Abstract
Background
Neoadjuvant therapies have significantly improved local control and survival of patients with rectal cancer. Nevertheless, although a complete pathologic response can be achieved in 30% of cases, a transabdominal surgical resection is always required. This study aimed, for the first time, to test in the literature the feasibility of local excision combined with transanal endoscopic microsurgery (TEM) as a surgical option for patients treated with neoadjuvant chemoradiation.
Methods
Between July 1997 and December 2002, 30 patients with rectal cancer affected by an extraperitoneal tumor entered a protocol consisting of neoadjuvant chemoradiation followed by surgery. The surgical treatment, consisting of open surgery, local excision, or TEM, was planned according to the patient’s clinical response after chemoradiation and distance from the anal verge.
Results
A significant clinical downstaging was observed in eight patients. Five of these patients underwent TEM, and three had local excision. Consequently, open surgery was performed for 22 patients. Histology showed six cases of complete pathologic response: three in the open surgery group and three in the transanal excision group. After a mean follow-up period of 47 months, the disease-free survival rate was 77% in the open surgery group and 100% in TEM or local excision group.
Conclusions
The findings suggest the complementary feasibility of TEM and local excision after neoadjuvant chemoradiation. However, randomized trials are needed to confirm the oncologic safety of this approach.
Similar content being viewed by others
References
Kapiteijn E, Marijnen CA, Nagtegaal ID, Putter H, Steup WH, Wiggers T, Rutten HJ, Pahlman L, Glimelius B, van Krieken JH, Leer JW, van de Velde CJ (2001) Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 345: 638–646
Theodoropoulos G, Wise WE, Padmanabhan A, Kerner BA, Taylor CW, Aguilar PS, Khanduja KS (2002) T-level downstaging and complete pathologic response after preoperative chemoradiation for advanced rectal cancer result in decreased recurrence and improved disease-free survival. Dis Colon Rectum 45: 895–903
Cass AW, Million RR, Pfaff WW (1976) Patterns of recurrence following surgery alone for adenocarcinoma of the colon and rectum. Cancer 37: 2861–2865
Joffe J, Gordon PH (1981) Palliative resection for colorectal carcinoma. Dis Colon Rectum 24: 355–360
Esnaola NF, Cantor SB, Johnson ML, Mirza AN, Miller AR, Curley SA, Crane CH, Cleeland CS, Janjan NA, Skibber JM (2002) Pain and quality of life after treatment in patients with locally recurrent rectal cancer. J Clin Oncol 20: 4361–4367
Wiig JN, Tveit KM, Poulsen JP, Olsen DR, Giercksky KE (2002) Preoperative irradiation and surgery for recurrent rectal cancer: will intraoperative radiotherapy (IORT) be of additional benefit? A prospective study. Radiother Oncol 62: 207–213
Ruo L, Tickoo S, Klimstra DS, Minsky BD, Saltz L, Mazumdar M, Paty PB, Wong WD, Larson SM, Cohen AM, Guillem JG (2002) Long-term prognostic significance of extent of rectal cancer response to preoperative radiation and chemotherapy. Ann Surg 236: 75–81
Habr-Gama A, de Souza PM, Ribeiro U Jr, Nadalin W, Gansl R, Sousa AH Jr, Campos FG, Gama-Rodrigues J (1998) Low rectal cancer: impact of radiation and chemotherapy on surgical treatment. Dis Colon Rectum 41: 1087–1096
Marks G, Mohiuddin M, Goldstein SD (1988) Sphincter preservation for cancer of the distal rectum using high-dose preoperative radiation. Int J Radiat Oncol Biol Phys 15: 1065–1068
Bonnen M, Crane C, Vauthey JN, Skibber J, Delclos ME, Rodriguez-Bigas M, Hoff PM, Lin E, Eng C, Wong A, Janjan NA, Feig BW (2004) Long-term results using local excision after preoperative chemoradiation among selected T3 rectal cancer patients. Int J Radiat Oncol Biol Phys. 60(4): 1098–1105 Nov 15
Ruo L, Guillem JG, Minsky BD, Quan SH, Paty PB, Cohen AM (2002) Preoperative radiation with or without chemotherapy and full-thickness transanal excision for selected T2 and T3 distal rectal cancers. Int J Colorectal Dis 17: 54–58
Schell SR, Zlotecki RA, Mendenhall WM, Marsh RW, Vauthey JN, Copeland EM III (2002) Transanal excision of locally advanced rectal cancers downstaged using neoadjuvant chemoradiotherapy. J Am Coll Surg 194: 584–590, discussion 590–591
Kim CJ, Yeatman TJ, Coppola D, Trotti A, Williams B, Barthel JS, Dinwoodie W, Karl RC, Marcet J (2001) Local excision of T2 and T3 rectal cancers after downstaging chemoradiation. Ann Surg 234: 352–358, discussion 358–359
Lezoche E, Guerrieri M, Paganini AM, D’Ambrosio G, Baldarelli M, Lezoche G, Feliciotti F, De Sanctis A (2005) Transanal endoscopic versus total mesorectal laparoscopic resections of T2-N0 low rectal cancers after neoadjuvant treatment: a prospective randomized trial with a 3-years minimum follow-up period. Surg Endosc 19(6): 754–756
Valentini V, Coco C, Cellini N, Picciocchi A, Rosetto ME, Mantini G, Marmiroli L, Barbaro B, Cogliandolo S, Nuzzo G, Tedesco M, Ambesi-Impiombato F, Cosimelli M, Rotman M (1999) Preoperative chemoradiation with cisplatin and 5-fluorouracil for extraperitoneal T3 rectal cancer: acute toxicity, tumor response, sphincter preservation. Int J Radiat Oncol Biol Phys 45: 1175–1184
Buess G, Hutterer F, Theiss J, Bobel M, Isselhard W, Pichlmaier H (1984) A system for a transanal endoscopic rectum operation. Chirurg 55: 677–680
Winde G, Nottberg H, Keller R, Schmid KW, Bunte H (1996) Surgical cure for early rectal carcinomas (T1): transanal endoscopic microsurgery vs anterior resection. Dis Colon Rectum 39: 969–976
Habr-Gama A, Perez RO, Nadalin W, Sabbaga J, Ribeiro U Jr, Silva e Sousa AH Jr, Campos FG, Kiss DR, Gama-Rodrigues J (2004) Operative versus nonoperative treatment for stage 0 distal rectal cancer following chemoradiation therapy: long-term results. Ann Surg 240: 711–717
Gavioli M, Bagni A, Piccagli I, Fundaro S, Natalini G (2000) Usefulness of endorectal ultrasound after preoperative radiotherapy in rectal cancer: comparison between sonographic and histopathologic changes. Dis Colon Rectum 43: 1075–1083
Kahn H, Alexander A, Rakinic J, Nagle D, Fry R (1997) Preoperative staging of irradiated rectal cancers using digital rectal examination, computed tomography, endorectal ultrasound, and magnetic resonance imaging does not accurately predict T0,N0 pathology. Dis Colon Rectum 40: 140–144
Calvo FA, Domper M, Matute R, Martinez-Lazaro R, Arranz JA, Desco M, Alvarez E, Carreras JL (2004) 18F-FDG positron emission tomography staging and restaging in rectal cancer treated with preoperative chemo radiation. Int J Radiot oncol Biol phys 55(2): 528–535
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Caricato, M., Borzomati, D., Ausania, F. et al. Complementary use of local excision and transanal endoscopic microsurgery for rectal cancer after neoadjuvant chemoradiation. Surg Endosc 20, 1203–1207 (2006). https://doi.org/10.1007/s00464-005-0567-x
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00464-005-0567-x