Locally Excised T1 Rectal Cancers: Need for Specialized Surveillance Protocols.

BACKGROUND: Local excision of T1 rectal cancers helps avoid major surgery, but the frequency and pattern of recurrence may be different than for patients treated with total mesorectal excision. OBJECTIVE: This study aims to evaluate pattern, frequency, and means of detection of recurrence in a closely followed cohort of patients with locally excised T1 rectal cancer. DESIGN: This study is a retrospective review. SETTINGS: Patients treated by University of Minnesota-affiliated physicians, 1994 to 2014, were selected. PATIENTS: Patients had pathologically confirmed T1 rectal cancer treated with local excision and had at least 3 months of follow-up. INTERVENTIONS: Patients underwent local excision of T1 rectal cancer, followed by multimodality follow-up with physical examination, CEA, CT, endorectal ultrasound, and proctoscopy. MAIN OUTCOME MEASURES: The primary outcomes measured were the presence of local recurrence and the means of detection of recurrence. RESULTS: A total of 114 patients met the inclusion criteria. The local recurrence rate was 11.4%, and the rate of distant metastasis was 2.6%. Local recurrences occurred up to 7 years after local excision. Of the 14 patients with recurrence, 10 of the recurrences were found by ultrasound and/or proctoscopy rather than by traditional methods of surveillance such as CEA or imaging. Of these 10 patients, 4 had an apparent scar on proctoscopy, and ultrasound alone revealed findings concerning for recurrent malignancy. One had recurrent malignancy demonstrated on ultrasound, but no concurrent proctoscopy was performed. LIMITATIONS: This was a retrospective review, and the study was conducted at an institution where endorectal ultrasound is readily available. CONCLUSIONS: Locally excised T1 rectal cancers should have specific surveillance guidelines distinct from stage I cancers treated with total mesorectal excision. These guidelines should incorporate a method of local surveillance that should be extended beyond the traditional 5-year interval of surveillance. An ultrasound or MRI in addition to or instead of flexible sigmoidoscopy or proctoscopy should also be strongly considered. See Video Abstract at http://links.lww.com/DCR/A979. CÁNCERES RECTALES T1 EXTIRPADOS LOCALMENTE: NECESIDAD DE PROTOCOLOS DE VIGILANCIA ESPECIALIZADOS: La escisión local de los cánceres de recto T1 ayuda a evitar una cirugía mayor, pero la frecuencia y el patrón de recurrencia pueden ser diferentes a los de los pacientes tratados con escisión mesorectal total. OBJETIVO: Evaluar el patrón, la frecuencia y los medios de detección de recidiva en una cohorte de pacientes con cáncer de recto T1 extirpado localmente bajo un régimen de seguimiento especifico. DISEÑO:: Revisión retrospectiva. AJUSTES: Pacientes tratados por hospitales afiliados a la Universidad de Minnesota, 1994-2014 PACIENTES:: Pacientes con cáncer de recto T1 confirmado patológicamente, tratados con escisión local y con al menos 3 meses de seguimiento. INTERVENCIONES: Extirpación local del cáncer de recto T1, con un seguimiento multimodal incluyendo examen físico, antígeno carcinoembrionario (CEA), TC, ecografía endorrectal y proctoscopia. PRINCIPALES MEDIDAS DE RESULTADO: Presencia de recurrencia local y medios de detección de recurrencia. RESULTADOS: Un total de 114 pacientes cumplieron con los criterios de inclusión. La tasa de recurrencia local fue del 11,4% y la tasa de metástasis a distancia fue del 2,6%. Las recurrencias locales se presentaron hasta 7 años después de la escisión local. De los 14 pacientes con recurrencia, 10 de las recurrencias se detectaron por ultrasonido y / o proctoscopia en lugar de los métodos tradicionales de vigilancia, como CEA o imágenes. De estos diez pacientes, cuatro tenían una cicatriz aparente en la proctoscopia y el ultrasonido solo reveló hallazgos relacionados con tumores malignos recurrentes. En una ecografía se demostró malignidad recurrente, pero no se realizó proctoscopia concurrente. LIMITACIONES: Revisión retrospectiva; estudio realizado en una institución donde se dispone fácilmente de ultrasonido endorrectal CONCLUSIONES:: Los cánceres de recto T1 extirpados localmente deben tener una vigilancia específica distinta de los cánceres en etapa I tratados con TME. El régimen de seguimiento deberá de extender más allá del intervalo tradicional de 5 años de vigilancia. También se debe considerar la posibilidad de realizar una ecografía o una resonancia magnética (IRM) además de la sigmoidoscopía flexible o la proctoscopía. Vea el Resumen del video en http://links.lww.com/DCR/A979.

Outcomes after transanal endoscopic microsurgery with intraperitoneal anastomosis.

BACKGROUND: Transanal endoscopic microsurgery has gained increasing popularity as a treatment alternative for early stage rectal neoplasms. With continued advances in technique and experience, more proximal rectal tumors are being surgically managed by using transanal endoscopic microsurgery with an intraperitoneal anastomosis. OBJECTIVE: The purpose of this study was to review the outcomes of patients who have undergone intraperitoneal anastomosis with the use of the transanal endoscopic microsurgery technique. DESIGN: A prospective, single-surgeon database documented 445 consecutive patients undergoing transanal endoscopic microsurgery from October 1, 1996 through January 1, 2012. We retrospectively reviewed information from all patients who underwent transanal endoscopic microsurgery with an intraperitoneal anastomosis in this prospective database. SETTINGS: All procedures took place in an inpatient hospital setting. PATIENTS: All patients satisfied workup criteria to undergo surgery for rectal neoplasm. INTERVENTIONS: All patients underwent transanal endoscopic microsurgery for rectal neoplasm. MAIN OUTCOME MEASURES: Size and pathology of lesion, length of procedure, hospital stay, estimated blood loss, margin status, and complications were the outcomes measured. RESULTS: Twenty-eight patients who underwent transanal endoscopic microsurgery had definitively documented intraperitoneal entry and anastomosis. Median follow-up was 12 months (range, 0.5-111 months). There were no operative mortalities. Procedure-related complications included urinary retention (11%), fever (11%), and fecal seepage (4%). Four patients (14%) had positive margins on final pathology. One patient (3%) required abdominal exploration for an anastomotic leak but did not require diversion. LIMITATIONS: Although this study analyzes prospectively collected data, it is nonetheless a retrospective analysis that can introduce bias. Because this is a single-center study with a relatively homogenous population, the results may not be generalizable. Our sample size may also be underpowered to detect clinically significant outcomes. CONCLUSIONS: Transanal endoscopic microsurgery with intraperitoneal anastomosis can be safely performed without fecal diversion by experienced surgeons.

Meta-analysis of histopathological features of primary colorectal cancers that predict lymph node metastases.

BACKGROUND: Treatment decisions for colorectal cancer vary based on lymph node status. While some histopathological features of the primary tumor correlate with lymph node spread, the relative influences of these risk factors are not well quantified. OBJECTIVE: This study aims to systematically review published studies relating histopathological features of primary colorectal cancer to the presence of lymph node metastases and to determine how reliable certain factors might be at predicting nodal metastasis when only the primary lesion is available for study. DATA SOURCES: Inclusive literature search using EMBASE and Ovid MEDLINE databases plus manual reference checks of all articles correlating lymphatic spread with colorectal cancer (any T stage) from 1984 to mid-2008 was performed. STUDY SELECTION: This search generated two levels of screening utilized on 602 citations, yielding 123 articles for full review. Data reported from 76 articles were chosen. MAIN OUTCOME MEASURES: The relative influence of each histopathological feature on the likelihood of lymphatic metastases was determined. Fixed-effects meta-analysis was performed, and results were reported as Mantel-Haenszel odds ratios (OR). RESULTS: Of 42 histopathological features analyzed, only 40.4% were reported in >2 articles. The positive predictive values for the top quartile of most frequently reported risk factors were 25.5-86.4%. Among the commonly reported histopathological findings, lymphatic invasion (OR, 8.62) significantly outperformed tumor depth (T2 vs. T1; OR, 2.62) and overall differentiation (OR, 2.38) in predicting nodal spread. For the rectal cancer subset, risk factors differed from the overall colorectal group in predictive ability; poor differentiation at the invasive front (OR, 6.08) and tumor budding (OR, 5.82) were the most predictive. LIMITATIONS: This literature search is limited by the small number of studies examining only rectal cancers and the potential changes in histological and/or surgical techniques over the study period. CONCLUSIONS: No single histopathological feature of colorectal cancer reliably predicted lymph node metastases. Several risk factors that correlate highly with nodal disease are not routine components of standard pathology reports. Until further research establishes histopathological or molecular patterns for predicting lymph node spread, caution should be exercised when basing treatment decisions solely on these factors.

Transanal endoscopic microsurgery resection of rectal tumors: outcomes and recommendations.

PURPOSE: Transanal endoscopic microsurgery provides a minimally invasive alternative to radical surgery for excision of benign and malignant rectal tumors. The purpose of this study was to review our experience with transanal endoscopic microsurgery to clarify its role in the treatment of different types of rectal pathology. METHODS: A prospective database documented all patients undergoing transanal endoscopic microsurgery from October 1996 through June 2008. We analyzed patient and operative factors, complications, and tumor recurrence. For recurrence analysis, we excluded patients with fewer than 6 months of follow-up, previous excisions, known metastases at initial presentation, and those who underwent immediate radical resection following transanal endoscopic microsurgery. RESULTS: Two hundred sixty-nine patients underwent transanal endoscopic microsurgery for benign (n = 158) and malignant (n = 111) tumors. Procedure-related complications (21%) included urinary retention (10.8%), fecal incontinence (4.1%), fever (3.8%), suture line dehiscence (1.5%), and bleeding (1.5%). Local recurrence rates for 121 benign and 83 malignant tumors were 5% for adenomas, 9.8% for T1 adenocarcinoma, 23.5% for T2 adenocarcinoma, 100% for T3 adenocarcinoma, and 0% for carcinoid tumors. All 6 (100%) recurrent adenomas were retreated with endoscopic techniques, and 8 of 17 (47%) recurrent adenocarcinomas underwent salvage procedures with curative intent. CONCLUSIONS: Transanal endoscopic microsurgery is a safe and effective method for excision of benign and malignant rectal tumors. Transanal endoscopic microsurgery can be offered for (1) curative resection of benign tumors, carcinoid tumors, and select T1 adenocarcinomas, (2) histopathologic staging in indeterminate cases, and (3) palliative resection in patients medically unfit or unwilling to undergo radical resection.

Transanal endoscopic microsurgery versus conventional transanal excision for patients with early rectal cancer.

OBJECTIVE: To compare transanal endoscopic microsurgery (TEMS) with conventional transanal excision (TAE) in terms of the quality of resection, local recurrence, and survival rates in patients with stage I rectal cancer. BACKGROUND: Although TEMS is often considered a superior surgical technique to TAE, it is poorly suited for excising tumors in the lower third of the rectum. Such tumors may confer a worse prognosis. METHODS: We retrospectively reviewed information on all patients with stage pT1 and pT2 rectal adenocarcinoma who underwent local excision from 1997 through mid-2006. We excluded patients with node-positive, metastatic, recurrent, previously irradiated, or snare-excised tumors. RESULTS: Our study included 42 TEMS and 129 TAE patients. We found no significant differences in patient characteristics, adjuvant therapy, tumor stage, or adverse histopathologic features. In the TAE group, 52 (40%) of tumors were <5 cm from the anal verge (AV); in the TEMS group, only 1 (2%) (P = 0.0001). Surgical margins were less often positive in the TEMS group (2%) than in the TAE group (16%) (P = 0.017). For patients with tumors > or =5 cm from the AV, the estimated 5-year disease-free survival (DFS) rate was similar between the TEMS group (84.1%) and the TAE group (76.1%) (P = 0.651). But within the TAE group, the estimated 5-year DFS rate was better for patients with tumors > or =5 cm from the AV (76.1%) vs. <5 cm from the AV (60.5%) (P = 0.029). In our multivariate analysis, the tumor distance from the anal verge, the resection margin status, the T stage, and the use of adjuvant therapy--but not the surgical technique (i.e., TEMS or TAE) itself--were independent predictors of local recurrence and DFS. CONCLUSIONS: The quality of resection is better with TEMS than with TAE. However, the apparently better oncologic outcomes with TEMS can be partly explained by case selection of lower-risk tumors of the upper rectum.

Perianal Paget's disease treated with wide excision and gluteal skin flap reconstruction: report of a case and review of the literature.

BACKGROUND: Paget's disease of the anus is a rare perianal disorder. The condition is often associated with underlying invasive carcinoma and the prognosis is poor when underlying adenocarcinoma is present. METHODS: We report the case of a 72-year-old woman suffering from a two-year history of perianal itching, bleeding, and irritation. Perianal Paget's disease was confirmed by histopathologic demonstration of Paget's cells from a biopsy. Synchronous malignancy and metastasis were excluded. RESULTS: A first-stage operation consisted of a wide excisional biopsy with frozen section margin assessment. Permanent sections confirmed absence of invasive carcinoma and clear margins. Four days after wide excision, bilateral gluteal skin flap reconstruction was performed with a temporary diverting colostomy. No adjuvant therapy was necessary, and after one-year follow-up, the patient remains disease free. CONCLUSION: Perianal Paget's disease continues to pose problems in diagnosis and treatment. Our case report of perianal Paget's disease shows one method of management for advanced non invasive disease.

Fistula-associated anal adenocarcinoma: good results with aggressive therapy.

PURPOSE: To evaluate the clinical features, pathology, treatment, and outcome of patients with fistula-associated anal adenocarcinoma. METHODS: We identified 14 patients with histologically proven fistula-associated anal adenocarcinoma. We reviewed their medical records and pathology specimens to characterize their presentation, treatment, and clinical outcome. RESULTS: Nine patients presented with a persistent fistula, 3 with a perianal mass, 1 with pain and drainage, and 1 with a recurrent perianal abscess. The average age at time of diagnosis was 59 (range, 37-76) years. Eleven patients had preexisting chronic anal fistulas. Ten had Crohn's disease, and 1 had previously received pelvic radiation therapy. The diagnosis of cancer was suspected during physical examination in 6 of the 14 patients (43 percent). Twelve patients had extensive local disease at presentation. Primary abdominoperineal resection was performed in 11 patients, 7 following neoadjuvant chemoradiation. Six patients received postoperative chemotherapy, and 2 received postoperative radiation. Four patients died with metastatic disease. The remaining 10 patients are alive without evidence of disease at a mean follow-up of 64.3 (range, 14-149) months. CONCLUSIONS: The diagnosis of fistula-associated anal adenocarcinoma is often unsuspected. Most patients can be cured with aggressive surgical and adjuvant chemoradiotherapy.

Endorectal ultrasound-directed biopsy: a useful technique to detect local recurrence of rectal cancer.

AIMS: This study assesses the value of endorectal ultrasound (ERUS)-directed biopsy in detecting local recurrence of rectal cancer. METHODS: We reviewed the records of patients undergoing ERUS by a single surgeon for surveillance after treatment of rectal adenocarcinoma. Lesions suggestive of local recurrence underwent ERUS-assisted core-needle biopsy (EAB) via a proctoscope after precise ERUS localization or direct ERUS-guided biopsy (EGB) via a B&K Medical probe. RESULTS: From 1991 to 2003, 525 patients underwent 2,490 surveillance ERUS. Of these patients, 51 underwent 62 biopsy sessions: 36 EGB and 26 EAB. The mean age of patients was 67.2 years (range 38-93 years); 22 (43%) were female. Only 11 patients (22%) had undergone prior radical resection of their primary tumor. No patient experienced a complication from the biopsies despite five being anticoagulated. Of 39 patients whose cancer recurrence was documented during follow-up, 32 (82%) were diagnosed at the initial biopsy session, and in five (13%), recurrence was detected only with ERUS. The combined sensitivity, specificity, and accuracy of EAB and EGB in detecting recurrence was 83, 100, and 87%, respectively. In 26 patients with local recurrence, resection was performed with curative intent. CONCLUSION: ERUS with biopsy is useful in detecting local recurrence after treatment of rectal cancer. It is safe, with a high diagnostic yield. It may be particularly useful in patients at higher risk for local recurrence (i.e., after endocavitary radiation and local excision) and may allow early detection of local recurrence, thereby permitting attempts at curative resection.

Endorectal ultrasound in the management of patients with malignant rectal polyps.

PURPOSE: This study was designed to determine the efficacy of endorectal ultrasound in the management of patients with malignant rectal polyps removed by snare excision during colonoscopy. METHODS: A retrospective review of the medical records and endorectal ultrasound images of 63 patients with endoscopically removed rectal polyps containing invasive adenocarcinoma subsequently staged by endorectal ultrasound. Patients underwent surgery or were followed at a single institution. The polyp characteristics and ultrasound images were compared with the presence of residual tumor in the surgical specimen in patients who underwent further surgery or with recurrence in patients who did not. RESULTS: The morphology of the polyps was described in 31 patients (49 percent); they were sessile in 26 (41 percent) and pedunculated in 6 (9 percent). The margins were positive in 22 patients (35 percent), negative in 19 (30 percent), and not specified in 22 (35 percent). Most tumors were well or moderately differentiated; only 3 (5 percent) were poorly differentiated. Thirty-three patients underwent further surgery (3 low anterior resection, and 30 transanal excision); 30 had no further surgery. The accuracy of endorectal ultrasound in assessing the presence of residual cancer in the rectal wall in patients who had surgery was 54 percent, with a 39 percent positive predictive value and 65 percent negative predictive value. Endorectal ultrasound accurately identified metastatic lymph nodes in two of three patients who had radical surgery. Endorectal ultrasound was more useful than polyp morphologic or histologic criteria to determine the presence of residual cancer in the rectal wall. CONCLUSIONS: Endorectal ultrasound does not definitely exclude the possibility of residual tumor in the rectal wall or mesenteric nodes of patients who had a malignant polyp snared endoscopically. Consequently, decisions regarding the definitive management of these patients cannot be based exclusively on the endorectal ultrasound images of the polypectomy site.

The effect of circumferential tumor location in clinical outcomes of rectal cancer patients treated with total mesorectal excision.

PURPOSE: A positive circumferential resection margin is associated with a high risk of local recurrence and distant metastasis after total mesorectal excision for rectal cancer. The mesorectum is thinner anteriorly than posteriorly, and the risk of a positive resection margin may be higher for anterior than for posterior tumors. We sought to determine the effect of the tumor's position in the circumference of the rectum on the treatment and outcomes of rectal cancer patients treated by total mesorectal excision. METHODS: We retrospectively analyzed 401 patients with rectal cancer staged by preoperative endorectal ultrasound and treated by sharp mesorectal excision with or without neoadjuvant therapy. Tumors were classified into four groups (anterior, posterior, lateral, and circumferential) according to the location of deepest point of penetration on endorectal ultrasound. Differences in recurrence and survival rates were analyzed with logistic regression analysis. RESULTS: Of the 401 tumors, 27 percent were anterior, 26 percent posterior, 32 percent lateral, and 15 percent circumferential. The groups did not differ in age, gender, tumor distance from the anal verge, or tumor grade. The ultrasound and pathology stages were more advanced in the circumferential group, and the proportion of uT4 tumors was higher in the anterior group. Circumferential and anterior tumors were more likely to receive preoperative adjuvant radiation. After an average follow-up of 44 months, 20 percent of patients had developed recurrence (13 percent distant, 6 percent local, and 1 percent distant and local). Recurrence was associated with advanced tumor stage, tumor proximity to the anal verge, and no preoperative adjuvant therapy. Early tumor stage and preoperative chemoradiation were associated with lower recurrence and improved survival. When tumor stage was controlled for, patients with poor or undifferentiated tumors and male patients with anterior tumors were shown to have a higher risk of recurrence or death. The estimated five-year disease-free survival for the entire group was 73 percent. CONCLUSIONS: Tumor stage is the main criterion to estimate prognosis in rectal cancer patients. The position of the tumor within the circumference of the rectum may provide valuable clinical information. Anterior tumors tend to be more advanced and, at least in male patients, has a higher risk of recurrence and death than tumors in other locations.

Endorectal ultrasound in the follow-up of rectal cancer patients treated by local excision or radical surgery.

PURPOSE: This study was designed to investigate the role of a scheduled follow-up protocol using endorectal ultrasonography for the diagnosis of local recurrence after local excision and radical surgery for rectal cancer. METHODS: A selected group of 275 patients with invasive rectal cancer followed prospectively by endorectal ultrasonography after curative-intent local excision (n = 108) or radical surgery (n = 167) was reviewed. For the radical-surgery group, results were compared with a group of 176 rectal cancer patients who had similar operations during the same period of time and were not entered in follow-up protocol. Excluded were patients with invasive cancers removed by snare excision, male patients treated by abdominoperineal resection, and patients treated by endocavitary radiation. Student's unpaired t-test was used to compare tumor and patient characteristics. Survival curves were estimated using the Kaplan-Meier method and compared using the log-rank test. RESULTS: In the local-excision group, 32 patients developed local recurrence, 26 (81 percent) were asymptomatic, and 10 of them (31 percent) were diagnosed only by endorectal ultrasound. We found no difference in the rates of salvage surgery or survival between patients diagnosed of recurrence by ultrasound or other methods. In the radical-surgery group, 12 patients developed local recurrence, 5 (42 percent) were asymptomatic, and 4 of them (33 percent) were diagnosed only by endorectal ultrasound. More patients with isolated local recurrence in the follow-up group underwent salvage surgery (4/9 patients; 44 percent) compared with patients without follow-up (3/13 patients; 23 percent), but the differences were not significant. CONCLUSIONS: Endorectal ultrasound identifies one-third of asymptomatic local recurrences that were missed by digital examination or proctoscopic examination. However, the impact of the earlier diagnosis in patient survival can only be determined by a larger, prospective, randomized trial.

Surgical therapy for anorectal melanoma.

BACKGROUND: Anorectal melanoma is a rare but highly lethal malignancy. Historically, radical resection was considered the "gold standard" for treatment of potentially curable anorectal melanoma. The dismal prognosis of this disease has prompted us to recommend wide local excision as the initial therapeutic approach. The purpose of this study was to review our results in patients who underwent wide local excision or radical surgery (abdominoperineal resection [APR]) for localized anorectal melanoma. STUDY DESIGN: We reviewed the charts of all patients referred for resection of anorectal melanoma between 1988 and 2002. Endpoints included overall survival, disease-free survival, and local, regional, or systemic recurrence. RESULTS: Fifteen patients underwent curative-intent surgery; four underwent APR and 11 underwent wide local excision. Eight patients (53%) are alive; 7 (47%) are disease-free (followup 6 months to 13 years). Of 12 patients who have been followed for more than 2 years, 4 are alive (33%) and 3 are disease-free (25%). Seven patients have been followed for more than 5 years and two are alive and disease-free (29%). All of the longterm survivors underwent local excision as the initial operation. There were no differences in local recurrence, systemic recurrence, disease-free survival, or overall survival between the APR group and the local excision group. Local recurrence occurred in 50% of the APR group and 18% of the local excision group; regional recurrence occurred in 25% versus 27%. Distant metastases were common (75% versus 36%). CONCLUSION: In patients who have undergone resection with curative intent for anorectal melanoma, most recurrences occur systemically regardless of the initial surgical procedure. Local resection does not increase the risk of local or regional recurrence. APR offers no survival advantage over local excision. We advocate wide local excision as primary therapy for anorectal melanoma when technically feasible.

Accuracy of endorectal ultrasonography in preoperative staging of rectal tumors.

PURPOSE: Preoperative staging of rectal tumors is considered essential to tailor treatment for individual patients. The aim of the present study was to evaluate the accuracy of endorectal ultrasonography in preoperative staging of rectal tumors. METHODS: Eleven hundred eighty-four patients with rectal adenocarcinoma or villous adenoma underwent endorectal ultrasonography evaluation at a single institution during a ten-year period. We compared the endorectal ultrasonography staging with the pathology findings based on the surgical specimens in 545 patients who had surgery (307 by transanal excision, 238 by radical proctectomy) without adjuvant preoperative chemoradiation. Comparisons between groups were performed using chi-squared tests and logistic regression analysis. RESULTS: Overall accuracy in assessing the level of rectal wall invasion was 69 percent, with 18 percent of the tumors overstaged and 13 percent understaged. Accuracy depended on the tumor stage and on the ultrasonographer. Overall accuracy in assessing nodal involvement in the 238 patients treated with radical surgery was 64 percent, with 25 percent overstaged and 11 percent understaged. CONCLUSION: The accuracy of endorectal ultrasonography in assessing the depth of tumor invasion, particularly for early cancers, is lower than previously reported. The technique is more precise in distinguishing between benign tumors and invasive cancers and between tumors localized to the rectal wall and tumors with transmural invasion. Differences in image interpretation may in part explain discrepancies in accuracy between studies.