Skip to main content
SpringerLink
Log in

An Algorithm for Local Excision for Early-Stage Rectal Cancer

  • Chapter
  • First Online:
Transanal Minimally Invasive Surgery (TAMIS) and Transanal Total Mesorectal Excision (taTME)

  • 795 Accesses

Abstract

Standard therapy of resectable rectal cancer involves total mesorectal excision with stage-appropriate neoadjuvant chemoradiation therapy. Patients with early-stage disease may be eligible for local excision which is associated with lower morbidity and improved anorectal function when compared to radical resection. Early reports of local excision of early-stage rectal cancer (T1-2 N0) demonstrated unacceptably high rates of local recurrence, likely related to suboptimal patient selection and inadequate margin clearance. Standard transanal excision (TAE) and transanal endoscopic surgery (TES) techniques, e.g., TEM, TEO, TAMIS, and robotic TAMIS, have been described, with reported improvement in quality of resected specimen in TES. In highly selected patients, contemporary series have demonstrated good oncologic outcomes with LE, provided negative margins can be obtained and no high-risk features (deep submucosal invasion or > T1, lymphovascular or perineural invasion, poorly differentiated histology, and tumor budding) are present. If high-risk features are identified after local excision, immediate radical resection has been associated with good oncologic outcomes.

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

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 139.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Hardcover Book
USD 179.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2018. CA Cancer J Clin. 2018;68(1):7–30.

    Article  Google Scholar 

  2. Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery: the clue to pelvic recurrence? Br J Surg. 1982;69(10):613–6.

    Article  CAS  Google Scholar 

  3. MacFarlane JK, Ryall RD, Heald RJ. Mesorectal excision for rectal cancer. Lancet. 1993;341(8843):457–60.

    Article  CAS  Google Scholar 

  4. Chessin DB, Enker W, Cohen AM, Paty PB, Wieser MR, Saltz LS, et al. Complications after preoperative combined modality therapy and radical resection of locally advanced rectal cancer: a 14 – year experience from a specialty service. J Am Coll Surg. 2005;200(6):876–84.

    Article  Google Scholar 

  5. Sammour T, Malakorn S, Bednarski DK, Kaur H, Shin US, Messick C, et al. Oncological outcomes after robotic proctectomy for rectal cancer: analysis of a prospective database. Ann Surg. 2018;267(3):521–6.

    Article  Google Scholar 

  6. Emmertsen KJ, Laurberg S. Low anterior resection syndrome score: development and validation of a symptom-based scoring system for bowel dysfunction after low anterior resection for rectal cancer. Ann Surg. 2012;255(5):922–8.

    Article  Google Scholar 

  7. Flegal KM, Kruszon-Moran D, Carroll MD, Fryar CD, Ogden CL. Trends in obesity among adults in the United States, 2005 to 2014. JAMA. 2016;315(21):2284–91.

    Article  CAS  Google Scholar 

  8. Park IJ, You YN, Skibber JM, Rodriguez-Bigas MA, Das P, Eng C, et al. Oncologic and functional hazards of obesity among patients with locally advanced rectal cancer following neoadjuvant chemoradiation therapy. Am J Clin Oncol. 2017;40(3):277–82.

    Article  CAS  Google Scholar 

  9. Kulu Y, Muller-Stich BP, Bruckner T, Gehrig T, Buchler MW, Bergmann F, et al. Radical surgery with total mesorectal excision in patients with T1 rectal cancer. Ann Surg Oncol. 2015;22:2051–8.

    Article  Google Scholar 

  10. Muldoon JP. Treatment of benign tumors of the rectum. Clin Gastroenterol. 1975;4(3):563–70.

    CAS  PubMed  Google Scholar 

  11. Neary P, Makin GB, White TJ, White E, Hartley J, MacDonald A, et al. Transanal endoscopic microsurgery: a viable operative alternative in selected patients with rectal lesions. Ann Surg Oncol. 2003;10(9):1106–11.

    Article  CAS  Google Scholar 

  12. 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(2):254–61.

    Article  Google Scholar 

  13. Atallah S, Albert M, Karach S. Transanal minimally invasive surgery: a giant leap forward. Surg Endosc. 2010;24:2200–5.

    Article  Google Scholar 

  14. Barendse RM, Dijkgraaf MG, Rolf UR, Bijnen AB, Consten EC, Hoff C, et al. Colorectal surgeons’ learning curve of transanal endoscopic microsurgery. Surg Endosc. 2013;27(10):3591–602.

    Article  Google Scholar 

  15. Teitelbaum EN, Arafat FO, Boller AM. Comparison of the effect of instrument type on transanal endoscopic surgery learning curves. Surg Laparosc Endosc Percutan Tech. 2016;26(4):304–7.

    Article  Google Scholar 

  16. Lee L, Kelly J, Nassif GJ, Keller D, deBeche-Adams TC, Mancuso PA, et al. Establishing the learning curve of transanal minimally invasive surgery for local excision of rectal neoplasms. Surg Endosc. 2018;32(3):1368–76.

    Article  Google Scholar 

  17. Atallah SB, Albert MR, deBeche-Adams TH, Larach SW. Robotic transanal minimally invasive surgery in a cadaveric model. Tech Coloproctol. 2011;15(4):461–4.

    Article  CAS  Google Scholar 

  18. Hompes R, Rauh SM, Ris F, Tuynman JB, Mortensen NJ. Robotic transanal minimally invasive surgery for local excision of rectal neoplasms. Br J Surg. 2014;101(5):578–81.

    Article  CAS  Google Scholar 

  19. Lee L, Burke JP, deBeche-Adams T, Nassif G, Martin-Perez B, Monson JRT, et al. Transanal minimally invasive surgery for local excision of benign and malignant rectal neoplasia: outcomes from 200 consecutive cases with midterm follow up. Ann Surg. 2018;267(5):910–6.

    Article  Google Scholar 

  20. Arezzo A, Passera R, Marchese N, Galloro G, Manta R, Cirocchi R. Systematic review and meta-analysis of endoscopic submucosal dissection vs endoscopic mucosal resection for colorectal lesions. United European Gastroenterol J. 2016;4(1):18–29.

    Article  CAS  Google Scholar 

  21. Aarons CB, Shanmugan S, Bleier JI. Management of malignant colon polyps: current status and controversies. World J Gastroenterol. 2014;20(43):16178–83.

    Article  Google Scholar 

  22. Verseveld M, Barendse RM, Dawson I, Vos EL, de Graaf EJR, Doornebosch PG. Intramucosal carcinoma of the rectum can be safely treated with transanal endoscopic microsurgery; clinical support of the revised Vienna classification. Surg Endosc. 2014;28:3210–5.

    Article  Google Scholar 

  23. Skibber JM. Local excision for rectal cancer. J Natl Compr Cancer Netw. 2005;3(4):531–9.

    Article  Google Scholar 

  24. Nitvatvongs S, Wolff BG. Technique of per anal excision for carcinoma of the low rectum. World J Surg. 1992;16(3):447–50.

    Article  Google Scholar 

  25. Guillem JG, Chessin DB, Shia J, Suriawinata A, Riedel E, Moore HG, et al. A prospective pathologic analysis using whole-mount sections of rectal cancer following preoperative combined modality therapy; implications for sphincter preservation. Ann Surg. 2007;245(1):88–93.

    Article  Google Scholar 

  26. Shimada Y, Takii Y, Maruyama S, Ohta T. Intramural and mesorectal distal spread detected by whole-mount sections in the determination of optimal distal resection margin in patients undergoing surgery for rectosigmoid or rectal cancer without preoperative therapy. Dis Colon Rectum. 2011;54(12):1510–20.

    Article  Google Scholar 

  27. Willett CG, Compton CC, Shellito PC, Efird JT. Selection factors for local excision or abdominoperineal resection for early stage rectal cancer. Cancer. 1994;73(11):2716–20.

    Article  CAS  Google Scholar 

  28. 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  Google Scholar 

  29. Nascimbeni R, Burgart LJ, Nivatvongs S, Larson DR. Risk of lymph node metastases in T1 carcinoma of the colon and rectum. Dis Colon Rectum. 2002;45(2):200–6.

    Article  Google Scholar 

  30. Shinto E, Mochizuki H, Ueno H, Matsubara O, Jass JR. A novel classification of tumour budding in colorectal cancer based on the presence of cytoplasmic pseudo-fragments around budding foci. Histopathology. 2005;47(1):25–31.

    Article  CAS  Google Scholar 

  31. Syk E, Lenander C, Nilsson PJ, Rubio CA, Glimelius B. Tumour budding correlates with local recurrence of rectal cancer. Color Dis. 2011;13(3):255–62.

    Article  CAS  Google Scholar 

  32. Beaton C, Twine CP, Williams GL, Radcliffe AG. Systematic review and meta-analysis of histopathological factors influencing the risk of lymph node Metastasis in early colorectal cancer. Color Dis. 2013;15(7):788–97.

    Article  CAS  Google Scholar 

  33. Nelson JC, Nimr AN, Thomford NR. Criteria for the selection of ‘early’ carcinomas of the rectum. Are they valid? Arch Surg. 1987;122(5):533–6.

    Article  CAS  Google Scholar 

  34. Doornebosch PG, Zeestraten E, de Graaf EJ, Hermsen P, Dawson I, Tollenaar RA, et al. Transanal endoscopic microsurgery for T1 rectal cancer: size matters! Surg Endosc. 2012;26(2):551–7.

    Article  Google Scholar 

  35. Graham RA, Garnsey L, Jessup JM. Local excision of rectal carcinoma. Am J Surg. 1990;160(3):306–12.

    Article  CAS  Google Scholar 

  36. 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  Google Scholar 

  37. Mellgren A, Sirivongs P, Rothenberger DA, Madoff RD, Garcia-Aguilar J. Is local excision adequate therapy for early rectal cancer? Dis Colon Rectum. 2000;43(8):1064–71.

    Article  CAS  Google Scholar 

  38. Lee W, Lee D, Choi S, Chun H. Transanal endoscopic microsurgery and radical surgery for T1 and T2 rectal cancer. Surg Endosc. 2003;17(8):1283–7.

    Article  CAS  Google Scholar 

  39. Nascimbeni R, Nivatvongs S, Larson DR, Burgart LJ. Long-term survival after local excision of T1 carcinoma of the rectum. Dis Colon Rectum. 2004;47(11):1773–9.

    Article  Google Scholar 

  40. Bentrem DJ, Okabe S, Wong WD, Guillem JG, Weiser MR, Temple LK, et al. T1 adenocarcinoma of the rectum: transanal excision or radical surgery? Ann Surg. 2005;242(4):472–7.

    PubMed  PubMed Central  Google Scholar 

  41. De Graaf EJ, Doornebosch PG, Tollenaar RA, Meershoek-Klein Kranenbarg E, de Boer AC, Bekkering FC, et al. Transanal endoscopic microsurgery versus total mesorectal excision of T1 rectal adenocarcinomas with curative intention. Eur J Surg Oncol. 2009;35(12):1280–5.

    Article  Google Scholar 

  42. Nash GM, Weiser MR, Guillem JG, Temple LK, Shia J, Gonen M, et al. Long-term survival after transanal excision of T1 rectal cancer. Dis Colon Rectum. 2009;52(4):577–82.

    Article  Google Scholar 

  43. Endreseth BH, Myrvold HE, Romundstad P, Hestvik UE, Bjerkeset T, Wibe A. Transanal excision vs. major surgery for T1 rectal cancer. Dis Colon Rectum. 2005;48(7):1380–8.

    Article  Google Scholar 

  44. 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  Google Scholar 

  45. Ptok H, Marusch F, Meyer F, Schubert D, Koeckerling F, Gastinger I, Lippert H. Oncological outcome of local vs radical resection of low-risk pT1 rectal cancer. Arch Surg. 2007;142(7):649–55.

    Article  Google Scholar 

  46. Folkesson J, Johansson R, Pahlman L, Gunnarsson U. Population-based study of local surgery for rectal cancer. Br J Surg. 2007;94(11):1421–6.

    Article  CAS  Google Scholar 

  47. Russell AH, Harris J, Rosenberg PJ, Sause WT, Fisher BJ, Hoffman JP, 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(2):313–22.

    Article  CAS  Google Scholar 

  48. Greenberg JA, Shibata D, Herndon JE 2nd, Steele GD Jr, Mayer R, Bleday R. Local excision of distal rectal cancer: an update of cancer and leukemia group B 8984. Dis Colon Rectum. 2008;51(8):1185–91.

    Article  Google Scholar 

  49. Paty PB, Nash GM, Baron P, Zakowski M, Minsky BD, Blumberg D, et al. Long-term results of local excision for rectal cancer. Ann Surg. 2002;236(4):522–9.

    Article  Google Scholar 

  50. Garcia-Aguilar J, Mellgren A, Sirivongs P, Buie D, Madoff RD, Rothenberger DA. Local excision of rectal cancer without adjuvant therapy: a word of caution. Ann Surg. 2000;231(3):345–51.

    Article  CAS  Google Scholar 

  51. Minsky BD, Cohen AM, Enker WE, Mies C. Sphincter preservation in rectal cancer by local excision and postoperative radiation therapy. Cancer. 1991;67(4):908–14.

    Article  CAS  Google Scholar 

  52. Benson R, Wong CS, Cummings BJ, Brierly 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  Google Scholar 

  53. Wagman R, Minsky BD, Cohen AM, Saltz L, Paty PB, Guillem JG. Conservative management of rectal cancer with local excision and postoperative adjuvant therapy. Int J Radiat Oncol Biol Phys. 1999;44(4):841–6.

    Article  CAS  Google Scholar 

  54. Bouvet M, Milas M, Giacco GG, Cleary KR, Janjan NA, Skibber JM. Predictors of recurrence after local excision and postoperative chemoradiation therapy of adenocarcinoma of the rectum. Ann Surg Oncol. 1999;6(1):26–32.

    Article  CAS  Google Scholar 

  55. Garcia-Aguilar J, Renfro LA, Chow OS, Shi Q, Carrero XW, Lynn PB, Thomas CR Jr, et al. Organ preservation for clinical T2N0 distal rectal cancer using neoadjuvant chemoradiotherapy and local excision (ACOSOG Z6041): Results of an open-label, single-arm, multi-institutional, phase 2 trial. Lancet Oncol. 2015;16(15):1537–46.

    Article  Google Scholar 

  56. Lynn PB, Renfro LA, Carrero XW, Shi Q, Strombom PL, Chow O, et al. Anorectal function and quality of life in patients with early stage rectal cancer treated with chemoradiation and local excision. Dis Colon Rectum. 2017;60(5):459–68.

    Article  Google Scholar 

  57. National Comprehensive Cancer Network. Rectal cancer (Version 2.2018). https://www.nccn.org/professionals/physician_gls/pdf/rectal.pdf. Accessed May 2018.

  58. Rullier E, Rouanet P, Tuech JJ, Valverge A, Lelong B, Rivoire M, Faucheron JL, et al. Organ preservation for rectal cancer (GRECCAR 2): a prospective, randomized, open-label, multicenter, phase 3 trial. Lancet. 2017;390(10093):469–79.

    Article  Google Scholar 

  59. Chakravarti A, Compton CC, Shelito PC, Wood WC, Landry J, Machuta SR, et al. Long-term follow-up of patients with rectal cancer managed by local excision with and without adjuvant irradiation. Ann Surg. 1999;230(1):49–54.

    Article  CAS  Google Scholar 

  60. Morino M, Risio M, Bach S, Beets-Tan R, Bukjo K, Panis Y, et al. Early rectal cancer: the European Association for Endoscopic Surgery (EAES) clinical consensus conference. Surg Endosc. 2015;29(4):755–73.

    Article  Google Scholar 

  61. Monson JR, Weiser MR, Buie WD, Chang GJ, Rafferty JF. Practice parameters for the management of rectal cancer (revised). Dis Colon Rectum. 2013;56(5):535–50.

    Article  CAS  Google Scholar 

  62. Watanabe T, Muro K, Ajioka Y, Hashiguchi Y, Ito Y, Saito Y, et al. Japanese Society for Cancer of the Colon and Rectum (JSSCR) guidelines 2016 for the treatment of colorectal cancer. Int J Clin Oncol. 2018;23(1):1–34.

    Article  Google Scholar 

  63. Boland GM, Chang GJ, Haynes AB, Chiang YJ, Chaqpar R, Xing Y, et al. Association between adherence to National Comprehensive Cancer Network treatment guidelines and improved survival in patients with colon cancer. Cancer. 2013;119(8):1593–601.

    Article  Google Scholar 

  64. Baron PL, Enker WE, Zakowski MF, Urmacher C. Immediate vs salvage resection after local treatment for early rectal cancer. Dis Colon Rectum. 1995;38(2):177–81.

    Article  CAS  Google Scholar 

  65. Ikoma N, You YN, Bednarski BK, Rodriguez-Bigas MA, Eng C, Das P, et al. Impact of recurrence and salvage surgery on survival after multidisciplinary treatment of rectal cancer. J Clin Oncol. 2017;35(23):2631–8.

    Article  Google Scholar 

  66. 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  Google Scholar 

  67. Jeong JU, Nam TK, Kim HR, Shim HJ, Kim YH, Yoon MS, et al. Adjuvant chemoradiotherapy instead of revision radical resection after local excision for high-risk early rectal cancer. Radiat Oncol. 2016;11(1):114.

    Article  Google Scholar 

  68. Rockwood TH, Church JM, Fleshman JW, Kane RL, Mavrantonis C, Thorson AG, et al. Patient and surgeon ranking of the severity of symptoms associated with fecal incontinence: the fecal incontinence severity index. Dis Colon Rectum. 1999;42(12):1525–32.

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. The University of Texas MD Anderson Cancer Center, Department of Surgical Oncology, Houston, TX, USA

    George J. Chang & T. Paul Nickerson

Authors
  1. George J. Chang
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. T. Paul Nickerson
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to T. Paul Nickerson .

Editor information

Editors and Affiliations

  1. AdventHealth Orlando, Oviedo Medical Center, and University of Central Florida College of Medicine, Orlando, FL, USA

    Sam Atallah

Rights and permissions

Reprints and permissions

Copyright information

© 2019 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Chang, G.J., Nickerson, T.P. (2019). An Algorithm for Local Excision for Early-Stage Rectal Cancer. In: Atallah, S. (eds) Transanal Minimally Invasive Surgery (TAMIS) and Transanal Total Mesorectal Excision (taTME). Springer, Cham. https://doi.org/10.1007/978-3-030-11572-2_3

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-11572-2_3

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-11571-5

  • Online ISBN: 978-3-030-11572-2

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation