Risk of Lymph Node Metastasis in T1 Carcinoma of the Colon and Rectum

PURPOSE: Several recent reports of high local recurrence and lymph node metastasis in T1 carcinoma of the rectum prompted us to study the risk factors for lymph node metastasis in these lesions. METHODS: We reviewed the clinical records of 7,543 patients who underwent operative treatment for carcinoma of the colon and rectum from 1979 to 1995. Only patients with sessile T1 lesions who underwent colorectal resection were included in the study, yielding an analysis cohort of 353 patients. The following carcinoma-related variables were assessed: size, mucinous subtype, carcinomatous component, grade, site in colon and rectum, lymphovascular invasion, and depth of submucosal invasion. For the depth, the submucosa was divided into upper third (sm1), middle third (sm2), and lower third (sm3). Chi-squared tests and logistic regression were used to evaluate the variables as potential risk factors for lymph node metastasis. RESULTS: The incidence of T1 lesions was 8.6 percent. In the analysis cohort, the lymph node metastasis rate was 13 percent. Significant predictors of lymph node metastasis both univariately and multivariately were sm3 (P = 0.001), lymphovascular invasion (P = 0.005), and lesions in the lower third of the rectum (P = 0.007). Poorly differentiated carcinoma was significant univariately (P = 0.001) but not in the multivariate model. No other parameter was associated with a significant risk. CONCLUSIONS: T1 colorectal carcinomas with lymphovascular invasion, sm3 depth of invasion, and location in the lower third of the rectum have a high risk of lymph node metastasis. These lesions should have an oncologic resection. In a case of the lesion in the lower third of the rectum, local excision plus adjuvant chemoradiation may be an alternative.     

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

Purpose Local excision of early rectal cancer is a controversial issue, which is in part because of differences in the evaluation of histopathologic criteria. This prospective study was designed to determine prognostic factors for recurrences and the need for reoperation. Methods In 105 of 118 patients with pT1 carcinomas and local excision, results of recurrence rates and ten-year cancer-free survival were studied separately according to different histologic criteria (R0, R1, Rx, R ≤ 1 mm, high-/low-risk situation), tumor localization (anterior, posterior, lateral wall and third of rectum), size, and degree of resection (full-thickness/partial wall). Patients were grouped into local excision (n = 89) and local excision followed by reoperation (n = 21). Risk classification was performed by division into “low-risk” carcinomas after local R0-resection (Group A) and unfavorable histologic results after local resection (R1, Rx, R ≤ 1 mm, high-risk situation; Group B). Results Local recurrence rates after local R0-resection of low-risk carcinomas were 6 percent, whereas patients in Group B with local resection were 39 percent. The recurrence risk in those patients was significantly reduced to 6 percent by reoperation (P = 0.015). In addition, ten-year, cancer-free survival was 93 percent in Group B after reoperation compared with 89 percent in patients of Group A after local excision alone. Conclusions Local R0-resection in cases with low-risk pT1 carcinomas represents an oncologically adequate therapy, which results in similar survival rates compared with primary radical surgery of pT1N0M0 rectal carcinomas. High recurrence rates are observed in tumors with unfavorable histologic result (Group B) requiring further treatment. In these cases immediate reoperation reduces the recurrence rate to 6 percent. Reprints are not available.     

Local recurrence after curative resection of cancer of the rectum without total mesorectal excision

PURPOSE: The aim of this article was to examine local recurrence after curative resection for carcinoma of the rectum in which the surgical technique of total mesorectal excision was not performed. METHODS: A single surgeon managed the patients and the data collected prospectively. Total excision of the distal mesorectum was not performed in the upper third or mid rectum. RESULTS: From 1969 to 1993 curative resections were performed in 549 patients, of which 17 died postoperatively, leaving 532 for analysis. Sphincter-saving resection was performed in 468 patients (88 percent) and abdominoperineal excision in 58 (10.9 percent). The pathology stages (Dukes) were A, 158 (29.7 percent); B, 184 (34.7 percent); and C, 190 (35.7 percent). Five hundred seventeen patients (97.2 percent) were followed up for a minimum of five years. The median period of follow-up was 82 months. Local recurrence confined to the pelvis occurred in 17 patients, and local recurrence associated with distant metastases occurred in 24 patients. The total five-year local recurrence rate was 7.6 percent. Local recurrence was increased in Stage C tumors (P=<0.0001). Diathermy dissection in the pelvis was associated with a decreased local recurrence rate (P=0.023). The five-year survival rate in curative resections was 72.5 percent. CONCLUSIONS: It is essential that articles presenting local recurrence rates should include both local recurrence in isolation and that which occurs with distant metastases. Although total mesorectal excision for rectal cancer was not performed in this study, the local recurrence rate is not materially different from that in several articles where total mesorectal excision has been used. Whether the distal mesorectum needs to be pursued in mid-rectal cancer is not yet proven.     

Coloanal anastomosis for distal third rectal cancer

PURPOSE: Jeopardizing cure and risking high local recurrence have served as arguments against sphincter-saving resection for patients with distal third rectal cancer. This prospective study examines and compares the local recurrence and survival rates in patients with distal third rectal cancer treated by either coloanal anastomosis or abdominoperineal resection. METHODS: Between 1977 and 1993, 174 patients underwent coloanal anastomoses and 38 patients underwent abdominoperineal resection. All tumors were located 4 to 7 cm from the anal verge. One hundred ninety-three patients (91 percent) underwent rectal excision with a curative intent. Mean follow-up was 66 months after sphincter-saving resection and 65 months after abdominoperineal resection. RESULTS: Mean anastomotic height from the anal verge was 2.3 cm after sphincter-saving resection. Overall local recurrence rate was 7.9 percent after sphincter-saving resection and 12.9 percent after abdominoperineal resection. The five-year actuarial survival rate was 78 percent after sphincter-saving resection and 74 percent after abdominoperineal resection. CONCLUSION: Local recurrence and survival are not compromised in patients with distal third rectal cancer when treated by sphincter-saving resection, provided that oncologic principles are not violated. Coloanal anastomosis can be performed with an acceptable morbidity.     

Outcomes for Abdominoperineal Resections Are Not Worse Than Those of Anterior Resections

Purpose Local recurrence and cure rates following abdominoperineal resections have been reported to be much worse than sphincter-preserving anterior resections. We compared the oncologic outcomes of patients treated by abdominoperineal resections with those following sphincter-preserving anterior resections. Methods The medical records of patients who underwent radical rectal resection for rectal carcinoma at the Colorectal Surgery Department, Singapore General Hospital, during the period from April 1989 to April 2002 were reviewed. A total of 791 cases were studied. Operative procedures were classified as either abdominoperineal resections or anterior resections with either straight or pouch anastomosis. Total mesorectal excision was routinely performed for carcinomas of the lower middle and lower third of the rectum. Sentinel events, including local and systemic recurrences or morbidity and mortality, were tracked prospectively. Results There were a total of 93 abdominoperineal resections (12.1 percent), 547 anterior resections with straight anastomoses (71 percent), and 130 anterior resections with pouch anastomoses (16.9 percent). Postoperative mortality was 2.6 percent and postoperative morbidity was 13.6 percent with an overall anastomotic leakage rate of 2.5 percent. The cumulative five-year local recurrence rate was 5.4 percent for abdominoperineal resections, 3.6 percent for anterior resections with straight anastomoses, and 3.8 percent for anterior resections with pouch anastomoses (P = 0.73 by log-rank test). The median time to local recurrence also did not differ significantly between the different procedures (abdominoperineal resections, 17 months, anterior resections with straight anastomoses, 18 months, anterior resections with pouch anastomoses, 13 months). Independent predictors for local recurrence included advanced tumor stage, tumor depth, and poorly differentiated tumors. The five-year cancer-specific survival was 70 percent. The type of anastomosis did not influence disease-free survival with median disease-free survival for patients who underwent abdominoperineal resections being 100 months, survival of anterior resections with straight anastomoses being 135 months, and survival of anterior resections with pouch anastomoses being 121 months (P = 0.33 by log-rank test). The independent factors for poor survival were age greater than 65 years, advanced tumor stage, tumor depth, and poorly differentiated tumors. Conclusion Both abdominoperineal resections and sphincter-preserving anterior resections can be performed safely with low morbidity and mortality in a specialized high-volume hospital unit without compromising oncologic outcomes. With appreciation of the anatomic relations in total mesorectal excision and standardized consistent surgical technique, the oncologic outcomes of patients treated by abdominoperineal resections are not worse than those treated by sphincter-preserving anterior resections. Reprints are not available.     

The Effect of Circumferential Tumor Location in Clinical Outcomes of Rectal Cancer Patients Treated With Total Mesorectal Excision

PURPOSE A positive circumferential resection margin is associated with a high risk of local recurrence and distant metastasis after total mesorectal excision for rectal cancer. The mesorectum is thinner anteriorly than posteriorly, and the risk of a positive resection margin may be higher for anterior than for posterior tumors. We sought to determine the effect of the tumor's position in the circumference of the rectum on the treatment and outcomes of rectal cancer patients treated by total mesorectal excision. METHODS We retrospectively analyzed 401 patients with rectal cancer staged by preoperative endorectal ultrasound and treated by sharp mesorectal excision with or without neoadjuvant therapy. Tumors were classified into four groups (anterior, posterior, lateral, and circumferential) according to the location of deepest point of penetration on endorectal ultrasound. Differences in recurrence and survival rates were analyzed with logistic regression analysis. RESULTS Of the 401 tumors, 27 percent were anterior, 26 percent posterior, 32 percent lateral, and 15 percent circumferential. The groups did not differ in age, gender, tumor distance from the anal verge, or tumor grade. The ultrasound and pathology stages were more advanced in the circumferential group, and the proportion of uT4 tumors was higher in the anterior group. Circumferential and anterior tumors were more likely to receive preoperative adjuvant radiation. After an average follow-up of 44 months, 20 percent of patients had developed recurrence (13 percent distant, 6 percent local, and 1 percent distant and local). Recurrence was associated with advanced tumor stage, tumor proximity to the anal verge, and no preoperative adjuvant therapy. Early tumor stage and preoperative chemoradiation were associated with lower recurrence and improved survival. When tumor stage was controlled for, patients with poor or undifferentiated tumors and male patients with anterior tumors were shown to have a higher risk of recurrence or death. The estimated five-year disease-free survival for the entire group was 73 percent. CONCLUSIONS Tumor stage is the main criterion to estimate prognosis in rectal cancer patients. The position of the tumor within the circumference of the rectum may provide valuable clinical information. Anterior tumors tend to be more advanced and, at least in male patients, has a higher risk of recurrence and death than tumors in other locations. Presented at the meeting of the Minnesota Surgical Society, St. Paul, Minnesota, April 27, 2001.     

Curative local excision in the treatment of carcinoma of the rectum

A safe, simple technique of curative local excision is used for early invasive carcinoma of the rectum. Strict criteria were applied in selecting patients for curative local excision: (1) the tumor was less than 3cm in diameter; (2) there were no clinically involved pelvic lymph nodes; (3) the tumor had a pedicle or pseudopedicle, and (4) subsequent histopathologic examination showed that the tumor was confined to the mucosa and submucosa of the bowel wall and completely excised. Curative local excision in 16 patients had no operative mortality or morbidity. The five-year cancer specific survival was 100 per cent, which compares favorably with the 88 per cent cancer specific survival rate in 268 patients managed by conventional curative resection for Dukes' stage A tumors. When the 7.1 per cent operative mortality of resection was additionally considered, the five-year survival fell to 81 per cent. The probability of lymph-node metastases in primary rectal tumors confined to the mucosa and submucosa was found to be 6.2 per cent irrespective of their diameter,i.e., slightly less than the mortality of resection. Supported by a grant from the Anti-Cancer Council of Victoria.     

Anorectal malignant melanoma in Sweden

Clinicopathologic features and prognosis of 49 patients with anal malignant melanoma were investigated in the total Swedish population between 1970 and 1984. Median age was 71 years (range, 50 to 87 years), and there was a female predominance (31 females, 18 males). The most common symptom at presentation was bleeding. The majority of tumors ranged between 2 and 5 cm in diameter and all invaded at least into the submucosa and/or the lamina propria. At diagnosis, one third of the patients had either regional or distant metastasis with a median survival of 5 months. The remaining patients were surgically treated with curative intent, either by abdominoperineal resection (APR) or local excision. Median survival was poor in both treatment groups (APR, 12 months; local excision, 13 months). Most patients died with distant metastasis. Our results confirm the opinion that APR offers no more curative potential than a more conservative surgical approach. However, tumor sizes were on average smaller in the group treated by local excision. This could indicate that, in the absence of known distant metastasis, radical surgery should be performed, particularly since local recurrences tended to be more common after a local excision.     

Endoscopic Posterior Mesorectal Resection After Transanal Local Excision of T1 Carcinomas of the Lower Third of the Rectum

Purpose The rectum-sparing transanal local excision is a well-established treatment of T1 carcinomas of the lower third of the rectum. A potentially increased locoregional recurrence rate by this procedure is tolerated because of the high morbidity and mortality risk of transabdominal rectal resection. Dorsoposterior extraperitoneal pelviscopy makes it possible to remove the relevant lymphatic drainage of the lower third of the rectum minimally invasively, in the sense of a rectum-sparing endoscopic posterior mesorectal resection. It has to be considered whether endoscopic posterior mesorectal resection in combination with transanal local excision allows for local radicality and an adequate tumor staging in T1 carcinomas of the lower third of the rectum, in terms of better-directed therapy planning compared with transanal local excision alone. Methods We operated on 11 consecutive patients with T1 carcinomas of the lower third of the rectum by transanal local excision in combination with endoscopic posterior mesorectal resection as a two-stage procedure in the period from 1998 to 2005. Results It was possible to perform a complete excision of the primary and to resect the posterior part of the mesorectum in all cases. Postoperative morbidity consisted of two transient neurologic complications and a pulmonary embolism. There was no mortality. Histologic analysis revealed a median of eight (range, 4–20) lymph nodes. Two patients diagnosed with lymph-node metastases received adjuvant radiochemotherapy. After a median follow-up of 48 (range, 4–60) months, there was noevidence for locoregional recurrence. In one patient liver metastasis was detected eight months postoperatively. Conclusions Radical excision of the primary tumor and an adequate tumor staging in T1 carcinomas of the lower third of the rectum seems to be achievable by means of transanal local excision and endoscopic posterior mesorectal resection.     

Oncologic and Functional Results of Total Mesorectal Excision and Autonomic Nerve-Preserving Operation for Advanced Lower Rectal Cancer

PURPOSE: Total mesorectal excision contains two different procedures: autonomic nerve preservation, and autonomic nerve sacrifice. It is unclear whether autonomic nerve preservation is suitable curative procedure. We clarify the significance of autonomic nerve preservation for an advanced lower rectal cancer.METHODS: All 403 patients curatively resected between 1975 and 1999 were clinicopathologically studied. Between 1975 and 1984, all patients routinely received total mesorectal excision without autonomic nerve preservation (TME-P(–) group). Since 1985, total mesorectal excision with autonomic nerve preservation has been performed in 81 percent of patients (TME-P(+) group). The remaining patients received TME-P(–) because of suspicious invasion to autonomic nerve plexus. All clinical and pathologic data were entered into a computer database. Long-term follow-up was used to analyze the oncologic and functional results of TME-P(+) group compared with TME-P(–) group.RESULTS: The follow-up rate was 98.1 percent. In either Dukes A+B or Dukes C disease, the TME-P(+) group did not increase local recurrence or decrease ten-year disease-free survival compared with the TME-P(–) group of Period 1975 to 1984. The TME-P(–) group of Period 1985 to 1999 had the highest distant metastasis and the lowest survival rates than any other groups. Urinary or sexual function was well preserved in the TME-P(+) group. CONCLUSIONS: Autonomic nerve preservation is oncologically and functionally excellent and suitable for almost all patients with advanced lower rectal cancer. Intensive chemotherapy is needed for patients whose autonomic nerves were killed in suspicion of nerve invasion.     

Recurrent colorectal cancer after endoscopic resection when additional surgery was recommended

AIM: To evaluate the type of recurrence after endoscopic resection in colorectal cancer patients and whether rescue was possible by salvage operation.METHODS: Among 4972 patients who underwent surgical resection at our institution for primary or recurrent colorectal cancers from January 2005 to February 2015, we experienced eight recurrent colorectal cancers after endoscopic resection when additional surgical resection was recommended.RESULTS: The recurrence patterns were: intramural local recurrence(five cases), regional lymph node recurrence(three cases), and associated with simultaneous distant metastasis(three cases). Among five cases with lymphatic invasion observed histologically in endoscopic resected specimens, four cases recurred with lymph node metastasis or distant metastasis. All cases were treated laparoscopically and curative surgery was achieved in six cases. Among four cases located in the rectum, three cases achieved preservation of the anus. Postoperative complications occurred in two cases(enteritis).CONCLUSION: For high-risk submucosal invasive colorectal cancers after endoscopic resection, additional surgical resection with lymphadenectomy is recommended, particularly in cases with lymphovascular invasion.     

Oncological outcome of ultra-low anterior resection with total mesorectal excision for carcinoma of the lower third of the rectum: Comparison of intrapelvic double-stapled anastomosis and transanal coloanal anastomosis

BACKGROUND/AIMS: The purpose of this study was to determine whether the type of ultra-low anterior resection (intrapelvic double-stapled anastomosis or transanal hand-sewn coloanal anastomosis) with total mesorectal excision for primary adenocarcinoma of the lower third of the rectum affects survival and recurrence after curative surgery. METHODOLOGY: This retrospective study included 112 patients who underwent curative surgery achieved by ultra-low anterior resection in combination with either intrapelvic anastomosis using a double-stapling technique (DST group; n=82) or transanal hand-sewn coloanal anastomosis (CAA group; n=30). Univariate and corrected (multivariate regression) analyses were used to evaluate data. Median follow-up was 51.2 months for patients alive at the conclusion of this study. RESULTS: Disease-free and disease-specific survivals, and the frequency and location of recurrence after surgery did not differ between the two types of operations. Multivariate analyses showed that the type of operation was not a significant independent variable in predicting disease-free survival or in the development of both local and distant recurrences after surgery. Tumor-related factors (stage or histologic grade) were significant predictors of oncological outcome. CONCLUSIONS: The type of ultra-low anterior resection (DST or CAA) did not affect survival and recurrence after curative resection for carcinoma of the lower third of the rectum.     

Evaluation of Prognosis for Malignant Rectal Gastrointestinal Stromal Tumor by Clinical Parameters and Immunohistochemical Staining

PURPOSE The aim of this study was to identify associated prognostic factors influencing the outcome of curative resection of rectal gastrointestinal stromal tumor.PATIENTS AND METHODS Diagnostic immunohistochemical staining with CD34, CD117, S-100, desmin, and muscle-specific actin was performed in 46 consecutive patients with previously diagnosed rectal leiomyosarcoma who underwent curative resection from 1979 to 1999. CD44, Bcl-2, P53, and Ki-67 staining were performed on tumors rediagnosed as gastrointestinal stromal tumor for the prognostic evaluation.RESULTS There were 42 (91.3 percent) patients with rectal gastrointestinal stromal tumor (18 females and 24 males; mean age, 58.4 years). Twenty-nine patients underwent radical surgical resections, such as abdominoperineal resection or low anterior resection, whereas the other 13 patients underwent wide local excision, such as transrectal excision or Kraskes operation. Sixteen tumors were classified as high-grade gastrointestinal stromal tumors, and 26 as low-grade. No tumor had a positive P53 stain. Twenty-seven patients (64.3 percent) developed recurrence or metastasis postoperatively (median follow-up, 52 months). The one-year, two-year, and five-year disease-free survival rates were 90.2 percent, 76.7 percent, and 43.9 percent, respectively. Of these patients with recurrence, subsequent resections in 12 patients with local recurrence, transarterial tumor embolism or STI-571 chemotherapies in 3 patients with distant mestastases were performed. The one-year, two-year, and five-year overall survival rates were 97.4 percent, 94.3 percent, and 83.7 percent, respectively. Bcl-2 (P = 0.007) and histologic grade (P = 0.05) in disease-free survival analysis and age <50 years (P = 0.03) and tumor size >5 cm (P = 0.02) in overall survival analysis were independent prognostic factors. The group with wide local excision had a higher local recurrence rate than that of the radical resection group (77 percent vs. 31 percent, P = 0.006), despite smaller tumors (4.5 vs. 7.2 cm, P = 0.05). There was no difference in the incidence of distant metastasis between the two groups.CONCLUSION Younger age (<50 years), higher histologic tumor grade, positive Bcl-2 status, and larger tumors (>5 cm) were factors associated with significantly poorer prognoses for rectal gastrointestinal stromal tumor. Radical resection was superior to wide local excision in the prevention of local recurrence, but not that of distant metastases.     

Evaluation of local excision for sessile-type lower rectal tumors.

BACKGROUND/AIMS: A study was undertaken to evaluate the surgical morbidity and risk of recurrence in patients undergoing local excision for rectal carcinoma. METHODOLOGY: Twenty patients with well or moderately differentiated lesions less than 6 cm in diameter, which were difficult to remove endoscopically but had no clinically involved regional nodes, were eligible for local excision. RESULTS: The transanal approach was simple and had few complications. After posterior parasacral excision, 3 patients developed rectocutaneous fistulas, and 1 of them died. None of the 12 patients with cancer extension limited to the lesser depth of the submucosa died of rectal cancer. Among 8 patients with cancer invasive into the greater depth of the submucosa or deeper, 5 underwent additional radical resection, and regional lymph node metastasis was revealed in 2. CONCLUSIONS: Transanal excision is suitable for curative resection of lower rectal tumors when the cancer extends only to the lesser depth of the submucosa. The procedure should be defined as a total excisional biopsy until the results of histologic examination are obtained.     

Leiomyosarcoma of the rectum

A case of leiomyosarcoma of the rectum is presented and followed by a review of 135 cases from the literature. The five- and ten-year survival figures were the same whether the patient was treated by radical or local excision; however, local excision was followed by 67.5 percent recurrence. Abdominoperineal resection is still the procedure of choice. Local excision might be considered for small tumors of low-grade malignancy in a poor-risk patient.     

Malignant recurrence and distal metastasis after complete local resection of colorectal “high-grade intraepithelial neoplasia”: incidence and risk factors

Background

Colorectal high-grade intraepithelial neoplasia is defined as a high-grade neoplastic lesion with no invasion of submucosa. Because pathological evaluation has inevitable sampling errors, invasive cancer may be underdiagnosed as high-grade intraepithelial neoplasia by regarding submucosa invasion as an indispensable criterion for malignancy. This study was to evaluate the reliability of colorectal “high-grade intraepithelial neoplasia” diagnosis and identify predictive factors of underdiagnosis.

Methods

Colorectal high-grade intraepithelial neoplasia patients treated with complete local excision were followed up. Clinicopathologic features were compared between cases with malignant recurrence or distal metastasis and those without.

Results

Of 491 lesions reviewed, 13 (2.6 %) developed local malignant recurrence or distal metastasis, which were statistically significantly associated with rectal location (p?=?0.047), sessile growth (p?=?0.002), large diameter (p?=?0.005), villous adenoma (p?=?0.00), transanal local resection (p?=?0.001), and piecemeal specimens (p?=?0.009). Of the 13 cases, 11 were located in the rectum, including 10 in the low position (<=6 cm from the anal verge, mean 3.6 cm). Deeper pathological examination was performed on the paraffin-embedded tissue blocks of the 13 primary tumors and revealed no evidence of submucosa invasion.

Conclusion

The diagnosis of colorectal high-grade intraepithelial neoplasia based on local resection is relatively reliable. However, regarding invasion of submucosa as an indispensable criterion for malignancy may contribute to the choice of overly conservative treatment, especially in the situation that the radical resection requires removing the anus.     

Recurrence After Transanal Excision of T1 Rectal Cancer: Should We Be Concerned?

PURPOSE Transanal excision is an appealing treatment for low rectal cancers because of its low morbidity, mortality, and better functional results than transabdominal procedures. However, controversy exists about whether it compromises the potential for cure. Several, recent reports of high recurrence rates after local excision prompted us to review our results of transanal excision alone in patients with T1 rectal cancers.METHODS All patients with T1 low rectal cancer undergoing local excision alone between 1980 through 1998 were reviewed for local recurrence, distant metastasis, disease-free interval, results of salvage surgery, and overall and disease-free survival. Demographics, tumor size, distance from anal verge, and preoperative endoluminal ultrasound results also were recorded. Patients with poorly differentiated tumors, perineural or lymphovascular invasion, or with mucinous component were excluded.RESULTS Fifty-two patients underwent transanal excision during the study period. Five-year recurrence was estimated to be 29.38 percent (95 percent confidence interval, 15.39–43.48). For 52 patients, five-year, cancer-specific and overall survival rates were 89 and 75 percent respectively. Fourteen of 15 patients with recurrence underwent salvage treatment with 56.2 percent (95 percent confidence interval, 35.2–90) five-year survival rate. Gender, preoperative staging by endorectal ultrasound, distance from the anal verge, tumor size, location, and T1 status discovered after transanal excision of a villous adenoma did not influence local recurrence or tumor-specific survival.CONCLUSIONS Transanal excision for T1 rectal tumors with low-grade malignancy has a high rate of recurrence. Although overall cancer survival rates might be regarded as satisfactory, this high recurrence and low salvage rate raises the issue about the role of transanal excision alone for early rectal cancer and the possible need for adjuvant therapy or increased role of resective surgery.Presented at the meeting of The American Society of Colon and Rectal Surgeons, Chicago, Illinois, June 3 to 7, 2002.     

Oncological Outcomes After Total Mesorectal Excision for Cure for Cancer of the Lower Rectum: Anterior vs. Abdominoperineal Resection

PURPOSE: This study was designed to examine the outcome of cancer of the lower rectum, particularly the rates of local recurrence and survival for tumors located in this area that have been treated by anterior or abdominoperineal resections. METHODS: A prospective, observational, national, cohort study which is part of the Norwegian Rectal Cancer Project. The present cohort includes all patients undergoing total mesorectal excision in 47 hospitals during the period November 1993 to December 1999. A total of 2,136 patients with rectal cancer within 12 cm of the anal verge were analyzed; there were 1,315 (62 percent) anterior resections and 821 (38 percent) abdominoperineal resections. The lower edge of the tumor was located 0 to 5 cm from the anal verge in 791 patients, 6 to 8 cm in 558 patients, and 9 to 12 cm in 787 patients. According to the TNM classification, there were 33 percent Stage I, 35 percent Stage II, and 32 percent Stage III. RESULTS: Univariate analyses: The five-year local recurrence rate was 15 percent in the lower level, 13 percent in the intermediate level, and 9 percent in the upper level (P = 0.014). It was 10 percent local recurrence after anterior resection and 15 percent after abdominoperineal resection (P = 0.008). The five-year survival rate was 59 percent in the lower level, 62 percent in the intermediate level, and 69 percent in the upper level (P < 0.001), respectively, and it was 68 percent in the anterior-resection group and 55 percent in the abdominoperineal-resection group (P < 0.001). Multivariate analyses: The level of the tumor influenced the risk of local recurrence (hazard ratio, 1.8; 95 percent confidence interval, 1.1–2.3), but the operative procedure, anterior resection vs. abdominoperineal resection, did not (hazard ratio, 1.2; 95 percent confidence interval, 0.7–1.8). On the contrary, operative procedure influenced survival (hazard ratio, 1.3; 95 percent confidence interval, 1–1.6), but tumor level did not (hazard ratio, 1.1; 95 percent confidence interval, 0.9–1.5). In addition to patient and tumor characteristics (T4 tumors), intraoperative bowel perforation and tumor involvement of the circumferential margin were identified as significant prognostic factors, which were more common in the lower rectum, explaining the inferior prognosis for tumors in this region. CONCLUSIONS: T4 tumors, R1 resections, and/or intraoperative perforation of the tumor or bowel wall are main features of low rectal cancers, causing inferior oncologic outcomes for tumors in this area. If surgery is optimized, preventing intraoperative perforation and involvement of the circumferential resection margin, the prognosis for cancers of the lower rectum seems not to be inherently different from that for tumors at higher levels. In that case, the level of the tumor or the type of resection will not be indicators for selecting patients for radiotherapy. Read at the meeting of The American Society of Colon and Rectal Surgeons, New Orleans, Louisiana, June 21 to 26, 2003     

Local recurrence after curative anterior resection with principally blunt dissection for carcinoma of the rectum and rectosigmoid

PURPOSE: The aim of this study was to determine the incidence of local pelvic recurrence of carcinoma of the rectum and rectosigmoid (tumors where the lower edge is 18 cm or less from the anal verge) in a consecutive series of patients operated on by a single surgeon. All patients underwent curative anterior resection and a formal anatomic dissection of the rectum where mobilization was achieved through a principally careful blunt manual technique along fascial planes, preserving an oncologic package. METHOD: During the period April 1986 to December 1997, 157 consecutive anterior resections for carcinoma of the rectum and rectosigmoid were performed by one surgeon (ALP). One hundred thirty-eight (87.9 percent) were curative, and 19 (12.1 percent) were palliative. The mean follow-up period was 46±31.6 (range, 2–140) months. Data were retrospectively collated and computer coded by an independent contracted medical research team. Follow-up data were available on all patients. RESULTS: Four (3.1 percent) of the 131 patients undergoing curative anterior resection had local recurrence. Local recurrences occurred between 16 and 38 months from the time of resection, and the cumulative risk of developing local recurrence at five years was 5.2 percent. All tumors in which pelvic recurrence occurred were high grade, and the probability of developing local recurrence at five years for this group was 13.9 percent, which is significantly higher compared with patients who had average or low-grade tumors (P=0.01). The probability of developing local recurrence at five years for Stage I tumors was 0, Stage II was 5.9 percent, and Stage III was 8.9 percent. In addition, there was a significantly higher incidence of local recurrence in the group of patients undergoing ultralow anterior resection (between 3 and 6 cm from the anal verge) as compared with patients undergoing low or high anterior resection (P=0.03). Local recurrence developed in 3 of 28 (10.7 percent) patients having ultralow anterior resection, 1 of 57 (1.8 percent) patients having low anterior resection (between 6 and 10 cm from the anal verge), and no patients having high anterior resection (above 10 cm from the anal verge). The clinical anastomotic leak rate for curative anterior resection was 7 of 131 patients (5.3 percent). Thirty-seven of the 131 (28.2 percent) required a proximal defunctioning stoma; 35 (41.2 percent) of these were established for low or ultralow anterior resections and 2 for high anterior resection. The overall five-year cancer-specific survival rate of the entire group of 131 patients was 81.8 percent, and the overall probability of being disease free at five years including both local and distal recurrence was 72.9 percent. Three local recurrences occurred in the 101 patients (77 percent) who did not receive any form of adjuvant therapy. One local recurrence occurred in the 18 patients (13.7 percent) who had adjuvant chemoradiation. No recurrence occurred in the 12 patients (9.2 percent) who had adjuvant chemotherapy alone. CONCLUSION: Curative anterior resection for carcinoma of the rectum and rectosigmoid with principally blunt dissection of the rectum in this study is associated with a 3.1 percent incidence and a 5.2 percent probability at five years of developing local recurrence. Evidence from this study indicates that, as with sharp pelvic dissection, a low incidence and probability of local recurrence can be achieved by a principally blunt mobilization technique through careful attention to preservation of fascial planes in the pelvis and removal of an oncologic package with selective rather than routine adjuvant or neoadjuvant chemoradiation.Supported by a research grant from the Cabrini Clinical Education and Research Foundation.Read at The American Society of Colon and Rectal Surgeons' 100th Anniversary and Tripartite Meeting, Washington, D.C., May 1 to 6, 1999.