Journal of Gastrointestinal Surgery

, Volume 12, Issue 10, pp 1797–1806 | Cite as

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

  • Rajesh M. Nair
  • Erin M. Siegel
  • Dung-Tsa Chen
  • William J. Fulp
  • Timothy J. Yeatman
  • Mokenge P. Malafa
  • Jorge Marcet
  • David Shibata
2008 plenary presentation

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.

Keywords

Rectal cancer Local excision Neoadjuvant chemoradiation 

References

  1. 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.PubMedCrossRefGoogle Scholar
  2. 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.PubMedCrossRefGoogle Scholar
  3. 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.PubMedCrossRefGoogle Scholar
  4. 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.PubMedCrossRefGoogle Scholar
  5. 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.PubMedCrossRefGoogle Scholar
  6. 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.PubMedGoogle Scholar
  7. 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.PubMedCrossRefGoogle Scholar
  8. 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.PubMedCrossRefGoogle Scholar
  9. 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.PubMedCrossRefGoogle Scholar
  10. 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.PubMedCrossRefGoogle Scholar
  11. 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.PubMedCrossRefGoogle Scholar
  12. 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.PubMedCrossRefGoogle Scholar
  13. 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.PubMedGoogle Scholar
  14. 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.PubMedGoogle Scholar
  15. 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.PubMedGoogle Scholar
  16. 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.PubMedCrossRefGoogle Scholar
  17. 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.PubMedCrossRefGoogle Scholar
  18. 18.
    Kaplan E, Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc 1958;53:457–481. doi:10.2307/2281868.CrossRefGoogle Scholar
  19. 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.PubMedCrossRefGoogle Scholar
  20. 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.PubMedCrossRefGoogle Scholar
  21. 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.PubMedCrossRefGoogle Scholar
  22. 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.PubMedCrossRefGoogle Scholar
  23. 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.PubMedCrossRefGoogle Scholar
  24. 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.PubMedCrossRefGoogle Scholar
  25. 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).PubMedGoogle Scholar
  26. 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.PubMedCrossRefGoogle Scholar
  27. 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.PubMedCrossRefGoogle Scholar
  28. 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.PubMedCrossRefGoogle Scholar
  29. 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.PubMedCrossRefGoogle Scholar
  30. 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.PubMedCrossRefGoogle Scholar
  31. 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.PubMedGoogle Scholar
  32. 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).PubMedGoogle Scholar
  33. 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.PubMedCrossRefGoogle Scholar
  34. 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.PubMedCrossRefGoogle Scholar
  35. 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.PubMedCrossRefGoogle Scholar
  36. 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.PubMedGoogle Scholar
  37. 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.PubMedGoogle Scholar
  38. 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.PubMedCrossRefGoogle Scholar
  39. 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.PubMedCrossRefGoogle Scholar
  40. 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.PubMedCrossRefGoogle Scholar
  41. 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.PubMedCrossRefGoogle Scholar
  42. 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.PubMedCrossRefGoogle Scholar
  43. 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.PubMedCrossRefGoogle Scholar
  44. 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.PubMedCrossRefGoogle Scholar
  45. 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.PubMedCrossRefGoogle Scholar
  46. 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.PubMedCrossRefGoogle Scholar
  47. 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.PubMedCrossRefGoogle Scholar
  48. 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.PubMedGoogle Scholar
  49. 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.PubMedCrossRefGoogle Scholar
  50. 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.PubMedCrossRefGoogle Scholar
  51. 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.PubMedCrossRefGoogle Scholar
  52. 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.PubMedCrossRefGoogle Scholar
  53. 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.PubMedCrossRefGoogle Scholar
  54. 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.PubMedCrossRefGoogle Scholar
  55. 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.PubMedCrossRefGoogle Scholar
  56. 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.PubMedCrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2008

Authors and Affiliations

  • Rajesh M. Nair
    • 1
  • Erin M. Siegel
    • 2
  • Dung-Tsa Chen
    • 3
  • William J. Fulp
    • 3
  • Timothy J. Yeatman
    • 1
  • Mokenge P. Malafa
    • 1
  • Jorge Marcet
    • 4
  • David Shibata
    • 1
  1. 1.Division of Gastrointestinal OncologyH. Lee Moffitt Cancer Center & Research InstituteTampaUSA
  2. 2.Risk Assessment, Detection and Intervention ProgramH. Lee Moffitt Cancer Center & Research InstituteTampaUSA
  3. 3.Biostatistics Core Facility of the Department of Interdisciplinary OncologyH. Lee Moffitt Cancer Center & Research InstituteTampaUSA
  4. 4.Department of SurgeryUniversity of South Florida College of MedicineTampaUSA

Personalised recommendations