Adjuvant radiotherapy after local excision of rectal cancer.

BACKGROUND: Local excision is now accepted as a standard treatment option for certain patients with early rectal cancer. However, there is a higher risk of local recurrence than after radical surgery with total mesorectal excision. Adjuvant radiotherapy after local excision may reduce this excess risk, and yet retain the benefits of local excision, with rectal preservation. METHODS: A review of the literature pertaining to the use of adjuvant radiotherapy after local excision of rectal cancer and a discussion of current practice. RESULTS: We first considered local excision as a treatment option for early rectal cancer, looking at technical developments and the risks and benefits of organ preservation, in particular, the advantages for quality of life and the risk of leaving residual disease which may result in local recurrence. We then looked at reported outcomes for studies using adjuvant radiotherapy after local excision. Few of the studies routinely used modern endoscopic methods of local excision and only the recent used chemoradiation. Local recurrence rates after adjuvant radiotherapy have improved over time, with rates of around 3.5% in the recent studies. Adverse effects of adjuvant radiotherapy are not commonly described, but generally, they are relatively mild when described. We then discussed current practice regarding adjuvant radiotherapy, including pathological criteria, discussion of local recurrence risk with the patient and the importance of a surveillance regime to detect any recurrence at an early stage. CONCLUSION: We conclude that the current state of knowledge regarding adjuvant radiotherapy after local excision suggests a potential role in decreasing the risk of local recurrence but further studies are required to better define this effect, clarify which patients will gain the most benefit from this pathway, and identify those who should avoid exposure to the risks of radiotherapy.

Radiotherapy after local excision of rectal cancer may offer reduced local recurrence rates.

AIM: Early rectal cancer can be managed effectively with local excision, which is now the standard of care for many T1 lesions. However, the presence of unexpected adverse histopathological factors may indicate an increased risk of local recurrence, prompting consideration of completion radical surgery. Many patients are unfit or prefer to avoid radical surgery, relying instead on surveillance and early detection of recurrent disease. Recently, radiotherapy has shown promise as an adjuvant therapy in this group. This study assesses local recurrence rates after local excision with adjuvant radiotherapy at a single centre. METHOD: This was a retrospective review of a prospective database of all patients undergoing transanal endoscopic microsurgery (TEM) in a single institution. Data covering a 10-year period were analysed. RESULTS: Of 197 patients undergoing TEM for rectal cancer, 33 (17%) had adjuvant radiotherapy because of adverse histopathological features. At 3.2 years' median follow-up, there were three instances of local recurrence (9.1%). Estimated local recurrence at 1 and 3 years was 0% and 6.9%, compared to 16.8% and 21.2% in a propensity-score-matched group who were followed by surveillance alone. Local recurrence was diagnosed at a median of 23 months post-TEM in the radiotherapy group, compared to 8 months in the matched group. CONCLUSION: Radiotherapy after TEM is associated with a trend towards a reduced rate of local recurrence, even for high-risk disease. Radiotherapy would appear to offer a viable alternative to radical completion surgery in the presence of unforeseen adverse histopathological features, as long as a meticulous surveillance programme is in place.

Modern management of T1 rectal cancer by transanal endoscopic microsurgery: a 10-year single-centre experience.

AIM: Minimally invasive, organ-sparing surgery has been used increasingly for early rectal cancer in recent years. However, local recurrence remains a concern. This study presents a 10-year single-centre experience of recurrence after local excision for T1 rectal cancer. METHOD: Data were collected prospectively on all patients undergoing local excision by transanal endoscopic microsurgery (TEM) in a single institution. Data covering a 10-year period were analysed. RESULTS: In all, 192 patients underwent TEM for rectal cancer; 70 of these had T1 tumour in the TEM specimen and did not have preoperative radiotherapy. Four were managed with completion surgery following TEM and a further six had radiotherapy; 60 underwent surveillance alone. Local recurrence occurred in six patients; three underwent salvage surgery. Estimated local recurrence at 3 years was 7.2% for the surveillance alone group. CONCLUSIONS: Local recurrence rates were lower than previous studies. Better preoperative assessment, more effective local excision surgery and postoperative radiotherapy may be contributory factors to a better-than-predicted outcome. Local excision should be offered as part of standard of care for T1 rectal cancer in the presence of good preoperative selection and meticulous surveillance.

Is group pelvic floor retraining as effective as individual treatment?

AIM: Traditionally, pelvic floor retraining for faecal incontinence or obstructed defaecation has been delivered to patients through individual sessions with a specialist pelvic floor nurse, a resource-intensive practice. This study aimed to assess whether a similar outcome can be achieved by delivering retraining to patients in small groups, allowing considerable savings in the use of resources. METHOD: Data were collected prospectively in a pelvic floor database. Patients received pelvic floor retraining either individually or in a small group setting and completed baseline and follow-up questionnaires. Two hundred and fifteen patients were treated, 119 individually and 96 in a small group setting. Scores before and after treatment for the two settings were compared for the Gastrointestinal Quality of Life Index, the Fecal Incontinence Severity Index and the Patient Assessment of Constipation Symptoms. Additionally patients receiving group treatment completed a short questionnaire on their experience. RESULTS: The median change in Gastrointestinal Quality of Life Index score was 5 (range -62 to 73) for individual treatment and 4 (range -41 to 47) for group treatment, both showing statistically significant improvement. However, there was no significant difference between the settings. Similar results were obtained with the Fecal Incontinence Severity Index and Patient Assessment of Constipation Symptoms scores for the faecal incontinence and obstructed defaecation subgroups respectively. CONCLUSION: The majority of patients experienced symptomatic improvement following pelvic floor retraining and there was no significant difference in the resulting improvement according to treatment setting. As treatment costs are considerably less in a group setting, group pelvic floor retraining is more cost-effective than individual treatment.