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, Jose Maria Enriquez-Navascues, Garazi Elorza-Echaniz, Ane Etxart-Lopetegui, Nerea Borda-Arrizabalaga, Yolanda Saralegui Ansorena, Carlos Placer-Galan
Published: 1 February 2021
Cirugía Española (English Edition), Volume 99, pp 89-107; doi:10.1016/j.cireng.2021.02.007

Abstract:
Local excision (LE) has arisen as an alternative to total mesorectal excision for the treatment of early rectal cancer. Despite a decreased morbidity, there are still concerns about LE outcomes. This systematic-review and meta-analysis design is based on the “PICO” process, aiming to answer to three questions related to LE as primary treatment for early-rectal cancer, the optimal method for LE, and the potential role for completion treatment in high-risk histology tumors and outcomes of salvage surgery. The results revealed that reported overall survival (OS) and disease-specific survival (DSS) were 71%–91.7% and 80%–94% for LE, in contrast to 92.3%–94.3% and 94.4%–97% for radical surgery. Additional analysis of National Database studies revealed lower OS with LE (HR: 1.26; 95%CI, 1.09–1.45) and DSS (HR: 1.19; 95%CI, 1.01–1.41) after LE. Furthermore, patients receiving LE were significantly more prone develop local recurrence (RR: 3.44, 95%CI, 2.50–4.74). Analysis of available transanal surgical platforms was performed, finding no significant differences among them but reduced local recurrence compared to traditional transanal LE (OR:0.24;95%CI, 0.15–0.4). Finally, we found poor survival outcomes for patients undergoing salvage surgery, favoring completion treatment (chemoradiotherapy or surgery) when high-risk histology is present. In conclusion, LE could be considered adequate provided a full-thickness specimen can be achieved that the patient is informed about risk for potential requirement of completion treatment. Early-rectal cancer cases should be discussed in a multidisciplinary team, and patient's preferences must be considered in the decision-making process. La escisión local (EL) se ha planteado como una alternativa a la escisión mesorrectal total en el tratamiento del cáncer de recto inicial. A pesar de la reducción de la morbilidad, los resultados de la EL todavía son motivo de preocupación. Esta revisión sistemática y metaanálisis se basa en el proceso «PICO» con el objetivo de responder a tres preguntas relacionadas con la EL, a saber, como tratamiento principal del cáncer de recto inicial, el método óptimo de EL y su posible papel en el tratamiento completo de tumores histológicos de alto riesgo y complicaciones de la cirugía de rescate. Los resultados han puesto de manifiesto que la supervivencia general (SG) y la supervivencia específica por enfermedad (SEE) notificadas fueron del 71-91% y del 80-94% en el caso de la EL, en comparación con el 92,3-94,3% y el 94,4-97% en el caso de la cirugía radical, respectivamente. Un análisis complementario de los estudios de la Base de Datos Nacional reveló una SG (HR: 1,26; IC 95%: 1,09-1,45) y una SEE inferiores (HR: 1,19; IC 95%: 1,01-1,41) después de EL. Además, los pacientes que aceptaron la EL fueron mucho más propensos a presentar una recidiva local (RR: 3,44; IC 95%: 2,50-4,74). Se llevó a cabo un análisis de los planteamientos quirúrgicos transanales disponibles. No se encontraron importantes diferencias entre ellos, pero las recidivas locales eran inferiores en comparación con las de la EL transanal tradicional (OR: 0,24; IC 95%: 0,15-0,4). Por último, hubo malos resultados de supervivencia entre los pacientes a quienes se les realizó cirugía de rescate, lo que favorece el tratamiento completo (quimiorradioterapia o cirugía) cuando hay histología de alto riesgo. En conclusión, la EL podría considerarse adecuada siempre que se pueda lograr una muestra de espesor completo y el paciente esté informado del riesgo de una posible necesidad de tratamiento completo. Los casos de cáncer de recto inicial deben tratarse en un equipo multidisciplinario y las preferencias del paciente deben tenerse en cuenta en el proceso de toma de decisiones.
, Jose Maria Enriquez-Navascues, Garazi Elorza-Echaniz, Ane Etxart-Lopetegui, Nerea Borda-Arrizabalaga, Yolanda Saralegui Ansorena, Carlos Placer-Galan
Published: 1 February 2021
Cirugía Española, Volume 99, pp 89-107; doi:10.1016/j.ciresp.2020.05.035

Abstract:
Local excision (LE) has arisen as an alternative to total mesorectal excision for the treatment of early rectal cancer. Despite a decreased morbidity, there are still concerns about LE outcomes. This systematic-review and meta-analysis design is based on the “PICO” process, aiming to answer to three questions related to LE as primary treatment for early-rectal cancer, the optimal method for LE, and the potential role for completion treatment in high-risk histology tumors and outcomes of salvage surgery. The results revealed that reported overall survival (OS) and disease-specific survival (DSS) were 71%–91.7% and 80%–94% for LE, in contrast to 92.3%–94.3% and 94.4%–97% for radical surgery. Additional analysis of National Database studies revealed lower OS with LE (HR: 1.26; 95%CI, 1.09–1.45) and DSS (HR: 1.19; 95%CI, 1.01–1.41) after LE. Furthermore, patients receiving LE were significantly more prone develop local recurrence (RR: 3.44, 95%CI, 2.50–4.74). Analysis of available transanal surgical platforms was performed, finding no significant differences among them but reduced local recurrence compared to traditional transanal LE (OR:0.24;95%CI, 0.15–0.4). Finally, we found poor survival outcomes for patients undergoing salvage surgery, favoring completion treatment (chemoradiotherapy or surgery) when high-risk histology is present. In conclusion, LE could be considered adequate provided a full-thickness specimen can be achieved that the patient is informed about risk for potential requirement of completion treatment. Early-rectal cancer cases should be discussed in a multidisciplinary team, and patient's preferences must be considered in the decision-making process. La escisión local (EL) se ha planteado como una alternativa a la escisión mesorrectal total en el tratamiento del cáncer de recto inicial. A pesar de la reducción de la morbilidad, los resultados de la EL todavía son motivo de preocupación. Esta revisión sistemática y metaanálisis se basa en el proceso «PICO» con el objetivo de responder a tres preguntas relacionadas con la EL, a saber, como tratamiento principal del cáncer de recto inicial, el método óptimo de EL y su posible papel en el tratamiento completo de tumores histológicos de alto riesgo y complicaciones de la cirugía de rescate. Los resultados han puesto de manifiesto que la supervivencia general (SG) y la supervivencia específica por enfermedad (SEE) notificadas fueron del 71-91% y del 80-94% en el caso de la EL, en comparación con el 92,3-94,3% y el 94,4-97% en el caso de la cirugía radical, respectivamente. Un análisis complementario de los estudios de la Base de Datos Nacional reveló una SG (HR: 1,26; IC 95%: 1,09-1,45) y una SEE inferiores (HR: 1,19; IC 95%: 1,01-1,41) después de EL. Además, los pacientes que aceptaron la EL fueron mucho más propensos a presentar una recidiva local (RR: 3,44; IC 95%: 2,50-4,74). Se llevó a cabo un análisis de los planteamientos quirúrgicos transanales disponibles. No se encontraron importantes diferencias entre ellos, pero las recidivas locales eran inferiores en comparación con las de la EL transanal tradicional (OR: 0,24; IC 95%: 0,15-0,4). Por último, hubo malos resultados de supervivencia entre los pacientes a quienes se les realizó cirugía de rescate, lo que favorece el tratamiento completo (quimiorradioterapia o cirugía) cuando hay histología de alto riesgo. En conclusión, la EL podría considerarse adecuada siempre que se pueda lograr una muestra de espesor completo y el paciente esté informado del riesgo de una posible necesidad de tratamiento completo. Los casos de cáncer de recto inicial deben tratarse en un equipo multidisciplinario y las preferencias del paciente deben tenerse en cuenta en el proceso de toma de decisiones.
, Christopher J. Anker, May Abdel-Wahab, Nilofer Azad, Prajnan Das, Jadranka Dragovic, Karyn A. Goodman, Joseph M. Herman, William Jones, Timothy Kennedy, et al.
International Journal of Radiation Oncology*Biology*Physics, Volume 105, pp 977-993; doi:10.1016/j.ijrobp.2019.08.020

Abstract:
The goal of treatment for early stage rectal cancer is to optimize oncologic outcome while minimizing impact of treatment on quality of life. The standard of care treatment for most early rectal cancers is radical surgery alone. Given the morbidity associated with radical surgery, local excision for early rectal cancers has been explored as an alternative approach associated with lower rates of morbidity. The American Radium Society Appropriate Use Criteria (ARS AUC) presented in this manuscript are evidence-based guidelines for the use of local excision in early stage rectal cancer that includes an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by a multidisciplinary expert panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. These guidelines are intended for the use of all practitioners and patients who desire information regarding the use of local excision in rectal cancer.
Jinhui Zhu, Kai Yu, Ramon Andrade De Mello
International Manual of Oncology Practice pp 351-378; doi:10.1007/978-3-030-16245-0_17

Abstract:
Rectal cancer is a disease in which cancer cells form in the tissues of the rectum; colorectal cancer occurs in the colon or rectum. Adenocarcinomas comprise the vast majority (98%) of colon and rectal cancers; more rare rectal cancers include lymphoma (1.3%), carcinoid (0.4%), and sarcoma (0.3%).The incidence and epidemiology, etiology, pathogenesis, and screening recommendations are common to both colon cancer and rectal cancer. The incidence of colorectal cancer rose dramatically following economic development and industrialization. The majority of colorectal cancers still occur in industrialized countries. Currently, the incidence of rectal cancer in the European Union is 15–25 cases/100 000 population per year and is predicted to increase further in both genders. High body mass index, body or abdominal fatness and diabetes type II are seen as risk factors. Longstanding ulcerative colitis and Crohn’s disease affecting the rectum, excessive consumption of red or processed meat and tobacco as well as moderate/heavy alcohol use increase the risk. The usual pathogenesis of colorectal cancer is an adenomatous polyp that slowly increases in size, followed by dysplasia and finally cancer. Screening for colorectal cancer is valuable because early detection and removal of premalignant adenomas or localized cancer can prevent cancer or cancer-related deaths. Although radical resection of rectum is the mainstay of therapy, surgery alone has a high recurrence rates. A multidisciplinary approach that includes colorectal surgery, medical oncology, and radiation oncology is required for optimal treatment of patients with rectal cancer. Therefore, determination of optimal treatment plan for patients with rectal cancer involves a complex decision-making process. Rectal cancer recurs in 5–30% of patients, usually in the first year after surgery. Tumor stage, grade, number of lymph node metastasis, lymphovascular involvement, signet cell appearance, achievement of negative radial margins, and distance from the radial margin are important prognostic indicators of local and distant recurrences.
, Arden M. Morris, Robert K. Cleary, George J. Chang
Published: 25 April 2019
Annals of Surgical Oncology, Volume 26, pp 2497-2506; doi:10.1245/s10434-019-07328-5

Abstract:
The most appropriate treatment for early-stage rectal cancers is controversial. The advantages of local excision regarding morbidity and function must be weighed against poorer oncologic efficacy. This study aimed to clarify further the role for local excision in the treatment of rectal cancer. A systematic review of Medline, SCOPUS, and Cochrane databases was conducted. Relevant studies were selected using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data addressing five key questions about outcomes of local versus radical resection of rectal cancer were analyzed. The 16 studies identified by this study were mostly retrospective, and none were randomized. Local excision was associated with fewer complications and better functional outcome than radical resection. Of 12 studies evaluating local recurrence, 6 showed a higher local recurrence rate among patients who underwent local excision. Two additional studies showed no increase in local recurrence rate among patients who underwent local excision of T1 lesions but a significantly higher local recurrence rate among those who underwent local excision of T2 lesions. High histologic grade, angiolymphatic invasion, perineural invasion, and depth within submucosa were features associated with a higher risk of local recurrence. In 7 of 15 studies, long-term survival was reduced compared with that of patients who underwent radical resection. Although local excision for early-stage rectal cancer is associated with increased local recurrence and decreased overall survival compared with radical resection, local excision may be appropriate for select individuals who have T1 tumors with no adverse pathologic features.
Kevin R. Kalisz, Michael D. Enzerra,
RadioGraphics, Volume 39, pp 538-556; doi:10.1148/rg.2019180075

Abstract:
MRI plays a critical role in the staging and restaging of rectal cancer. Although newly diagnosed early-stage rectal cancers may immediately be amenable to surgical resection, patients with advanced disease first undergo neoadjuvant therapy that consists of a combination of chemotherapy and radiation therapy. Evaluation of rectal cancer after neoadjuvant therapy is best performed with MRI, given its superior soft-tissue contrast and its ability to allow multiplanar imaging and functional evaluation. In this setting, MRI allows accurate evaluation of primary tumor staging, which is determined on the basis of the depth of invasion within and through the rectal wall and the involvement of adjacent organs. MRI can also be used to evaluate posttreatment morphologic components within the tumors, including fibrosis and mucinous changes that have been shown to correlate with the response to treatment. Additional features such as the circumferential resection margin and extramural vascular invasion—factors shown to affect prognosis and local recurrence—are also assessed before and after therapy. Functional assessment with diffusion-weighted MRI and perfusion MRI plays a role in predicting tumor aggressiveness and the likelihood of response to treatment, as well as the extent of residual tumor after therapy. Lymph node staging is also performed at MRI, with assessment of not only lymph node size but also the internal architecture and signal intensity characteristics.©RSNA, 2019See discussion on this article by Wasnik and Al-Hawary.
Kamlesh Ahirwar, Avinash Kumar Gautam
Journal of Evolution of Medical and Dental Sciences, Volume 7, pp 2628-2633; doi:10.14260/jemds/2018/590

Juan Pablo Celentano, Flavia Alexandre, Bruna Borba Vailati,
Clinics in Colon and Rectal Surgery, Volume 30, pp 313-323; doi:10.1055/s-0037-1606108

Abstract:
Radical surgery is considered as the standard treatment for rectal cancer. Transanal local excision has been considered an interesting alternative for the management of selected patients with rectal cancers for many decades. Different approaches had been considered for local excision, from endoscopic submucosal dissection to resections using platforms, such as transanal endoscopic microsurgery or transanal minimally invasive surgery. Identifying the ideal candidate for this approach is crucial, as a local failure after local excision is associated with poor outcomes, even for an initial early rectal tumor. In this article, the diagnostic tools and criteria to select patients for local excision, the different modalities used, and the outcomes are discussed.
, Ursula Goenner, Mirjam Hitzler, Tong T. Trinh, Achim Heintz, Wilfried Roth, Maria Blettner, Daniel Wollschlaeger
International Journal of Colorectal Disease, Volume 32, pp 265-271; doi:10.1007/s00384-016-2715-2

Abstract:
Rates of local recurrence (LR) after transanal endoscopic microsurgery (TEM) for rectal carcinoma vary; the reasons remain unclear. We analyzed LR after TEM for low-risk pT1 (G1/2/X, L0/X) rectal carcinoma to investigate the influence of completeness of resection and occult lymph node metastasis on risk of LR. LR location and stage, completeness of resection of primary carcinoma (minimal distance between tumor and resection line ≤1 mm vs >1 mm), and incidence of involved lymph nodes in resected LR specimens were collected, and tumor characteristics of LR were compared with primary carcinoma. Distant metastasis and overall and cancer-specific survival were determined. LR developed in 14 patients; in 2/4 with R1/X resection, in 3/8 (38%) with clear margins (R0) but a minimal distance of ≤1 mm, and in 9/88 (10%) with formally complete resection. Six of nine patients with formally complete resection underwent radical surgery for LR; in five out of these six, lymph nodes were not involved. In 5/14 patients, LR was poorly differentiated compared to primary carcinoma. Main LR causes were incomplete tumor resection or tumor persistence after formally complete resection. Overall (p = 0.008) and cancer-specific (p < 0.001) survival was lower in LR patients compared to non-LR patients, even if lymph nodes were uninvolved. The results suggest that most LRs after TEM for low-risk rectal cancer were caused by residual tumor at the previous excision site and not by undetected lymph node metastases. By improved standardization of surgical techniques to ensure complete resection of carcinomas and thorough pathological assessments, most LRs seem to be avoidable.
Suzanne Russo, A. William Blackstock, Joseph M. Herman, May Abdel-Wahab, Nilofer Azad, Prajnan Das, , Theodore S. Hong, Salma K. Jabbour, William E. Jones, et al.
American Journal of Clinical Oncology, Volume 38, pp 520-525; doi:10.1097/coc.0000000000000197

Abstract:
Low anterior resection or abdominoperineal resection are considered standard treatments for early rectal cancer but may be associated with morbidity in selected patients who are candidates for early distal lesions amenable to local excision (LE). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. The panel recognizes the importance of accurate staging to identify patients who may be candidates for a LE approach. Patients who may be candidates for LE alone include those with small, low-lying T1 tumors, without adverse pathologic features. Several surgical approaches can be utilized for LE however none include lymph node evaluation. Adjuvant radiation±chemotherapy may be warranted depending on the risk of nodal metastases. Patients with high-risk T1 tumors, T2 tumors not amenable to radical surgery may also benefit from adjuvant treatment; however, patients with positive margins or T3 lesions should be offered abdominoperineal resection or low anterior resection. Neoadjuvant radiation±chemotherapy followed by LE in higher risk patients results in excellent local control, but it is not clear if this approach reduces recurrence rates over surgery alone.
International Manual of Oncology Practice pp 281-303; doi:10.1007/978-3-319-21683-6_13

Abstract:
Colorectal cancer is the second leading cause of cancer-related deaths among both men and women in Western countries with rectal carcinoma accounting for approximately 28 % of cases arising from the large bowel. The majority of colorectal cancers still occur in industrialized countries. With the dramatic changes in socioeconomic circumstances and lifestyles, recent rises in colorectal cancer incidence have been observed in economic transitioning countries worldwide. The usual pathogenesis of colorectal cancer is an adenomatous polyp that slowly increases in size, followed by dysplasia and finally cancer. Screening for colorectal cancer is valuable because early detection and removal of premalignant adenomas or localized cancer can prevent cancer or cancer-related deaths. Although radical resection of rectum is the mainstay of therapy, surgery alone has a high recurrence rates. A multidisciplinary approach that includes colorectal surgery, medical oncology, and radiation oncology is required for optimal treatment of patients with rectal cancer. Therefore, determination of optimal treatment plan for patients with rectal cancer involves a complex decision-making process. Rectal cancer recurs in 5–30 % of patients, usually in the first year after surgery. Tumor stage, grade, number of lymph node metastasis, lymphovascular involvement, signet cell appearance, achievement of negative radial margins, and distance from the radial margin are important prognostic indicators of local and distant recurrences.
M. M. Elmessiry, J. A. M. Van Koughnett, A. Maya, G. DaSilva, S. D. Wexner, P. Bejarano, M. Berho
Published: 13 August 2014
Colorectal Disease, Volume 16, pp 703-709; doi:10.1111/codi.12657

M. M. Elmessiry, J. A. M. Van Koughnett, A. Maya, G. DaSilva, S. D. Wexner, P. Bejarano,
Published: 13 August 2014
Colorectal Disease, Volume 16

Abstract:
This study aimed to compare the clinical outcome between local excision (LE) and total mesorectal excision (TME) for early rectal cancer. After Institutional Review Board approval, charts of patients with T1 or T2 N0M0 rectal adenocarcinoma treated by curative LE or TME without preoperative radiotherapy from 2004 to 2012 were reviewed. Categorical and continuous variables were compared using chi‐square analysis and the ANOVA test. Kaplan–Meier analysis compared survival rates. The study included 153 patients: 79 underwent TME and 74 LE. Postoperative infection was more common after TME (P = 0.009). There was tumour involvement of the margins in 13.5% after LE compared with 0% after TME (P = 0.001). Of the patients treated initially by LE, 13.5% had additional surgery for unfavourable histological findings and 4.1% had residual tumour. Median follow up was 35 (17–96) months. No deaths were recorded in 56 patients with a pT1 lesion. There was no significant difference in local recurrence (P = 0.332) or 3‐year disease‐free survival (DFS; P = 0.232) between patients having LE or TME. The 68 patients with a T2 lesion had higher local recurrence (P = 0.025) and lower DFS following LE compared with TME (P = 0.044). There was no difference in overall survival (P = 0.351). LE of early rectal cancer is associated with higher local recurrence and decreased DFS. These disadvantages are significant for T2 lesions.
, Worabhong Anubhonganant, Siriluck Prapasrivorakul, Cherdsak Iramaneerat, Woramin Riansuwan, Wiroon Boonnuch, Darin Lohsiriwat
Asian Pacific Journal of Cancer Prevention, Volume 14, pp 5141-5144; doi:10.7314/apjcp.2013.14.9.5141

Abstract:
This study aimed to determine clinical outcomes of local excision for early rectal cancer from a University Hospital in Thailand.
Alice Dewdney, ,
Published: 11 May 2013
The Oncologist, Volume 18, pp 833-842; doi:10.1634/theoncologist.2013-0022

Abstract:
Rectal cancer remains a significant problem worldwide. Outcomes vary significantly according to the stage of disease and prognostic factors, including the distance of the tumor from the circumferential resection margin. Accurate staging, including high-resolution magnetic resonance imaging, allows stratification of patients into low-, moderate-, and high-risk disease; this information can be used to inform multidisciplinary team decisions regarding the role of neoadjuvant therapy. Both neoadjuvant short-course radiotherapy and long-course chemoradiation reduce the risk of local recurrence compared with surgery alone, but they have little impact on survival. Although there remains a need to reduce overtreatment of those patients at moderate risk, evaluation of intensified regimens for those with high-risk disease is still required to reduce distant failure rates and improve survival in these patients with an otherwise poor prognosis.
, David Schwartz, Justin Rineer, Angela Wortham, Sonal Sura, , Marvin Rotman, David Schreiber
Journal of Gastrointestinal Cancer, Volume 44, pp 305-312; doi:10.1007/s12029-013-9493-7

Abstract:
The use of local excision (LE) for early stage rectal adenocarcinoma is increasing due to the associated morbidity of radical resection. To determine if survival in stage I rectal cancer differs following LE or abdominoperineal resection (APR), we analyzed the Surveillance, Epidemiology, and End Results Database. We selected patients diagnosed between 1988 and 2002 with T1-2N0M0 rectal adenocarcinoma measuring ≤4 cm who underwent either local excision with (LE + RT) or without adjuvant radiation (LE alone) or APR alone. Overall survival (OS) and disease-specific survival (DSS) curves were calculated using the Kaplan–Meier method. Univariate and multivariate Cox regression was also performed to determine the effect of covariates on OS and DSS. A total of 2,391 patients were identified including 981 (41 %) treated with APR, 1,018 (43 %) treated with LE alone, and 392 (16 %) treated with LE + RT. With a median follow-up of 69 months, there was no difference in OS or DSS seen between the three groups (p > 0.05 for all comparisons). When stratifying by T-stage, there was a significant difference in overall survival between LE alone and APR for T2 disease. However, there was no difference in DSS between these two subgroups. There were no other significant survival differences between all comparable subgroups. In this large population-based study, there was no difference in long-term DSS between patients who underwent an APR compared to selected patients who underwent LE with or without adjuvant radiation. Although these data further reinforce the promising data regarding the selected use of LE, further prospective studies are needed to further elucidate the role of LE in this setting.
Published: 1 January 2013
Radiation Oncology, Volume 8, pp 290-290; doi:10.1186/1748-717X-8-290

Abstract:
Stage T1-2 rectal cancers are unlikely to have lymph node metastases and neoadjuvant therapy is not routinely administered. Postoperative management is controversial if lymph node metastases are detected in the resected specimen. We studied the outcomes of patients with pT1-2 node-positive rectal cancer in order to determine whether adjuvant radiotherapy was beneficial. We conducted a retrospective analysis of 284 patients with pathological T1-2 node-positive rectal cancer from a single institution. Outcomes, including local recurrence (LR), distant metastasis (DM), disease free survival (DFS) and overall survival (OS), were studied in patients with detailed TN staging and different adjuvant treatment modalities. The overall 5-year LR, DM, DFS and OS rates for all patients were 12.5%, 32.9%, 36.4% and 76.8%, respectively. Local control was inferior among patients who received no adjuvant therapy. Patients could be divided into three risk subsets: Low-risk, T1N1; Intermediate-risk, T2N1 and T1N2; and High-risk, T2N2. The 5-year LR rates were 5.3%, 9.8% and 26.4%, respectively (p = 0.005). In High-risk patients, addition of radiotherapy achieved a 5-year LR rate of 9.1%, compared 34.8% without radiotherapy. In our study, we provide the detailed outcomes and preliminary survival analysis in a relatively infrequent subset of rectal cancer. Three risk subsets could be identified based on local control for pT1-2 node positive rectal cancer. Postoperative treatment needs to be individualized for patients with pT1-2 node-positive rectal cancer.
Terence C. Chua, Chanel H. Chong, Winston Liauw,
International Journal of Surgical Oncology, Volume 2012, pp 1-9; doi:10.1155/2012/247107

Abstract:
Rectal cancer is a distinct subset of colorectal cancer where specialized disease-specific management of the primary tumor is required. There have been significant developments in rectal cancer surgery at all stages of disease in particular the introduction of local excision strategies for preinvasive and early cancers, standardized total mesorectal excision for resectable cancers incorporating preoperative short- or long-course chemoradiation to the multimodality sequencing of treatment. Laparoscopic surgery is also increasingly being adopted as the standard rectal cancer surgery approach following expertise of colorectal surgeons in minimally invasive surgery gained from laparoscopic colon resections. In locally advanced and metastatic disease, combining chemoradiation with radical surgery may achieve total eradication of disease and disease control in the pelvis. Evidence for resection of metastases to the liver and lung have been extensively reported in the literature. The role of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal metastases is showing promise in achieving locoregional control of peritoneal dissemination. This paper summarizes the recent developments in approaches to rectal cancer surgery at all these time points of the disease natural history.
Published: 30 March 2012
Current Oncology Reports, Volume 14, pp 267-276; doi:10.1007/s11912-012-0234-z

Abstract:
Neoadjuvant short-course radiotherapy and long-course chemoradiation (CRT) reduce local recurrence rates when compared to surgery alone and remain widely accepted as standard of care for patients with locally advanced rectal cancer. However, surgery is not without complications and a non-surgical approach in carefully selected patients warrants evaluation. A pathological complete response to CRT is associated with a significant improvement in survival and it has been suggested that a longer time interval between the completion of CRT and surgery increases tumor downstaging. Intensification of neoadjuvant treatment regimens to increase tumor downstaging has been evaluated in a number of clinical trials and more recently the introduction of neoadjuvant chemotherapy prior to CRT has demonstrated high rates of radiological tumor regression. Careful selection of patients using high-resolution MRI may allow a non-surgical approach in a subgroup of patients achieving a complete response to neoadjuvant therapies after an adequate time period. Clearly this needs prospective evaluation within a clinical trial setting, incorporating modern imaging techniques, and tissue biomarkers to allow accurate prediction and assessment of response.
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