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14 Local Treatment of Rectal Cancer (TEM Versus TAMIS Versus Transanal Excision)
221
A radiographic evaluation of the level of penetration is
best carried out using endorectal ultrasound and/or MRI
evaluation. Endorectal ultrasound (ERUS) is helpful in
delineating the depth of invasion in early-stage rectal cancers
with approximately 90 % accuracy and in identifying mesorectal adenopathy with 70 % accuracy. ERUS is useful in
establishing if a tumor breeches the muscularis propria (T3).
It can also be helpful in sorting whether a tumor extends into
the submucosa (T1) or involves the muscularis propria (T2).
Nodes visualized on ERUS are likely metastatic and in fi t
patients should preclude consideration of local excision of
the primary tumor without using neoadjuvant chemoradiation in favor for more “radical” abdominal surgery.
Pelvic MRI is becoming more commonly used for staging
rectal lesions. It is very useful in the case of locally advanced
cancers in determining relationships with the mesorectal
margin and assessing for adjacent organ involvement (circumferential resection margin). Unfortunately, both of these
will be altered in their accuracy, dependent upon previous
biopsies and/or if the patient has had a snare polypectomy or
partial snare polypectomy prior to being referred to your
offi ce. The thermal injury that results from these energy
sources can potentially obscure the differentiation between
the mucosa and submucosa, submucosa and muscularis propria, and even muscularis propria and perirectal fat.
Additionally, the resolution of MRI does not typically allow
delineation of the layers of the rectal wall, thus making it
diffi cult to distinguish T1 from T2 cancers. This limited resolution, along with the unreliability of MRI to differentiate
benign from malignant nodes, often makes it of limited value
in determining suitability for local excision. Endorectal
ultrasound and/or MRI should be added to the clinical evaluation with a fl exible or rigid sigmoidoscope. We often fi nd it
very helpful to use both in those tumors that are above the
reach of the fi nger. We fi nd the fl exible scope very helpful in
gaining a better view of the lesion itself. However, position
of the mass that cannot be palpated can only reliably be
determined with a rigid sigmoidoscope as orienting a lesion
anterior, posterior, left, and right with a fl exible scope is
often diffi cult. While it is usually not emphasized, a careful
digital examination probably represents the single most
important component of the evaluation.
The second issue that should be addressed if one is looking at a lesion, and there is some question as to whether or
not there is an invasive component to it, is what will be the
preferred approach for this patient should there be an underlying cancer. In this fashion, sometimes we advocate a submucosal excision using a transanal or TEM/TAMIS/TEO
approach in order to have an effective excisional biopsy on a
lesion if it is felt from clinical and radiographic evaluation to
be benign and if the determination is that more dramatic surgery would be entertained if there was an invasive component to the lesion. Further pathologic subclassifi cation of T1
tumors has been performed looking at the depth of invasion
Table 14.1 Risk of lymph node metastases in T1 rectal lesions by
submucosal invasion
% of patients with lymph node metastases
SM1 0 %
SM2 10 %
SM3 25 %
into the submucosa. The depth of invasion can be designated
as SM1, SM2, or SM3, in accordance with what “third” of
the submucosa the lesion extends. This pathologic subclassifi cation can provide further information regarding the risk
of lymph node metastases and, thus, local recurrence.
Kikuchi et al. reported that in a study of 182 patients, no
patients with SM1 lesions had lymph node metastasis, but
10 % of SM2 patients and 25 % of SM3 patients did have
metastases to the lymph nodes. They found that SM3 was an
independent, statistically signifi cant risk factor for lymph
node metastases (Table 14.1 ) [ 6 ].
Why Do Lesions Recur After Local Excision?
Key Concept: Under-staging, tumor biology, and technical
factors all play a role in the development of recurrence following local excision for rectal cancer.
Reasons for “local recurrence” for local therapy of rectal
cancer are fourfold. Oftentimes, these include:
1. Untreated involved lymph nodes
2. Tumor implantation at the time of surgery
3. Tubular lymphatic spread or persistence at the time of
surgery
4. A positive margin leaving a residual cancer (i.e., an R1
resection)
Local recurrence in these settings has more to do with
local persistence of the cancer as the lymph nodes have not
been treated either surgically or sterilized with radiation. The
reasons for these issues being central to local recurrence of
rectal cancer have to do with the challenge of local therapy.
First, working transanally, it is diffi cult to gain adequate
resection of the cancer. This must entail clearance distally,
cephalad, and in the deep fashion. It is often diffi cult for the
surgeon operating transanally to gain a good cephalad margin, and this is the main reason why the higher incidence of
failure exists for transanal incision as opposed to other techniques. Additionally, in operating endoluminally with an
intact cancer, there is a much higher risk of tumor implantation. The basic tenets of colon and rectal surgery are to
exclude the cancer with a clamp or stapler and then irrigate
and have your margin of resection at that point, distal to the
clamp. Unfortunately, when operating within the lumen of
the rectum with a live cancer in place, this is always a challenge and speaks of the need for irrigation of the operative
fi eld once the tumor is out with a tumoricidal agent. Third,
222
J.H. Marks and H. Reynolds
lymph node resection in an endoluminal fashion can be carried out only for the few perirectal nodes that may be found
immediately deep to the cancer itself. However, a real thorough mesorectal excision is never carried out using a traditional local excision or TEM/TAMIS/TEO approach. The
last challenge, of course, is that of lymph node staging. The
ability to identify which patients being operated on have
lymph node metastases impacts markedly the way the patient
is addressed. Any evidence of lymph node metastases should
make you highly question the indication of a transanal
approach—especially in the absence of combined modality
therapy.
Location
Key Concept: Distal lesions recur at higher rates and have
overall worse survival.
In looking at matters of failure of treatment of rectal cancer more closely, the level of the cancer becomes of primary
importance. Following radical surgery, Wibe in 2004 found
the failure rate of low rectal cancers to be statistically signifi cantly worse. In a study of over 2,000 patients, they demonstrated a statistically signifi cant increase in local failure of
cancers in the distal third of the rectum (0–5 cm level), with
a 15 % local recurrence rate compared to a 9 % failure rate
for tumors in the upper third of the rectum in the same study.
This correlated with a signifi cantly worse survival for cancers in the distal third of the rectum (59 % in the distal rectum vs. 69 % in the upper rectum and 62 % in the mid-rectum)
[
7 ]. The reason for this is not surprising and has to do with
the issues brought up earlier. As one gets down further into
the pelvis, it is more diffi cult to operate cleanly without compromising the lateral margins. Additionally, even when operating in the proper TME plane, the mesorectum is much
thinner as the rectum prepares to traverse the sphincter
mechanism, so the lateral aspect of the tumor, and the deep
margin, would put a cancer cell directly against the levators,
increasing the likelihood of failure. These same factors are in
play when addressing a low rectal cancer transanally.
Impact of Lymph Nodes
Table 14.2 Rate of mesorectal node positivity by pathologic T stage
Pathologic T stage Pathologic N stage (%)
pT1 6–12
pT2 17–22
pT3 >60
undergoing proctectomy show disturbingly high rates of
mesorectal node positivity: for a T1 cancer, nodal involvement ranges between 5 and 12 %; for T2 cancers, in the
range of 17–25 %; and for T3 cancers, between 40 and 60 %
(Table 14.2 ) [ 7 – 11 ].
This being the case, the clinician has predictably fallen
back on staging mechanisms focused on evaluating T stage.
Unfortunately, ERUS is our best preoperative imaging modality for determining node positivity, and it is only approximately 70 % sensitive. To date, endorectal ultrasound remains
the gold standard, although as previously mentioned, more
and more interest has been raised by excellent results by Gina
Brown and her group looking at MRI studies of rectal cancer
[ 12 ]. T stage accuracy has been reported between 80 and
90 % with N stage accuracy between 70 and 80 %. However,
even noted by such distinguished experts as the late Doug
Wong, “unfortunately, fi ne distinction between deep tumors
of one T stage and early tumors of the next T stage … are
often diffi cult to make. Additionally regional lymphatic
involvement is often diffi cult to determine because endorectal
ultrasound cannot detect nodes further away in the mesorectum or fi nd micrometastatic disease in a perirectal lymph
node” [ 13 ]. When one looks at a gross specimen on a radical
resection after neoadjuvant therapy and TME resection, one
can see why it is diffi cult to fi nd small microscopic deposits
that would reside in the perirectal fat or the muscularis propria (Fig. 14.1 ). It was Fidler who described “the metastatic
decathlon” through which a primary cancer anywhere in the
body, not just the rectum, liberated tumor cells created via a
vascularity entrance into the bloodstream, interacting with the
intravascular immunocompetent cells, gaining endothelial
contact, and either taking a hold in the lymph nodes or proliferating and having metastases develop [ 14 ]. To detect scant
cells in a lymph node that have completed this course remains
a challenge for all staging strategies to date.
Key Concept: Accurate staging dramatically predicts lymph
node positivity and guides proper selection of patients.
Unfortunately, limitations with both MRI and ERUS make
this more inherently diffi cult.
The next challenge for local therapy of rectal cancer has
to do with lymph nodes. The best predictor for lymph node
involvement, even in the year 2013, unfortunately, is still the
tumor T stage. Controversy exists as to which T stages are
appropriate for local excision techniques. Studies of patients
So Whom Should You Select for a Transanal Approach (for Cure)?
Key Concept: In general, T1 lesions with no evidence of
lymph node metastases and good histopathological factors
are the best patients. However, there will still be a small percentage of patients that will recur.
As we look at some of the larger trials of rectal cancer
treated locally, we see alarmingly high rates of failure.
14 Local Treatment of Rectal Cancer (TEM Versus TAMIS Versus Transanal Excision)
223
Bleday and Steele in the late 1990s reported on 48 patients
treated with full-thickness local excision and noted a 10 %
failure rate in the T1 cancers and a 40 % failure rate in the T3
cancers. Fifteen percent of these patients developed some
form of fecal fi stula [
15 ]. The CALBG group in 1999
reported on 110 patients treated locally with local excision
for rectal cancer. The T1 cancers in that group had a 6 %
failure rate and the T2 cancers a 14 % failure rate.
Additionally, 15 % of the patients in this group had positive
margins at the time of surgery [ 16 ]. Rothenberger in 2000
reported on 108 patients with rectal cancer treated locally
from the University of Minnesota and showed an 18 %
Fig. 14.1 Gross specimen on radical resection after neoadjuvant therapy and TME resection
failure rate for T1 cancer and a 47 % failure rate for T2 cancer [ 17 ]. The University of Minnesota data was updated in
2005, showing 101 T1 cancers operated on with a 19 % local
recurrence rate and 50 T2 cancers operated on with a 45 %
local recurrence rate [ 18 ]. Additionally, the Cleveland Clinic
reported on their failure rate in T1 cancers, and this showed
a striking 29.4 % local recurrence rate in 52 patients with T1
cancers treated locally [ 19 ]. These experiences led the
University of Minnesota to conclude in their paper that oncologic outcomes in T1 cancers may be compromised by local
excision alone and that local excision alone is inappropriate
for T2 patients for surgery (Table 14.3 ).
The Norwegian rectal cancer group reported their T1 cancers operated upon either radically or with local excision
[ 20 ]. It is noteworthy that in 256 patients who had radical
resection, as would be expected in these early cancers, there
was 100 % R0 resection. An 11 % rate of node positivity was
also found. The local failure rate in that group was 6 % compared to the 38 patients in the local excision group of which
there was a 17 % R2 resection and a 12 % local recurrence
rate. In looking at this data more closely, it is actually somewhat surprising that there was not a higher failure rate due to
a high rate of positive margins. What is noteworthy is that the
failure rate for local excision is nearly exactly the same as
the node positivity rate for T1 cancers undergoing radical
resection. Looking at the data regarding local recurrence rate
and lymph nodes together, we see lymph node involvement
in between 6 and 12 % in the radically resected groups, and
the failure rate with local recurrence after transanal excision
in these experiences remains between 6 and 29 %. The conclusion we have reached in evaluating this data is that there
are two possibilities for this. One is the persistence of
untreated cancer in the lymph nodes, and two is the disturbance of the specimen cancer with incomplete resection and
handling of the tissue transanally resulting in implantation of
tumor at the time of surgery.
So whom should you select for a transanal approach?
This obviously is a complex question with no quick and easy
answer. In general, the decision to pursue local treatment of
rectal cancer has to do both with the patient’s comorbid conditions and the stage of the cancer. For a polyp with a small
focus of cancer, this is an ideal approach for a full-thickness
local excision. Patients with higher comorbidities such as
obesity and preoperative pelvis are going to have a higherrisk profi le for a major operative procedure. A greater
Table 14.3 Local recurrence rates by T stage
Bleday et al. (1997)
15 ] ( n = 48)
[
T1 10 % 6 % 18 % 19 % 29.4 %
T2 0 % 14 % 47 % 45 %
T3 40 %
Steele et al. CALBG
(1999) [ 16 ] ( n = 110)
Mellgren et al. (2000 ) [
( n = 108)
17 ]
Mellgren et al. (2005)
18 ] ( n = 151)
[
Madbouly et al. (2005)
[ 19 ] ( n = 52)
224
J.H. Marks and H. Reynolds
consideration of local excision would be entertained.
Ultimately, our approach in general for local excision alone
is only early T1 cancers with low risk for lymph node spread.
That would be an SM1 with no lymphovascular invasion or
poor differentiation.
Operative Approaches
“Traditional” Local Excision
Key Concept: More distal lesions that can be more easily
directly visualized to ensure negative resection margins provide the best patients for this approach.
In patients deemed appropriate for local excision, a variety of approaches are available. Preoperative evaluation is
undertaken as outlined above. Patient positioning is determined by tumor location as emphasized previously.
Anteriorly based tumors necessitate prone positioning, while
posteriorly based tumors are approached via lithotomy.
Standard transanal techniques are best suited for middle and
lower third lesions. A safe, reproducible operative technique
is discussed below. A set of multiple operating proctoscopes
of varying lengths and diameters is essential (Fig. 14.2 ).
Anal effacement sutures are placed to facilitate exposure and
placement of operating proctoscopes (Fig. 14.3 ). A headlight
is essential if lighted proctoscopes are not available. An
appropriately sized proctoscope is chosen which centers the
lesion in the operative fi eld (Figs. 14.4 and 14.5 ). Dissection
can be performed with the use of standard long instruments.
However, laparoscopic instruments can be very helpful. Stay
sutures are placed at the lateral borders of the lesion. A dissection margin of one cm is marked with the cautery, and the
excision is begun, proceeding with a full-thickness excision
(Figs. 14.6 and 14.7 ). The deep margin extends to the meso-
rectal fat (Fig. 14.8 ). Care is taken to ensure the specimen is
not fragmented. The lesion is retrieved and pinned on a foam
board and the margins oriented (Fig.
carefully reviews the margins with the pathologist and takes
additional tissue if necessary. The defect is closed transversely. The previously placed stay sutures facilitate the closure (Fig.
14.10 ). The closure is examined with the
proctoscope to ensure adequacy of the closure and patency
of the rectal lumen. Proximal, anteriorly based lesions are
particularly challenging. If above the peritoneal refl ection,
one must be sure of adequate closure. A preoperative discussion should be done with the patient regarding the possible
need for laparoscopy or laparotomy and the potential need
for proximal diverting loop ileostomy. If the integrity of the
anastomosis is unclear, laparoscopy with proctoscopy and
leak testing can be performed. Revision of the closure or formal proctectomy with or without diversion may be necessary
if an intraperitoneal leak is found.
14.9 ). The surgeon
Fig. 14.2 Operating proctoscopes
Fig. 14.3 Prone for anterior tumor, anal effacement sutures
Fig. 14.4 Operating proctoscope placed and secured
14 Local Treatment of Rectal Cancer (TEM Versus TAMIS Versus Transanal Excision)
225
Fig. 14.5 Tumor viewed
Fig. 14.6 Setup for excision
Minimally Invasive Options
Key Concept: Both TEM and TAMIS provide transanal
approaches to higher lesions that were previously not possible with traditional transanal excision. For anterior and
more proximal lesions, you should counsel the patient as to
the possible need for a laparotomy/laparoscopy or possible
diversion if the intraperitoneal cavity is breached.
Particularly with middle and upper third lesions, the question that comes to mind is whether the operative approach
can be improved, and if so, how? This begs the question
about the role of endoluminal surgery, be it TAMIS or TEM.
Transanal Endoscopic Microsurgery (TEM)
The technique of TEM uses an operating proctoscope 4 cm
in diameter, which is attached to the table with a Martin’s
Arm. Using a video attachment or an operating microscope,
Fig. 14.7 Stay sutures and margin marking
Fig. 14.8 Full-thickness excision
an airtight insuffl ation is gently placed, and this gives access
to the rectum from the anal canal up to the rectosigmoid or at
times even higher (Fig.
14.11 ). The equipment comes with
three types of shafts: a beveled 20 cm shaft for higher lesions,
a 15 cm shaft for smaller lesions, and a 10 cm fl at
TEM equipment for lesions with an inferior margin at the
226
J.H. Marks and H. Reynolds
Fig. 14.9 Pinned and oriented
gently insuffl ated such that a 1 cm margin can be clearly
marked, and this is marked circumferentially to start the
operation (Video 14.1 ). The electrocautery is then used to
incise circumferentially around the lesion through the
muscularis and down to the mesorectum, taking as much of
the mesorectum as is desired. The general rules for indications are that TEM should be avoided for lesions in the upper
rectum as well as particularly anteriorly so as to avoid entering into the peritoneal cavity. That said, with increased experience, this can be done safely with good closure. We recently
reviewed our experience of 26 patients with TEM excision of
tumors that had entrance into the peritoneal cavity during
their excision. The group included patients with polyps as
well as invasive cancer. Fifty percent of the patients had neoadjuvant radiation prior to their excision. There was a minor
morbidity rate of 7 and 3 % wound disruptions, all of whom
had radiation prior to surgery and all of whom were treated
conservatively. In our hands, the threat of entrance into the
peritoneal cavity during transanal excision is not a contraindication to surgery and is not a complication to be avoided
(Fig. 14.12 ). That being said, it is still prudent to have a dis-
cussion with the patient preoperatively about the potential
need for laparoscopy and/or laparotomy if closure is diffi cult
or a leak is suspected. Just as with standard transanal excision techniques, it is always important to be prepared for
potential revision or resection, with or without diversion, if
one fi nds a particularly diffi cult tumor or closure. This mental and physical preparation of the patient, the surgeon, and
the remainder of the OR team is important, regardless of the
surgeon’s skill level, so that appropriate equipment is
available and a seamless transition to an abdominal approach
can be made (if needed) when a diffi cult dissection or closure is encountered.
Fig. 14.10 Transverse closure
anorectal ring. Saclarides looked at T1 cancers treated with
TEM, the aggregate being 221 patients operated upon, and
found a local failure rate of 6.3 % [ 21 ]. In a comparison of
TEM and transanal excision patients for cancer, Moore
described a statistically signifi cant improvement in clear
margins with TEM as well as the ability to avoid fragmentation of the specimen using a TEM compared to a transanal
operation [ 22 ]. While this has not been, and likely will not
be, done with a TAMIS approach, it is predictable that a similar outcome would be achieved as this technique also permits pneumo-distention of the rectum with excellent optics
and reach of the instruments.
From a technical standpoint, the operating microscope
allows clear visualization of the lesion, and the rectum is
Transanal Minimally Invasive Surgery (TAMIS)
First described in 2009, transanal minimally invasive surgery
(TAMIS) coupled the experiences built on the emerging single-port technology with traditional laparoscopic equipment
[ 23 ]. As most operating rooms possess standard laparoscopic
equipment and insuffl ation, and surgeons are becoming
increasingly familiar with the technical skills required to
resect the specimen and close the resultant defect, TAMIS
allows for another minimally invasive means to reach of
tumors as high as 15 cm from the anal verge without the
expensive equipment required for TEM (Videos 14.2 and
14.3 ). More recently, TAMIS platforms, such as the SILS TM
port (Covidien, Mansfi eld, MA) and Gelpoint Path (Applied
Medical, Rancho Santa Margarita), provide standardized
endoluminal rectal access to aid in ease of the procedure.
TAMIS outcomes thus far have been similar to both
transanal and TEM approaches, though lack the long-term
follow- up. Albert and colleagues reported on their fi rst 50
patients (56 % malignant) undergoing a TAMIS procedure
14 Local Treatment of Rectal Cancer (TEM Versus TAMIS Versus Transanal Excision)
a
b
c
227
Fig. 14.11 TEM apparatus. ( a ) Operating proctoscope. ( b ) Proctoscope with Martin’s Arm. ( c ) Proximal end of proctoscope, showing TEM
instruments and camera
in one of the largest series to date. Overall, a recurrence
The Role of Radiation Therapy
occurred in 4 %, with positive margins occurring in 6 %,
and development of early (6 %) and long-term (0 %)
complications at a median follow-up of 20 months [ 24 ]. The
authors concluded that operative times are faster than TEM,
with overall outcomes being equivalent to TEM, and
improved when compared to local excision series. Other
TAMIS series have reported conversion to laparotomy for
resection or diverting stoma (0–10 %), bleeding [ 5 – 10 ], per-
foration, infection (<5 %), and temporary incontinence (10–
30 %) [ 25 ]. Late complications including stricture, fi stula,
and recurrence have been reported, though are generally
rare. Technical tips for intraperitoneal entry involve a twolayer closure, placement of the patient in steep Trendelenburg
position to facilitate retraction of the abdominal viscera
from the pelvis, and a water-soluble enema in the early postoperative period to confi rm absence of a leak. Another
option is to perform laparoscopy at the time of the peritoneal entry to help with repair and placement of a drain and
to perform a leak test [ 25 ] .
Key Concept: Radiation therapy decreases local recurrence
for stages 1–3 lesions, and we feel it should be given for all
patients preoperatively. Postoperative radiation therapy
should be reserved only for select cases.
Regardless of local excision technique chosen, what is the
role of radiation for stage I rectal cancer? Should preoperative radiation be utilized in early-stage cancers in the rectum
if local excision is being considered? In looking at the MRC
CR07 trial, comparing preoperative radiotherapy versus
selective postoperative radiotherapy, interesting results were
found. This was a multicenter randomized trial involving
1,350 patients who were operated on radically. It is noteworthy that there was a 31.5 % abdominoperineal resection rate
in these patients. It is also of note that the local failure rate at
3 years for T1 cancers treated with preoperative radiation
was 1.9 %, compared to 2.8 % treated postoperatively. For
T2 lesions, local failure with preoperative radiotherapy
was 1.9 % compared with a 6.4 % local failure rate with
228
a
d
J.H. Marks and H. Reynolds
b
c
Fig. 14.12 ( a ) Margin marked by electrocautery. ( b ) Full-thickness, hemi-circumferential local excision. ( c ) TEM anastomosis. ( d ) Specimen,
oriented and pinned out on cork board
postoperative treatment for selective postoperative treatment. Additionally, the failure rate for T3 cancers was down
to 7.4 % when compared to 15.4 % in the postoperative
radiotherapy group. All of these were statistically signifi cant. This led the authors to conclude that for stage I as well
as stage II and III disease, their data showed statistical
improvement in terms of local control for cancers treated
preoperatively with radiation therapy and advocated preoperative radiation treatment [ 26 ].
Our experience with radiation therapy followed by local
excision dates back to 1984. This was the fi rst experience in
the world of local excision after preoperative radiation therapy. This was performed at Jefferson with the Marks and
Mohiuddin method [
27 , 28 ]. In 2004, we reported on 44
patients treated with T2, N0 cancer in the distal 7 cm and
found an overall local recurrence rate of 6.9 %. Twenty-three
percent of these patients had complete responses, and there
were no failures in that group. There was a 91 % 5-year survival rate [
29 ]. Only a quarter of those patients were operated
on using TEM. The others were done in transanal approaches.
As we compared our experience with T2 rectal cancers following neoadjuvant treatment with TEM versus total mesorectal excision (TME), we found in 73 patients the local
recurrence rate was not statistically different. It was 3.3 %
for the TEM group compared with 2.3 % for the TME group.
Additionally, survival was no different: 95 % in the TEM
group compared with 97 % in the TME group [ 30 ]. Lezoche
published similar results for full-thickness local excision
14 Local Treatment of Rectal Cancer (TEM Versus TAMIS Versus Transanal Excision)
a
Fig. 14.13 Endoscopic images of rectal lesion before and after neoadjuvant chemoradiation. ( a ) Before, ( b ) after
b
229
after chemoradiation: 5 % local recurrence rate and an 89 %
survival rate [ 31 ] (Fig. 14.13 ).
In general, postoperative radiation is never, in our minds,
the ideal treatment plan. The only time this is employed has to
do when there is a more advanced local stage of disease than
originally anticipated by preoperative staging. For patient
staged as an early T1 cancer or polyp that ends up having a T2
cancer but clean deep margins, I would consider postoperative
radiation therapy as an option as opposed to proceeding always
to radical surgery. Again, a discussion regarding the risk profi le of the patient and the risk of leaving not fully treated lymph
nodes in place has to be undertaken with the patient.
Summary Pearls
In conclusion, local excision for early-stage cancer is generally not suffi cient. In a select case of medically compromised
patients, of course, this is an ideal approach. For early T1
cancers or polyps with a small focus of cancer, local excision
is clearly suffi cient. However, for signifi cant T1 cancers, a
more aggressive approach is necessary. Undoubtedly, surgical technique matters, whether standard transanal excision
techniques or TEM/TAMIS is utilized. One of the authors
prefers a selective approach to the use of TEM/TAMIS versus standard TAE, reserving TEM/TAMIS for middle third
and higher lesions. The other prefers the routine use of TEM
for all levels. The choice of approach should be based not
only on the location and characteristics of the tumor but also
on the skill set of the operating surgeon and the equipment
that is available. Selected reports of TEM results suggest
improved local recurrence rates with TEM versus TAE; however, others suggest similarly high rates with TEM (10–20 %
local recurrence rates with T1 lesions) [ 32 , 33 ].
Chemoradiation holds promise to diminish the high failure
rate for T1 and T2 cancers. Our general treatment algorithm
is to treat high-risk unfavorable patients with rectal cancer
with chemoradiation preoperatively. High-risk patients are
defi ned as any T3 or node-positive patients and all cancers in
the distal third of the rectum. The tumor’s response to radiation therapy dictates whether a local approach to their cancer
is warranted. In general, the tumor must have regressed to a
size less than 4 cm without deep ulceration and felt to be
confi ned to the bowel wall. The local excision is carried out.
If there is full-thickness penetration or node positivity, radical surgery is then recommended. If there is a ypT1 or T2
cancer present, this serves as defi nitive therapy.
By combining local excision techniques and chemoradiation, the problem of persistent disease from untreated lymphatics is addressed. In higher lesions, TEM/TAMIS helps
address the problem of specimen fragmentation and the challenge of achieving clear margins by operating with an endoluminal approach. With the combination of these approaches,
the patient has an increased chance for success with an
expanded role of local therapy for stage I rectal cancer. The
challenge that persists, unfortunately, remains to better stage
rectal cancers, so we can clearly identify those that have no
lymphatic involvement. With more reliable information on
staging in hand, we would have the technical ability with
TEM and TAMIS to treat cancers in the upper rectum itself.
Unquestionably, the future will see wider application of these
techniques as additional work with these multidisciplinary,
minimally invasive approaches to rectal cancer progresses.
Take-Home Points
1. Local excision is suffi cient for early T1 cancers/polyps
with a small focus of cancer.
2. Combining local excision and chemoradiation may
address the problem of persistent disease from untreated
lymphatics.
230
J.H. Marks and H. Reynolds
3. TEM/TAMIS addresses visualization, margin identifi cation, and specimen fragmentation in higher rectal lesions.
4. A continued challenge is the need for better staging of
rectal cancers to identify those cancers that have no lymph
node involvement.
References
1. Miles WE. A method of performing abdomino-perineal excision
for carcinoma of the rectum and of the terminal portion of the pelvic colon. CA Cancer J Clin. 1908;21:361–4.
2. Marks G, Mohiuddin M, Borenstein B. Preoperative radiation ther-
apy and sphincter preservation by the combined abdominotranssacral technique in selected rectal cancers. Dis Colon Rectum.
1985;28(8):565.
3. Buess G, Kipfmuller K, Hack D, et al. Technique of transanal endo-
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