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Salvage Surgery After TAMIS
Excision ofEarly-Stage
Rectal Cancer
SookC.Hoang andCharlesM.Friel
5
Introduction
Radical resection with a total mesorectal excision (TME) is the gold standard for mid and low
rectal cancers. Utilizing these techniques there
has been substantial improvement in rates of
local control and in some studies overall survival
over the last several decades. However, these
procedures are associated with considerable
morbidity and, in some series, a 1–2% rate of
mortality. Furthermore, many patients will
require either a permanent or a temporary stoma.
Understandably, while recognizing the importance of a TME for patients with locally advanced
rectal cancers, many investigators have questioned the need for such an aggressive approach
for patients with an early (T1) rectal cancer.
Under these circumstances the rate of lymph
node metastases can be less than 10% which
begs the question of whether a TME is oncologically necessary. Because of this, local excision is
very appealing for the treatment of early-stage
rectal cancer. In principle, if the tumor can be
completely excised and the surgeon is condent
there is no lymph node metastases, patients can
be saved from the considerable morbidity of
S. C. Hoang (*) · C. M. Friel
Department of Surgery, University of Virginia Health
System, Charlottesville, VA, USA
e-mail: sh7je@virginia.edu; cmf2x@virginia.edu
TME.Initially, local excision was performed via
a transanal approach using anal retractors.
However, there are now more elegant options to
a transanal excision (TAE) which include transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS) using
either a laparoscopic or robotic platform. These
newer techniques allow for improved visibility
resulting in surgical specimens that are more
likely to remain intact with negative margins.
However, despite improvements in imaging and
surgical techniques and our understanding of
rectal cancers, local excision for a T1 rectal cancer, independent of approach, still has a local
recurrence rate of approximately 10%.
Furthermore, once a tumor is completely excised
and analyzed pathologically, there will be some
patients with tumors who have aggressive pathological features that mandate an immediate
TME.In both circumstances surgeons must now
perform a radical proctectomy with a TME in an
attempt to salvage the initial failed local excision. It is critical, therefore, for surgeons to
understand the outcomes of these salvage procedures so that patients are fully informed of
potential outcomes. For the purpose of this discussion, salvage proctectomy will be classied
as delayed, when it is done for a locally recurrent
cancer, or immediate, when performed for unexpected aggressive pathological features. The outcomes will focus on both local control and
surgical morbidity.
© Springer Nature Switzerland AG 2019
S. Atallah (ed.), Transanal Minimally Invasive Surgery (TAMIS) and Transanal Total Mesorectal
Excision (taTME), https://doi.org/10.1007/978-3-030-11572-2_5
43
44
S. C. Hoang and C. M. Friel
Immediate Salvage Surgery
forDisease Upstage
Patients with T1 rectal cancers who are candidates for local excision must be thoroughly
assessed prior to surgery. This includes imaging
studies to accurately determine the depth of invasion. Prior studies have shown that T1 rectal cancers can have lymph node metastases in
approximately 10% of patients, while those with
T2 cancer, the rate of lymph node metastases
approaches 20% [1, 2]. Both endorectal ultrasound (ERUS) and high-denition MRI have
been used to determine the depth of invasion and
to detect pathological lymph nodes in the mesorectum. Unfortunately, neither is 100% reliable
resulting in rectal lesions that can be either understaged or overstaged. One study found 44.3% of
pT1 and 31.2% of pT2 tumors were thought to be
benign lesions prior to surgery [3], highlighting
the imperfections of current selection processes.
Underestimation of T category preoperatively
can lead to partial-thickness rectal wall excision
and a subsequent sixfold increase in odds of an
R1 margin [3]. Furthermore, tumors may have
aggressive pathological features (poor differentiation, lymphovascular invasion, tumor budding)
that increase the chances of having lymph node
metastases substantially but are only fully identied once a complete excision is performed.
While surgeons strive for perfect patient selection, the reality is that a local excision serves as
an excisional biopsy of the lesion. Most of the
time, the nal pathology is consistent with preoperative evaluation, and compulsive surveillance is
all that is necessary. However, in approximately
4–23% of patients, the nal tumor will either
have unrecognized aggressive features, be deeper
than expected, or have a close surgical margin [3,
4]. Because of a high rate of local failure under
any of these circumstances immediate salvage
surgery, with TME, is indicated.
It is currently unclear if the outcomes of
immediate salvage TME for disease upstaging
vary from upfront radical surgery with
TME. Some studies suggest immediate salvage
TME after a failed local excision does not compromise oncologic outcomes compared to pri-
mary upfront radical surgery [5, 6]. For example,
Baron et al. noted no difference in long-term
oncologic outcomes in patients that had immediate salvage surgery following a failed local excision [6]. They compared patients who underwent
immediate resection for adverse features encountered in the local excision specimen with patients
who underwent delayed resection only after the
emergence of local recurrence. The disease-free
survival in the immediate resection group was
94.1% compared to 55.5% in the delayed resection group. Similarly, a study performed by Levic
etal. found that the recurrence rates for radical
surgery after TEM for rectal cancer were similar
to historical controls [7]. They identied 25
patients within their institution who underwent
TME after local excision with TEM.Outcomes
were matched with historical controls who had
primary upfront radical excision with TME.There
were no signicant differences between the two
groups in the number of harvested lymph nodes,
median circumferential resection margin, and
completeness of mesorectal fascial plane.
Additionally, there were no recurrences in the
salvage TME group within 25months. Despite
these promising oncologic results, this study
reports a compromise in oncologic principles
during denitive resection including:
1. Intraoperative perforation was reported at
20%, likely secondary to weakening of the
specimen from the previous TEM.
2. Thirty-seven percent of patients had an incomplete mesorectal excision.
The signicance of these ndings remains
unclear but does suggest there may be some
oncologic compromise as a result of the previous
attempt at local therapy.
While at rst glance there seems to be no sig-
nicant compromise to rst attempting a local
excision, this algorithm certainly raises some
concern. Patients are subjected to two surgical
procedures often within a short period of time.
Additionally, there is currently no consensus in
the timing of salvage surgery following TEM for
lesions that are upstaged on pathology. Some
centers report salvage surgery as early as 4weeks
5 Salvage Surgery After TAMIS Excision ofEarly-Stage Rectal Cancer
45
from the initial TEM, and some centers report
delay of up to 3months [5]. What is clear is that
surgical morbidity after salvage TME is reported
to be as high as 56% [7]. More importantly, in the
same study from Levic etal., 40% of the patients
having a salvage procedure required an APR and
permanent colostomy which raises the possibility
that these patients could have had a LAR if
upfront radical surgery was performed and the
surgical planes not disrupted by the previous fullthickness excision. These ndings suggest that
salvage TME after local excision may be more
technically challenging. The local excision scar
has to be completely excised, resulting in a more
distal resection margin, which could increase the
rate of a permanent colostomy. Van Gijn et al.
evaluated the risk of local recurrence, effects on
survival, and rate of ostomy after immediate salvage TME [8]. Patients who had a local excision
for presumed benign or supercial malignant rectal lesions and had subsequent pathologic upstaging underwent salvage TME within 15 weeks.
They found a greater risk for colostomy (OR
2.51, p< 0.0006) and a greater local recurrence
rate (HR 6.8, p<0.0001) in patients who had salvage surgery. There was no difference in development of distant metastasis at 2.5 years. These
data suggest that salvage TME is technically
more challenging in a re-operative eld. Because
of these challenges, both rates of local recurrence
and colostomy creation are likely increased.
In summary, following a local excision, some
patients will have unfavorable pathological features that mandate a radical resection. Under
these circumstances immediate (within 3months)
salvage surgery is recommended since waiting
for a local recurrence tends to have worse oncological outcomes. When performed early survival
may be equivalent to upfront radical resection.
However, radical surgery may be more technically challenging as a result of scarring and brosis from a previous local excision. Unfortunately,
this may increase the likelihood of requiring a
permanent colostomy. Furthermore, the impact
on local recurrence remains ill-dened with some
studies suggesting similar outcomes and others
hinting at a higher rate of local failure. What does
seem clear, however, is that a failed local excision
has important repercussions which highlight the
importance of proper preoperative selection.
Delayed Salvage Surgery
forRecurrent Disease
While local excision for an early rectal cancer
may be an excellent option for carefully selected
patients, there is little doubt it is an oncologically
inferior option when compared to a radical resection. Local excision removes the tumor with a
limited mucosal margin and spares the mesorectal lymph nodes. Unresected disease in regional
lymphatics has been identied as a cause of failure after local excision [9]. As a result, there is an
increased risk for recurrence after local excision
compared to proctectomy with a TME [3]. Local
recurrence rates after local excision can range
from 0 to 33% compared to local recurrence rates
after upfront proctectomy with total mesorectal
excision at 0–2.4% [10].
Surveillance and follow-up of patients who
have undergone local excision for T1 rectal cancer are therefore critical for detection of local
recurrence. Since local recurrence may present as
an intraluminal or extraluminal mass, a multimodal surveillance scheme should be followed.
Current guidelines recommend proctoscopy
every 3months for the rst 2years and then every
6 months for a total of 5 years [11]. However,
surveillance with proctoscopy alone may still
lead to missed recurrences. Additionally, despite
imaging modalities such as MRI or endorectal
ultrasound (ERUS), lymph node metastasis may
also be missed [12]. For these reasons, some centers argue for aggressive surveillance with surveillance proctoscopy and ERUS in addition to
yearly pelvic MRI for patients who have had
local excision for early rectal cancer [12, 13].
Close surveillance may lead to an earlier detection of recurrence and subsequent need for a less
involved salvage surgery. However, even with
active surveillance, outcomes following salvage
surgery is poor with 3-year overall survival at
31% and disease-free survival of 58% [12].
Bach et al. sought to identify predictors to
recurrence after local excision for rectal cancer.
46
S. C. Hoang and C. M. Friel
Recurrence after local excision occurs at a
median of 13 months (range of 3–55 months)
[3]. They found that recurrence is independently
predicted by depth of tumor invasion, maximum
tumor diameter, and presence of intramural lymphovascular invasion. Additionally, as the maximum tumor diameter increased by 1cm, the risk
of recurrence also increased by 18% (95% CI,
3–35%). Lymphovascular invasion was noted to
increase the risk of recurrence by a factor of
1.86. This is consistent with previous studies that
have found lymphovascular invasion to be an
independent predictor of local recurrence [9].
In general, local recurrence portends a poor
prognosis. In most patients, when recurrence
occurs after local excision, the stage of the recurrent tumor is more advanced than the initial primary tumor [14]. Another study noted 41% nding
of positive node involvement in the surgical specimen, despite the use of preoperative radiation therapy in patients with recurrence [14]. Bikhchandani
etal. identied 27 patients who underwent multimodal salvage therapy for locally recurrent rectal
cancer after previous local excision for early rectal
cancer [15]. Compared to 5-year disease-free sur-
vival rates of 92–97% after upfront proctectomy
for a T1 lesion, they found a 5-year overall survival rate of 50% (95% CI, 30–74%) and a 5-year
recurrence-free survival rate of 47% (95% CI,
25–68%) after salvage surgery for recurrence.
There are now several studies (Table5.1) showing
similar disappointing outcomes with overall survival hovering around 50%. Recalling that upfront
TME for a T1 rectal cancer has nearly a 100%
overall survival, these data remind us that salvage
surgery for a local recurrence does not achieve
similar oncologic success and therefore cannot be
relied upon for patients that have a recurrence following a local excision.
Additionally, salvage TME for recurrence after
local excision for early-stage rectal cancer often
involves an extensive operation with increased
morbidity. Pelvic recurrence is often advanced
requiring an extended pelvic resection of adjacent
pelvic organs to achieve salvage [16]. For example, in the study from Weiser et al., 50 patients
underwent attempted surgical salvage for local
recurrence following initial transanal excision
[16]. Thirty-one of the 50 patients underwent an
APR and only 11 patients had an
Table 5.1 Summary of studies regarding salvage surgery after local excision for rectal cancer
Author, year
Friel etal.,
2002 [14]
Weiser etal.,
2005 [16]
Doornebosch
etal., 2010 [12]
You etal., 2012
[17]
Bikhchandani
etal., 2015 [15]
OS overall survival, DFS disease-free survival, −not reported
N (study
years)
1988–
1999
50
(1970–
2003)
88
(1996–
2010)
43
(1993–
2011)
27
(1997–
2013)
Initial
tumor stage
T1, T2 – – 34% DFS 55%
T1, T2 20months 17 patients within
pT1 10months Intraluminal 10
cT1 43%
cT2 7%
cT3 22%
unknown
28%
T1, T2 52weeks Luminal 23 patients,
Median time
to recurrence Location of recurrence
rectal mucosa,
metastatic disease
8 patients
(11%),
Extraluminal 6
(6.8%),
Distant mets 39%
1.9years Local/regional 67%,
Distant 18%,
Both 15%
Locoregional
3 patients,
Locally advanced
disease(T3/T4) 73%
Sphincter
preservation OS, DFS
– 5-year OS 53%
56% 3-year OS 31%,
33% 5-year OS 63%,
33% 5-year OS 50%,
cancer-related
survival 58%
3-year
recurrence-free
survival 43%
recurrence-free
survival 47%
5 Salvage Surgery After TAMIS Excision ofEarly-Stage Rectal Cancer
47
LAR. Additionally, 55% of patients required an
extended resection involving the pelvic sidewall,
prostate, seminal vesicle, bladder, vagina, ureter,
and ovary, with a resulting 5-year disease-free
survival rate of 53%. Similarly, in a series by You
etal., 33% of patients with recurrence after local
excision required a multivisceral resection and
5% required a pelvic exenteration to achieve R0
disease [17]. Additionally, they noted that only
33% of patients who underwent salvage surgery
achieved sphincter preservation which was consistent with sphincter preservation rates of
30–50% across studies [12, 15, 17]. The goal of
salvage surgery is to achieve R0 resection which
often requires extensive resection and sphincter
compromise. When R0 resection is achieved,
survival rates of up to 59% can be achieved.
However, in situations where an R1 or R2 resection is achieved, survival rates drop to 0% [16].
In efforts to improve outcomes and survival
after salvage surgery, multimodality therapy is
frequently adopted. This includes the use of both
neoadjuvant and adjuvant chemotherapy and
radiation, in addition to intraoperative radiotherapy in some centers [15]. However, morbidity
rates after salvage surgery is consistently reported
at 40–50%. Bikhchandani et al. were able to
achieve R0 resection in 93% of patients with the
use of multimodality therapy and salvage surgery
[15]. Despite this, they reported 5-year
recurrence- free survival rate and 5-year overall
survival rate of <50%. Similarly, despite aggressive multimodal therapy including neoadjuvant
chemoradiation and intraoperative radiation to
achieve R0 resection in 80% of patients, You
etal. also reported modest outcomes (5-year OS
63%, 3-year re-recurrence-free survival 43%)
[17]. Therefore, even with the use of multimodality therapy, recurrences after a failed local excision are signicant challenges with overall
outcomes which remain disappointing given the
initial stage of these tumors.
Summary
There have been signicant advances in the treatment of rectal cancer. Local excision for benign
rectal lesions and T1 rectal cancers has become
more technically possible with the introduction
of TEM and TAMIS, with lower associated morbidity compared to radical surgery. For many reasons, local excision for properly selected patients
with a T1 rectal cancer remains an appealing
option. Since T1 rectal cancers have up to a 10%
risk for lymph node metastasis, preoperative
staging is extremely important. Unfortunately,
available modalities such as MRI and endorectal
ultrasound are not able to detect micrometastases
that may be associated with T1 lesions [18].
Therefore, despite careful patient selection, some
patients will require a salvage TME for either
poor pathological features or a local recurrence.
Initially surgeons believed that outcomes of these
salvage procedures would likely be similar to primary surgery for these early rectal cancers. When
performed in a timely fashion, salvage surgery
for pathologic upstaging results in acceptable
survivability. However, salvage surgery can be
technically more challenging compared to
upfront radical surgery which increases the likelihood of a permanent colostomy. Furthermore,
local recurrence rates for a salvage TME is likely
higher. For patients that recur following a local
excision, the recurrence is often at a higher stage
compared to the initial stage of presentation. As a
result, more extensive surgical resection is needed
to achieve tumor-free resection, resulting in
greater morbidity and compromised functional
outcomes. This includes diminished sphincter
preservation rates of only 30–50% across studies
and often requires an extended resection to
achieve an R0 resection. Survival outcomes following salvage surgery, even with multimodality
therapy, are also disappointing and hover at about
50%. These data suggest that salvage surgery is
not a panacea for the patients who develop a local
recurrence. What it does suggest is that compulsive and aggressive surveillance is critical in the
management of these patients. Presumably if
local recurrences are found early, then salvage
surgery may have better overall outcomes. It is
our recommendation that all patients be followed
by endoscopic evaluation and careful exam every
3months for 2years and biannually until 5years.
Since there are examples of late recurrence, an
annual exam after 5 years may be reasonable.
Ideally this is done by the operating surgeon who
48
S. C. Hoang and C. M. Friel
is more attuned to subtle recurrence patterns.
While most recurrences are intraluminal, there
will be some local recurrence outside of the
lumen. Therefore, a pelvic MRI should be done
at least once per year. Similarly, some patients
will develop distant metastases so a CT scan of
the chest, abdomen, and pelvis annually is also
reasonable. By staggering the CT scans and the
pelvic MRI every 6months, the patient can get
pelvic imaging every 6months with this approach.
Conclusion
Since salvage surgery cannot be relied upon for a
failed local excision, the best opportunity to
improve outcomes for local excision is by
improving the patient selection process. Until we
can reliably rule out disease within the mesorectum, there will be patients that will recur. We now
know that salvage surgery clearly results in inferior outcomes. Therefore, since our “rst shot is
our best shot,” when considering local excision
as a treatment option, we must choose and inform
our patients carefully.
References
1. Chang HC, Huang SC, Chen JS, Tang R, Changchien
CR, Chiang JM, et al. Risk factors for lymph node
metastasis in pT1 and pT2 rectal cancer: a singleinstitute experience in 943 patients and literature
review. Ann Surg Oncol. 2012;19(8):2477–84.
2. Rasheed S, Bowley DM, Aziz O, Tekkis PP, Sadat AE,
Guenther T, etal. Can depth of tumour invasion predict
lymph node positivity in patients undergoing resection
for early rectal cancer? A comparative study between
T1 and T2 cancers. Color Dis. 2008;10(3):231–8.
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Merrie A, etal. A predictive model for local recurrence after transanal endoscopic microsurgery for rectal cancer. Br J Surg. 2009;96(3):280–90.
4. Borschitz T, Heintz A, Junginger T.The inuence of
histopathologic criteria on the long-term prognosis
of locally excised pT1 rectal carcinomas: results of
local excision (transanal endoscopic microsurgery)
and immediate reoperation. Dis Colon Rectum.
2006;49(10):1492–506. discussion 500-5
5. Hahnloser D, Wolff BG, Larson DW, Ping J,
Nivatvongs S.Immediate radical resection after local
excision of rectal cancer: an oncologic compromise?
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6. Baron PL, Enker WE, Zakowski MF, Urmacher
C. Immediate vs. salvage resection after local treatment for early rectal cancer. Dis Colon Rectum.
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7. Levic K, Bulut O, Hesselfeldt P, Bulow S. The outcome of rectal cancer after early salvage surgery
following transanal endoscopic microsurgery seems
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8. van Gijn W, Brehm V, de Graaf E, Neijenhuis PA,
Stassen LP, Leijtens JW, et al. Unexpected rectal
cancer after TEM: outcome of completion surgery
compared with primary TME. Eur J Surg Oncol.
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9. Paty PB, Nash GM, Baron P, Zakowski M, Minsky
BD, Blumberg D, etal. Long-term results of local excision for rectal cancer. Ann Surg. 2002;236(4):522–9.
discussion 9-30
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Madoff RD, Rothenberger DA.Local excision of rectal cancer without adjuvant therapy: a word of caution. Ann Surg. 2000;231(3):345–51.
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I, Tetteroo GW, de Graaf EJ.Treatment of recurrence
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13. de Anda EH, Lee SH, Finne CO, Rothenberger DA,
Madoff RD, Garcia-Aguilar J.Endorectal ultrasound
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Organ Preservation andPalliative
Options forRectal Cancer
Nienkeden Dekker, StefanErikVan Oostendorp,
andJurriaanBenjaminTuynman
6
Introduction
Local excision is a well-accepted organ preserving
method for early rectal cancer with substantial
lower morbidity and impact on quality of life compared to radical surgery. However, only rectal cancers staged as a T1 tumor limited to the supercial
third of the submucosa (sm1) and less than 3cm in
diameter without signs of poor differentiation,
lymphatic or vascular invasion, budding, or clustering in the nal pathology are oncologically
safely treated with radical local excision [1]. These
tumors have local recurrence rates of less than 5%.
Small locally excised lesions with more risk factors as budding, poor differentiation, and lymphovascular invasion or even T2 lesions have been
associated with relatively high recurrence rates
[2–4]. Due to the increased recurrence rate, most
guidelines recommend completion radical surgery
after local excision of high-risk lesions [5].
Local excision for palliation could be considered in patients who are either too fragile for or
who refuse radical surgery. This seems to be a
valuable option for those that have symptomatic
bleeding, changed defecation, or even incontinence. However, local excision alone for higher-
risk tumors in the rectum is not without risks. The
relatively high recurrence rate within 2–3years is
a substantial problem, since recurrences are often
symptomatic. Combining local excision with radiation for palliative reasons could be an option, but
unfortunately data to support this theory are scarce.
Other organ-preserving strategies after local
excision of high-risk lesions are being investigated in prospective cohorts and randomized trials. A potential curative option is adjuvant
chemoradiation (CRT) following local excision,
which has proven to decrease local recurrence
rates and offers acceptable morbidity with organ
preservation. The other option is no further therapy but instead offer close surveillance with salvage radical surgery if a local recurrence presents
itself (about 20%).
Several combinations of local excision, radiotherapy, chemotherapy, and/or close observation
are being investigated for treatment of higherstaged tumors. The aim of this chapter is to summarize data of organ preservation options with a
focus to palliative options.
Treatment Options
N. den Dekker · S. E. Van Oostendorp (*)
J. B. Tuynman
Department of Surgery, Amsterdam University
Medical Center, location VUmc, Cancer Center
Amsterdam, Amsterdam, The Netherlands
e-mail: s.vanoostendorp@vumc.nl
© Springer Nature Switzerland AG 2019
S. Atallah (ed.), Transanal Minimally Invasive Surgery (TAMIS) and Transanal Total Mesorectal
Excision (taTME), https://doi.org/10.1007/978-3-030-11572-2_6
Local Excision
Treatment with solely local excision offers the
lowest burden for patients, since it is a minimally
invasive technique and results in low morbidity
49
50
N. den Dekker et al.
and colostomy rates. You etal. reported an overall 30-day morbidity rate of 5.6% compared to
14.6% for radical resections, because of less gastrointestinal and infectious complications, with a
consequent shorter hospital stay after local excision [6]. However, the question remains whether
it is a sufcient treatment since local excision
only treats the primary tumor and not the potential remaining tumor cells in the mesorectum.
The clinically pathological features such as depth
of submucosal invasion, differentiation, lymphovascular invasion, budding, and clustering are
related to recurrence, whether endoluminal or
within the mesorectum. When local excision is
carried out, the surrounding muscular wall and
mesorectum are left untreated. Therefore, tumor
cells are potentially left behind where they may
propagate and eventually develop into a clinically
detectable local recurrence.
Many cohorts and population-based studies
have provided data concerning oncological outcome after local excisions for T1 and T2 tumors.
A meta-analysis of local excision as sole treatment, covering all published data from 1990 to
2018, revealed local recurrence rates of 10% in
2120 patients with a T1 tumor and 32% in 357
patients with a T2 tumor as shown in Table6.1
(Tuynman etal. in preparation [7]). Distant failures occurred in 6% of 1805 patients and 12% of
230 patients with, respectively, T1 and T2 tumors.
The substantial increase in recurrences of T2
tumors indicates the reduced effectiveness of
local excision for more advanced early rectal
cancer.
Table 6.1 Recurrence rates
T1 T2 T3
Local recurrence
LE 10%
(n=2120)
LE+adjuvant 7%
(n=278)
Distant recurrence
LE 6%
(n=1805)
LE+adjuvant 5%
(n=214)
n number of patients included in this analysis, LE local
excision, adjuvant (chemo)radiation
32%
(n=357)
16%
(n=382)
12%
(n=230)
7%
(n=254)
58%
(n=19)
33%
(n=27)
31%
(n=13)
4%
(n=23)
The recurrence rates after local excision of T3
cancer are expected to be even higher and are the
reason that local excision for T3 is not supported
by clinical guidelines as treatment strategy with
curative intent. As expected, data is scarce concerning this group of advanced disease. Some
publications report a few cases of patients who
refused radical surgery or were deemed unt for
major surgery. In seven publications which
address this subject, an overall recurrence rate of
68% (15 of 22 patients) was reported [8–14].
This increase in recurrences might be an
acceptable clinical outcome if a radical resection
is not desirable nor possible in frail patients who
present unacceptably high risk of perioperative
morbidity and mortality. Therefore, expected
longevity and predicted survival rates are important factors when a deliberate choice for a substandard operation is carried out by performing
local excision. Allaix et al. [15] reported 5-year
survival rates of 76% in 32 patients after TEM
and 96% of 33 patients after anterior resection or
APR.However, radical resection was indicated in
all patients. Those who underwent a TEM procedure were either not t for surgery or refused
radical surgery. A meta-analysis showed overall
5-year survival rates of 65–100% for T1 tumors
and 30–95% for T2 tumors [7]. The majority of
all recurrences appears within 3years after initial
treatment. Salvage treatment usually consists of
major surgery or less effective radiotherapy, and
it is often associated with complications.
In conclusion, local excision for rectal cancer
is accompanied by low morbidity rates and good
functional outcome. However, it is also associated with poor oncological outcome in high-risk
tumors which increases with tumor (T) stage. In
case of low-risk T1 tumors, local excision alone
is a viable and accepted treatment strategy.
Local Excision withAdjuvant Therapy
Especially for inrm patients, local excision is an
attractive strategy compared to radical surgery
concerning morbidity. Therefore, other additional
options to improve the associated oncological
compromise have been studied. One of these