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M. L. Westfal and M. G. Mutch
and this has been studied in clinical trials but remains controversial [28, 40–42].
Taira etal. looked at the prognosis of patients with T1 rectal cancer stratied by
pre-operative chemo-radiation therapy. In 86 patients there was no signicant difference in relapse-free survival but they did nd that in a multivariate analysis,
tumor location within 5cm from the anal verge was a signicant risk factor associated with a poor relapse-free survival [43].
In terms of adjuvant therapy, Minsky etal. concluded that post-operative radiation therapy is not needed after local excision in patients with T1 tumors and negative prognostic features [44]. On the other hand, Taylor etal [45] and Lamont etal.
[46] reported that adjuvant radiation therapy improved both recurrence rate and
survival in their patient cohorts. Paty etal. [47] reported that local recurrence was
delayed in patient that received adjuvant pelvic radiation. Finally, Borstlap et al.
concluded that local recurrence rates in T1 rectal cancer between patients with local
excision with adjuvant therapy and those who underwent radical surgery were comparable [48].
When patients with high-risk T1 lesions refuse radical resection or prioritize
sphincter preservation, adjuvant chemoradiation in combination with local excision
has been considered. A systematic review of patients with T1/T2 rectal lesions
removed by local excision compared the patients who received adjuvant chemoradiation with those that underwent radical resection. The authors report a 10% recurrence rate after local excision with adjuvant therapy versus a 6% recurrence rate
after radical resection of T1 tumors [49]. Oostendorp et al. performed a metaanalysis of 73 studies and showed a local recurrence rate of 6.7% for low risk T1
tumors with local excision alone and no local recurrences in patients treated with
adjuvant pelvic radiation and concurrent chemotherapy. High risk T1 tumors had a
local recurrence rate of 13.6% compared to 3.9% with LE alone versus adjuvant
therapy, therefore the authors concluded that local excision with adjuvant chemoradiation therapy may provide an alternative approach to radical surgery for patients
with high-risk features. In a small study, Balyasnikova etal. found no recurrence at
a median follow-up of 4years in 18 patients with high-risk rectal cancer after undergoing local excision with adjuvant radiotherapy [50]. Al-Sawat etal. concluded that
local excision with adjuvant radiotherapy is a better treatment option to avoid complications and stoma formation compared with radical excision and is a safe alternative for patients with T1 rectal cancer with fewer than three high-risk features [51].
Finally, Swanton etal. found similar results and concluded that local excision followed by adjuvant pelvic radiation is feasible, safe and yields good locoregional
control in T1 rectal cancers, thereby avoiding denitive surgery and the morbidity
associated with LAR or APR. [52]
In summary, the NCCN guidelines8 recommend that for node negative T1 rectal
cancer, lesions can be treated with trans-abdominal resection or trans-anal resection
as appropriate. If pathology review after local excision reveals no high-risk features,
then no further treatment is required. However, if pathology shows poorly differentiated histology, positive margins, invasion into the deepest third of the submucosa
(sm3), LVI or PNI, then additional treatment is required. Trans-abdominal resection
is the preferred next step in management followed by adjuvant therapy based on
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pathologic stage. If patients instead undergo adjuvant chemoradiation therapy after
local excision, additional treatment will be determined by whether there is evidence
of residual disease. If there is no evidence of disease, observation or additional chemotherapy can be considered based the patient’s risk factors. If there is evidence of
disease, then trans-abdominal resection should be performed with or without adjuvant chemotherapy. It is imperative that the patient undergo careful surveillance if
they forego trans-abdominal resection.
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Surveillance
Whether or not patients with T1N0M0 rectal cancer require further surveillance
remains controversial. ASCRS and NCCN guidelines both recommend surveillance
for stage 1 rectal cancer with a regular history and exam, CEA, exible sigmoidoscopy/proctoscopy and colonoscopy. There is no role for routine imaging for these
patients [1, 8]. On the other hand the Cancer Care Ontario (CCO) and the American
Society of Clinical Oncology (ASCO) do not recommend surveillance for stage I
patients for colon or rectal cancer [53]. The decision regarding surveillance for
patients with T1 rectal cancer should be made on an individual basis based on the
patient’s risk factors.
Outcomes
Local Recurrence
The risk of local recurrence for patients undergoing local excision remains unknown.
One retrospective study by Nash etal. showed that in 282 patients undergoing either
transanal local excision or radical resection for T1 rectal cancer, the respective local
recurrence rates were 13.2% and 2.7% respectively [23]. A similar retrospective
study by You etal. showed local recurrence rates of 12.5% for transanal excision
patients and 6.9% for radical resection patients [27]. Rates of local control following local excision have been shown to be favorable in T1 sm1–2 tumors [54], while
prognostic factors for increased local recurrence rates include high grade tumors,
LVI, PNI, tumor budding, sm3 tumors, mucinous type tumors, and positive resection margins [36, 37, 55]. Overall, several studies have found recurrence rates of
10–30% for patients undergoing local resection for T1 rectal cancer [45, 56–58].
In high-risk patients the risk of local recurrence is higher. One meta-analysis
looking at local recurrence in patients with high-risk T1 and T2 rectal cancer who
did not receive additional therapy showed a substantial risk of local recurrence.
Completion TME or adjuvant chemoradiation for T1 patient was found to mitigate
that risk. This provides support for using full thickness local excision as a guide to
denitive management. Another meta-analysis reported a substantial risk of local
recurrence in patients with high-risk T1 and T2 rectal cancer who received no additional therapy following local excision. The authors conclude that neo-adjuvant
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chemoradiation therapy followed by local excision may be safe and effective alternative for patients with any T stage of cancer who refuse or are unt for transabdominal resection but understand that further studies are needed to explore this
management suggestion [59].
Finally, Madbouly etal [60] showed that the 5-year recurrence rate after transanal excision was 29.4%. 5-year cancer specic and overall survival were 89% and
75% respectively. Nearly all patients with a recurrence underwent salvage treatment
with a 56.3% ve-year survival rate. They concluded that although overall cancer
survival rates might be regarded as satisfactory, the high recurrence and low salvage
rate raises the issue about the role of transanal excision alone for early rectal cancer
and the potential need to consider adjuvant therapy for these patients.
M. L. Westfal and M. G. Mutch
Metastasis
Lymph node (LN) metastasis occurs in 2–35% of T1 lesions. When looking at the
depth of tumor involvement into the submucosa and LN metastasis in T1 rectal
cancer, the rates of LN metastasis for sm1, sm2 and sm3 tumors was 2%, 9%, and
35% respectively [25]. Additionally, Kitajima etal. established the method for measuring submucosal invasion depth (SID) and found that lesions with SID less than
1000 micrometers had no evidence of lymph node metastasis. The clinical guidelines of the Japanese Society for Cancer of the Colon and Rectum describe the
method of measuring an SID and advise additional surgical resection with lymph
node dissection after endoscopic treatment for lesions with SID greater than 1000
micrometers. This “1000 micrometer rule” is recommended as a criterion for additional resection in many previous papers [34, 61, 62] and is used as a gold-standard
indicator for endoscopic diagnoses, such as magnifying endoscopy or imageenhanced endoscopy [63]. As endoscopic techniques progress, endoscopic treatment is becoming more widely acceptable for lesions with SID greater than or equal
to 1000 micrometers [61, 64, 65].
Disease Free andOverall Survival
Although limited, some data suggests that TEM may have similar oncologic outcomes
in patients with T1N0M0 rectal cancer compared with radical resection, while additionally offering patients the benets of local resection [66, 67]. Additionally, Lu etal.
showed that although the local recurrence rate after TEM was higher than that after
TME, distant metastasis, overall survival and disease-free survival rates did not differ
between these groups [68]. Clancy etal. performed a meta-analysis in 2015 and found
that TEM provides superior oncologic outcomes compared to transanal local excision
as it had a higher rate of negative microscopic margins, reduced rate of specimen
fragmentation, and reduced rate of lesion recurrence [69]. Endreseth etal. completed
a prospective study from the Norwegian Rectal Cancer Project looking at 291 patients
with T1 rectal cancer treated with radical resection or trans-anal excision. They found
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that the 5-year survival for trans-anal excision was 70% compared to 80% in the radical resection group [55]. Hyun etal. performed a retrospective review from multicenter data and used propensity score matching to form two groups of patients who
underwent local excision and compared them to patients who underwent TME for T1
rectal cancer. They found that although patients who underwent local excision had
higher local recurrence rates, there was no difference in disease-free survival or overall survival [70]. Several other studies found that there was not a signicant difference
in overall survival rate between patients undergoing local excision versus TME with
T1 rectal cancer [27, 57, 71].
251
Quality ofLife
Local excision is associated with improved quality of life secondary to overall decreased
morbidity in terms of bowel function, sexual function, and micturition function. In the
NSABP R-04 trial, patients who had an APR reported worse body image, worse micturition symptoms, and less sexual enjoyment at 1year post- surgery compared to those
who had sphincter-sparing surgery [8]. An extra-levator APR may have benets over a
conventional APR approach, including lower rates of intra-operative perforation, CRM
involvement and local recurrence although the data remains varied [72, 73]. Further
studies comparing the quality of life of patients after radical resection and local excision are needed to further delineate these outcomes in more detail.
Conclusion
In patients found to have T1 rectal cancer, a careful review of the pathology as well
was local and distant staging is necessary in order to determine if a local excision or
a radical resection is appropriate. All resected specimens should undergo pathologic
review to assess for high-risk features because presence of these features are associated with an increased likelihood of mesorectal lymph node involvement and therefore a radical resection with TME would be warranted in this setting. If the patient
has signicant co-morbidities and is not a candidate for radical resection, then a
local excision should be considered. Although this is the safer approach from an
operative standpoint in terms of morbidity, mortality and sphincter function, there is
a possible increased risk of local and distant failure. For patients that opt for a local
excision, close surveillance is necessary in order to identify local recurrence quickly
should it occur. The use of either neo-adjuvant and/or adjuvant chemoradiation
therapy remains controversial but may provide better outcomes for patients opting
to undergo local excision. A multi-disciplinary clinical team should be utilized in
order to review each case on an individual basis and provide the patient with all possible options for the management of T1 rectal cancer. Overall, it is important to
match the treatment plan approach to the individual patient and all risk factors must
be explained to the patient in order to allow them to make an informed decision that
considers short and long-term risks and benets.
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M. L. Westfal and M. G. Mutch
References
1. You YN, Hardiman KM, Bafford A, etal. The American Society of Colon and Rectal Surgeons
clinical practice guidelines for the Management of Rectal Cancer. Dis Colon Rectum.
2020;63(9):1191–222.
2. Kudo S, Tamegai Y, Yamano H, etal. Endoscopic mucosal resection of the colon: the Japanese
technique. Gastrointest Endosc Clin N Am. 2001;11(3):519–35.
3. Marijnen CA, Kapiteijn E, van de Velde CJ, etal. Acute side effects and complications after
short-term preoperative radiotherapy combined with total mesorectal excision in primary rectal cancer: report of a multicenter randomized trial. J Clin Oncol. 2002;20(3):817–25.
4. Snijders HS, Wouters MW, van Leersum NJ, etal. Meta-analysis of the risk for anastomotic
leakage, the postoperative mortality caused by leakage in relation to the overall postoperative
mortality. Eur J Surg Oncol. 2012;38(11):1013–9.
5. Guillou PJ, Quirke P, Thorpe H, etal. Short-term endpoints of conventional versus laparoscopicassisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet. 2005;365(9472):1718–26.
6. Hamilton S.Carcinoma of the colon and rectum. Pathology and genetics of tumours of the
digestive system. 2000:103–43.
7. Cooper HS, Deppisch LM, Gourley WK, etal. Endoscopically removed malignant colorectal
polyps: clinicopathologic correlations. Gastroenterology. 1995;108(6):1657–65.
8. Benson AB, Venook AP, Al-Hawary MM, etal. Rectal cancer, version 2.2022, NCCN clinical
practice guidelines in oncology. J Natl Compr Cancer Netw. 2022;20(10):1139–67.
9. Yoshii S, Nojima M, Nosho K, etal. Factors associated with risk for colorectal cancer recurrence
after endoscopic resection of T1 tumors. Clin Gastroenterol Hepatol. 2014;12(2):292–302 e293.
10. Tarantino I, Warschkow R, Worni M, etal. Elevated preoperative CEA is associated with worse
survival in stage I-III rectal cancer patients. Br J Cancer. 2012;107(2):266–74.
11. Adloff M, Arnaud JP, Bergamaschi R, Schloegel M.Synchronous carcinoma of the colon and
rectum: prognostic and therapeutic implications. Am J Surg. 1989;157(3):299–302.
12. Barillari P, Ramacciato G, De Angelis R, et al. Effect of preoperative colonoscopy on the
incidence of synchronous and metachronous neoplasms. Acta Chir Scand. 1990;156(2):163–6.
13. Bat L, Neumann G, Shemesh E.The association of synchronous neoplasms with occluding
colorectal cancer. Dis Colon Rectum. 1985;28(3):149–51.
14. Isler JT, Brown PC, Lewis FG, Billingham RP. The role of preoperative colonoscopy in
colorectal cancer. Dis Colon Rectum. 1987;30(6):435–9.
15. Beets-Tan RGH, Lambregts DMJ, Maas M, etal. Magnetic resonance imaging for clinical
management of rectal cancer: updated recommendations from the 2016 European Society
of Gastrointestinal and Abdominal Radiology (ESGAR) consensus meeting. Eur Radiol.
2018;28(4):1465–75.
16. Lahaye MJ, Engelen SM, Nelemans PJ, et al. Imaging for predicting the risk factors—the
circumferential resection margin and nodal disease—of local recurrence in rectal cancer: a
meta-analysis. Semin Ultrasound CT MR. 2005;26(4):259–68.
17. Faletti R, Gatti M, Arezzo A, etal. Preoperative staging of rectal cancer using magnetic resonance imaging: comparison with pathological staging. Minerva Chir. 2018;73(1):13–9.
18. Klessen C, Rogalla P, Taupitz M.Local staging of rectal cancer: the current role of MRI.Eur
Radiol. 2007;17(2):379–89.
19. Benson AB, Venook AP, Al-Hawary MM, etal. Rectal cancer, version 2.2018, NCCN clinical
practice guidelines in oncology. J Natl Compr Cancer Netw. 2018;16(7):874–901.
20. Xie H, Zhou X, Zhuo Z, etal. Effectiveness of MRI for the assessment of mesorectal fascia
involvement in patients with rectal cancer: a systematic review and meta-analysis. Dig Surg.
2014;31(2):123–34.
21. Chaudhri S, Brown L, Hassan I, Horgan AF.Preoperative intensive, community-based vs. traditional stoma education: a randomized, controlled trial. Dis Colon Rectum. 2005;48(3):504–9.
22. Crooks S.Foresight that leads to improved outcome: stoma care nurses’ role in siting stomas.
Prof Nurse. 1994;10(2):89–92.
21 Management ofT1 Rectal Cancer
https://t.me/medicina_free
23. Nash GM, Weiser MR, Guillem JG, etal. Long-term survival after transanal excision of T1
rectal cancer. Dis Colon Rectum. 2009;52(4):577–82.
24. Berger NF, Sylla P. The role of Transanal endoscopic surgery for early rectal cancer. Clin
Colon Rectal Surg. 2022;35(2):113–21.
25. Nascimbeni R, Burgart LJ, Nivatvongs S, Larson DR.Risk of lymph node metastasis in T1
carcinoma of the colon and rectum. Dis Colon Rectum. 2002;45(2):200–6.
26. Rogers AC, Winter DC, Heeney A, etal. Systematic review and meta-analysis of the impact of
tumour budding in colorectal cancer. Br J Cancer. 2016;115(7):831–40.
27. You YN, Baxter NN, Stewart A, Nelson H.Is the increasing rate of local excision for stage
I rectal cancer in the United States justied?: a nationwide cohort study from the National
Cancer Database. Ann Surg. 2007;245(5):726–33.
28. Shaikh I, Askari A, Ouru S, etal. Oncological outcomes of local excision compared with radical surgery after neoadjuvant chemoradiotherapy for rectal cancer: a systematic review and
meta-analysis. Int J Color Dis. 2015;30(1):19–29.
29. Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery—the clue to
pelvic recurrence? Br J Surg. 1982;69(10):613–6.
30. Lindsetmo RO, Joh YG, Delaney CP.Surgical treatment for rectal cancer: an international
perspective on what the medical gastroenterologist needs to know. World J Gastroenterol.
2008;14(21):3281–9.
31. Baxter NN, Garcia-Aguilar J. Organ preservation for rectal cancer. J Clin Oncol.
2007;25(8):1014–20.
32. Yamamoto S, Watanabe M, Hasegawa H, et al. The risk of lymph node metastasis in T1
colorectal carcinoma. Hepato-Gastroenterology. 2004;51(58):998–1000.
33. Seitz U, Bohnacker S, Seewald S, etal. Is endoscopic polypectomy an adequate therapy for
malignant colorectal adenomas? Presentation of 114 patients and review of the literature. Dis
Colon Rectum. 2004;47(11):1789–96. discussion 1796–1787
34. Ueno H, Mochizuki H, Hashiguchi Y, etal. Risk factors for an adverse outcome in early invasive colorectal carcinoma. Gastroenterology. 2004;127(2):385–94.
35. Volk EE, Goldblum JR, Petras RE, Carey WD, Fazio VW.Management and outcome of patients
with invasive carcinoma arising in colorectal polyps. Gastroenterology. 1995;109(6):1801–7.
36. Maeda K, Koide Y, Katsuno H.When is local excision appropriate for "early" rectal cancer?
Surg Today. 2014;44(11):2000–14.
37. Bach SP, Hill J, Monson JR, etal. A predictive model for local recurrence after transanal endoscopic microsurgery for rectal cancer. Br J Surg. 2009;96(3):280–90.
38. Baron PL, Enker WE, Zakowski MF, Urmacher C.Immediate vs. salvage resection after local
treatment for early rectal cancer. Dis Colon Rectum. 1995;38(2):177–81.
39. Friel CM, Cromwell JW, Marra C, etal. Salvage radical surgery after failed local excision for
early rectal cancer. Dis Colon Rectum. 2002;45(7):875–9.
40. Garcia-Aguilar J, Renfro LA, Chow OS, etal. Organ preservation for clinical T2N0 distal
rectal cancer using neoadjuvant chemoradiotherapy and local excision (ACOSOG Z6041):
results of an open-label, single-arm, multi-institutional, phase 2 trial. Lancet Oncol.
2015;16(15):1537–46.
41. Rullier E, Vendrely V, Asselineau J, etal. Organ preservation with chemoradiotherapy plus
local excision for rectal cancer: 5-year results of the GRECCAR 2 randomised trial. Lancet
Gastroenterol Hepatol. 2020;5(5):465–74.
42. Lezoche E, Baldarelli M, Lezoche G, etal. Randomized clinical trial of endoluminal locoregional resection versus laparoscopic total mesorectal excision for T2 rectal cancer after neoadjuvant therapy. Br J Surg. 2012;99(9):1211–8.
43. Taira T, Nozawa H, Kawai K, etal. Oncological outcomes of pathological T1 lower rectal cancer patients with or without preoperative Chemoradiotherapy. In Vivo. 2020;34(6):3559–64.
44. Minsky BD. Conservative treatment of rectal cancer with local excision and postoperative
radiation therapy. Eur J Cancer. 1995;31A(7–8):1343–6.
45. Taylor RH, Hay JH, Larsson SN.Transanal local excision of selected low rectal cancers. Am
J Surg. 1998;175(5):360–3.
253
254
https://t.me/medicina_free
46. Lamont JP, McCarty TM, Digan RD, et al. Should locally excised T1 rectal cancer receive
adjuvant chemoradiation? Am J Surg. 2000;180(6):402–5. discussion 405–406
47. Paty PB, Nash GM, Baron P, etal. Long-term results of local excision for rectal cancer. Ann
Surg. 2002;236(4):522–9. discussion 529–530
48. Borstlap WAA, van Oostendorp SE, Klaver CEL, etal. Organ preservation in rectal cancer: a
synopsis of current guidelines. Color Dis. 2017;
49. Borstlap WA, Tanis PJ, Koedam TW, etal. A multi-centred randomised trial of radical surgery
versus adjuvant chemoradiotherapy after local excision for early rectal cancer. BMC Cancer.
2016;16:513.
50. Balyasnikova S, Read J, Tait D, etal. The results of local excision with or without postoperative adjuvant chemoradiotherapy for early rectal cancer among patients choosing to avoid radical surgery. Color Dis. 2017;19(2):139–47.
51. Al-Sawat A, Bae JH, Kim HH, et al. Short- and long-term outcomes of local excision
with adjuvant radiotherapy in high-risk T1 rectal cancer patients. Ann Surg Treat Res.
2022;102(1):36–45.
52. Swanton C, Marcus S, Jayamohan J, etal. Can adjuvant pelvic radiation therapy after local
excision or polypectomy for T1 and T2 rectal cancer offer an alternative option to radical surgery? Clin Transl Radiat Oncol. 2021;31:97–101.
53. Meyerhardt JA, Mangu PB, Flynn PJ, etal. Follow-up care, surveillance protocol, and secondary prevention measures for survivors of colorectal cancer: American Society of Clinical
Oncology clinical practice guideline endorsement. J Clin Oncol. 2013;31(35):4465–70.
54. Morino M, Risio M, Bach S, etal. Early rectal cancer: the European Association for Endoscopic
Surgery (EAES) clinical consensus conference. Surg Endosc. 2015;29(4):755–73.
55. Endreseth BH, Myrvold HE, Romundstad P, etal. Transanal excision vs. major surgery for T1
rectal cancer. Dis Colon Rectum. 2005;48(7):1380–8.
56. Garcia-Aguilar J, Mellgren A, Sirivongs P, etal. Local excision of rectal cancer without adjuvant therapy: a word of caution. Ann Surg. 2000;231(3):345–51.
57. Mellgren A, Sirivongs P, Rothenberger DA, Madoff RD, Garcia-Aguilar J.Is local excision
adequate therapy for early rectal cancer? Dis Colon Rectum. 2000;43(8):1064–71. discussion
1071–1064
58. Chorost MI, Petrelli NJ, McKenna M, Kraybill WG, Rodriguez-Bigas MA.Local excision of
rectal carcinoma. Am Surg. 2001;67(8):774–9.
59. van Oostendorp SE, Smits LJH, Vroom Y, etal. Local recurrence after local excision of early
rectal cancer: a meta-analysis of completion TME, adjuvant (chemo)radiation, or no additional
treatment. Br J Surg. 2020;107(13):1719–30.
60. Madbouly KM, Remzi FH, Erkek BA, etal. Recurrence after transanal excision of T1 rectal
cancer: should we be concerned? Dis Colon Rectum. 2005;48(4):711–9. discussion 719–721
61. Tanaka S, Asayama N, Shigita K, et al. Towards safer and appropriate application of endoscopic submucosal dissection for T1 colorectal carcinoma as total excisional biopsy: future
perspectives. Dig Endosc. 2015;27(2):216–22.
62. Kawachi H, Eishi Y, Ueno H, etal. A three-tier classication system based on the depth of submucosal invasion and budding/sprouting can improve the treatment strategy for T1 colorectal
cancer: a retrospective multicenter study. Mod Pathol. 2015;28(6):872–9.
63. Kitajima K, Fujimori T, Fujii S, etal. Correlations between lymph node metastasis and depth
of submucosal invasion in submucosal invasive colorectal carcinoma: a Japanese collaborative
study. J Gastroenterol. 2004;39(6):534–43.
64. Asayama N, Oka S, Tanaka S, et al. Endoscopic submucosal dissection as total excisional
biopsy for clinical T1 colorectal carcinoma. Digestion. 2015;91(1):64–9.
65. Saito Y, Sakamoto T, Nakajima T, Matsuda T.Colorectal ESD: current indications and latest
technical advances. Gastrointest Endosc Clin N Am. 2014;24(2):245–55.
66. Kidane B, Chadi SA, Kanters S, Colquhoun PH, Ott MC. Local resection compared with
radical resection in the treatment of T1N0M0 rectal adenocarcinoma: a systematic review and
meta-analysis. Dis Colon Rectum. 2015;58(1):122–40.
M. L. Westfal and M. G. Mutch
21 Management ofT1 Rectal Cancer
https://t.me/medicina_free
67. Sajid MS, Farag S, Leung P, et al. Systematic review and meta-analysis of published trials
comparing the effectiveness of transanal endoscopic microsurgery and radical resection in the
management of early rectal cancer. Color Dis. 2014;16(1):2–14.
68. Lu JY, Lin GL, Qiu HZ, et al. Comparison of Transanal endoscopic microsurgery and
Total Mesorectal excision in the treatment of T1 rectal cancer: a meta-analysis. PLoS One.
2015;10(10):e0141427.
69. Clancy C, Burke JP, Albert MR, O’Connell PR, Winter DC.Transanal endoscopic microsurgery versus standard transanal excision for the removal of rectal neoplasms: a systematic
review and meta-analysis. Dis Colon Rectum. 2015;58(2):254–61.
70. Hyun JH, Alhanafy MK, Park HC, etal. Initial local excision for clinical T1 rectal cancer
showed comparable overall survival despite high local recurrence rate: a propensity-matched
analysis. Ann Coloproctol. 2022;38(2):166–75.
71. Bentrem DJ, Okabe S, Wong WD, etal. T1 adenocarcinoma of the rectum: transanal excision
or radical surgery? Ann Surg. 2005;242(4):472–7. discussion 477–479
72. Huang A, Zhao H, Ling T, et al. Oncological superiority of extralevator abdominoperineal
resection over conventional abdominoperineal resection: a meta-analysis. Int J Color Dis.
2014;29(3):321–7.
73. Negoi I, Hostiuc S, Paun S, Negoi RI, Beuran M.Extralevator vs conventional abdominoperineal resection for rectal cancer-a systematic review and meta-analysis. Am J Surg.
2016;212(3):511–26.
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Can Total Mesorectal Excision
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BeAvoided inT2 Rectal Cancer?
AnthonyLoria andFergalJ.Fleming
Introduction
In 2020, there were approximately 43,000 incident cases of rectal cancer in the
United States and over 700,000 incident cases worldwide [1, 2]. Patients with clinical stage one rectal cancer (T1–2N0) represent approximately 25–30% of incident
cases at the population level [3]. For patients with T2N0 disease, total mesorectal
excision (TME) is the standard of care due to durable oncologic outcomes [4].
However TME can be associated with considerable morbidity. Balancing the risk of
undertreatment with minimizing surgical morbidity has prompted a growing interest in using local excision among patients with T2N0 rectal cancer. Moreover,
recent data on neoadjuvant chemoradiation followed by local excision is challenging the paradigm that TME is associated with superior oncologic outcomes in
patients with T2N0 disease. This chapter aims to articulate the rationale for seeking
alternatives to TME, weigh the contemporary evidence, and provide expert opinion
on the rapidly advancing management of early (T1-T2, node-negative) rectal cancer.
22
Search Strategy
For this narrative review, a comprehensive literature search of PubMed identied
studies comparing local excision with TME published between 2002 and 2023
(Table22.1). Local excision in the context of early rectal (T1–2N0) cancer refers to
transanal endoscopic microsurgery (TEMS) or transanal minimally invasive surgery
A. Loria · F. J. Fleming (*)
Division of Colorectal Surgery, Department of Surgery, University of Rochester Medical
Center, Rochester, NY, USA
e-mail: anthony_loria@urmc.rochester.edu; fergal_eming@urmc.rochester.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
K. Umanskiy, N. Hyman (eds.), Difcult Decisions in Colorectal Surgery,
Difcult Decisions in Surgery: An Evidence-Based Approach,
https://doi.org/10.1007/978-3-031-42303-1_22
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Table 22.1 PICO
P (patients)
T2N0 rectal cancer TME Local excision
I (intervention) C (comparison)
(TEMS, TAMIS)
A. Loria and F. J. Fleming
O (outcomes)
Morbidity (short-term)
Survival (overall, disease free)
Patient reported
(TAMIS). The search included “rectal neoplasms,” “natural orice endoscopic surgery,” “microsurgery,” “minimally invasive surgical procedures,” or “watchful waiting” [5]. Representative title or abstract limited terms included “early rectal cancer,”
“T1 rectal cancer,” “T2 rectal cancer,” “TEM,” “local excision,” “TAMIS,” “EMR,”
among others. Non-English and non-comparative studies were excluded. The references were reviewed to identify additional studies not captured in the primary search.
Results
Difculties in accurately staging early rectal cancer must be acknowledged. Tumor
invasion (T) and nodal involvement (N) are assessed by either endorectal ultrasound
(EUS) or magnetic resonance imaging (MRI) [4]. Unfortunately, for T2 lesions,
MRI over stages 42% and EUS over stages 18% [6–8]. Similarly, accurately detecting nodal involvement is a diagnostic challenge. A meta-analysis found that the
sensitivity and specicity for accurately detecting nodal involvement of EUS were
67% and 78%, and for MRI, they were 66% and 76% [6]. Consequently, European
guidelines focus heavily on the area where MRI excels, tumor involvement of the
circumferential resection margin [9].
TME Works: Why Replace it?
Benchmarking the short-term morbidity, functional, and oncologic outcomes associated with TME and local excision is essential. Expectedly, the short-term morbidity prole favors local excision. In a large retrospective study of 2124 patients with
Stage I (T1–2N0) disease, 5.6% of patients who underwent local excision experienced a 30-day complication compared to 14.6% following TME (p<0.001) [10].
Neoadjuvant therapy was less common in the era of those retrospective data, however, multi-institutional, randomized controlled trials suggest the postoperative
morbidity following TME alone is higher than patients who receive neoadjuvant
chemoradiation and local excision (50.6% vs. 20.7%, p<0.001) [11]. Similarly, in
a trial comparing neoadjuvant short-course radiation (SCRT) followed by local
excision to TME alone, the rates of serious adverse events among the TME group
were signicantly higher than those who had SCRT followed by local excision
(39% vs. 15%) [12]. Contemporary 30-day mortality rates following TME are low
(approximately 1–1.5%), but it is notable that at 3-months post-TME, the mortality
rate in four European nations ranged from 5.6–8.3% among patients 80years or
older with stage I rectal cancer [13, 14].
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