Advertisement

Annals of Surgical Oncology

, Volume 23, Issue 4, pp 1143–1148 | Cite as

Transanal Endoscopic Microsurgery (TEM) Following Neoadjuvant Chemoradiation for Rectal Cancer: Outcomes of Salvage Resection for Local Recurrence

  • Rodrigo Oliva PerezEmail author
  • Angelita Habr-Gama
  • Guilherme Pagin São Julião
  • Igor Proscurshim
  • Laura Melina Fernandez
  • Rafael Ulysses de Azevedo
  • Bruna B. Vailati
  • Felipe Alexandre Fernandes
  • Joaquim Gama-Rodrigues
Colorectal Cancer

Abstract

Background

Transanal endoscopic microsurgery (TEM) has been considered an alternative for selected patients with rectal cancer following neoadjuvant chemoradiation (CRT). Immediate total mesorectal completion for all patients with unfavorable pathological features would result in unnecessary protectomies in a significant proportion of patients. Instead, salvage total mesorectal excision (TME) could be restricted for patients developing local recurrence. The aim of the present study is to determine oncological outcomes of salvage resection for local recurrences following CRT and TEM.

Methods

Consecutive patients undergoing TEM following neoadjuvant CRT for rectal cancer were reviewed. Patients with “near” complete response to CRT (≤3 cm; ycT1-2N0) were offered TEM. Salvage surgery was attempted in the event of a local recurrence.

Results

A total of 53 patients were managed by CRT followed by TEM. Unfavorable pathological features were present in 36 patients (68 %). None of the patients underwent immediate completion TME. There were 12 patients who developed local recurrence resulting in a 2-year local recurrence-free survival of 77 % (95 % CI, 53–100 %). Of these patients, 9 developed exclusively local recurrences, and all had at least 1 unfavorable pathological feature in the specimen after TEM (100 %). Eight patients (8 of 9) underwent salvage resection (abdominoperineal resection [APR] in 87 %) with CRM+ in 7 of 8 patients (87 %). Four patients developed local re-recurrence after a median 36 months of follow-up. The 2-year local re-recurrence free survival was 60 %.

Conclusions

Salvage resection for local recurrence following CRT and TEM is associated with high rates of R1 resection (CRM+) and local re-recurrence. Immediate completion of TME should be considered for patients with unfavorable pathological features after TEM.

Keywords

Local Recurrence Total Mesorectal Excision Ultralow Anterior Resection Salvage Resection Total Mesorectal Excision Specimen 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Disclosure

No financial disclosures.

References

  1. 1.
    Sauer R, Liersch T, Merkel S, et al. Preoperative versus postoperative chemoradiotherapy for locally advanced rectal cancer: results of the German CAO/ARO/AIO-94 Randomized Phase III Trial after a median follow-up of 11 years. J Clin Oncol. 2012;30:1926–33.CrossRefPubMedGoogle Scholar
  2. 2.
    Smith FM, Waldron D, Winter DC. Rectum-conserving surgery in the era of chemoradiotherapy. Br J Surg. 2010;97:1752–64.CrossRefPubMedGoogle Scholar
  3. 3.
    Habr-Gama A, Perez RO. Non-operative management of rectal cancer after neoadjuvant chemoradiation. Br J Surg. 2009;96:125–7.CrossRefPubMedGoogle Scholar
  4. 4.
    Juul T, Ahlberg M, Biondo S, et al. Low anterior resection syndrome and quality of life: an international multicenter study. Dis Colon Rectum. 2014;57:585–91.CrossRefPubMedGoogle Scholar
  5. 5.
    Bregendahl S, Emmertsen KJ, Lindegaard JC, Laurberg S. Urinary and sexual dysfunction in women after resection with and without preoperative radiotherapy for rectal cancer: a population-based cross-sectional study. Colorectal Dis. 2015;17:26–37.CrossRefPubMedGoogle Scholar
  6. 6.
    Moore JS, Cataldo PA, Osler T, Hyman NH. Transanal endoscopic microsurgery is more effective than traditional transanal excision for resection of rectal masses. Dis Colon Rectum. 2008;51:1026–30; discussion 1030–1.CrossRefPubMedGoogle Scholar
  7. 7.
    Perez RO, Habr-Gama A, Lynn PB, Sao Juliao GP, Bianchi R, Proscurshim I, Gama-Rodrigues J. Transanal endoscopic microsurgery for residual rectal cancer (ypT0–2) following neoadjuvant chemoradiation therapy: another word of caution. Dis Colon Rectum. 2013;56:6–13.CrossRefPubMedGoogle Scholar
  8. 8.
    Perez RO, Habr-Gama A, Sao Juliao GP, Coelho AQ, Figueiredo MN, Fernandez LM, Gama-Rodrigues J. Transanal local excision for distal rectal cancer and incomplete response to neoadjuvant chemoradiation—does baseline staging matter? Dis Colon Rectum. 2014;57:1253–9.CrossRefPubMedGoogle Scholar
  9. 9.
    Pucciarelli S, De Paoli A, Guerrieri M, et al. Local excision after preoperative chemoradiotherapy for rectal cancer: results of a multicenter phase II clinical trial. Dis Colon Rectum. 2013;56:1349–56.CrossRefPubMedGoogle Scholar
  10. 10.
    Bujko K, Richter P, Smith FM, et al. Preoperative radiotherapy and local excision of rectal cancer with immediate radical re-operation for poor responders: a prospective multicentre study. Radiother Oncol. 2013;106:198–205.CrossRefPubMedGoogle Scholar
  11. 11.
    Habr-Gama A, Perez RO, Wynn G, Marks J, Kessler H, Gama-Rodrigues J. Complete clinical response after neoadjuvant chemoradiation therapy for distal rectal cancer: characterization of clinical and endoscopic findings for standardization. Dis Colon Rectum. 2010;53:1692–8.CrossRefPubMedGoogle Scholar
  12. 12.
    Habr-Gama A, Sabbaga J, Gama-Rodrigues J, et al. Watch and wait approach following extended neoadjuvant chemoradiation for distal rectal cancer: are we getting closer to anal cancer management? Dis Colon Rectum. 2013;56:1109–17.CrossRefPubMedGoogle Scholar
  13. 13.
    Habr-Gama A, Gama-Rodrigues J, Sao Juliao GP, Proscurshim I, Sabbagh C, Lynn PB, Perez RO. Local recurrence after complete clinical response and watch and wait in rectal cancer after neoadjuvant chemoradiation: impact of salvage therapy on local disease control. Int J Radiat Oncol Biol Phys. 2014;88:822–8.CrossRefPubMedGoogle Scholar
  14. 14.
    Morino M, Allaix ME, Arolfo S, Arezzo A. Previous transanal endoscopic microsurgery for rectal cancer represents a risk factor for an increased abdominoperineal resection rate. Surg Endosc. 2013;27:3315–21.CrossRefPubMedGoogle Scholar
  15. 15.
    Levic K, Bulut O, Hesselfeldt P, Bulow S. The outcome of rectal cancer after early salvage TME following TEM compared with primary TME: a case-matched study. Tech Coloproctol. 2013;17:397–403.CrossRefPubMedGoogle Scholar
  16. 16.
    Hompes R, McDonald R, Buskens C, et al. Completion surgery following transanal endoscopic microsurgery: assessment of quality and short- and long-term outcome. Colorectal Dis. 2013;15:e576–81.CrossRefPubMedGoogle Scholar
  17. 17.
    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;50:1520–5.CrossRefPubMedGoogle Scholar
  18. 18.
    Hayden DM, Jakate S, Pinzon MC, Giusto D, Francescatti AB, Brand MI, Saclarides TJ. Tumor scatter after neoadjuvant therapy for rectal cancer: are we dealing with an invisible margin? Dis Colon Rectum. 2012;55:1206–12.CrossRefPubMedGoogle Scholar
  19. 19.
    Perez RO, Habr-Gama A, Smith FM, et al. Fragmented pattern of tumor regression and lateral intramural spread may influence margin appropriateness after TEM for rectal cancer following neoadjuvant CRT. J Surg Oncol. 2014;109:853–8.CrossRefPubMedGoogle Scholar
  20. 20.
    Smith FM, Wiland H, Mace A, Pai RK, Kalady MF. Depth and lateral spread of microscopic residual rectal cancer after neoadjuvant chemoradiation: implications for treatment decisions. Colorectal Dis. 2014;16:610–5.CrossRefPubMedGoogle Scholar
  21. 21.
    Hahnloser D, Wolff BG, Larson DW, Ping J, Nivatvongs S. Immediate radical resection after local excision of rectal cancer: an oncologic compromise? Dis Colon Rectum. 2005;48:429–37.CrossRefPubMedGoogle Scholar
  22. 22.
    Baron PL, Enker WE, Zakowski MF, Urmacher C. Immediate vs. salvage resection after local treatment for early rectal cancer. Dis Colon Rectum. 1995;38:177–81.CrossRefPubMedGoogle Scholar

Copyright information

© Society of Surgical Oncology 2015

Authors and Affiliations

  • Rodrigo Oliva Perez
    • 1
    • 2
    • 3
    Email author
  • Angelita Habr-Gama
    • 1
    • 4
  • Guilherme Pagin São Julião
    • 1
  • Igor Proscurshim
    • 1
  • Laura Melina Fernandez
    • 1
  • Rafael Ulysses de Azevedo
    • 1
    • 4
  • Bruna B. Vailati
    • 1
  • Felipe Alexandre Fernandes
    • 1
    • 4
  • Joaquim Gama-Rodrigues
    • 1
    • 4
  1. 1.Angelita and Joaquim Gama InstituteSão PauloBrazil
  2. 2.Colorectal Surgery DivisionUniversity of São Paulo School of MedicineSão PauloBrazil
  3. 3.São Paulo BranchLudwig Institute for Cancer ResearchSão PauloBrazil
  4. 4.University of São Paulo School of MedicineSão PauloBrazil

Personalised recommendations