Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Annals of Surgical Oncology
Published in: Annals of Surgical Oncology 8/2019

01-08-2019 | Rectal Cancer | Colorectal Cancer

For Patients with Early Rectal Cancer, Does Local Excision Have an Impact on Recurrence, Survival, and Quality of Life Relative to Radical Resection?

Authors: Amy L. Halverson, MD, Arden M. Morris, MD, Robert K. Cleary, MD, George J. Chang, MD

Published in: Annals of Surgical Oncology | Issue 8/2019

Login to get access

Abstract

Background

The most appropriate treatment for early-stage rectal cancers is controversial. The advantages of local excision regarding morbidity and function must be weighed against poorer oncologic efficacy. This study aimed to clarify further the role for local excision in the treatment of rectal cancer.

Methods

A systematic review of Medline, SCOPUS, and Cochrane databases was conducted. Relevant studies were selected using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data addressing five key questions about outcomes of local versus radical resection of rectal cancer were analyzed.

Results

The 16 studies identified by this study were mostly retrospective, and none were randomized. Local excision was associated with fewer complications and better functional outcome than radical resection. Of 12 studies evaluating local recurrence, 6 showed a higher local recurrence rate among patients who underwent local excision. Two additional studies showed no increase in local recurrence rate among patients who underwent local excision of T1 lesions but a significantly higher local recurrence rate among those who underwent local excision of T2 lesions. High histologic grade, angiolymphatic invasion, perineural invasion, and depth within submucosa were features associated with a higher risk of local recurrence. In 7 of 15 studies, long-term survival was reduced compared with that of patients who underwent radical resection.

Conclusions

Although local excision for early-stage rectal cancer is associated with increased local recurrence and decreased overall survival compared with radical resection, local excision may be appropriate for select individuals who have T1 tumors with no adverse pathologic features.
Literature
1.
Bhangu A, Brown G, Nicholls RJ, Wong J, Darzi A, Tekkis P. Survival outcome of local excision versus radical resection of colon or rectal carcinoma: a Surveillance, Epidemiology, and End Results (SEER) population-based study. Ann Surg. 2013;258:563–9; discussion 9–71.
2.
Gillern SM, Mahmoud NN, Paulson EC. Local excision for early-stage rectal cancer in patients over age 65 years: 2000–2009. Dis Colon Rectum. 2015;58:172–8.CrossRefPubMed
3.
Stitzenberg KB, Sanoff HK, Penn DC, Meyers MO, Tepper JE. Practice patterns and long-term survival for early-stage rectal cancer. J Clin Oncol. 2013;31:4276–82.CrossRefPubMedPubMedCentral
4.
Sengupta S, Tjandra JJ. Local excision of rectal cancer: what is the evidence? Dis Colon Rectum. 2001;44:1345–61.CrossRefPubMed
5.
Steele GD Jr, Herndon JE, Bleday R, et al. Sphincter-sparing treatment for distal rectal adenocarcinoma. Ann Surg Oncol. 1999;6:433–41.CrossRefPubMed
6.
Winde G, Nottberg H, Keller R, Schmid KW, Bunte H. Surgical cure for early rectal carcinomas (T1): transanal endoscopic microsurgery vs anterior resection. Dis Colon Rectum. 1996;39:969–76.CrossRefPubMed
7.
Battersby NJ, Juul T, Christensen P, et al. Predicting the risk of bowel-related quality-of-life impairment after restorative resection for rectal cancer: a multicenter cross-sectional study. Dis Colon Rectum. 2016;59:270–80.CrossRefPubMed
8.
Arezzo A, Arolfo S, Allaix ME, et al. Results of neoadjuvant short-course radiation therapy followed by transanal endoscopic microsurgery for T1–T2 N0 extraperitoneal rectal cancer. Int J Radiat Oncol Biol Phys. 2015;92:299–306.CrossRefPubMed
9.
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;58:254–61.CrossRefPubMed
10.
de Graaf EJ, Burger JW, van Ijsseldijk AL, Tetteroo GW, Dawson I, Hop WC. Transanal endoscopic microsurgery is superior to transanal excision of rectal adenomas. Colorectal Dis. 2011;13:762–7.CrossRefPubMed
11.
Kawaguti FS, Nahas CS, Marques CF, et al. Endoscopic submucosal dissection versus transanal endoscopic microsurgery for the treatment of early rectal cancer. Surg Endosc. 2014;28:1173–9.CrossRefPubMed
12.
Langer C, Liersch T, Süss M, et al. Surgical cure for early rectal carcinoma and large adenoma: transanal endoscopic microsurgery (using ultrasound or electrosurgery) compared to conventional local and radical resection. Int J Colorectal Dis. 2003;18:222–9.PubMed
13.
Lebedyev A, Tulchinsky H, Rabau M, Klausner JM, Krausz M, Duek SD. Long-term results of local excision for T1 rectal carcinoma: the experience of two colorectal units. Tech Coloproctol. 2009;13:231–6.CrossRefPubMed
14.
Moore JS, Cataldo PA, Osler T, Hyman NH. Transanal endoscopic microsurgery is more effective than traditional transanal excision for resection of rectal masses. Dis Colon Rectum. 2008;51:1026–30; discussion 30–1.
15.
Sgourakis G, Lanitis S, Gockel I, et al. Transanal endoscopic microsurgery for T1 and T2 rectal cancers: a meta-analysis and meta-regression analysis of outcomes. Am Surg. 2011;77:761–72.PubMed
16.
Garcia-Aguilar J, Mellgren A, Sirivongs P, Buie D, Madoff RD, Rothenberger DA. Local excision of rectal cancer without adjuvant therapy: a word of caution. Ann Surg. 2000;231:345–51.CrossRefPubMedPubMedCentral
17.
Smith FM, Chang KH, Sheahan K, Hyland J, O’Connell PR, Winter DC. The surgical significance of residual mucosal abnormalities in rectal cancer following neoadjuvant chemoradiotherapy. Br J Surg. 2012;99:993–1001.CrossRefPubMed
18.
Heald RJ, Moran BJ, Ryall RD, Sexton R, MacFarlane JK. Rectal cancer: the Basingstoke experience of total mesorectal excision, 1978–1997. Arch Surg. 1998;133:894–9.CrossRefPubMed
19.
Mellgren A, Sirivongs P, Rothenberger DA, Madoff RD, Garcia-Aguilar J. Is local excision adequate therapy for early rectal cancer? Dis Colon Rectum. 2000;43:1064–71; discussion 71–4.
20.
Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. Ann Intern Med. 2009;151:W65–94.CrossRefPubMed
21.
You YN, Baxter NN, Stewart A, Nelson H. Is the increasing rate of local excision for stage I rectal cancer in the United States justified? A nationwide cohort study from the National Cancer Database. Ann Surg. 2007;245:726–33.CrossRefPubMedPubMedCentral
22.
Allaix ME, Arezzo A, Cassoni P, Famiglietti F, Morino M. Recurrence after transanal endoscopic microsurgery for large rectal adenomas. Surg Endosc. 2012;26:2594–600.CrossRefPubMed
23.
De Graaf EJR, Doornebosch PG, Tollenaar RAEM, et al. Transanal endoscopic microsurgery versus total mesorectal excision of T1 rectal adenocarcinomas with curative intention. Eur J Surg Oncol. 2009;35:1280–5.CrossRefPubMed
24.
Elmessiry MM, Van Koughnett JAM, Maya A, et al. Local excision of T1 and T2 rectal cancer: proceed with caution. Colorectal Dis. 2014;16:703–9.CrossRefPubMed
25.
Endreseth BH, Wibe A, Svinsås M, Mårvik R, Myrvold HE. Postoperative morbidity and recurrence after local excision of rectal adenomas and rectal cancer by transanal endoscopic microsurgery. Colorectal Dis. 2005;7:133–7.CrossRefPubMed
26.
Folkesson J, Johansson R, Påhlman L, Gunnarsson U. Population-based study of local surgery for rectal cancer. Br J Surg. 2007;94:1421–6.CrossRefPubMed
27.
Hazard LJ, Sklow B, Pappas L, Boucher KM, Shrieve DC. Local excision vs radical resection in T1–2 rectal carcinoma: results of a study from the Surveillance, Epidemiology, and End Results (SEER) registry data. Gastrointest Cancer Res. 2009;3:105–14.PubMedPubMedCentral
28.
Lee W, Lee D, Choi S, Chun H. Transanal endoscopic microsurgery and radical surgery for T1 and T2 rectal cancer: retrospective study. Surg Endosc. 2003;17:1283–7.CrossRefPubMed
29.
Lezoche E, Baldarelli M, Lezoche G, Paganini AM, Gesuita R, Guerrieri M. Randomized clinical trial of endoluminal locoregional resection versus laparoscopic total mesorectal excision for T2 rectal cancer after neoadjuvant therapy. Br J Surg. 2012;99:1211–8.CrossRefPubMed
30.
Lezoche E, Paganini AM, Fabiani B, et al. Quality-of-life impairment after endoluminal locoregional resection and laparoscopic total mesorectal excision. Surg Endosc Other Intervent Tech. 2014;28:227–34.CrossRef
31.
Nascimbeni R, Nivatvongs S, Larson DR, Burgart LJ. Long-term survival after local excision for T1 carcinoma of the rectum. Dis Colon Rectum. 2004;47:1773–9.CrossRefPubMed
32.
Peng J, Chen W, Venook AP, et al. Long-term outcome of early-stage rectal cancer undergoing standard resection and local excision. Clin Colorect Cancer. 2011;10:37–41.CrossRef
33.
Ptok H, Marusch F, Meyer F, et al. Oncological outcome of local vs radical resection of low-risk pT1 rectal cancer. Arch Surg. 2007;142:649–55.CrossRefPubMed
34.
Saraste D, Gunnarsson U, Janson M. Local excision in early rectal cancer outcome worse than expected: a population-based study. Eur J Surg Oncol. 2013;39:634–9.CrossRefPubMed
35.
Allaix ME, Arezzo A, Giraudo G, Morino M. Transanal endoscopic microsurgery vs laparoscopic total mesorectal excision for T2N0 rectal cancer. J Gastrointest Surg. 2012;16:2280–7.CrossRefPubMed
36.
Endreseth BH, Myrvold HE, Romundstad P, Hestvik UE, Bjerkeset T, Wibe A. Transanal excision vs. major surgery for T1 rectal cancer. Dis Colon Rectum. 2005;48:1380–8.CrossRefPubMed
37.
Peng J, Chen W, Sheng W, et al. Oncological outcome of T1 rectal cancer undergoing standard resection and local excision. Colorect Dis. 2011;13:e14–e9.CrossRef
38.
Christoforidis D, Cho HM, Dixon MR, Mellgren AF, Madoff RD, Finne CO. Transanal endoscopic microsurgery versus conventional transanal excision for patients with early rectal cancer. Ann Surg. 2009;249:776–82.CrossRefPubMed
39.
Chakravarti A, Compton CC, Shellito PC, et al. Long-term follow-up of patients with rectal cancer managed by local excision with and without adjuvant irradiation. Ann Surg. 1999;230:49–54.CrossRefPubMedPubMedCentral
40.
Garcia-Aguilar J, Renfro LA, Chow OS, et al. 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;16:1537–46.CrossRefPubMedPubMedCentral
41.
Pucciarelli S, De Paoli A, Guerrieri M, et al. Local excision after preoperative chemoradiotherapy for rectal cancer: results of a multicenter phase II clinical trial. Dis Colon Rectum. 2013;56:1349–56.CrossRefPubMed
42.
Smart CJ, Korsgen S, Hill J, et al. Multicentre study of short-course radiotherapy and transanal endoscopic microsurgery for early rectal cancer. Br J Surg. 2016;103:1069–75.CrossRefPubMed
43.
Verseveld M, de Graaf EJ, Verhoef C, et al. Chemoradiation therapy for rectal cancer in the distal rectum followed by organ-sparing transanal endoscopic microsurgery (CARTS study). Br J Surg. 2015;102:853–60.CrossRefPubMed
44.
Marks JH, Valsdottir EB, Denittis A, et al. Transanal endoscopic microsurgery for the treatment of rectal cancer: comparison of wound complication rates with and without neoadjuvant radiation therapy. Surg Endosc Other Intervent Tech. 2009;23:1081–7.CrossRef
45.
Kundel Y, Brenner R, Purim O, et al. Is local excision after complete pathological response to neoadjuvant chemoradiation for rectal cancer an acceptable treatment option? Dis Colon Rectum. 2010;53:1624–31.CrossRefPubMed
46.
Jung SM, Yu CS, Park IJ, et al. Oncologic safety of local excision compared with total mesorectal excision for ypT0–T1 rectal cancer: a propensity score analysis. Med Baltim. 2016;95:e3718.CrossRef
47.
Belluco C, De Paoli A, Canzonieri V, et al. Long-term outcome of patients with complete pathologic response after neoadjuvant chemoradiation for cT3 rectal cancer: implications for local excision surgical strategies. Ann Surg Oncol. 2011;18:3686–93.CrossRefPubMedPubMedCentral
48.
Belluco C, Forlin M, Olivieri M, et al. Long-term outcome of rectal cancer with clinically (EUS/MRI) metastatic mesorectal lymph nodes treated by neoadjuvant chemoradiation: role of organ preservation strategies in relation to pathologic response. Ann Surg Oncol. 2016;23:4302–9.CrossRefPubMedPubMedCentral
Metadata
Title
For Patients with Early Rectal Cancer, Does Local Excision Have an Impact on Recurrence, Survival, and Quality of Life Relative to Radical Resection?
Authors
Amy L. Halverson, MD
Arden M. Morris, MD
Robert K. Cleary, MD
George J. Chang, MD
Publication date
01-08-2019
Publisher
Springer International Publishing
Published in
Annals of Surgical Oncology / Issue 8/2019
Print ISSN: 1068-9265
Electronic ISSN: 1534-4681
DOI
https://doi.org/10.1245/s10434-019-07328-5

Other articles of this Issue 8/2019

Annals of Surgical Oncology 8/2019 Go to the issue

Endocrine Tumors

The Pancreas as a Site of Metastasis or Second Primary in Patients with Small Bowel Neuroendocrine Tumors

Peritoneal Surface Malignancy

Preoperative Nutrition Status and Postoperative Outcomes in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

Hepatobiliary Tumors

Predictors and Cumulative Frequency of Hepatocellular Carcinoma in High and Intermediate LI-RADS Lesions: A Cohort Study from a Canadian Academic Institution

Breast Oncology

Sentinel Node Biopsy After Neoadjuvant Systemic Therapy for Breast Cancer: The Method Matters

Peritoneal Surface Malignancy

RAS Mutation Decreases Overall Survival After Optimal Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy of Colorectal Peritoneal Metastasis: A Modification Proposal of the Peritoneal Surface Disease Severity Score

Endocrine Tumors

Papillary Thyroid Cancers with Focal Tall Cell Change are as Aggressive as Tall Cell Variants and Should Not be Considered as Low-Risk Disease