Management of early rectal Management of early rectal carcinomacarcinoma

Joint Hospital Surgical Grand Round

Jeren LimUnited Christian Hospital

Early rectal carcinomaEarly rectal carcinomaAdenocarcinoma

invaded into, but not beyond the submucosa

T1N0M0 tumour3 – 8.6% of all

resected rectal carcinomas

Tytherleigh et al, Br J Surg 2008; 95: 409-423

TreatmentTreatmentRadical surgery

◦Total mesorectal excision (TME)◦Abdominoperineal resection (APR)

Local excision (full thickness)◦Transanal endoscopic microsurgery

(TEM)◦Transanal endoscopic operation

(TEO)◦Others: Transanal excision

TEMTEMFull thickness excision1cm resection marginTumours 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 TEM advantages vs radical surgerysurgeryLess 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 TEM advantages vs radical surgerysurgeryLower 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

TEOTEOModification of TEMHigh definition 2D TFT monitorStandard universal laparoscopic

instruments

TEO vs TEMTEO vs TEMLess steep learning curveRelatively shorter surgical timeLower overall costs (€2031 vs

€2603, P=0.003)

Nieuwenhuis et al, Surg Endosc 2009; 23: 80-86Serra-Aracil et al, World J Gastroenterol 2014; 20: 11538-11545

QuestionQuestionHow effective is local excision in

terms of oncological control?

Local excision vs radical Local excision vs radical surgerysurgeryA nationwide cohort studyNational Cancer Database of

American College of SurgeonsT1 rectal cancersHigher 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 surgeryTEM vs radical surgerySystemic review and meta-

analysisCompared oncological controlT1N0M0 rectal adenocarcinoma1 randomized controlled trial and

12 observational studies2855 patients

Kidane et al, Dis Colon Rectum 2015; 58: 122-140

TEM vs radical surgeryTEM vs radical surgery5-year local recurrence

Kidane et al, Dis Colon Rectum 2015; 58: 122-140

TEM vs radical surgeryTEM vs radical surgery5-year overall survival

Kidane et al, Dis Colon Rectum 2015; 58: 122-140

QuestionQuestionHow to select the suitable

patients for local excision?

Management controversyManagement controversyLocal excision does not remove

the mesorectum and regional LNProblem of predicting the N

(nodal) staging in T1 tumours

Tytherleigh et al, Br J Surg 2008; 95: 409-423

Lymph node metastasisLymph node metastasisT1 tumours: 0-12%T2 tumours: 12-28%T3 tumours: 36-79%

Chang et al, J Surg Educ 2008; 65(1): 67-72

Preoperative locoregional Preoperative locoregional stagingstagingEndorectal ultrasound (ERUS)

◦T-staging accuracy: 69-97%◦N-staging accuracy: 61-80%

Klessen et al, Eur Radiol 2007; 17: 379-389

Preoperative locoregional Preoperative locoregional stagingstagingMagnetic resonance imaging

(MRI)◦T-staging accuracy: 67-86%◦N-staging accuracy: 57-85%

Klessen et al, Eur Radiol 2007; 17: 379-389

Preoperative locoregional Preoperative locoregional stagingstagingDifficult for MRI to differentiate

between T1 and T2 tumours.ERUS is more valuable for T-

stagingCombination of ERUS and MRI is

useful for N-staging

Mulla et al, Indian J Radiol Imaging 2010; 20: 118-121Muthusamy et al, Clin Cancer Res 2007; 13: 6877-6884

Preoperative stagingPreoperative stagingNo 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 classificationHaggitt classification

Tytherleigh et al, Br J Surg 2008; 95: 409-423

Kikuchi classificationKikuchi classification

Kikuchi et al, Dis Colon Rectum 1995; 38: 1286-1295

0-3.2%

8-11%

12-25%

Lymph node metastasis

Histopathological features of Histopathological features of T1 tumoursT1 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 riskLow risk vs high riskLong term results from the

Memorial Sloan-Kettering Cancer Center

Paty et al, Ann Surg 2002; 236: 522-529

Disease specific survival

Immediate salvage Immediate salvage surgerysurgeryHigh risk T1 tumoursNo 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 recurrenceLocal recurrenceSalvage surgeryOutcomes 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

QuestionQuestionIs there a role for adjuvant

therapy?

Adjuvant therapyAdjuvant therapyLocal excision for T1 and T2

tumoursWith and without RT

Chakravarti et al, Ann Surg 1999; 230: 49-54

5-year actuarial local control

Adjuvant therapyAdjuvant therapyLocal excision + RT +

chemotherapyT1 and T2 cancers5-year local control rates

increased from 81% to 96%Not significant (P=0.15)

Chakravarti et al, Ann Surg 1999; 230: 49-54

Adjuvant therapyAdjuvant therapySystemic review of 11 studiesLocal excision with chemoRT in

T1 and T2 cancersLocal recurrence 10%Overall survival 75%Disease specific survival 89%

Ung et al, Colorectal Dis 2014; 16: 502-515

NCCN guidelines 2015NCCN guidelines 2015Early rectal carcinoma

High risk pT1, NX T2, NX

Low risk pT1, NX

ERUS, MRI

cT1, N0(Size <3cm, <30% bowel circumference, mobile)

Local excision

Salvage surgery

Surveillance

ConclusionConclusionTEM has a comparable overall

survival rate to radical surgery in T1N0M0 rectal cancers

Higher local recurrence ratePatient selection is importantImaging and histopathological

features help to predict lymph node metastases

ConclusionConclusionFull 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 youThank you