Experience of minimally invasive treatment for early rectal cancer

Objective. The aim of this study is to evaluate the experience with minimally invasive transanal operations and to improve treatment results in patients with early rectal cancer; to assess the accuracy of endorectal ultrasound (ERUS) in preoperative staging of rectal cancer. Materials and methods. The present clinical trial includes 38 selected patients who were underwent minimally invasive transanal procedures for early rectal cancers. 22 (58 %) patients were operated by transanal endoscopic microsurgery, 16 (42 %) were underwent transanal local excision. The study population consisted of 20 men and 18 women; average age was 64 (range 42–84) years. The main outcome measures included the operation time, the intra- and postoperative complication rate, negative microscopic margin rate, specimen fragmentation rate, oncological results (local recurrence and distant metastasis rate). Comparison of ERUS preoperative staging and pathological staging was performed to identify the accuracy of ERUS. The postoperative surveillance protocol was applied to all patients. Results. The median operative time was 56 (30–110) minutes. Postoperative complications occurred in 2 patients (5.2 %). There was no mortality. All pathological specimens were removed en block without fragmentation. Final histology revealed pTis – 10 (26 %), pT1sm1 – 9 (24 %), pT1sm2 – 12 (32 %), pT1sm3 – 5 (13 %) and pT2 – 2 (5 %) adenocarcinomas with negative resection margins (R0). The overall accuracy of ERUS for preoperative T stage was 78.9 %; for Tis was 80.0 % and for T1 – 85.0 %. All 7 patients in the pT1sm3 and pT2 groups were offered immediate radical surgery or adjuvant chemoradiotherapy. The follow-up period was from 5 to 60 (median 36) months. There was one local recurrence (2.6 %) in 6 months after local excision in a patient with pT1sm3. This patient underwent total mesorectumectomy. Conclusions. Selected patients with “low-risk” early rectal cancer and favorable features may be effectively treated with minimally invasive transanal operations without jeopardizing long-term oncological results. The lack of lymphadenectomy represents the main concern of this approach for the treatment of rectal cancer. Further follow-up is necessary. Preoperative ERUS has a good accuracy with pathologic T stage and can guide transanal procedure in early rectal cancer.

1. Васильев С.В., Смирнова Е.В., Попов Д.Е. и др. Сравнение иммуногистохимического теста Colon View Hb and Hb/Ht с гваяковым тестом в диагностике новообразований толстой кишки. Колопроктология 2015;3(53):17–22. [Vasil’ev S.V., Smirnova E.V., Popov D.A. et al. Comparison of immunohistochemi-cal View Colon test Hb and Hb/Ht with the guaiac test in the diagnosis of tumors of the colon. Koloproktologiya = Coloproctology 2015;3(53):17–22. (In Russ.)].

2. Kav T., Bayraktar Y. How useful is rectal endosonography in the staging of rectal cancer? World J Gastroenterol 2010;16(6):691–7. PMID: 20135716.

3. Zorcolo L., Fantola G., Cabras F. et al. Preoperative staging of patients with rectal tumors suitable for transanal endoscopic microsurgery (TEM): comparison of en-dorectal ultrasound and histopathologic findings. Surg Endosc 2009;23(6):1384–9. DOI: 10.1007/s00464-009-0349-y.

4. Glancy D.G., Pullyblank A.M., Thomas M.G. The role of colonoscopic endoanal ultrasound scanning (EUS) in selecting patients suitable for resection by transanal endoscopic microsurgery (TEM). Colorectal Dis 2005;7(2):148–50. DOI: 10.1111/j.1463-1318.2004.00728.x. PMID: 15720352.

5. Kwok H., Bissett I.P., Hill G.L. Preoperative staging of rectal cancer. Int J Colorectal Dis 2000;15(1):9–20. PMID: 10766086.

6. Koebrugge B., Bosscha K., Jager G., Ernst M. Accuracy of transrectal ultrasonography in staging rectal tumors that are clinically eligible for transanal endoscopic microsurgery. J Clin Ultrasound 2010;38(5):250–3. DOI: 10.1002/jcu.20680.

7. Kulig J., Richter P., Gurda-Duda A. et al. The role and value of endorectal ultrasonography in diagnosing T1 rectal tumors. Ultrasound Med Biol 2006;32(4):469–72. DOI: 10.1016/j.ultrasmedbio.2005.12.014. PMID: 16616592.

8. American Joint Committee on Cancer. AJCC Cancer Staging Manual. 7th edn. New York: Springer, 2010.

9. Buess G. Review: transanal endoscopic microsurgery (TEM). J R Coll Surg Edinb 1993;38(4):239–45. PMID: 7693935.

10. Kikuchi R., Takano M., Takagi K. et al. Management of early invasive colorectal cancer. Risk of recurrence and clinical guidelines. Dis Colon Rectum 1995;38(12):1286–95. PMID: 7497841.

11. Nascimbeni R., Burgart L.J., Nivatvongs S., Larson D.R. Risk of lymph node metastasis in T1 carcinoma of the colon and rectum. Dis Colon Rectum 2002;45(2): 200–6. PMID: 11852333.

12. Akasu T., Kondo H., Moriya Y. et al. En-dorectal ultrasonogrаphy and treatment of early stage rectal cancer. World J Surg 2000;24(9):1061–8. PMID: 11036283.

13. Allaix M.E., Arezzo A., Caldart M. et al. Transanal endoscopic microsurgery for rectal neoplasms: experience of 300 consecutive cases. Dis Colon Rectum 2009;52(11):1831–6. DOI: 10.1007/DCR.0b013e3181b14d2d.

14. Palma P., Freudenberg S., Samel S. et al. Transanal endoscopic microsurgery: indications and results after 100 cases. Colorectal Dis 2004;6(5):350–5. DOI: 10.1111/j.1463-1318.2004.00671.x. PMID: 15335369.

15. Moore J.S., Cataldo P.A., Osler T. et al. Transanal endoscopic microsurgery

16. is more effective than traditional transanal excision for resection of rectal masses. Dis Colon Rectum 2008;51(7):1026–30. DOI: 10.1007/s10350-008-9337-x.

17. Sakamoto G.D., MacKeigan J.M., Sena-gore A.J. Transanal excision of large, rectal villous adenomas. Dis Colon Rectum 1991;34(10):880–5. PMID: 1914721.

18. Whitehouse P.A., Tilney H.S., Armitage J.N., Simson J.N.Transanal endoscopic microsurgery: risk factors for local recurrence of benign rectal adenomas. Colorectal Dis 2006;8(9):795–9. DOI: 10.1111/j.1463-1318.2006.01098.x. PMID: 17032328.

19. Araki Y., Isomoto H., Shirouzu K. Clinical efficacy of video-assisted gasless trans-anal endoscopic microsurgery (TEM) for rectal carcinoid tumor. Surg Endosc 2001;15(4):402–4. DOI: 10.1007/s004640000332. PMID: 11395824.

20. Baatrup G., Endreseth B.H., Isaksen V. et al. Preoperative staging and treatment options in T1 rectal adenocarcinoma. Acta Oncol 2009;48(3):328–42. DOI: 10.1080/02841860802657243.

21. Hahnloser D., Wolff B.G., Larson D.W. et al. Immediate radical resection after local excision of rectal cancer: an oncologic compromise. Dis Colon Rectum 2005;48(3):429–37. DOI: 10.1007/s10350-004-0900-9. PMID: 15747069.

22. Mellgren A., Sirivongs P., Rothenberger D.A. et al. Is local excision adequate therapy for early rectal cancer. Dis Colon Rectum 2000;43(8):1064–74. PMID: 10950004.

23. Willett C.G., Compton C.C., Shellito P.C., Efird J.T. Selection factors for local excision or abdominoperineal resection of early stage rectal cancer. Cancer 1994;73(11):2716–20. PMID: 8194011.