低位直肠癌局部切除术疗效分析

目的：探讨局部切除术治疗直肠癌的临床应用指征和疗效。方法：回顾性分析1996～2002年我院行局部切除术治疗42例中低位直肠癌病人的治疗情况及随诊资料。结果：42例中有Tis期6例，T1期20例，T2期16例。围手术期死亡率为零，无严重术后并发症。随访中7例（16．7％）局部复发，包括T1期2例和T2期5例。χ^2检验显示，肿瘤大体类型、肿瘤直径、T分期与术后复发相关（P〈0．05）。本组总体5年生存率为83．3％，Tis、T1、T2期病变分别为100％、90．0％、68．8％。结论：早期（Tis、T1期）高中分化癌、具良好的生物学特性及无淋巴、血管浸润的直肠癌行局部切除术可作为有效的治疗方案。T2期及以上的肿瘤应首选根治性手术。对不能忍受根治术者或拒行腹壁人工肛门者，无耐时，可考虑行姑息性局部切除术后加行辅助放、化疗。     

直肠癌局部切除术的外科疗效与预后分析

目的 分析局部切除术治疗直肠癌的疗效及影响复发和预后的因素.方法 回顾性分析采用局部切除术治疗的46例中低位直肠癌患者临床资料,并对其预后影响因素进行单因素及多因素分析.结果 46例患者中经肛门局部切除38例,经骶尾部切除8例;术后并发症发生率为10.9%,围手术期病死率为0;局部复发率为17.4%,Tis、T1及T2期病变的局部复发率分别为0,12.0%,33.3%.肿瘤大体类型、肿瘤直径和分化程度与术后局部复发相关.总体5年生存率为83.3%,Tis、T1、T2期5年生存率分别为100%、90.9%、66.7%.单因素分析显示,肿瘤大小、分化程度、术后放化疗、脉管癌栓和局部复发是影响预后的因素.多因素分析显示,局部复发是影响预后的主要因素.结论 早期（Tis、T1期）高中分化癌,病灶直径≤3 cm,无脉管浸润的隆起型直肠癌,局部切除术是有效的治疗方法.T2期及以上的肿瘤应首选根治性手术,不能耐受根治术者或拒行腹壁人工肛门者,可考虑姑息性局部切除术后加行辅助放、化疗.     

经肛门括约肌直肠肿瘤切除术97例临床疗效

目的探讨经肛门括约肌手术在中低位直肠肿瘤局部切除术中的作用和疗效。方法对1990年3月至2007年3月采用经肛门括约肌手术的97例中低位直肠肿瘤病例进行回顾性分析。结果全组行直肠部分切除术91例,直肠节段切除术6例。术后并发伤口感染5例（5．2％）,直肠皮肤瘘4例（4．2％）。术后病理结果为：直肠绒毛状腺瘤35例,直肠癌50例,直肠类癌等12例。直肠癌中Tis期17例,T1期21例,T2期7例,T3期2例,T4期3例。术后平均随访6．4年（2个月～16年）。术后肿瘤局部复发3例（6．2％）。术后3年和5年生存率分别为93．7％和87．5％。本组无手术死亡,无术后肛门失禁。结论经肛门括约肌直肠肿瘤局部切除术具有手术创伤小、风险低和易于保留肛门等优点,适用于中低位直肠肿瘤的治疗。     

中低位直肠癌系膜浸润程度的临床研究

目的探讨中低位直肠癌直肠系膜浸润程度与临床病理特征及预后的关系。方法采用大组织切片技术,测量行全直肠系膜切除术的49例中低位直肠癌标本的肿瘤浸润深度及直肠系膜厚度,计算直肠系膜浸润程度;并分析其临床病理特征和随访结果。结果本组中低位直肠癌术后局部复发率为12．2％（6／49）,远处转移率为26．5％（13／49）。直肠癌直肠系膜浸润程度Ⅰ度20例（40．8％）,Ⅱ度13例（26．5％）,Ⅲ度16例（32．7％）,Ⅰ、Ⅱ、Ⅲ度者术后局部复发率分别为0、7．7％和31．3％（X^2=7．357,P=0．015）;远处转移率分别为10％、23．1％和50％（X^2=7．405,P=0．025）;5年生存率则分别为90．9％、69．2％和28．6％（p=0．013）。直肠系膜浸润程度与肿瘤直径（X^2=6．849,P=0．033）、T分期（X^2=34．845,P=0．000）、N分期（X^2=17．266,P=0．002）有关。结论直肠系膜浸润程度是影响直肠癌预后的重要因素。     

低位直肠癌保肛术与腹会阴联合切除术后生存和复发多因素分析

目的 探讨低位直肠癌保肛术与腹会阴联合切除术对病人术后生存和肿瘤复发影响。方法 随访1995年1月至2005年6月期间，汕头大学医学院肿瘤医院外科手术治疗286例低位直肠癌，对保肛手术（SPO）与经腹会阴联合切除术（APR）两组病人的临床病理指标、存活率和局部复发状况进行统计学分析。结果 保肛手术组160例，术后局部复发率10％，生存期24．4个月，5年存活率为61.6％；经腹会阴切除术（APR）组126例，术后局部复发率13．5％，生存期33，2个月，5年存活率为68.8％，两组存活率比较差异无显著意义（P=0．22）。两组术后局部复发率比较差异也无统计学意义（P=0．23）。结论 低位直肠癌保肛术与腹会阴联合切除术并不影响低位直肠癌病人术后的生存和肿瘤复发。     

Mason手术在低位直肠肿瘤切除术中的作用

目的探讨Mason手术在低位直肠肿瘤切除术中的作用。方法对采用Mason手术治疗的85例低位直肠肿瘤病例进行回顾性分析。结果病理检查结果为直肠绒毛状腺瘤29例，直肠癌47例，直肠类癌等9例。直肠癌中Tis期17例，T1期19例，T2期7例，T3期1例，T4期3例。术后合并伤口感染2例（2．3％），直肠皮肤瘘2例（2．3％）。无手术死亡，无术后肛门失禁。术后3年和5年生存率分别为100％和95．5％。结论Mason手术具有手术径路直达，术野宽敞，显露良好，十分适用于低位直肠肿瘤的治疗。     

经肛门局部切除术治疗Ⅰ期低位直肠癌

目的 探讨Ⅰ期低位直肠癌局部切除术临床应用的合理性.方法 回顾性分析93例Ⅰ期(T1-2N0M0)低位直肠癌患者的资料.按手术方式不同分为:局部切除术组(45例)和根治术组(48例).局部切除术组均行经肛门局部切除术,术后T1期(24例)行辅助放疗,T2期(21例)行辅助放、化疗.根治术组(T1期18例,T2期30例)均行根治术(行腹会阴联合切除术42例,低位前切除术6例),术后未行放、化疗.所有患者均随访5年以上.对两组患者的生存率、复发率、并发症发生率进行比较分析.结果 (1)局部切除术组和根治术组5年生存率T1期均为100%(24/24,18/18),T2期分别为86%(18/21)和93%(28/30),两组比较差异无统计学意义(P＞0.05).(2)局部切除术组和根治术组5年复发率T1期分别为4%(1/24)和0(0/18),T2期分别为19%(4/21)和7%(2/30),两组比较差异无统计学意义(P＞0.05).(3)局部切除术组并发症发生率为2%(1/45),根治术组为15%(7/48),前者显著低于后者(P＜0.05).结论 对于Ⅰ期低位直肠癌,经肛门局部切除术联合术后放、化疗可获得与根治术相近的5年生存率,是一种合理的治疗方式.     

经骶尾局部切除治疗直肠中下段肿瘤

目的探讨经骶尾局部扩大切除术在中下段直肠肿瘤治疗中的应用效果。方法回顾性分析1994年9月至2005年9月间在江苏省肿瘤医院普通外科接受经骶尾局部扩大切除术治疗的133例中下段直肠肿瘤患者的临床资料。结果全组无手术死亡者,6例（4．5％）并发粪瘘。全组患者肿瘤切缘与基底均阴性。术后诊断为腺瘤28例,增生性息肉3例．类癌8例,间质瘤1例,腺瘤伴黏膜内癌变29例,黏膜下癌64例。64例T1期腺癌患者中位随访期76个月,5年累计局部复发率2．0％。5年总生存率100％。其余患者均无局部复发。结论经骶尾局部扩大切除术简便、安全,适合中低位直肠良性肿瘤的治疗与低位T1期直肠癌的选择性保肛手术治疗。     

低位Ⅰ期直肠癌患者的外科治疗与预后分析

目的探讨低位Ⅰ期直肠癌的外科治疗效果及影响复发和预后的因素。方法回顾性分析166例低位Ⅰ期直肠癌患者的临床资料。结果本组根治性手术138例，均按直肠全系膜切除（TME）手术原则进行；其中93例行腹会阴联合根治术，45例行保肛手术；肿瘤局部切除术28例。局部复发率根治性手术者为5．1％（7／138），其中腹会阴联合根治术组为6．5％（6／93），保肛术组为2．2％（1／45）；局部切除术组为17．9％（5／28）。X^2检验显示，肿瘤分化程度（P=0．009）和手术方式（P=0．039）与局部复发相关。腹会阴联合根治术组5年生存率为90．4％，保肛术组为95．5％。局部切除术组为82．6％。单因素分析显示，肿瘤分化程度（P=0．000）和局部复发（P=0．000）与预后相关；多因素分析显示，局部复发是影响预后的主要因素（P=0．000）。结论低位Ⅰ期直肠癌根治性手术切除复发率低、预后好。局部切除术的选择应严格把握指征。     

双吻合器低位前切除术治疗低位直肠癌

1993年1月至1996年12月,笔者采用双吻合器低位前切除术治疗直肠癌183例,占同期全部直肠癌242的75.62％,其中属低位直肠癌者124例,占同期低位直肠癌174例的71.26％。内有61例属超低位吻合(吻合距肛缘≤3cm),占低位直肠癌的35.06％和低位前切除术49.19％。全组无手术死亡。在此124例低位直肠癌行双吻合器低位前切除术患者中,术后发生吻合口漏者5例,占4.03％;吻合口狭窄14例,占11.29％;术后出现局部复发者8例,复发率为6.45％,其中属吻合口复发3例,盆腔复发5例。本组资料充分显示低位直肠癌时应用双吻合器低位前切除术行保肛手术,不但显著提高了肛门保留的成功率,也保证了最佳的控便功能,是一个安全,有效的首选保肛术式。     

Endorectal Ultrasonography and Treatment of Early Stage Rectal Cancer

The purpose of this study was to evaluate the accuracy of preoperative staging by endorectal ultrasonography (EUS) and its contribution to treatment of early stage rectal cancer (ESRC). The results of EUS for 154 consecutive patients with ESRC (pTis to pT2) were compared prospectively with histologic findings, assessed according to the TNM classification. Results of treatment selection and long-term outcomes were analyzed retrospectively. There were 35 patients histologically staged as pTis, 8 as pT1-slight (invasion confined to the superficial one-third of the submucosa), 37 as pT1-massive (invasion extending to the deeper submucosa), and 74 as pT2. The equipment used was an echoendoscope GF-UM2 or GF-UM3 (Olympus, Tokyo, Japan). Sensitivity/specificity/overall accuracy rates for detection of slight submucosal invasion, massive submucosal invasion, and muscularis propria invasion were 99%/74%/96%, 98%/88%/97%, and 97%/93%/96%, respectively. Incidences of lymph node metastasis in pTis, pTis to pT1-slight, pT1, pT1-massive, and pT2 cases were 0%, 0%, 18%, 22%, and 30%, respectively. Incidences of lymph node metastasis in ESRCs staged by EUS (u) as uTis, uT1-slight, uT1-massive, uT2, and uT3 by EUS were 0%, 0%, 26%, 36%, and 64%, respectively. Sensitivity, specificity, and overall accuracy rates for detection of positive nodes in overall ESRCs were 53%, 77%, and 72%, respectively. Of the 43 patients with pTis to pT1-slight tumors, 22 underwent endoscopic polypectomy or local excision, 20 radical surgery, and 1 radical surgery after endoscopic polypectomy due to vascular invasion. All these patients are alive and all but one (who refused radical surgery due to vascular invasion after local excision and developed liver and lung metastases) are disease-free. Of the 37 patients with pT1-massive tumors, 34 underwent radical surgery and 3 transcoccygeal segmental resection. All these patients are alive disease-free except for one who died of peritoneal carcinomatosis after radical surgery. All patients with pT2 tumors underwent radical surgery. The overall 5-year survival rates for pTis, pT1, and pT2 cases were 100%, 98%, and 97%, respectively. EUS is an accurate method for evaluating invasion depth in ESRC. Patients with uTis or uT1-slight tumors staged by EUS are at low risk of positive nodes and good candidates for endoscopic polypectomy or local excision. Those with uT1-massive or uT2 lesions should be treated with a radical operation because of the high incidence of positive nodes. E-pub: 3 July 2000     

直肠癌经肛门内镜显微手术疗效及复发危险因素分析

目的 分析直肠癌经肛门内镜显微手术（TEM）疗效及复发危险因素,以探讨直肠癌TEM适应证.方法 对2006年6月至2009年6月间山东省千佛山医院胃肠外科收治的60例行TEM的直肠癌患者的临床资料进行回顾性分析.结果 本组直肠癌pTis期12例,pT1期38例 pT2期10例.全部病灶均一次性全层整块切除,标本切缘均阴性.手术时间30～190（65.0±36.5）min,术中失血量9～75（10.5±5.8）ml,住院时间3～9（4.5±2.7）d,无手术死亡和严重并发症出现.随访时间12～48（平均28.5）个月,无一例死亡.pTis患者均未现复发 38例pT1期患者中1例（2.6%）出现局部复发 10例pT2期患者中有4例（40.0%）出现局部复发,显著高于pT1期患者（P＜0.05）.肿瘤直径大于3 cm的21例患者中有4例复发,显著高于肿瘤直径小于3 cm者（1/39,P＜0.05）.多因素复发危险因素分析证实,浸润深度和肿瘤大小是TEM术后复发的独立风险因素.结论 对pTis、pT1期及肿瘤小于3 cm的早期直肠癌患者,TEM安全有效,值得推广.     

Local excision of rectal carcinoma

The purpose of this study was to identify the recurrence rate, the salvage rate after recurrence, and the overall survival after local excision of rectal adenocarcinomas. A retrospective medical chart review was performed in 31 consecutive patients with rectal adenocarcinoma who underwent local excision at Roswell Park Cancer Institute from January 1990 through December 1999. After excision nine patients were excluded from further analysis because they were found to have advanced stage on pathologic examination (T2 primary tumors with vascular invasion or T3 tumors). Eight of the nine patients underwent abdominoperineal resection as definitive therapy. In the remaining 22 patients who underwent transanal excision as definitive surgical therapy there were 13 patients with T1 tumors and nine patients with T2 tumors. Overall seven patients (32%) developed local recurrences after local excision. This included four patients with T1 and three patients with T2 primary tumors. All recurrences occurred in the seven patients who did not receive adjuvant chemoradiation. All patients underwent salvage resection of the recurrence. Four patients who underwent salvage resection of the recurrence remain without evidence of disease at a median follow-up of 19.5 months. Local excision without adjuvant therapy has an unacceptably high rate of local recurrence. Although most patients who recur locally are salvaged by radical resection the long-term results after resection remain unknown. The use of adjuvant chemoradiation appears to reduce this high recurrence rate and may eventually become a standard adjunct to local excision of rectal cancer.     

Local excision of rectal cancer without adjuvant therapy: a word of caution

OBJECTIVE: To evaluate the results of local excision alone for the treatment of rectal cancer, applying strict selection criteria. BACKGROUND DATA: Several retrospective studies have demonstrated that tumor control in properly selected patients with rectal cancer treated locally is comparable to that observed after radical surgery. Although there is a consensus regarding the need for patient selection for local excision, the specific criteria vary among centers. METHODS: The authors reviewed 82 patients with T1 (n = 55) and T2 (n = 27) rectal cancer treated with transanal excision only during a 10-year period. At pathologic examination, all tumors were localized to the rectal wall, had negative excision margins, were well or moderately differentiated, and had no blood or lymphatic vessel invasion, nor a mucinous component. End points were local and distant tumor recurrence and patient survival. RESULTS: Ten of the 55 patients with T1 tumors (18%) and 10 of the 27 patients with T2 tumors (37%) had recurrence at 54 months of follow-up. Average time to recurrence was 18 months in both groups. Seventeen of the 20 patients with local recurrence underwent salvage surgery. The survival rate was 98% for patients with T1 tumors and 89% for patients with T2 tumors. Preoperative staging by endorectal ultrasound did not influence local recurrence or tumor-specific survival. CONCLUSION: Local excision of early rectal cancer, even in the ideal candidate, is followed by a much higher recurrence rate than previously reported. Although most patients in whom local recurrence develops can be salvaged by radical resection, the long-term outcome remains unknown.     

Long-term results of local excision for rectal cancer

OBJECTIVE: To review the authors' experience with local excision of early rectal cancers to assess the effectiveness of initial treatment and of salvage surgery. SUMMARY BACKGROUND DATA: Local excision for rectal cancer is appealing for its low morbidity and excellent functional results. However, its use is limited by inability to assess regional lymph nodes and uncertainty of oncologic outcome. METHODS: Patients with T1 and T2 adenocarcinomas of the rectum treated by local excision as definitive surgery between 1969 to 1996 at the authors' institution were reviewed. Pathology slides were reviewed. Among 125 assessable patients, 74 were T1 and 51 were T2. Thirty-one patients (25%) were selected to receive adjuvant radiation therapy. Fifteen of these 31 patients received adjuvant radiation in combination with 5-fluorouracil chemotherapy. Median follow-up was 6.7 years. One hundred fifteen patients (92%) were followed until death or for greater than 5 years, and 69 patients (55%) were followed until death or for greater than 10 years. Recurrence was recorded as local, distant, and overall. Survival was disease-specific. RESULTS: Ten-year local recurrence and survival rates were 17% and 74% for T1 rectal cancers and 26% and 72% for T2 cancers. Median time to relapse was 1.4 years (range 0.4-7.0) for local recurrence and 2.5 years (0.8-7.5) for distant recurrence. In patients receiving radiotherapy, local recurrence was delayed (median 2.1 years vs. 1.1 years), but overall rates of local and overall recurrence and survival rates were similar to patients not receiving radiotherapy. Among 26 cancer deaths, 8 (28%) occurred more than 5 years after local excision. On multivariate analysis, no clinical or pathologic features were predictive of local recurrence. Intratumoral vascular invasion was the only significant predictor of survival. Among 34 patients who developed tumor recurrence, the pattern of first clinical recurrence was predominantly local: 50% local only, 18% local and distant, and 32% distant only. Among the 17 patients with isolated local recurrence, 14 underwent salvage resection. Actuarial survival among these surgically salvaged patients was 30% at 6 years after salvage. CONCLUSIONS The long-term risk of recurrence after local excision of T1 and T2 rectal cancers is substantial. Two thirds of patients with tumor recurrence have local failure, implicating inadequate resection in treatment failure. In this study, neither adjuvant radiotherapy nor salvage surgery was reliable in preventing or controlling local recurrence. The postoperative interval to cancer death is as long as 10 years, raising concern that cancer mortality may be higher than is generally appreciated. Additional treatment strategies are needed to improve the outcome of local excision.     

经肛门内镜显微手术局部切除早期直肠癌后续治疗策略对临床结局影响研究

目的 探讨经肛门内镜显微手术（TEM）局部切除早期直肠癌后续治疗方式的选择。方法 回顾性分析北京协和医院于2013-2019年间收治的105例经TEM切除直肠癌病人资料,所有病人均在知情同意后接受TEM。结果 105例病人经术前检查［直肠腔内超声和（或）直肠MRI］评估为cT1期且除外淋巴结转移,经病理学活检报告为腺瘤局部癌变或者直肠腺癌,均通过TEM完成直肠癌的局部扩大切除。105例病人术后36例行补救性根治性手术,29例行补救性放化疗,40例仅随访观察。105病人术后接受平均40（12～69）个月随访。随访期间,13例（12.4%）局部复发,2例（1.9%）远处转移,3例（2.9%）死亡。单因素分析结果显示,T分期（P=0.003）、是否R0切除（P＜0.01）和术后处理策略（P=0.036）是复发及死亡预测因子。在多因素分析中,T分期（HR 7.36,95%CI 1.82~29.85,P=0.005）、是否R0切除（HR 20.82,95%CI 2.71~159.64,P=0.003）及术后处理策略（HR 0.57,95%CI 0.08~0.38,P=0.003）与复发及死亡密切相关。结论 TEM局部切除pT1期直肠癌安全、有效。而对于pT2期或未达R0切除直肠癌病人术后复发风险高,后续积极采取根治术或辅助放化疗的补救性治疗可提高病人预后。     

Transanal endoscopic microsurgery for carcinoma of the rectum

Background The authors present their experience with rectal cancers managed by transanal endoscopic microsurgery (TEM). Methods This prospective study investigated patients undergoing primary TEM excision for definitive treatment of rectal cancer between January 1996 and December 2003 by a single surgeon in a tertiary referral colorectal surgical unit. Results For this study, 52 patients (30 men and 22 women) underwent TEM excision of a rectal cancer. Their mean age was 74.3 years (range, 48–93 years). The median diameter of the lesions was 3.44 cm (range, 1.6–8.5 cm). The median distance of the lesions from the anal verge was 8.8 cm (range, 3–15 cm), with the tumor more than 10 cm from the anal verge in 36 patients. The median operating time was 90 min (range, 20–150 min), and the median postoperative stay was 2 days. All patients underwent full-thickness excisions. There were 11 minor complications, 2 major complications, and no deaths. The mean follow-up period was 40 months (range, 22–82 months). None of the pT1 rectal cancers received adjuvant therapy. Eight patients with pT2 rectal cancer and two patients with pT3 rectal cancer received postoperative adjuvant therapy. The overall local rate of recurrence was 14%, and involved cases of T2 and T3 lesions, with no recurrence after excision of T1 cancers. Three patients died during the follow-up period, but no cancer-specific deaths occurred. Conclusions The findings warrant the conclusion that TEM is a safe, effective treatment for selected cases of rectal cancer, with low morbidity and no mortality. The TEM procedure broadens the range of lesions suitable for local resection to include early cancers (pTis and pT1) and more advanced cancers only in frail people.     

Mesorectal lymph node dissection: is it beneficial?

Locoregional recurrences and distant metastases are the determinants of the long-term prognosis following curative resection of rectal carcinoma. While distant metastases cannot be affected by the surgical treatment of the primary tumor, avoidance of local recurrence by the surgeon is of special significance as the predominant prognostic factor. Analysis of the long-term results achieved by various surgeons led to the concept of mesorectal excision – the removal of the rectum together with all additional tissue invested by the adjacent visceral fascia, that is, fatty tissue, lymph nodes, and lymphatic vessels, by sharp dissection of the appropriate anatomical plane. In our own patient material the 5-year survival rate following R0 resection was 85% for all stages, provided no local recurrence developed. This contrasts with a figure of only 23% in those who did develop local recurrence. The local recurrence rate decreased from 39.4%, with a 50% 5-year survival rate in 1974, to 9.8% and a 71% survival rate in 1991, although the rate of distant metastases remained constant. Among the patients treated between 1988 and 1994 the local recurrence rate was determined by depth of infiltration (1987 UICC classification: pT1 0%, pT2 10%, pT3 14%, pT4 28%), extent of lymph node infiltration (pN0 6%, pN1 15%, pN2 26%, pN3 25%), grading (G1 9%, G2 12%, G3 21%), and location within the rectum (upper third 13%, middle third 8%, lower third 17%), with combinations of unfavorable initial factors leading to higher local recurrence rates. The elevated local recurrence rates seen in the 1970s, in particular in the case of tumors of the lower third, were traced retrospectively to incomplete mesorectal excision, the implementation of which reduced the local recurrence rate initially to less than 10%, and then to the current 4.1%. From the oncological point of view, mesorectal excision must be considered to confer considerable benefit. In the case of carcinomas of the upper third of the rectum, mesorectal resection carried out to just 5 cm below the lower tumor edge is sufficient, however, without coning, while deeper carcinomas mandate total mesorectal excision. Received: 21 October 1998 / Accepted: 26 October 1998     

The indication and surgical results of local excision following radiotherapy for low rectal cancer

Aim Radical surgery of rectal cancer is associated with significant morbidity, and some patients with low‐lying lesions must accept a permanent colostomy. The objective of this study was to evaluate the outcome of local excision followed by adjuvant radiotherapy for rectal cancer for curative purposes. Method One hundred and seven patients with rectal carcinoma performed with local excision were analysed retrospectively. Results The procedures of local excision were trans‐anal resection in 83 patients, trans‐sacral resection in 16, trans‐sphincteric local resection in five, and trans‐vaginal resection in three. The overall disease‐free survival rate was 80.4% (86/107), including 90.0% (54/60) for T1 and 72.3% (34/47) for T2 tumours, respectively. Eighty‐two of 107 patients underwent adjuvant postoperative radiotherapy after local excision, and 25 did not, and the DFS rates between radiation and nonradiation group were significantly different for T2 [81.6% (31/38) vs 33.3% (3/9), P < 0.05], but not for T1 tumours (90.9%vs 87.5%, P > 0.05). The rates of local recurrence and distant metastasis were 13.1% (14/107) and 4.7% (5/106), respectively, and the median time to relapse was 15 months (range: 10–53) for local recurrence and 30 months (21–65) for distant recurrence. The risk factors for local recurrence were large tumour (≥3 cm), poorly differentiated adenocarcinoma and T2 tumour. Conclusions Local excision followed adjuvant radiotherapy is an alternative and feasible technique for small T1 rectal cancer in selected cases.     

Decision for salvage treatment after transanal endoscopic microsurgery

BACKGROUND: Transanal endoscopic microsurgery (TEM) has emerged as an alternative to classic radical operation for early rectal cancer. Early rectal cancer can be treated by adequate local excision such as TEM. If there are adverse risk factors, especially poor cellular differentiation, close resection margin, or positive lymphovascular invasion or incomplete excision, a radical resection is indicated. This study aimed to clarify the factors related to recurrence for patients required to undergo a salvage operation after TEM. METHODS: This retrospective study analyzed 167 patients who underwent TEM for rectal cancer between 1994 and 2004. Of these patients, 36 with poor differentiation, mucinous carcinoma, proper muscle invasion, lymphovascular invasion, and positive resection margin were included in the analysis. RESULTS: Of the 36 patients, 12 underwent a salvage operation, and the remaining 24 did not because of poor physical condition or refusal of radical surgery. There were a total of 6 (16.7%) recurrences. One (8.3%) of the 12 patients who underwent salvage surgery had systemic recurrence. Five (20.8%) of the 24 patients who did not receive surgery had recurrence (3 local recurrences, 2 distant recurrences). Analysis of the subgroups showed that 2 (28.6%) of 7 patients with lymphovascular invasion had recurrence, and that 1 patient (100%) had a T3 lesion. Three (17.6%) of 17 patients had T2 lesions. CONCLUSIONS: For high-risk patients, TEM followed by radical surgery is the most beneficial in preventing local recurrence. Radical salvage surgery is strongly recommended if pathologic results after TEM show T3 lesion or lymphovascular invasion.