Zusammenfassung
Einleitung
Ziel unserer Studie war die Erfassung der Genauigkeit der präoperativen Diagnostik (rektal-digitale Untersuchung, Biopsie und transanale Endosonographie) bei durch lokale Exzision behandelten Rektumtumoren.
Patienten und Methode
552 Patienten mit Rektumkarzinom, Adenom, Karzinoiden oder seltenen benignen Tumoren wurden lokal exzidiert. Die Ergebnisse der rektal-digitalen Untersuchung, der Biopsie und der transanalen Endosonographie wurden mit dem postoperativen pathohistologischen Befund verglichen.
Ergebnisse
Der präoperative histologische Nachweis des Karzinoms ist abhängig von der Tumorgröße (52% bei Karzinomen <3 cm, 25% bei Karzinomen >3 cm; p=0,001) und war korrekt in 56% aller Karzinome. Die transanale Endosonographie (uT0/1) ist sensitiver (95% vs. 78%) und hat einen höheren positiven Vorhersagewert (93% vs. 85%) als die rektal-digitale Untersuchung (CS I) für die Diagnostik des Adenoms und des pT1-Rektumkarzinoms. Die Spezifität beider Untersuchungen ist vergleichbar gut (62% vs. 58%). Zeigte die präoperative Biopsie histologisch ein Adenom, ergab sich bei dem ultrasonographischen Befund uT0/1 postoperativ in 97% der Fälle ein Adenom bzw. ein pT1-Karzinom, während sich bei präoperativ bekanntem Rektumkarzinom (uT0/1) diese Situation bei 71% bestätigte.
Schlussfolgerung
Endosonographie und Biopsie erlauben bei den meisten Patienten mit Rektumpolyp die richtige Indikationsstellung zur lokalen Exzision.
Abstract
Introduction
The aim of our study was to evaluate the accuracy of clinical staging (CS), biopsies, and endoluminal ultrasonic examination (EUS) in preoperative staging of rectal tumors treated with transanal local excision. This local excision is an adequate procedure for benign rectal polyps and low-risk T1 carcinoma.
Patients and methods
The study included 552 patients with rectal adenocarcinoma, villous adenoma, or tumors with other histologic characteristics who underwent a transanal excision (transanal endoscopic microsurgery n=513 or transanal excision n=39). We compared the results of CS, biopsies, and EUS with postoperative pathology findings.
Results
Preoperative histological diagnosis of the rectal carcinoma depended on tumor size (52% in cancers <3 cm, 25% in cancers >3 cm; p=0.001) and was correct in 56% of cases. Transanal ultrasonography (uT0/1) had superior sensitivity (95% vs 78%) and a higher positive predictive value (93% vs 85%) than clinical staging (CS I) in detecting adenoma or T1 rectal carcinoma, whereas specificity was similar in both (62% vs 58%). In patients in whom preoperative histological analysis revealed adenomas, transanal ultrasonography was accurate (uT0/1) for the postoperatively assessed adenoma pT1 in 97%, whereas diagnosis (uT0/1) was correct in only 71% of cases in which preoperative histological analyses showed rectal carcinomas.
Conclusions
In patients with rectal tumors, preoperative staging with transanal ultrasonography and biopsy is essential for the indication and allows selection of patients for transanal local excision.
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Literatur
Blumberg D, Paty Ph, Guillem J et al. (1999) All patients with small intramural rectal cancers are at risk for lymph node metastasis. Dis Colon Rectum 42:881
Buess G, Hutterer J, Theiß M et al. (1984) Das System für transanale, endoskopische Rektumoperation. Chirurg 55:677
Chakravarti A, Compton C, Shellito PC et al. (1999) Long-term follow-up of patients with rectal cancer managed by local excision with and without adjuvant irradiation. Ann Surg 230:49
Cooper HS, Deppisch LM, Gourley WK et al. (1995) Endoscopically removed malignant colorectal polyps: clinicopathologic correlations. Gastroenterology 108:1657
Garcia-Aguilar J, Pollack J, Lee SH et al. (2002) Accuracy of endorectal ultrasonography in preoperative staging of rectal tumors. Dis Colon Rectum 45:10
Harewood GC, Wiersema MJ, Nelson H et al. (2002) A prospective, blinded assessment of the impact of preoperative staging on the management of rectal cancer. Gastroenterology 123:24
Heintz A., Buess G, Frank K et al. (1989) Endoluminal ultrasonic examination of sessile polyps and early carcinomas of the rectum. Surg Endosc 3:92
Heintz A, Mörschel M, Junginger Th (1998) Comparison of results after transanal endoscopic microsurgery and radical resection for T1 carcinoma of the rectum. Surg Endosc 12:1145
Heintz A, Mörschel M, Junginger Th (1999) Rektumkarzinom, Optimierung der Therapie durch lokale Exzision. Zentralbl Chir 124:436
Heintz A, Mörschel M, Seifert J, Junginger Th (1996) Local excision in rectal carcinoma. Zentralbl Chir 121:184
Hermanek P, Spiessl B, Scheibe O, Wagner G (2002) TNM-Klassifikation maligner Tumoren. 4. Aufl. Springer, Berlin Heidelberg New York
Herzog U, Flüe v M, Tondelli P, Schuppisser JP (1993) How accurate is endorectal ultrasound in the preoperative staging of rectal cancer. Dis Colon Rectum 36:127
Hildebrandt U, Feifel G (1985) Preoperative staging of rectal cancer by intrarectal ultrasound. Dis Colon Rectum 28:42
Hildebrandt U, Klein T, Feifel G, Schwarz HP Scherr O (1986) Endorectal ultrasound: instrumentation and clinical aspects. Int J Colorect Dis 1:203
Kikuchi R, Takano M et al. (1995) Mangement of early invasive colorectal cancer. Dis Colon Rectum 38:1286
Kim NK, Kim MJ, Yun SH, Sohn SK, Min JS (1999) Comparative study of transrectal ultrasonography, pelvic computerized tomography and magnetic resonance imaging in preoperative staging of rectal cancer. Dis Colon Rectum 42:770
Miller L, Smith C, Canto MI (2000) Endoscopic ultrasonography (EUS) and EUS-guided fine needle aspiration for accurate staging of rectal cancer: explantation of tumor staging and a case report. Gastroenterol Nurs 23:97
Minsky BD (1997) Results of local excision followed by postoperative radiation therapy for rectal cancer. Radiat Oncol Invest 5:246
Nascimbeni R, Burgart LJ, Nivatvongs S, Larson DR (2002) Risk of lymph node metastasis in T1 carcinoma of the colon and rectum. Dis Colon Rectum 45:200
Nicholls RJ, Galloway DJ, Mason AY, Boyle P (1985) Clinical local staging of rectal cancer. Br J Surg 72:551
Nicholls RJ, Mason AY, Morson BC et al. (1982) The clinical staging of rectal cancer. Br J Surg 69:404
Paty PB, Nash GM et al. (2002) Long-term results of local excision for rectal cancer. Ann Surg 236:522
Russell AH, Harris J, Rosenberg PJ et al. (2000) Anal sphincter conservation for patients with adenocarcinoma of the distal rectum: long-term results of radiation therapy, oncology group protocol. Int J Radiat Oncol Biol Phys 46:313
Sailer M, Leppert R, Kraemer M et al. (1997) The value of endorectal ultrasound in the assessment of adenomas, T1- and T2-carcinomas. Int J Colorect Dis 12:214–219
Scheele J, Gall FP, Hermanek P. Lokale Tumorentfernung beim Rektumkarzinom. In: Winkler R (Hrsg) Anorectale Kontinenz. W. Zuckschwerdt, München Bern Wien
Steele GD, Herndon JE, Bleday R et al. (1999) Sphincter-sparing treatment for distal rectal carcinoma. Ann Surg Oncol 6:433
Wagmann R, Minsky BD, Cohen AM et al. (1999) Conservative management of rectal cancer with local excision and postoperative adjuvant therapy. Int J Rad Onc Biol Phys 44:841
Waizer A, Zitron S, Ben-Baruch D et al. (1989) Comparative study for preoperative staging of rectal cancer. Dis Colon Rectum 32:53
Winde G, Nottberg H, Keller R et al. (1996) Surgical cure for early rectal carcinomas (T1). Dis Colon Rectum 39:969
Woodward T, Menke D (2000) Diagnosis of recurrent rectal carcinoma by EUS-guided fine-needle aspiration. Gastrointest Endosc 51:223
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Kneist, W., Terzic, A., Burghardt, J. et al. Selektion von Patienten mit Rektumtumoren zur lokalen Exzision aufgrund der präoperativen Diagnostik. Chirurg 75, 168–175 (2004). https://doi.org/10.1007/s00104-003-0746-z
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DOI: https://doi.org/10.1007/s00104-003-0746-z