Transcript Management of early rectal carcinoma

Management of early rectal carcinoma
Joint Hospital Surgical Grand Round
Jeren Lim
United Christian Hospital
Early rectal carcinoma
Adenocarcinoma invaded
into, but not beyond the
submucosa
 T1N0M0 tumour
 3 – 8.6% of all resected
rectal carcinomas

Tytherleigh et al, Br J Surg 2008; 95: 409-423
Treatment

Radical surgery
◦ Total mesorectal excision (TME)
◦ Abdominoperineal resection (APR)

Local excision (full thickness)
◦ Transanal endoscopic microsurgery (TEM)
◦ Transanal endoscopic operation (TEO)
◦ Others: Transanal excision
TEM
Full thickness excision
 1cm resection margin
 Tumours at 6-15cm from anal verge

Sharma et al, Surg Oncol 2003; 12: 51-61
Karita et al, Gastrointest Endosc 1991; 37: 128-132
TEM advantages vs radical surgery
Less major postoperative complications
(RR 0.16, P<0.0001)
 Lower perioperative mortality (RR 0.15,
P=0.03)
 Avoids need for stoma (RR 0.11,
P<0.00001)

Kidane et al, Dis Colon Rectum 2015; 58: 122-140
TEM advantages vs radical surgery
Lower blood loss (P<0.001)
 Shorter operative time (103 vs 149mins,
P<0.05)
 Shorter hospital stay (5.7 vs 15.4 days,
P<0.0001)

Kunitake et al, Perm J 2012; 16: 45-50
TEO
Modification of TEM
 High definition 2D TFT monitor
 Standard universal laparoscopic
instruments

TEO vs TEM
Less steep learning curve
 Relatively shorter surgical time
 Lower overall costs (€2031 vs €2603,
P=0.003)

Nieuwenhuis et al, Surg Endosc 2009; 23: 80-86
Serra-Aracil et al, World J Gastroenterol 2014; 20: 11538-11545
Question

How effective is local excision in terms of
oncological control?
Local excision vs radical surgery
A nationwide cohort study
 National Cancer Database of American
College of Surgeons
 T1 rectal cancers
 Higher 5-year local recurrence rate
(12.5% vs 6.9%, P<0.003)
 Lower 5-year disease specific survival rate
(93.2% vs 97.2%, P=0.004)

You et al, Ann Surg 2007; 245: 726-733
TEM vs radical surgery
Systemic review and meta-analysis
 Compared oncological control
 T1N0M0 rectal adenocarcinoma
 1 randomized controlled trial and 12
observational studies
 2855 patients

Kidane et al, Dis Colon Rectum 2015; 58: 122-140
TEM vs radical surgery
5-year local recurrence
Kidane et al, Dis Colon Rectum 2015; 58: 122-140
TEM vs radical surgery
5-year overall survival
Kidane et al, Dis Colon Rectum 2015; 58: 122-140
Question

How to select the suitable patients for
local excision?
Management controversy
Local excision does not remove the
mesorectum and regional LN
 Problem of predicting the N (nodal)
staging in T1 tumours

Tytherleigh et al, Br J Surg 2008; 95: 409-423
Lymph node metastasis
T1 tumours: 0-12%
 T2 tumours: 12-28%
 T3 tumours: 36-79%

Chang et al, J Surg Educ 2008; 65(1): 67-72
Preoperative locoregional staging

Endorectal ultrasound (ERUS)
◦ T-staging accuracy: 69-97%
◦ N-staging accuracy: 61-80%
Klessen et al, Eur Radiol 2007; 17: 379-389
Preoperative locoregional staging

Magnetic resonance imaging (MRI)
◦ T-staging accuracy: 67-86%
◦ N-staging accuracy: 57-85%
Klessen et al, Eur Radiol 2007; 17: 379-389
Preoperative locoregional staging
Difficult for MRI to differentiate between
T1 and T2 tumours.
 ERUS is more valuable for T-staging
 Combination of ERUS and MRI is useful
for N-staging

Mulla et al, Indian J Radiol Imaging 2010; 20: 118-121
Muthusamy et al, Clin Cancer Res 2007; 13: 6877-6884
Preoperative staging
No imaging modality can completely rule
out mesorectal nodal involvement
 Thus pathological examination after local
excision is necessary
 Categorize T1 tumours into low or high
risk

Iafrate et al, Radiographics 2006; 26: 701-714
Haggitt classification
Tytherleigh et al, Br J Surg 2008; 95: 409-423
Kikuchi classification
0-3.2%
8-11%
12-25%
Lymph node metastasis
Kikuchi et al, Dis Colon Rectum 1995; 38: 1286-1295
Histopathological features of T1
tumours
Low risk
High risk
Differentiation
Well, moderate
Poor
Haggitt level
1-3
-
Kikuchi level
Sm1, +/- Sm2
Sm3, +/- Sm2
Lymphatic or vascular
invasion
No
Yes
Resection margin
involvement
No
Yes
Tytherleigh et al, Br J Surg 2008; 95: 409-423
Low risk vs high risk

Long term results from the Memorial
Sloan-Kettering Cancer Center
Disease specific survival
Paty et al, Ann Surg 2002; 236: 522-529
Immediate salvage surgery
High risk T1 tumours
 No compromise in outcome when
performed immediately after local
excision
 30-day mortality (P=0.49)
 Local recurrence (P=0.49)
 Distant metastasis (P=0.61)

Levic et al, Tech Coloproctol 2013; 17: 397-403
Local recurrence
Salvage surgery
 Outcomes are inferior to those who
initially received radical surgery
 Only 59% were disease free at a mean
follow-up of 39 months after salvage
surgery

Friel et al, Dis Colon Rectum 2002; 45: 875-879
Question

Is there a role for adjuvant therapy?
Adjuvant therapy
Local excision for T1 and T2 tumours
 With and without RT

5-year actuarial local control
Chakravarti et al, Ann Surg 1999; 230: 49-54
Adjuvant therapy
Local excision + RT + chemotherapy
 T1 and T2 cancers
 5-year local control rates increased from
81% to 96%
 Not significant (P=0.15)

Chakravarti et al, Ann Surg 1999; 230: 49-54
Adjuvant therapy
Systemic review of 11 studies
 Local excision with chemoRT in T1 and
T2 cancers
 Local recurrence 10%
 Overall survival 75%
 Disease specific survival 89%

Ung et al, Colorectal Dis 2014; 16: 502-515
NCCN guidelines 2015
Early rectal carcinoma
ERUS, MRI
cT1, N0
(Size <3cm, <30% bowel circumference, mobile)
Local excision
Low risk pT1, NX
High risk pT1, NX
T2, NX
Surveillance
Salvage surgery
Conclusion
TEM has a comparable overall survival
rate to radical surgery in T1N0M0 rectal
cancers
 Higher local recurrence rate
 Patient selection is important
 Imaging and histopathological features
help to predict lymph node metastases

Conclusion
Full thickness local excision by TEM / TEO
is suitable for low risk T1 rectal
carcinomas
 Immediate salvage surgery recommended
if high risk features present
 Adjuvant therapy showed no significant
benefit in T1 cancers

Thank you