rojanasakul A, Reiman HM, Dozois RR. The fate of patients following polypectomy alone for polyps containing invasive carcinoma. Dis Colon Rectum. 1992;35(10):933–7.

    Article  CAS  PubMed  Google Scholar 

  46. 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(9):1234–9.

    Article  PubMed  Google Scholar 

  47. Weiser MR, Landmann RG, Wong WD, et al. Surgical salvage of recurrent rectal cancer after transanal excision. Dis Colon Rectum. 2005;48(6):1169–75.

    Article  PubMed  Google Scholar 

  48. Wagman RT, Minsky BD. Conservative management of rectal cancer with local excision and adjuvant therapy. Oncology (Williston Park). 2001;15(4):513–9, 524; discussion 524–8.

    CAS  Google Scholar 

  49. Lamont JP, McCarty TM, Digan RD, Jacobson R, Tulanon P, Lichliter WE. Should locally excised T1 rectal cancer receive adjuvant chemoradiation? Am J Surg. 2000;180(6):402–5; discussion 405–6.

    Article  CAS  PubMed  Google Scholar 

  50. Stitzenberg KB, Sanoff HK, Penn DC, Meyers MO, Tepper JE. Practice patterns and long-term survival for early-stage rectal cancer. J Clin Oncol. 2013;31(34):4276–82.

    Article  PubMed Central  PubMed  Google Scholar 

  51. Benson R, Wong CS, Cummings BJ, Brierley J, Catton P, Ringash J, et al. Local excision and postoperative radiotherapy for distal rectal cancer. Int J Radiat Oncol Biol Phys. 2001;50(5):1309–16.

    Article  CAS  PubMed  Google Scholar 

  52. Guerrieri M, Feliciotti F, Baldarelli M, Zenobi P, De Sanctis A, Lezoche G, et al. Sphincter-saving surgery in patients with rectal cancer treated by radiotherapy and transanal endoscopic microsurgery: 10 years’ experience. Dig Liver Dis. 2003;35(12):876–80.

    Article  CAS  PubMed  Google Scholar 

  53. Lezoche E, Guerrieri M, Paganini AM, Baldarelli M, De Sanctis A, Lezoche G. Long-term results in patients with T2–3 N0 distal rectal cancer undergoing radiotherapy before transanal endoscopic microsurgery. Br J Surg. 2005;92(12):1546–52.

    Article  CAS  PubMed  Google Scholar 

  54. Caricato M, Borzomati D, Ausania F, et al. Complementary use of local excision and transanal endoscopic microsurgery for rectal cancer after neoadjuvant chemoradiation. Surg Endosc. 2006;20(8):1203–7.

    Article  CAS  PubMed  Google Scholar 

  55. 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(5):1081–7.

    Article  PubMed  Google Scholar 

  56. Kulu Y, Buchler MW, Ulrich A. [Radiotherapy-associated morbidity and mortality in rectal surgery [in German]. Chirurg. 2013;84(11):951–6.

    Article  CAS  PubMed  Google Scholar 

  57. Kulu Y, Ulrich A, Buchler MW. Resectable rectal cancer: which patient does not need preoperative radiotherapy? Dig Dis. 2012;30 Suppl 2:118–25.

    Article  PubMed  Google Scholar 

  58. Garcia-Aguilar J, Shi Q, Thomas CR Jr, 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(2):384–91.

    Article  PubMed  Google Scholar 

  59. Zerz A, Beck J, Szinicz G. [Dorso-posterior extraperitoneal pelviscopy (DEP). From experiment to initial clinical application (in German). Chirurg. 1999;70(3):294–7.

    Article  CAS  PubMed  Google Scholar 

  60. Zerz A, Muller-Stich BP, Beck J, Linke GR, Tarantino I, Lange J. Endoscopic posterior mesorectal resection after transanal local excision of T1 carcinomas of the lower third of the rectum. Dis Colon Rectum. 2006;49(6):919–24.

    Article  PubMed  Google Scholar 

  61. Koninger J, Muller-Stich BP, Autschbach F, Kienle P, Weitz J, Buchler MW, et al. Endoscopic posterior mesorectal resection as an option to combine local treatment of early stage rectal cancer with partial mesorectal lymphadenectomy. Langenbecks Arch Surg. 2007;392(5):567–71.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany

    Yakup Kulu MD, Beat P. Müller-Stich MD, Tobias Gehrig MD, Markus W. Büchler MD & Alexis Ulrich MD

  2. Institute for Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany

    Thomas Bruckner PhD

  3. Institute of Pathology, University of Heidelberg, Heidelberg, Germany

    Frank Bergmann MD

Authors
  1. Yakup Kulu MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Beat P. Müller-Stich MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Thomas Bruckner PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Tobias Gehrig MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Markus W. Büchler MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Frank Bergmann MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Alexis Ulrich MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Markus W. Büchler MD.

Additional information

Frank Bergmann and Alexis Ulrich have contributed equally to this work.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kulu, Y., Müller-Stich, B.P., Bruckner, T. et al. Radical Surgery with Total Mesorectal Excision in Patients with T1 Rectal Cancer. Ann Surg Oncol 22, 2051–2058 (2015). https://doi.org/10.1245/s10434-014-4179-3

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1245/s10434-014-4179-3

Keywords

Search

Navigation