Skip to main content
SpringerLink
Log in

Long-Term Results of Transanal Excision After Neoadjuvant Chemoradiation for T2 and T3 Adenocarcinomas of the Rectum

  • 2008 plenary presentation
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Introduction

Traditionally, selected early distal rectal cancers have been considered for treatment by transanal excision (TAE) with acceptable oncologic results. With the frequent use of neoadjuvant chemoradiation (NCR) for the treatment of locally advanced rectal cancer, there is growing interest in the application of TAE for such lesions. We report our experience of TAE for T2 and T3 rectal cancers following NCR.

Material and Methods

Between July 1994 and August 2006, 44 patients were identified as having undergone full-thickness TAE of pretreatment ultrasound-staged T2 and T3 rectal cancers that were treated with NCR. Fifteen patients were deemed medically unfit for radical resection, and 29 would have required abdominoperineal resection but were opposed to colostomy.

Results

Our patient population consisted of 26 men and 18 women, with a median age of 69 (range, 43–89) and a median follow up of 64 months (6–153). Thirty-one patients had a clinical complete response (cCR) to NCR of which 19 (61%) had a pathologic CR (pCR). Seven (16%) of 44 patients sustained disease recurrence of which two were local only, two local and systemic, and three systemic only. Only four (9%) patients had died of disease at current follow up. Overall 5-year survival rates for T2/T3N0 and T2/T3N1 patients were 84% and 81%, respectively. Five patients underwent radical resection immediately following TAE for either positive margins or residual cancer. There was minimal morbidity with no perioperative mortality associated with TAE.

Conclusions

TAE of T2 and T3 rectal cancers following NCR is a safe alternative to radical resection in a highly select group of patients for which recurrence and survival rates comparable to radical resection can be achieved. This study supports ongoing efforts to assess this approach in prospective, multi-center trials.

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

Figure 1
Figure 2
Figure 3

Similar content being viewed by others

References

  1. Nastro P, Beral D, Hartley J, Monson JR. Local excision of rectal cancer: review of literature. Dig Surg 2005;22(1–2):6–15. doi:10.1159/000084345.

    Article  PubMed  Google Scholar 

  2. Sengupta S, Tjandra JJ. Local excision of rectal cancer: what is the evidence? Dis Colon Rectum 2001;44(9):1345–1361. doi:10.1007/BF02234796.

    Article  PubMed  CAS  Google Scholar 

  3. 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):345–351. doi:10.1097/00000658-200003000-00007.

    Article  PubMed  CAS  Google Scholar 

  4. Madbouly KM, Remzi FH, Erkek BA, Senagore AJ, Baeslach CM, Khandwala F, et al. Recurrence after transanal excision of T1 rectal cancer: should we be concerned? Dis Colon Rectum 2005;48(4):711–719. (discussion 719–21). doi:10.1007/s10350-004-0666-0.

    Article  PubMed  Google Scholar 

  5. Chakravarti A, Compton CC, Shellito 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. doi:10.1097/00000658-199907000-00008.

    Article  PubMed  CAS  Google Scholar 

  6. Lezoche E, Guerrieri M, Paganini A, Feliciotti F, Di Pietrantonj F. Is transanal endoscopic microsurgery (TEM) a valid treatment for rectal tumors? Surg Endosc 1996;10(7):736–741.

    PubMed  CAS  Google Scholar 

  7. 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):1064–1071. (discussion 1071–1074). doi:10.1007/BF02236551.

    Article  PubMed  CAS  Google Scholar 

  8. Minsky BD, Rich T, Recht A, Harvey W, Mies C. Selection criteria for local excision with or without adjuvant radiation therapy for rectal cancer. Cancer 1989;63(7):1421–1429. doi:10.1002/1097-0142(19890401)63:7<1421::AID-CNCR2820630732>3.0.CO;2-H.

    Article  PubMed  CAS  Google Scholar 

  9. 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):1185–1191.

    Article  PubMed  Google Scholar 

  10. Steele GD Jr, Herndon JE, Bleday R, Russell A, Benson A 3rd, Hussain M, et al. Sphincter-sparing treatment for distal rectal adenocarcinoma. Ann Surg Oncol 1999;6(5):433–441. doi:10.1007/s10434-999-0433-5.

    Article  PubMed  Google Scholar 

  11. Sauer R, Becker H, Hohenberger W, Rodel C, Wittekind C, Fietkau R, et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 2004;351(17):1731–1740. doi:10.1056/NEJMoa040694.

    Article  PubMed  CAS  Google Scholar 

  12. Chari RS, Tyler DS, Anscher MS, Russell L, Clary BM, Hathorn J, et al. Preoperative radiation and chemotherapy in the treatment of adenocarcinoma of the rectum. Ann Surg 1995;221(6):778–786. (discussion 786–787). doi:10.1097/00000658-199506000-00016.

    Article  PubMed  CAS  Google Scholar 

  13. Chen ET, Mohiuddin M, Brodovsky H, Fishbein G, Marks G. Downstaging of advanced rectal cancer following combined preoperative chemotherapy and high dose radiation. Int J Radiat Oncol Biol Phys 1994;30(1):169–175.

    PubMed  CAS  Google Scholar 

  14. Janjan NA, Khoo VS, Abbruzzese J, Pazdur R, Dubrow R, Cleary KR, et al. Tumor downstaging and sphincter preservation with preoperative chemoradiation in locally advanced rectal cancer: the M. D. Anderson Cancer Center experience. Int J Radiat Oncol Biol Phys 1999;44(5):1027–1038. doi:10.1016/S0360-3016(99)00099-1.

    PubMed  CAS  Google Scholar 

  15. Minsky BD, Cohen AM, Kemeny N, Enker WE, Kelsen DP, Reichman B, et al. Combined modality therapy of rectal cancer: decreased acute toxicity with the preoperative approach. J Clin Oncol 1992;10(8):1218–1224.

    PubMed  CAS  Google Scholar 

  16. Kim CJ, Yeatman TJ, Coppola D, Trotti A, Williams B, Barthel JS, et al. Local excision of T2 and T3 rectal cancers after downstaging chemoradiation. Ann Surg 2001;234(3):352–358. (discussion 358–359). doi:10.1097/00000658-200109000-00009.

    Article  PubMed  CAS  Google Scholar 

  17. Charlson ME, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40(5):373–383. doi:10.1016/0021-9681(87)90171-8.

    Article  PubMed  CAS  Google Scholar 

  18. Kaplan E, Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc 1958;53:457–481. doi:10.2307/2281868.

    Article  Google Scholar 

  19. Heintz A, Morschel M, Junginger T. Comparison of results after transanal endoscopic microsurgery and radical resection for T1 carcinoma of the rectum. Surg Endosc 1998;12(9):1145–1148. doi:10.1007/s004649900802.

    Article  PubMed  CAS  Google Scholar 

  20. Palma P, Freudenberg S, Samel S, Post S. Transanal endoscopic microsurgery: indications and results after 100 cases. Colorectal Dis 2004;6(5):350–355. doi:10.1111/j.1463-1318.2004.00671.x.

    Article  PubMed  CAS  Google Scholar 

  21. Varma MG, Rogers SJ, Schrock TR, Welton ML. Local excision of rectal carcinoma. Arch Surg 1999;134(8):863–867. (discussion 867–868). doi:10.1001/archsurg.134.8.863.

    Article  PubMed  CAS  Google Scholar 

  22. 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):969–976. doi:10.1007/BF02054683.

    Article  PubMed  CAS  Google Scholar 

  23. Habr-Gama A, de Souza PM, Ribeiro U Jr, Nadalin W, Gansl R, Sousa AH Jr, et al. Low rectal cancer: impact of radiation and chemotherapy on surgical treatment. Dis Colon Rectum 1998;41(9):1087–1096. doi:10.1007/BF02239429.

    Article  PubMed  CAS  Google Scholar 

  24. 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):1380–1388. doi:10.1007/s10350-005-0044-6.

    Article  PubMed  Google Scholar 

  25. Zieren HU, Jacobi CA, Zieren J, Muller JM. Assessment of quality of life after resection of colorectal carcinoma. Chirurg 1996;67(7):703–708. (discussion 709).

    PubMed  CAS  Google Scholar 

  26. Enker WE, Havenga K, Polyak T, Thaler H, Cranor M. Abdominoperineal resection via total mesorectal excision and autonomic nerve preservation for low rectal cancer. World J Surg 1997;21(7):715–720. doi:10.1007/s002689900296.

    Article  PubMed  CAS  Google Scholar 

  27. Enker WE, Merchant N, Cohen AM, Lanouette NM, Swallow C, Guillem J, et al. Safety and efficacy of low anterior resection for rectal cancer: 681 consecutive cases from a specialty service. Ann Surg 1999;230(4):544–552. (discussion 552–554). doi:10.1097/00000658-199910000-00010.

    Article  PubMed  CAS  Google Scholar 

  28. Rothenberger DA, Wong WD. Abdominoperineal resection for adenocarcinoma of the low rectum. World J Surg 1992;16(3):478–485. doi:10.1007/BF02104451.

    Article  PubMed  CAS  Google Scholar 

  29. Averbach AM, Chang D, Koslowe P, Sugarbaker PH. Anastomotic leak after double-stapled low colorectal resection. Dis Colon Rectum 1996;39(7):780–787. doi:10.1007/BF02054444.

    Article  PubMed  CAS  Google Scholar 

  30. Williamson ME, Lewis WG, Finan PJ, Miller AS, Holdsworth PJ, Johnston D. Recovery of physiologic and clinical function after low anterior resection of the rectum for carcinoma: myth or reality? Dis Colon Rectum 1995;38(4):411–418. doi:10.1007/BF02054232.

    Article  PubMed  CAS  Google Scholar 

  31. Petrelli NJ, Nagel S, Rodriguez-Bigas M, Piedmonte M, Herrera L. Morbidity and mortality following abdominoperineal resection for rectal adenocarcinoma. Am Surg 1993;59(7):400–404.

    PubMed  CAS  Google Scholar 

  32. Habr-Gama A, Perez RO, Nadalin W, Sabbaga J, Ribeiro U Jr, Silva e Sousa AH Jr, et al. Operative versus nonoperative treatment for stage 0 distal rectal cancer following chemoradiation therapy: long-term results. Ann Surg 2004;240(4):711–717. (discussion 717–718).

    PubMed  Google Scholar 

  33. Habr-Gama A, Perez RO, Proscurshim I, Campos FG, Nadalin W, Kiss D, et al. Patterns of failure and survival for nonoperative treatment of stage c0 distal rectal cancer following neoadjuvant chemoradiation therapy. J Gastrointest Surg 2006;10(10):1319–1328. (discussion 1328–1329). doi:10.1016/j.gassur.2006.09.005.

    Article  PubMed  Google Scholar 

  34. Guillem JG, Chessin DB, Shia J, Moore HG, Mazumdar M, Bernard B, et al. Clinical examination following preoperative chemoradiation for rectal cancer is not a reliable surrogate end point. J Clin Oncol 2005;23(15):3475–3479. doi:10.1200/JCO.2005.06.114.

    Article  PubMed  Google Scholar 

  35. Maldjian C, Smith R, Kilger A, Schnall M, Ginsberg G, Kochman M. Endorectal surface coil MR imaging as a staging technique for rectal carcinoma: a comparison study to rectal endosonography. Abdom Imaging 2000;25(1):75–80. doi:10.1007/s002619910015.

    Article  PubMed  CAS  Google Scholar 

  36. Calvo FA, Domper M, Matute R, Martinez-Lazaro R, Arranz JA, Desco M, et al. 18F-FDG positron emission tomography staging and restaging in rectal cancer treated with preoperative chemoradiation. Int J Radiat Oncol Biol Phys 2004;58(2):528–535. doi:10.1016/j.ijrobp.2003.09.058.

    PubMed  Google Scholar 

  37. Delrio P, Lastoria S, Avallone A, Ravo V, Guida C, Cremona F, et al. Early evaluation using PET-FDG of the efficiency of neoadjuvant radiochemotherapy treatment in locally advanced neoplasia of the lower rectum. Tumori. 2003;89(Suppl 4):50–53.

    PubMed  CAS  Google Scholar 

  38. Gagliardi G, Bayar S, Smith R, Salem RR. Preoperative staging of rectal cancer using magnetic resonance imaging with external phase-arrayed coils. Arch Surg 2002;137(4):447–451. doi:10.1001/archsurg.137.4.447.

    Article  PubMed  Google Scholar 

  39. Kuo LJ, Chern MC, Tsou MH, Liu MC, Jian JJ, Chen CM, et al. Interpretation of magnetic resonance imaging for locally advanced rectal carcinoma after preoperative chemoradiation therapy. Dis Colon Rectum 2005;48(1):23–28. doi:10.1007/s10350-004-0787-5.

    Article  PubMed  Google Scholar 

  40. Tulchinsky H, Rabau M, Shacham-Shemueli E, Goldman G, Geva R, Inbar M, et al. Can rectal cancers with pathologic T0 after neoadjuvant chemoradiation (ypT0) be treated by transanal excision alone? Ann Surg Oncol 2006;13(3):347–352. doi:10.1245/ASO.2006.03.029.

    Article  PubMed  Google Scholar 

  41. Bedrosian I, Rodriguez-Bigas MA, Feig B, Hunt KK, Ellis L, Curley SA, et al. Predicting the node-negative mesorectum after preoperative chemoradiation for locally advanced rectal carcinoma. J Gastrointest Surg 2004;8(1):56–62. (discussion 62–63). doi:10.1016/j.gassur.2003.09.019.

    Article  PubMed  Google Scholar 

  42. Hiotis SP, Weber SM, Cohen AM, Minsky BD, Paty PB, Guillem JG, et al. Assessing the predictive value of clinical complete response to neoadjuvant therapy for rectal cancer: an analysis of 488 patients. J Am Coll Surg 2002;194(2):131–135. (discussion 135–136). doi:10.1016/S1072-7515(01)01159-0.

    Article  PubMed  Google Scholar 

  43. Medich D, McGinty J, Parda D, Karlovits S, Davis C, Caushaj P, et al. Preoperative chemoradiotherapy and radical surgery for locally advanced distal rectal adenocarcinoma: pathologic findings and clinical implications. Dis Colon Rectum 2001;44(8):1123–1128. doi:10.1007/BF02234632.

    Article  PubMed  CAS  Google Scholar 

  44. Onaitis MW, Noone RB, Fields R, Hurwitz H, Morse M, Jowell P, et al. Complete response to neoadjuvant chemoradiation for rectal cancer does not influence survival. Ann Surg Oncol 2001;8(10):801–806. doi:10.1007/s10434-001-0801-2.

    Article  PubMed  CAS  Google Scholar 

  45. Pucciarelli S, Capirci C, Emanuele U, Toppan P, Friso ML, Pennelli GM, et al. Relationship between pathologic T-stage and nodal metastasis after preoperative chemoradiotherapy for locally advanced rectal cancer. Ann Surg Oncol 2005;12(2):111–116. doi:10.1245/ASO.2005.03.044.

    Article  PubMed  Google Scholar 

  46. Stipa F, Zernecke A, Moore HG, Minsky BD, Wong WD, Weiser M, et al. Residual mesorectal lymph node involvement following neoadjuvant combined-modality therapy: rationale for radical resection? Ann Surg Oncol 2004;11(2):187–191. doi:10.1245/ASO.2004.06.010.

    Article  PubMed  Google Scholar 

  47. 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):1546–1552. doi:10.1002/bjs.5178.

    Article  PubMed  CAS  Google Scholar 

  48. Bonnen M, Crane C, Vauthey JN, Skibber J, Delclos ME, Rodriguez-Bigas M, 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(4):1098–1105. doi:10.1016/j.ijrobp.2004.04.062.

    PubMed  Google Scholar 

  49. Caricato M, Borzomati D, Ausania F, Tonini G, Rabitti C, Valeri S, et al. Complementary use of local excision and transanal endoscopic microsurgery for rectal cancer after neoadjuvant chemoradiation. Surg Endosc 2006;20(8):1203–1207. doi:10.1007/s00464-005-0567-x.

    Article  PubMed  CAS  Google Scholar 

  50. Ruo L, Guillem JG, Minsky BD, Quan SH, Paty PB, Cohen AM. Preoperative radiation with or without chemotherapy and full-thickness transanal excision for selected T2 and T3 distal rectal cancers. Int J Colorectal Dis 2002;17(1):54–58. doi:10.1007/s003840100327.

    Article  PubMed  CAS  Google Scholar 

  51. Schell SR, Zlotecki RA, Mendenhall WM, Marsh RW, Vauthey JN, Copeland EM 3rd. Transanal excision of locally advanced rectal cancers downstaged using neoadjuvant chemoradiotherapy. J Am Coll Surg 2002;194(5):584–590. (discussion 590–591). doi:10.1016/S1072-7515(02)01128-6.

    Article  PubMed  Google Scholar 

  52. Das P, Skibber JM, Rodriguez-Bigas MA, Feig BW, Chang GJ, Hoff PM, et al. Clinical and pathologic predictors of locoregional recurrence, distant metastasis, and overall survival in patients treated with chemoradiation and mesorectal excision for rectal cancer. Am J Clin Oncol 2006;29(3):219–224. doi:10.1097/01.coc.0000214930.78200.4a.

    Article  PubMed  Google Scholar 

  53. Wexner SD, Rotholtz NA. Surgeon influenced variables in resectional rectal cancer surgery. Dis Colon Rectum 2000;43(11):1606–1627. doi:10.1007/BF02236751.

    Article  PubMed  CAS  Google Scholar 

  54. Lezoche G, Baldarelli M, Guerrieri M, Paganini AM, De Sanctis A, Bartolacci S, 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(2):352–358. doi:10.1007/s00464-007-9596-y.

    Article  PubMed  CAS  Google Scholar 

  55. Borschitz T, Wachtlin D, Mohler M, Schmidberger H, Junginger T. Neoadjuvant chemoradiation and local excision for T2–3 rectal cancer. Ann Surg Oncol 2008;15(3):712–720. doi:10.1245/s10434-007-9732-x.

    Article  PubMed  Google Scholar 

  56. 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):522–529. (discussion 529–530). doi:10.1097/00000658-200210000-00015.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, WCB-2, Tampa, FL, 33612-9497, USA

    Rajesh M. Nair, Timothy J. Yeatman, Mokenge P. Malafa & David Shibata

  2. Risk Assessment, Detection and Intervention Program, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA

    Erin M. Siegel

  3. Biostatistics Core Facility of the Department of Interdisciplinary Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA

    Dung-Tsa Chen & William J. Fulp

  4. Department of Surgery, University of South Florida College of Medicine, Tampa, FL, USA

    Jorge Marcet

Authors
  1. Rajesh M. Nair
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Erin M. Siegel
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Dung-Tsa Chen
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. William J. Fulp
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Timothy J. Yeatman
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Mokenge P. Malafa
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Jorge Marcet
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. David Shibata
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to David Shibata.

Additional information

Alessandro Fichera, M.D. (Chicago, IL): The group from Moffitt really needs to be congratulated for a very provoking study, a timely study as well. They have reviewed a large series of patients with T2/T3 rectal cancer that underwent transanal excision after combined modality therapy at their institution in the neoadjuvant setting. As I said, this is a very timely study, since this is a topic of prospective, randomized evaluations at this point.

To take a little bit of a step back and give you a little bit of an historical background, the Memorial Sloan-Kettering and the University of Minnesota group have shown that the recurrence rate after local excision alone for T2 rectal cancer could be as high as 47%, obviously not an acceptable rate. In the CALGB 8984 trial, chemoradiation therapy was utilized in the adjuvant setting after local excision for patients found to have a T2/T3 lesion with a significant improvement in local recurrence rate. Now, with the results of the German rectal cancer trial that was presented during the talk, it is clear that neoadjuvant chemoradiation therapy offers significant advantages and should be considered the treatment of choice for locally advanced rectal cancer. The authors have applied this approach to T2 and T3 lesions in their series. The study I thought was very well presented, and their pathologic complete response rate of 25 out of 44 patients is quite impressive.

There are some limitations to the study. Obviously, this is a retrospective evaluation, and there is obviously a selection bias inherent to the group of 29 patients that were opposed to a colostomy. Furthermore, during the 20 years of the study, our ability to stage rectal cancers and to deliver radiation therapy has changed dramatically. Notwithstanding these limitations, their results are very impressive. I would like to ask the authors a few questions.

Although the numbers are small, it appears that disease-free survival is somewhat reduced, 79% versus 88% at 5 years and 92% at 3 years, in the groups with positive lymph nodes. Should a local excision be offered to these patients at all, accepting a failure rate of 21%? On the same line, we do know that the risk of local recurrence is delayed by radiation therapy. The Brazilian study has also shown a slight increase in the number of recurrences as the follow-up continues. Even though your disease-free survival changes only slightly between 3 and 5 years, what are you expecting to see 5 years from now, and how are you going to follow these patients up? In view of the results of the study, what options are you offering to a patient that presents to your clinic with a T3 N0 rectal lesion at the dentate line at this point?

I truly enjoyed your presentation that was kindly provided to me ahead of schedule. Thank you also for the opportunity to discuss the paper.

Rajesh Nair, M.D. (Tampa, FL):Dr. Fichera, thank you very much for your review of our study and your critical appraisal. I will try and answer the questions in order.

In terms of patients with node-positive disease, the setup of the current prospective trial with ACOSOG includes patients with early stage, T2 node-negative cancers, and we agree, ideally, that this approach should be limited to node-negative patients. As we and others have demonstrated, the rates of recurrence with node-positive disease are too high. I think attempts at local excision can be made in patients, again, who are completely opposed to radical surgery and/or colostomy or are medically unfit for surgery. However, they need to understand that they will be accepting a higher rate of recurrence utilizing this approach.

In terms of long-term follow-up, the data from the Memorial group has clearly shown that local recurrences can occur more than 5 years beyond the initial time of treatment. Therefore, we will need to change our approach in follow-up, especially if this approach becomes utilized, extending from 5 to 10 years and maybe longer.

And in terms of a patient who presents to us with a T3 N0 cancer, our approach, again, would be to offer them neoadjuvant chemoradiation and then make a decision based upon the clinical response. In a patient who has a complete clinical response, our recommendation would still be to tell them that the standard of care is to undergo full radical surgical resection. However, if they are, again, opposed to colostomy and/or radical surgery or are medically unfit, we can offer this procedure, again, with the understanding that there may be an increased rate of local recurrence with this technique.

Bruce A. Orkin, M.D. (Washington, DC): I enjoyed your presentation very much. This is actually a very critical area that we are trying to evaluate ourselves. I have probably done over 200 of these cases, about a third of them for malignancies. Our experience has been that those patients who have had preoperative radiation and chemotherapy have a much, much higher complication rate. We primarily use transanal endoscopic microsurgery, and we have seen a lot of failures in terms of the wounds falling apart. I actually had a discussion about that with one of our colleagues yesterday.

Are you seeing such an increase in complications? Are you using TEM for any of these cases now? If so, are you prospectively evaluating it?

Dr. Nair: In terms of TEM, none of the patients in this particular study underwent TEM. However, within the last 12 months, almost all of the patients who have undergone local excision have been treated using TEM. In terms of complications, we have not noticed a significant change in our overall morbidity rate. In this current cohort, there was one patient who had a disruption of their suture line and subsequently required dilatation for an anorectal stenosis.

In a group of patients treated too recently to have been included in this study, we have seen two patients with rectal drainage secondary to minor suture line dehiscence. In both of these cases, symptoms were self-limited and completely resolved.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Nair, R.M., Siegel, E.M., Chen, DT. et al. Long-Term Results of Transanal Excision After Neoadjuvant Chemoradiation for T2 and T3 Adenocarcinomas of the Rectum. J Gastrointest Surg 12, 1797–1806 (2008). https://doi.org/10.1007/s11605-008-0647-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11605-008-0647-z

Keywords

Search

Navigation