Local excision of small rectal tumors carries increased risk of local recurrence
Posted by Kate Murphy on October 7th, 2005
Although some surgeons believe that removing small, early rectal tumors through the anus rather than a larger opening in the abdomen is safer surgery for patients and reduces the need for colostomy, two studies show this treatment carries a higher risk of local recurrence.
A study published in the October, 2005 edition of [*Annals of Surgery*](http://www.mdlinx.com/HemeOncLinx/thearts.cfm?artid=1337876&specid=17&ok=yes) reviewed outcomes for 319 consecutive patients treated for T1 rectal cancers over a 17 year period. 151 were treated with ransanal excision (LE). A second group of 160 had surgery that opened the abdomen and removed the tumor and part of the rectum (RAD). This group actually had more poor progrostic factors than the local excision group including larger tumors and an 18% rate of lymph node spread.
Despite poorer expected prognosis the RAD group had fewer local recurrences at the surgical site, fewer distant recurrences, and significantly better recurrence-free survival. However, overall survival and disease-specific survival were similar for both groups.
A [T1 tumor](http://www.cancer.gov/cancertopics/pdq/treatment/rectal/Patient/page2) is limited to the inner lining of the colon and does not extend into the muscular layers. These cancers have not spread to lymph nodes or distant sites. Transanal excision can avoid removing the sphincter requiring colostomy in some situations so patients and surgeons may choose the more limited operation.
David J. Bentrem, M.D. headed the study team, who concluded,
Despite a similar risk profile in the 2 surgical groups, patients with T1 rectal cancer treated by local excision were observed to have a 3- to 5-fold higher risk of tumor recurrence compared with patients treated by radical surgery. Local excision should be reserved for low-risk cancers in patients who will accept an increased risk of tumor recurrence, prolonged surveillance, and possible need for aggressive salvage surgery. Radical resection is the more definitive surgical treatment of T1 rectal cancers
In a different study published in the June 2005 Supplement of the [*Journal of Clinical Oncology*](http://meeting.jco.org/cgi/content/abstract/23/16_suppl/3526), researchers analyzed information in the National Cancer Database. In the database, there were 1114 patients who had T1 rectal cancers that were treated with surgery only. Slightly more than half (616 or 55.3%) were treated with local excision through the anus (LE). The other group (498 or 44.7%) had surgical resections that opened the abdomen (SR).
Local excision was more likely to be chosen by patients and surgeons if:
+ tumor was close to the anus: for tumors within 5 cm of the anal verge 58% were removed by local excision (LE) versus 42% treated with standard resection (SR)
+ tumor was small: for tumors less than 1 cm, 77% were treated by LE versus 23% by SR.
+ patients had no other serious medical problems: 58% for LE versus 42%. SR
Mortality and morbidity due to surgery were significantly worse for standard open resection than local excision: Thirty-day mortality was 2.4% for SR compared to 0.5% for LE; morbidity rates for SR was 12.7% versus 4.4% for local excision.
However, local recurrence rates significantly favored standard resection at both 5 years and 8 years. At 5 years 12.7% of patients treated with local excision had experienced local recurrence compared to 6.1% of those who had standard resections. This difference was 14.4% versus 9.5% eight years after surgery. At five years there was no difference in overall survival between the groups.
Y. N. You MD and colleagues reported their results at the 2005 ASCO meeting, and they were published in the June 1, 2005 supplement to the *Journal of Clinical Oncology.* She wrote.
Patients considering LE for T1 rectal cancer may expect lower rates of perioperative morbidity and mortality, but are likely to face greater risks of local/regional tumor recurrence. For those treated with LE, long-term and vigilant oncological follow-up is essential.
[Read the abstract of the Bentrem research in the *Annals of Surgery.*](http://www.mdlinx.com/HemeOncLinx/thearts.cfm?artid=1337876&specid=17&ok=yes)
[Read the abstract of the You study in the *Journal of Clinical Oncology.*](http://meeting.jco.org/cgi/content/abstract/23/16_suppl/3526)
[See the slides of Dr. Nancy You's presentation at the 2005 meeting of the American Society of Clinical Oncology](http://asco.org/ac/1,1003,_12-002511-00_18-0034-00_19-003345,00.asp)
A.Abasahl,MD.,FACS.
May 11, 2006 at 1:40pm
I think it is better to do an adjuvant radiation therapy after local excision of rectal tumor.This has proved that post operative radiotherapy will reduce the local recurrence of the tumor and probably the survival,therefore I am not agree for the statement of 3 to 5 fold more recurrence of LE than SR because the real statement is LE + Radiotherapy = SR.
Thanks regards
A.Abasahl,MD.,FACS
Dan Foster
February 28, 2007 at 7:18pm
I would like to know if you have any information on TME Surgery (Total Mesorectal Excision)for Rectal Cancer. That is the type of surgery I had and I’m now a 10 year survivor
Jaynee Weiss
June 13, 2007 at 1:16am
I originally had a T3N0M0 tumor diagnosed in 6/06. After chemoradiation for 5 weeks, then a 6-7 week break, I did 5 more cycles of Xeloda and had a full thickness transanal excision in April ‘07. Good clear margins. Pathology showed no cancer cells. Tumor had shrunk from 5cm to a scar about 1/2cm. Less than 10% of circumference involved. Not fair to compare plain LE without therapy to neoadjuvant chemoradiation (& in my case extra 5 chemos) & then LE. Serious consideration should be given to the protocol of more chemo pre-op to those patients who show significant downsizing after chemoradiation. It’s possible that more pre-op chemo could eradicate cancer cells in that group of patients who would have had microscopic disease after the chemoradiation.