Endorectal ultrasound detection of focal carcinoma within rectal adenomas

BACKGROUND: The misdiagnosis of a rectal adenoma by biopsy and subsequent finding of invasive cancer after transanal excision is associated with a number of pitfalls. Problems include suboptimal therapy for a potentially curable cancerous lesion, potential tumor transgression of the local site with increased chance for local recurrence, and increased potential for more radical surgery or adjuvant chemoradiation. The utility of endorectal ultrasound (ERUS) in guiding treatment decisions of rectal villous adenomas has been reported, but series are small and are from single institutions. To determine the utility of ERUS in the diagnosis of rectal adenomas, we compared diagnosis made by biopsy alone to diagnosis made by a combination of biopsy and ERUS. METHODS: A systematic literature review was performed by way of a PubMed search to find articles with the following terms: "biopsy-negative rectal adenomas," "preoperative ERUS diagnosis," and "surgical histopathology." Five studies met the criteria, thus providing data for 258 adenomas. A quantitative meta-analysis was performed on the data. RESULTS: Among the 258 biopsy-negative rectal adenomas, 24% had focal carcinoma on histopathology. ERUS correctly established a cancer diagnosis in 81% (95% confidence interval 69 to 90) of these misdiagnosed lesions. Thus, ERUS diagnosis of biopsy-negative rectal adenomas could be expected to decrease the need for additional surgery and other associated problems caused by misdiagnosis from 24% to 5%. CONCLUSIONS: ERUS is a useful adjunct to biopsy in the preoperative workup of rectal villous adenomas, and we recommend its routine use. Accurate preoperative assessment allows the surgeon to counsel the patient appropriately regarding the best operation, the perioperative risks, and the chances of local recurrence.     

The MRI assessment of SPECC (significant polyps and early colorectal cancer) lesions

The development of high‐resolution magnetic resonance imaging (MRI) has resulted in the ability to clearly depict the finer details of rectal wall anatomy. Careful specialist assessment of images obtained in patients with significant polyps and early rectal cancer lesions enables the identification of lesions that are confined to the bowel wall and amenable to organ preserving local excision. Currently, one‐third of screen detected rectal cancers are limited to the bowel wall without nodal spread yet more than 90% undergo major excision surgery resulting in significant loss of bowel function, quality of life and at high economic cost. The SPECC initiative has highlighted the need for specialist training and accreditation of radiology specialists in precision assessment of significant polyps and early rectal cancer. The detailed assessment will enable provision of detailed roadmaps for surgeons and gastroenterologists to facilitate definitive excision of more lesions using minimally invasive endoscopic technique. Finally, the use of high resolution MRI in surveillance will enable the close monitoring of such patients where the preservation of the rectum has been achieved.     

Transanal excision of early rectal carcinoma—review of a personal series

Transanal excision of small rectal tumours is a relatively minor procedure that is potentially curable and can be employed in selected cases of rectal cancer. The outcome of 22 cases treated by local excision was reviewed. This represented 9% of patients treated for rectal cancer over the study period. All patients had a transanal excision with curative intent and included three patients who were medically unfit for a major procedure. Follow up was for a minimum of 5 years or until death if this was earlier. The mean age was 65.7 years with 10 males and 12 females. The 5‐year recurrence rate was 27% (five of 22). The crude 5‐year survival for curative resection was 77%. Of the 22 local excisions, 10 were T1 and 12 were T2. The size of tumour varied from 0.5 cm to 3.5 cm. Eight were well differentiated, 10 moderate and two poorly differentiated. Two of the earlier cases in the series were unclassified. There were six recurrences, all of which were extraluminal. Three recurrences were in less than 3 years (early recurrence) and three beyond this time. Of the recurrences, one presented with liver metastases within 2 months of surgery, one was unfit for a major procedure and subsequently died of a myocardial infarction. The remaining patients with recurrences had salvage surgery. Three are still alive and one died over 5 years after a local excision, with the presence of recurrence. All recurrences were of T2 stage, with moderate (n=5) or poor differentiation (n=1). Three of the six tumours measuring > 3 cm recurred compared with three of the 16 tumours between 0.5 cm and 3 cm. Analysis of these cases demonstrates that local resection of small rectal tumours can give good results and salvage operation is possible in the event of recurrence. Long term follow up is recommended because of risks of late recurrence. The best prognosis group appears to be with the well‐differentiated T1 tumours with no involved margins.     

中低位直肠癌局部复发诊断和治疗

中低位直肠癌根治手术后局部复发是诊断和治疗上的难题,常见复发的部位包括吻合口、会阴部、骨性骨盆、盆内邻近脏器,表现为便血、会阴部疼痛不适,盆腔和骶前肿物等。手术后定期体格检查、CT、核磁、肿瘤标记物是目前诊断直肠癌局部复发的重要方法。对局部复发直肠癌的治疗决策,应根据局部复发的类型、复发癌的生物学特性和浸润范围等因素进行综合分析,从而决定是采取手术为主的综合治疗还是行放化疗等策略。     

Local methods of treatment of rectal cancer

Over 11 000 new cases of rectal cancer are reported in the UK each year. Recent technical advances have increased interest in local management of the disease. The introduction of screening for colorectal cancer will potentially lead to an increased number of early rectal cancers suitable for local curative treatment. In addition, as the proportion of elderly patients in the population rises, local methods of treatment of rectal cancer will become increasingly important in this group of patients with comorbid disease. A literature search was performed on Medline database for English language publications on local treatments of rectal carcinoma. Preoperative assessment, selection of patients, local therapeutic and palliative methods of treatment were evaluated. Local methods of treatment can be used for potentially curative operations for rectal cancer. Preoperative endoanal ultrasound appears to be the most useful investigation for determining depth of local invasion. Transanal endoscopic microsurgery has extended the boundaries of local surgery and permits access to the mid and upper rectum with results similar to those of conventional local techniques. Laser therapy and transanal resection provide the best form of palliation for more advanced rectal carcinomas.     

Preoperative staging of patients with rectal tumors suitable for transanal endoscopic microsurgery (TEM): comparison of endorectal ultrasound and histopathologic findings

Background  Accurate preoperative staging is the key to correct selection of rectal tumors for local excision. This study aims to assess the accuracy of endorectal ultrasound (ERUS) at our institution. Patients and methods  Retrospective analysis was carried out of patients treated by transanal endoscopic microsurgery (TEM) from 1996 to 2008. TEM was considered the treatment of choice for uT0-1/N0 lesions located between 2 and 12 cm from the anal verge. It was also proposed in selected uT2-3 patients. Preoperative staging was compared with histopathologic findings. Results  Eighty-one patients (46 males, mean age 66 years) underwent TEM. Mean distance of the tumor from the anal verge was 6.6 cm (range 2–12 cm). ERUS staged 15 of 27 adenomas (55%) as uT1. Of 54 carcinomas, 5 were pT0 because TEM was performed to remove resection margins of a malign polyp already snared. Five of 19 pTis (26%) were overstaged uT1, while 7 of 17 pT1 (41%) were understaged. Overall, ERUS enabled distinction between early and advanced rectal lesion with 96% sensitivity and 85% specificity, giving accuracy of 94% (65/67). Thirteen patients had advanced lesions (eight pT2 and five pT3). Only in two of them (15%) was depth of invasion underestimated by ERUS (one uT0, one uT1) and thus was subsequent salvage surgery necessary. Conclusions  ERUS is useful to confirm the diagnosis of adenoma and predict depth of mural invasion in early rectal cancer. Differentiation between T0/is and T1 lesions remains challenging, however this does not usually influence surgical strategy.     

Categorization of major and minor complications in the treatment of patients with resectable rectal cancer using short-term pre-operative radiotherapy and total mesorectal excision: a Delphi round

Background To properly balance the benefit (reduction of local recurrence) of short‐term pre‐operative radiotherapy for resectable rectal cancer against its harm (complications), a consensus concerning the severity of complications is required. The aim of this study was to reach consensus regarding major and minor complications after short‐term radiotherapy followed by total mesorectal excision in the treatment of rectal carcinoma, using the Delphi technique. Methods A Delphi round was performed in cooperation with 21 colo‐rectal surgeons from the Netherlands, United Kingdom and Sweden. The key‐question was: ‘Which of the predefined complications, caused or substantially aggravated by radiotherapy, are so important (major) that they might lead to the decision to abandon short‐term pre‐operative radiotherapy (5 × 5Gy) when treating patients with resectable rectal cancer (T_1?3N_0?2M₀)?’ Results After three rounds, consensus was reached for 37 (68%) of 54 complications of which 13 were considered major and 24 considered minor. The following complications were considered to be major: mortality, anastomotic leakage managed by relaparotomy, anastomotic leakage resulting in persisting fistula, postoperative haemorrhage managed by relaparotomy, intra‐abdominal abscess without healing tendency, sepsis, pulmonary embolism, myocardial infarction, compartment syndrome of the lower legs, long‐term incontinence for solid stool, long‐term problems with voiding, pelvic fracture with persisting pain, and neuropathy with persisting pain (legs). Three of 17 complications without consensus showed a tendency to be considered as major: perineal wound dehiscence managed by surgical treatment, small bowel obstruction leading to relaparotomy and long‐term incontinence for liquid stool. Conclusion The 13 major and three ‘accepted as major’ complications can be used to properly balance the benefit and harm of short‐term pre‐operative radiotherapy in resectable rectal cancer. This may eventually lead to improved treatment strategies for these patients.     

经肛门局部切除术与根治术治疗早期直肠癌远期疗效比较

目的比较经肛门局部切除及根治术治疗早期直肠癌的远期疗效。方法通过PubMed、CNKI数据库及文献追踪法检索直肠癌经肛门局部切除及根治术治疗早期(T1期和T2期)直肠癌远期疗效比较的文献,应用RevMan 5.0软件对各研究结果进行异质性检验和效应值合并。结果共筛选出符合入选标准的临床研究15项,局部切除术3504例,根治术6925例。早期直肠癌局部切除和根治术比较,局部切除术会增加T1、T2期术后5年局部复发率;局部切除术明显降低T1、T2期术后5年总生存率;局部切除术降低T1期术后5年无病生存率,而并不能改善T2期术后5年无病生存率。结论与直肠癌根治术相比,早期直肠癌经肛门局部切除术的远期疗效差,临床上要慎重考虑局部切除术的利弊。     

A critical appraisal of endorectal ultrasound and transanal endoscopic microsurgery and decision-making in early rectal cancer

Aim Transanal endoscopic microsurgery (TEM) for early rectal cancer (ERC) gives results similar to major surgery in selected cases. Endorectal ultrasound (ERUS) is an important part of the preoperative selection process. This study reports its accuracy and impact for patients entered on the UK TEM database. Method The UK TEM database comprises prospectively collected data on 494 patients. This data set was used to determine the prevalence of ERUS in preoperative staging and its accuracy by comparing preoperative T‐stage with definitive pathological staging following TEM. Results ERUS was performed in 165 of 494 patients who underwent TEM for rectal cancer. It inaccurately staged rectal cancer in 44.8% of tumours: 32.7% were understaged and 12.1% were overstaged. There was no significant difference in the depth of TEM excision or R1 rate between the patients who underwent ERUS before TEM and those who did not (P = 0.73). Conclusion The data show that ERUS is employed in a minority of patients with rectal cancers undergoing TEM in the UK and its accuracy in this ‘Real World’ practice is disappointing.