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Organ Preservation and Palliative Options for Rectal Cancer

  • Nienke den Dekker
  • Stefan Erik Van OostendorpEmail author
  • Jurriaan Benjamin Tuynman
Chapter

Abstract

Local excision is a well-accepted organ preserving method for early rectal cancer with substantial lower morbidity and impact on quality of life compared to radical surgery. However, only rectal cancers staged as a T1 tumor limited to the superficial third of the submucosa (sm1) and less than 3 cm in diameter without signs of poor differentiation, lymphatic or vascular invasion, budding, or clustering in the final pathology are oncologically safely treated with radical local excision. These tumors have local recurrence rates of less than 5%. Small locally excised lesions with more risk factors as budding, poor differentiation, and lymphovascular invasion or even T2 lesions have been associated with relatively high recurrence rates. Due to the increased recurrence rate, most guidelines recommend completion radical surgery after local excision of high-risk lesions.

Keywords

Organ preservation Palliative options Rectal cancer Local excision Adjuvant therapy Palliative radiotherapy 

References

  1. 1.
    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.CrossRefGoogle Scholar
  2. 2.
    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. Colorectal Dis. 2013;15(7):788–97.CrossRefGoogle Scholar
  3. 3.
    Bosch SL, Teerenstra S, de Wilt JH, Cunningham C, Nagtegaal ID. Predicting lymph node metastasis in pT1 colorectal cancer: a systematic review of risk factors providing rationale for therapy decisions. Endoscopy. 2013;45(10):827–34.CrossRefGoogle Scholar
  4. 4.
    Bach SP, Hill J, Monson JR, Simson JN, Lane L, Merrie A, et al. A predictive model for local recurrence after transanal endoscopic microsurgery for rectal cancer. Br J Surg. 2009;96(3):280–90.CrossRefGoogle Scholar
  5. 5.
    Borstlap WAA, van Oostendorp SE, Klaver CEL, Hahnloser D, Cunningham C, Rullier E, et al. Organ preservation in rectal cancer: a synopsis of current guidelines. Colorectal Dis. 2017.  https://doi.org/10.1111/codi.13960.
  6. 6.
    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.CrossRefGoogle Scholar
  7. 7.
    Van Oostendorp SE, Vroom Y, Tuynman JB. Local recurrence rates after local excision of early rectal cancer followed by watchful waiting, completion TME and adjuvant (chemo) radiation; a meta-analysis. In preparation.Google Scholar
  8. 8.
    Lamont JP, McCarty TM, Digan RD, Jacobson R, Tulanon P, Lichliter WE. Should locally excised T1 rectal cancer receive adjuvant chemoradiation? Am J Surg. 2000;180(6):402–5; discussion 5–6.CrossRefGoogle Scholar
  9. 9.
    Morino M, Allaix ME, Caldart M, Scozzari G, Arezzo A. Risk factors for recurrence after transanal endoscopic microsurgery for rectal malignant neoplasm. Surg Endosc. 2011;25(11):3683–90.CrossRefGoogle Scholar
  10. 10.
    Min BS, Kim NK, Ko YT, Lee KY, Baek SH, Cho CH, et al. Long-term oncologic results of patients with distal rectal cancer treated by local excision with or without adjuvant treatment. Int J Color Dis. 2007;22(11):1325–30.CrossRefGoogle Scholar
  11. 11.
    Tsai BM, Finne CO, Nordenstam JF, Christoforidis D, Madoff RD, Mellgren A. Transanal endoscopic microsurgery resection of rectal tumors: outcomes and recommendations. Dis Colon Rectum. 2010;53(1):16–23.CrossRefGoogle Scholar
  12. 12.
    Gopaul D, Belliveau P, Vuong T, Trudel J, Vasilevsky CA, Corns R, et al. Outcome of local excision of rectal carcinoma. Dis Colon Rectum. 2004;47(11):1780–8.CrossRefGoogle Scholar
  13. 13.
    Zacharakis E, Freilich S, Rekhraj S, Athanasiou T, Paraskeva P, Ziprin P, et al. Transanal endoscopic microsurgery for rectal tumors: the St. Mary’s experience. Am J Surg. 2007;194(5):694–8.CrossRefGoogle Scholar
  14. 14.
    Allaix ME, Arezzo A, Caldart M, Festa F, Morino M. Transanal endoscopic microsurgery for rectal neoplasms: experience of 300 consecutive cases. Dis Colon Rectum. 2009;52(11):1831–6.CrossRefGoogle Scholar
  15. 15.
    Allaix ME, Arezzo A, Giraudo G, Morino M. Transanal endoscopic microsurgery vs. laparoscopic total mesorectal excision for T2N0 rectal cancer. J Gastrointest Surg. 2012;16(12):2280–7.CrossRefGoogle Scholar
  16. 16.
    Ganai S, Kanumuri P, Rao RS, Alexander AI. Local recurrence after transanal endoscopic microsurgery for rectal polyps and early cancers. Ann Surg Oncol. 2006;13(4):547–56.CrossRefGoogle Scholar
  17. 17.
    Giannoulopoulos D, Nastos C, Gavriatopoulou M, Vezakis A, Dellaportas D, Sotirova I, et al. The role of TAMIS (Transanal minimally invasive surgery) in the Management of Advanced Rectal Cancer – one shared story of three exceptional cases. J Invest Surg. 2018.  https://doi.org/10.1080/08941939.2017.1418462.
  18. 18.
    Maslekar S, Pillinger SH, Monson JR. Transanal endoscopic microsurgery for carcinoma of the rectum. Surg Endosc. 2007;21(1):97–102.CrossRefGoogle Scholar
  19. 19.
    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.CrossRefGoogle Scholar
  20. 20.
    Lee L, Kelly J, Nassif GJ, Atallah SB, Albert MR, Shridhar R, et al. Chemoradiation and local excision for T2N0 rectal Cancer offers equivalent overall survival compared to standard resection: a national Cancer database analysis. J Gastrointest Surg. 2017;21(10):1666–74.CrossRefGoogle Scholar
  21. 21.
    Borstlap WA, Tanis PJ, Koedam TW, Marijnen CA, Cunningham C, Dekker E, et al. A multi-centred randomised trial of radical surgery versus adjuvant chemoradiotherapy after local excision for early rectal cancer. BMC Cancer. 2016;16:513.CrossRefGoogle Scholar
  22. 22.
    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):1546–52.CrossRefGoogle Scholar
  23. 23.
    Hershman MJ, Myint AS, Makin CA. Multi-modality approach in curative local treatment of early rectal carcinomas. Colorectal Dis. 2003;5(5):445–50.CrossRefGoogle Scholar
  24. 24.
    Perez RO, Habr-Gama A, Lynn PB, Sao Juliao GP, Bianchi R, Proscurshim I, et al. Transanal endoscopic microsurgery for residual rectal cancer (ypT0-2) following neoadjuvant chemoradiation therapy: another word of caution. Dis Colon Rectum. 2013;56(1):6–13.CrossRefGoogle Scholar
  25. 25.
    Perez RO, Habr-Gama A, Sao Juliao GP, Proscurshim I, Scanavini Neto A, Gama-Rodrigues J. Transanal endoscopic microsurgery for residual rectal cancer after neoadjuvant chemoradiation therapy is associated with significant immediate pain and hospital readmission rates. Dis Colon Rectum. 2011;54(5):545–51.CrossRefGoogle Scholar
  26. 26.
    Marks JH, Valsdottir EB, DeNittis A, Yarandi SS, Newman DA, Nweze I, et al. Transanal endoscopic microsurgery for the treatment of rectal cancer: comparison of wound complication rates with and without neoadjuvant radiation therapy. Surg Endosc. 2009;23(5):1081–7.CrossRefGoogle Scholar
  27. 27.
    Rombouts AJM, Al-Najami I, Abbott NL, Appelt A, Baatrup G, Bach S, et al. Can we save the rectum by watchful waiting or TransAnal microsurgery following (chemo) radiotherapy versus Total mesorectal excision for early REctal Cancer (STAR-TREC study)?: protocol for a multicentre, randomised feasibility study. BMJ Open. 2017;7(12):e019474.PubMedPubMedCentralGoogle Scholar
  28. 28.
    Glynne-Jones R, Hughes R. Critical appraisal of the ‘wait and see’ approach in rectal cancer for clinical complete responders after chemoradiation. Br J Surg. 2012;99(7):897–909.CrossRefGoogle Scholar
  29. 29.
    Dattani M, Heald RJ, Goussous G, Broadhurst J, Sao Juliao GP, Habr-Gama A, et al. Oncological and survival outcomes in watch and wait patients with a clinical complete response after neoadjuvant Chemoradiotherapy for rectal Cancer: a systematic review and pooled analysis. Ann Surg. 2018;268:955.CrossRefGoogle Scholar
  30. 30.
    Smith FM, Rao C, Oliva Perez R, Bujko K, Athanasiou T, Habr-Gama A, et al. Avoiding radical surgery improves early survival in elderly patients with rectal cancer, demonstrating complete clinical response after neoadjuvant therapy: results of a decision-analytic model. Dis Colon Rectum. 2015;58(2):159–71.CrossRefGoogle Scholar
  31. 31.
    Cameron MG, Kersten C, Vistad I, Fossa S, Guren MG. Palliative pelvic radiotherapy of symptomatic incurable rectal cancer – a systematic review. Acta Oncol. 2014;53(2):164–73.CrossRefGoogle Scholar
  32. 32.
    Picardi V, Deodato F, Guido A, Giaccherini L, Macchia G, Frazzoni L, et al. Palliative short-course radiation therapy in rectal Cancer: a phase 2 study. Int J Radiat Oncol Biol Phys. 2016;95(4):1184–90.CrossRefGoogle Scholar
  33. 33.
    Hoskin PJ, de Canha SM, Bownes P, Bryant L, Glynne Jones R. High dose rate afterloading intraluminal brachytherapy for advanced inoperable rectal carcinoma. Radiother Oncol. 2004;73(2):195–8.CrossRefGoogle Scholar
  34. 34.
    Rijkmans EC, Cats A, Nout RA, van den Bongard D, Ketelaars M, Buijsen J, et al. Endorectal brachytherapy boost after external beam radiation therapy in elderly or medically inoperable patients with rectal Cancer: primary outcomes of the phase 1 HERBERT study. Int J Radiat Oncol Biol Phys. 2017;98(4):908–17.CrossRefGoogle Scholar
  35. 35.
    Manceau G, Karoui M, Werner A, Mortensen NJ, Hannoun L. Comparative outcomes of rectal cancer surgery between elderly and non-elderly patients: a systematic review. Lancet Oncol. 2012;13(12):e525–36.CrossRefGoogle Scholar
  36. 36.
    Surgery for colorectal cancer in elderly patients: a systematic review. Colorectal Cancer Collaborative Group. Lancet. 2000;356(9234):968–74.Google Scholar
  37. 37.
    Damhuis RA, Meurs CJ, Meijer WS. Postoperative mortality after cancer surgery in octogenarians and nonagenarians: results from a series of 5390 patients. World J Surg Oncol. 2005;3:71.CrossRefGoogle Scholar
  38. 38.
    Mamidanna R, Eid-Arimoku L, Almoudaris AM, Burns EM, Bottle A, Aylin P, et al. Poor 1-year survival in elderly patients undergoing nonelective colorectal resection. Dis Colon Rectum. 2012;55(7):788–96.CrossRefGoogle Scholar
  39. 39.
    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; discussion 71–4.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Nienke den Dekker
    • 1
  • Stefan Erik Van Oostendorp
    • 1
    Email author
  • Jurriaan Benjamin Tuynman
    • 1
  1. 1.Department of SurgeryAmsterdam University Medical Center, location VUmc, Cancer Center AmsterdamAmsterdamThe Netherlands

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