Annals of Surgical Oncology

, Volume 15, Issue 3, pp 712–720 | Cite as

Neoadjuvant Chemoradiation and Local Excision for T2-3 Rectal Cancer

  • Thomas Borschitz
  • Daniel Wachtlin
  • Markus Möhler
  • Heinz Schmidberger
  • Theodor Junginger
Gastrointestinal Oncology

Abstract

Background

Local excision (LE) of T1 low-risk (G1–2/L0/V0) rectal cancer is an established approach with local recurrence (LR) rates of ∼5%, whereas LE of ≥T2 high-risk tumors or inadequate resections (R1/RX/R ≤1 mm) showed high recurrence rates. Because of the favorable results after neoadjuvant chemoradiotherapy (nCRT) and radical surgery of disease that completely responds (CR) with almost absent LR even of T3–4 tumors, an extension of the indication for LE is controversially discussed, and therefore, we assessed this therapeutic option.

Methods

Including our own data, seven studies about LE after nCRT of cT2–3 tumors (n = 237) were analyzed after a PubMed search for cT categories, tumor height, nCRT regimens, schedule and technique of surgery, complications, freedom of stoma, response rates (ypT0–3), length of follow-up, LR, and metastases.

Results

Subgroups that we formed (retrospective vs. prospective/retractor vs. transanal endoscopic microsurgery) showed differences in the distribution of cT categories. However, neither the studies we considered nor our own patients showed LR in CR (ypT0). In addition, patients with ypT1 tumor consistently showed low LR rates of 2% (range, 0%–6%), whereas in ypT2 findings, less favorable LR rates of 6% to 20% were observed, and disease that did not respond to therapy (ypT3) displayed LR rates in up to 42%.

Conclusions

Despite of a highly selected patient collective, an extended indication for LE of cT2–3 rectal cancer after nCRT may be considered. The strongest prognostic factors were a CR (ypT0) or responses on submucosa level (ypT1). These first results will have to be confirmed in a prospective trial with an appropriate sample size to ensure high statistical power.

Keywords

Rectal cancer Neoadjuvant chemoradiation Local excision Tumor response 

References

  1. 1.
    Bernardshaw SV, Ovrebo K, Eide GE, et al. Treatment of rectal cancer: reduction of local recurrence after the introduction of TME—experience from one University Hospital. Dig Surg 2006;23:51–9PubMedCrossRefGoogle Scholar
  2. 2.
    Carlsen E, Schlichting E, Guldvog I, et al. Effect of the introduction of total mesorectal excision for the treatment of rectal cancer. Br J Surg 1998;85:526–9PubMedCrossRefGoogle Scholar
  3. 3.
    Goldberg S, Klas JV. Total mesorectal excision in the treatment of rectal cancer: a view from the USA. Semin Surg Oncol 1998;15:87–90PubMedCrossRefGoogle Scholar
  4. 4.
    Kapiteijn E, van de Velde CJ. The role of total mesorectal excision in the management of rectal cancer. Surg Clin North Am 2002;82:995–1007PubMedCrossRefGoogle Scholar
  5. 5.
    Kapiteijn E, Putter H, van de Velde CJ. Cooperative investigators of the Dutch ColoRectal Cancer Group. Impact of the introduction and training of total mesorectal excision on recurrence and survival in rectal cancer in The Netherlands. Br J Surg 2002;89:1142–9PubMedCrossRefGoogle Scholar
  6. 6.
    Mahteme H, Pahlman L. Good colorectal cancer surgery. Tech Coloproctol 2005;9:1–7PubMedCrossRefGoogle Scholar
  7. 7.
    Martling AL, Holm T, Rutqvist LE, et al. Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm. Stockholm Colorectal Cancer Study Group, Basingstoke Bowel Cancer Research Project. Lancet 2000;356:93–6PubMedCrossRefGoogle Scholar
  8. 8.
    Moore E, Heald RJ, Cecil TD, et al. Almost all five year disease free survivors are cured following rectal cancer surgery, but longer term follow-up detects some late local and systemic recurrences. Colorectal Dis 2005;7:403–5PubMedCrossRefGoogle Scholar
  9. 9.
    Piso P, Dahlke MH, Mirena P, et al. Total mesorectal excision for middle and lower rectal cancer: a single institution experience with 337 consecutive patients. J Surg Oncol 2004;86:115–21PubMedCrossRefGoogle Scholar
  10. 10.
    Wibe A, Carlsen E, Dahl O, et al. The Norwegian Rectal Cancer Group. Nationwide quality assurance of rectal cancer treatment. Colorectal Dis 2006;8:224–9PubMedCrossRefGoogle Scholar
  11. 11.
    Bedrosian I, Rodriguez-Bigas MA, Feig B, et al. Predicting the node-negative mesorectum after preoperative chemoradiation for locally advanced rectal carcinoma. J Gastrointest Surg 2004;8:56–62PubMedCrossRefGoogle Scholar
  12. 12.
    Brown CL, Ternent CA, Thorson AG, et al. Response to preoperative chemoradiation in stage II and III rectal cancer. Dis Colon Rectum 2003;46:1189–93PubMedCrossRefGoogle Scholar
  13. 13.
    Chan AK, Wong A, Jenken D, et al. Posttreatment TNM staging is a prognostic indicator of survival and recurrence in tethered or fixed rectal carcinoma after preoperative chemotherapy and radiotherapy. Int J Radiat Oncol Biol Phys 2005;61:665–77PubMedGoogle Scholar
  14. 14.
    Fietkau R, Barten M, Klautke G, et al. Postoperative chemotherapy may not be necessary for patients with ypN0-category after neoadjuvant chemoradiotherapy of rectal cancer. Dis Colon Rectum 2006;49:1284–92PubMedCrossRefGoogle Scholar
  15. 15.
    Garcia-Aguilar J, Hernandez de Anda E, Sirivongs P, et al. A pathologic complete response to preoperative chemoradiation is associated with lower local recurrence and improved survival in rectal cancer patients treated by mesorectal excision. Dis Colon Rectum 2003;46:298–304PubMedCrossRefGoogle Scholar
  16. 16.
    Hughes R, Glynne-Jones R, Grainger J, et al. Can pathological complete response in the primary tumour following pre-operative pelvic chemoradiotherapy for T3–T4 rectal cancer predict for sterilisation of pelvic lymph nodes, a low risk of local recurrence and the appropriateness of local excision? Int J Colorectal Dis 2006;21:11–7PubMedCrossRefGoogle Scholar
  17. 17.
    Onaitis MW, Noone RB, Hartwig M, et al. Neoadjuvant chemoradiation for rectal cancer: analysis of clinical outcomes from a 13-year institutional experience. Ann Surg 2001;233:778–85PubMedCrossRefGoogle Scholar
  18. 18.
    Reerink O, Verschueren RC, Szabo BG, et al. A favourable pathological stage after neoadjuvant radiochemotherapy in patients with initially irresectable rectal cancer correlates with a favourable prognosis. Eur J Cancer 2003;39:192–5PubMedCrossRefGoogle Scholar
  19. 19.
    Rodel C, Martus P, Papadoupolos T, et al. Prognostic significance of tumor regression after preoperative chemoradiotherapy for rectal cancer. J Clin Oncol 2005;23:8688–96PubMedCrossRefGoogle Scholar
  20. 20.
    Theodoropoulos G, Wise WE, Padmanabhan A, et al. T-level downstaging and complete pathologic response after preoperative chemoradiation for advanced rectal cancer result in decreased recurrence and improved disease-free survival. Dis Colon Rectum 2002;45:895–903PubMedCrossRefGoogle Scholar
  21. 21.
    Tulchinsky H, Rabau M, Shacham-Shemueli E, et al. Can rectal cancers with pathologic T0 after neoadjuvant chemoradiation (ypT0) be treated by transanal excision alone? Ann Surg Oncol 2006;13:347–52PubMedCrossRefGoogle Scholar
  22. 22.
    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;62:752–60PubMedGoogle Scholar
  23. 23.
    Coco C, Valentini V, Manno A, et al. Long-term results after neoadjuvant radiochemotherapy for locally advanced resectable extraperitoneal rectal cancer. Dis Colon Rectum 2006;49:311–8PubMedCrossRefGoogle Scholar
  24. 24.
    Gavioli M, Luppi G, Losi L, et al. Incidence and clinical impact of sterilized disease and minimal residual disease after preoperative radiochemotherapy for rectal cancer. Dis Colon Rectum 2005;48:1851–7PubMedCrossRefGoogle Scholar
  25. 25.
    Habr-Gama A. Assessment and management of the complete clinical response of rectal cancer to chemoradiotherapy. Colorectal Dis 2006;8:21–4PubMedCrossRefGoogle Scholar
  26. 26.
    Rengan R, Paty P, Wong WD, et al. Distal cT2N0 rectal cancer: is there an alternative to abdominoperineal resection? J Clin Oncol 2005;23:4905–12PubMedCrossRefGoogle Scholar
  27. 27.
    Gimbel MI, Paty PB. A current perspective on local excision of rectal cancer. Clin Colorectal Cancer 2004;4:26–35PubMedCrossRefGoogle Scholar
  28. 28.
    Bonnen M, Crane C, Vauthey JN, et al. Long-term results using local excision after preoperative hemoradiation among selected T3 rectal cancer patients. Int J Radiat Oncol Biol Phys 2004;60:1098–105PubMedCrossRefGoogle Scholar
  29. 29.
    Hershman MJ, Myint AS, Makin CA. Multi-modality approach in curative local treatment of early rectal carcinomas. Colorectal Dis 2003;5:445–50PubMedCrossRefGoogle Scholar
  30. 30.
    Kim CJ, Yeatman TJ, Coppola D, et al. Local excision of T2 and T3 rectal cancers after downstaging chemoradiation. Ann Surg 2001;234:352–8PubMedCrossRefGoogle Scholar
  31. 31.
    Lezoche E, Guerrieri M, Paganini AM, et al. Long-term results in patients with T2–3 N0 distal rectal cancer undergoing radiotherapy before transanal endoscopic microsurgery. Br J Surg 2005;92:1546–52PubMedCrossRefGoogle Scholar
  32. 32.
    Ruo L, Guillem JG, Minsky BD, et al. Preoperative radiation with or without chemotherapy and full-thickness transanal excision for selected T2 and T3 distal rectal cancers. Int J Colorectal Dis 2002;17:54–8PubMedCrossRefGoogle Scholar
  33. 33.
    Schell SR, Zlotecki RA, Mendenhall WM, et al. Transanal excision of locally advanced rectal cancers downstaged using neoadjuvant chemoradiotherapy. J Am Coll Surg 2002;194:584–90PubMedCrossRefGoogle Scholar
  34. 34.
    Stipa F, Lucandri G, Ferri M, et al. Local excision of rectal cancer with transanal endoscopic microsurgery (TEM). Anticancer Res 2004;24:1167–72PubMedGoogle Scholar
  35. 35.
    Greene FL, Page DL, Fleming ID, et al. AJCC Cancer Staging Manual. 6th ed. New York: Springer-Verlag, 2002Google Scholar
  36. 36.
    Sobin LH, Wittekind CH. UICC TNM Classification of Malignant Tumours. 6th ed. New York: John Wiley & Sons, 2002Google Scholar
  37. 37.
    Bartram C, Brown G. Endorectal ultrasound and magnetic resonance imaging in rectal cancer staging. Gastroenterol Clin North Am 2002;31:827–39PubMedCrossRefGoogle Scholar
  38. 38.
    Beets-Tan RG, Beets GL. Rectal cancer: review with emphasis on MR imaging. Radiology 2004;232:335–46PubMedCrossRefGoogle Scholar
  39. 39.
    Bipat S, Glas AS, Slors FJ, et al. Rectal cancer: local staging and assessment of lymph node involvement with endoluminal US, CT, and MR imaging—a meta-analysis. Radiology 2004;232:773–83PubMedCrossRefGoogle Scholar
  40. 40.
    Brown G, Davies S, Williams GT, et al. Effectiveness of preoperative staging in rectal cancer: digital rectal examination, endoluminal ultrasound or magnetic resonance imaging? Br J Cancer 2004;91:23–9PubMedCrossRefGoogle Scholar
  41. 41.
    Garcia-Aguilar J, Pollack J, Lee SH, et al. Accuracy of endorectal ultrasonography in preoperative staging of rectal tumors. Dis Colon Rectum 2002;45:10–5PubMedCrossRefGoogle Scholar
  42. 42.
    Junginger T, Hermanek P, Oberholzer K, et al. Rectal carcinoma: is too much neoadjuvant therapy performed? Proposals for a more selective MRI based indication. Zentralbl Chir 2006;131:275–84PubMedGoogle Scholar
  43. 43.
    Heald RJ, O’Neill BD, Moran B, et al. MRI in predicting curative resection of rectal cancer: new dilemma in multidisciplinary team management. BMJ 2006;333:808PubMedCrossRefGoogle Scholar
  44. 44.
    Kim JC, Kim HC, Yu CS, et al. Efficacy of 3-dimensional endorectal ultrasonography compared with conventional ultrasonography and computed tomography in preoperative rectal cancer staging. Am J Surg 2006;192:89–97PubMedCrossRefGoogle Scholar
  45. 45.
    Kneist W, Terzic A, Burghardt J, et al. Selection of patients with rectal tumors for local excision based on preoperative diagnosis. Results of a consecutive evaluation study of 552 patients. Chirurg 2004;75:168–75PubMedCrossRefGoogle Scholar
  46. 46.
    Koh DM, Brown G, Husband JE. Nodal staging in rectal cancer. Abdom Imaging 2006; 31:652–9PubMedCrossRefGoogle Scholar
  47. 47.
    Kramann B, Hildebrandt U. Computed tomography versus endosonography in the staging of rectal carcinoma: a comparative study. Int J Colorectal Dis 1986;1:216–8PubMedCrossRefGoogle Scholar
  48. 48.
    Maretto I, Pomerri F, Pucciarelli S, et al. The potential of restaging in the prediction of pathologic response after preoperative chemoradiotherapy for rectal cancer. Ann Surg Oncol 2007;14:455–61PubMedCrossRefGoogle Scholar
  49. 49.
    Mathur P, Smith JJ, Ramsey C, et al. Comparison of CT and MRI in the pre-operative staging of rectal adenocarcinoma and prediction of circumferential resection margin involvement by MRI. Colorectal Dis 2003;5:396–401PubMedCrossRefGoogle Scholar
  50. 50.
    Siddiqui AA, Fayiga Y, Huerta S. The role of endoscopic ultrasound in the evaluation of rectal cancer. Int Semin Surg Oncol 2006;3:36PubMedCrossRefGoogle Scholar
  51. 51.
    Kaminsky-Forrett MC, Conroy T, Luporsi E, et al. Prognostic implications of downstaging following preoperative radiation therapy for operable T3–T4 rectal cancer. Int J Radiat Oncol Biol Phys 1998;42:935–41PubMedGoogle Scholar
  52. 52.
    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;17:2396PubMedGoogle Scholar
  53. 53.
    Glehen O, Chapet O, Adham M, et al. Lyons Oncology Group. Long-term results of the Lyons R90-01 randomized trial of preoperative radiotherapy with delayed surgery and its effect on sphincter-saving surgery in rectal cancer. Br J Surg 2003;90:996–8PubMedCrossRefGoogle Scholar
  54. 54.
    Marr R, Birbeck K, Garvican J, et al. The modern abdominoperineal excision: the next challenge after total mesorectal excision. Ann Surg 2005;242:74–82PubMedCrossRefGoogle Scholar
  55. 55.
    Nagtegaal ID, van de Velde CJ, van der Worp E, et al. Cooperative Clinical Investigators of the Dutch Colorectal Cancer Group. Macroscopic evaluation of rectal cancer resection specimen: clinical significance of the pathologist in quality control. J Clin Oncol 2002;20:1729–34PubMedCrossRefGoogle Scholar
  56. 56.
    Tekkis PP, Heriot AG, Smith J, et al. Association of Coloproctology of Great Britain and Ireland. Comparison of circumferential margin involvement between restorative and nonrestorative resections for rectal cancer. Colorectal Dis 2005;7:369–74PubMedCrossRefGoogle Scholar
  57. 57.
    Wibe A, Syse A, Andersen E, et al. Norwegian Rectal Cancer Group. Oncological outcomes after total mesorectal excision for cure for cancer of the lower rectum: anterior vs. abdominoperineal resection. Dis Colon Rectum 2004;47:48–58PubMedCrossRefGoogle Scholar
  58. 58.
    Morson BC, Vaughan EG, Bussey HJR. Pelvic recurrence after excision of rectum for carcinoma. Br Med J 1963;ii:13–8Google Scholar
  59. 59.
    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;240:711–7PubMedGoogle Scholar
  60. 60.
    Borschitz T, Junginger T. Value of local surgical therapy of rectal cancer. A literature analysis. Zentralbl Chir 2003;128:1066–74Google Scholar
  61. 61.
    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;49:1492–506PubMedCrossRefGoogle Scholar
  62. 62.
    Borschitz T, Heintz A, Junginger T. Transanal endoscopic microsurgical excision of pT2 rectal cancer: results and possible indications. Dis Colon Rectum 2007;50:292–301PubMedCrossRefGoogle Scholar
  63. 63.
    Sengupta S, Tjandra JJ. Local excision of rectal cancer: what is the evidence? Dis Colon Rectum 2001;44:1345–61PubMedCrossRefGoogle Scholar
  64. 64.
    Sharma A, Hartley J, Monson JR. Local excision of rectal tumours. Surg Oncol 2003;12:51–61PubMedCrossRefGoogle Scholar
  65. 65.
    Baron PL, Enker WE, Zakowski MF, et al. Immediate vs. salvage resection after local treatment for early rectal cancer. Dis Colon Rectum 1995;38:177–81PubMedCrossRefGoogle Scholar
  66. 66.
    Guillem JG, Chessin DB, Jeong SY, et al. Contemporary applications of transanal endoscopic microsurgery: technical innovations and limitations. Clin Colorectal Cancer 2005;5:268–73PubMedGoogle Scholar
  67. 67.
    Hahnloser D, Wolff BG, Larson DW, et al. radial resection after local excision of rectal cancer: an oncologic compromise? Dis Colon Rectum 2005;48:429–37PubMedCrossRefGoogle Scholar
  68. 68.
    Nakagoe T, Ishikawa H, Sawai T, et al. Long-term outcomes of radical surgery after gasless video endoscopic transanal excision of T1/T2 rectal cancers. Eur J Surg Oncol 2004;30:638–42PubMedCrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2007

Authors and Affiliations

  • Thomas Borschitz
    • 1
  • Daniel Wachtlin
    • 2
  • Markus Möhler
    • 3
  • Heinz Schmidberger
    • 4
  • Theodor Junginger
    • 1
  1. 1.Clinic of General and Abdominal SurgeryJohannes Gutenberg-University HospitalMainzGermany
  2. 2.Coordination Center for Clinical TrialsJohannes Gutenberg-UniversityMainzGermany
  3. 3.First Department of Internal MedicineJohannes Gutenberg-University HospitalMainzGermany
  4. 4.Clinic of Radiation Oncology and Radiation TherapyJohannes Gutenberg-University HospitalMainzGermany

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