REVIEW ARTICLE Debate and update issues for surgical treatment of mid and lower rectal cancer Professor Department of Surgery Yonsei University College of Medicine Seoul, Korea Nam Kyu Kim, M.D. Debate and update issues for surgical treatment of mid and lower rectal cancer 9
Table 1. Selected Series of Local Excision Alone for T1 Rectal Cancers Study Number of patients patients 5-year local recurrence rate(%) 5-year disease free survival rate(%) Chakravartl et al(1999) [7] 52 11 80 Steele et al(1999) [8] 59 7 87 Garcla-Agullar et al(2000) [9] 55 18 77 Paty et al(2002) [10] 45 14 92 Nascimbeni et al(2004) [11] 70 24 76 Madbouly et al(2005) [12] 52 28 71 Endreseth et al(2007) [13] 35 12 64 You et al(2007) [14] 601 8 93 Ptok et al(2007) [15] 105 5 91 10 Nam Kyu Kim
Korean Journal of Clinical Oncology Summer 2012;Vol.8,NO.1: Table 2. Selected Series of Local Excision Alone for T2 Rectal caner Study Number of patients patients 5-year local recurrence rate(%) 5-year disease free survival rate(%) Garcla-Agullar et al(2000) [9] 55 18 77 Paty et al(2002) [10] 45 14 92 Gao et al(2003) [16] 70 24 76 You et al(2007) [15] 601 8 93 Table 3. Results of Retrospective Series Comparing Local Excision with Radical Surgery for T1 Rectal caner Study 5 year local recurrence rate(%) 5 year overall survival rate(%) Median Follow up(years) Local Excision Radical Resection Local Excision Radical Resection Mellgren et al(2000) [18] 18 0 72 80 4.6 Nascimbeni et al(2004) [11] 6.6 2.8 72 90 8.1 Endreseth et al(2005) [13] 12 6 70 80 Range 2-8 Bentrem et al(2005) [17] 15 3 89 93 4.3 You et al(2007) [14] 12.5 6.9 77 82 6.3 Ptok et al(2007) [15] 5.1 1.4 84 92 3.5 Folkesson et al(2007) (Mix of T1 and T2) [19] 7 2 87 93 Not reported Nash et al(2009) [20] 13.2 2.7 87 96 5.6 Debate and update issues for surgical treatment of mid and lower rectal cancer 11
Table 4. Transanal Endoscopic Microsurgery versus Radical Surgery for T1 and T2 Rectal cancer TEM Radical resection T stage Local recurrence Overall survival Local recurrence Overall survival Follow-up(months) rate(%) rate(%) rate(%) rate(%) Winde et al(1996) [22] 1 4.2 96 0 96 46 Heintz et al(1998) [23] 1(low risk) 4.4 79 2.9 81 42-52 1(high risk) 33 62 18.2 69 Lee et al(2003) [24] 1 4.1 100 0 93 31-35 2 19.5 95 9.4q 96 De Graaf(2009) [26] 1 24 75 0 77 42-84 Fig. 1. Transanal Endoscopic Operation (TEO) 12 Nam Kyu Kim
Korean Journal of Clinical Oncology Summer 2012;Vol.8,NO.1: Table 5. Transanal excision with adjuvant treatment for rectal cancer Study Number of patients Follow-up(months) 5-year local recurrence rate(%) 5-year disease free survival rate(%) Coco et al(1992) [28] 15 68 6 74 Fortunato et al(1995) [29] 21 56 19 77 Steele et al(1999) [30] 51 48 13.7 85(6 year) Le Voyer et al(1999) [31] 35 46 11.4 91(DFS) Russell et al(2000) [32] 51 73.2 13.7 75(DFS) YUHS et al(2007) [33] 76 84.9 7.9 100(pT1, with RT) 76(pT1, without RT) 75(pT2) Table 6. Outcome of patients with rectal cancer undergoing local excision after achieving pathological T0 following neoadjuvant chemoradiation Study Patients with pt0 Follow up median(range) Local recurrence n(%) Distant recurrence n(%) Schell et al(2002) [35] 8 48(18-105) 0 1(12) Ruo et al(2002) [36] 3 29(2-89) 0 0 Hershman et al(2003) [37] 7 33(3-120) 0 0 Bonnen et al(2004) [38] 14 42(5-109) 0 1 Stipa et al(2004) [39] 7 37(18-118) 0 NR Caricato et al(2006) [40] 3 47 0 0 Borschitz et al(2007) [41] 1 24(12-79) 0 0 Lezoche et al(2008) [42] 11 84(72-96) 0 0 Nair et al(2008) [43] 19 64(6-153) 1(5) 1(5) YUHS et al(2008) [44] 4 91(50-127) 0 1(25) Yulia et al(2010) [34] 14 48(5-123) 0 0 Debate and update issues for surgical treatment of mid and lower rectal cancer 13
Table 7. Oncologic outcomes after ultra low anterior resection with coloanal anastomosis Study Follow up median(months) Local recurrence n(%) Distant recurrence n(%) Drake et al(1987) [57] 20 27 5 Cavaliere et al(2002) [58] 62 27 5 Parc et al(2003) [59] 17 17 6 Huguet et al(2004) [60] 20 15 5 Hautefeuille et al(2004) [61] 20 16 5 YUHS et al(2006) [62] 36.3 18.7 5.2 YUHS et al(robotic CAA) (2012) [63] 21.3 16.3 NR 14 Nam Kyu Kim
Korean Journal of Clinical Oncology Summer 2012;Vol.8,NO.1: Table 8. Oncological outcomes following intersphincteric resection for low rectal cancer. Median R0 Local 5-year survival (%) Operative Overall Continence Study n follow-up resection recurrence Overall Disease-free mortality morbidity (mean bowel (months) (%) (%) (%) (%) movements in 24 h) Braun et al(1992) [53] 63 80 100 11 62 NR 6 35 2.2 Bannon et al(1995) [54] 109 40 NR 11 87 NR 1 10 NR Kohler et al(2000) [55] 31 82 100 10 79 NR 0 65 3.3 Rullier et al(2005) [56] 92 40 89 2 81 70 0 27 NR Schiessel et al(2005) [57] 121 94 96.7 5.3 88 NR 0.8 17.1 2.2 Saito et al(2006) [58] 228 41 98.7 5.3 92 83 0.4 24.0 NR Chamlou et al(2007) [59] 90 56 94 7 82 75 0 19 2.3 Akasu et al(2008) [60] 120 42 96.7 6.7 91 77 0.8 33.0 NR Krand et al(2009) [61] 47 68 98 2 85 82 0 38 2.3 Han et al(2009) [62] 40 43 100 11 62 NR 6 35 2.2 Saito et al(2009) [63] 132 40 100 10.6 80 69 0 30.3 NR Weiser et al(2009) [64] 44 47 92 0 96 83 0 39 NR Yamada et al(2009) [65] 107 41 100 2.5 92 87 0 27.0 3.7 Debate and update issues for surgical treatment of mid and lower rectal cancer 15
Fig. 2. Intersphincteric resection after neoadjuvant chemoradiation 16 Nam Kyu Kim
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Korean Journal of Clinical Oncology Summer 2012;Vol.8,NO.1: Debate and update issues for surgical treatment of mid and lower rectal cancer Department of Surgery, Yonsei University College of Medicine, Seoul, Korea Nam Kyu Kim, M.D. Updates and Debate issues form the surgical treatment of middle or low rectal cancer The main goals for the surgical treatment of rectal cancer were the complete removal of the rectal cancer with surrounding lymphatic draining area, which subsequently result in decreasing the rate of local recurrence as well as prolong patient survival. If the tumor located at the near the anal canal, concerning issues will be whether anal sphincter can be preserved or not and furthermore autonomic pelvic nervous system could be saved or not. Multidisciplinary approach for rectal cancer has been more popular and treatment strategy rapidly changing based on more accurate preoperative local staging finding and minimal invasive surgical techniques become popular too. One of the advance technology is the development of transanal local excision techniques such Transanal endoscopic microsurgery technique such as TEM(transendoscopic microsurgery), TEO(transendoscopic operation) and TAMIS (transanal minimal invasive surgery). Those techniques make us be able to excise early rectal cancer with full thickness as well as unfragmented state, also can be approached to the upper rectum, which can not approach with previous conventional transanal approach method. Local excision for early T1 rectal cancer has been regards as good treatment option because patient can avoid complication related to the radial proctotectomy such as anastomoitc leakage, postoperative sexual and voiding dysfunction and dysregulated bowel movements. Neoadjuvant chemoradiation therapy has been recommended for patient with ct3n0 or ct3 N+ rectal cancer because some clinical trials showed us preoperative chemoradiation therapy showed better local control rate and less toxicities than postoperative chemoradiation treatment. Recent clinical trial both retrospective and prospective showed us a promising results about local excision after neoadjuvant chemoradiation selectively in patients with low rectal cancer. Neoadjuvant chemoradiation therapy for ct2n0 followed by local excision reported excellent oncologic outcomes quite comparable to the radical surgery group. In addition to that, there has been some reports which showed clinical complete remission after neoadjuvant chemoradiation therapy could be wait and see. A couple of observational studies showed wait and see can be possible option of treatment in selective patients. Radial surgery for middle and low rectal cancer still remains a cornerstone of surgical treatment Ultralow anterior resection with or without intersphincteric resection became a more standard surgical method for low rectal cancer. Oncologic and functional outcomes has been reported as safe even functional outcomes study was rare. Furthermore, Abdominoperineal resection has been famous for high intraoperative tumor perforation and positive circumferential resection margin, those factors have been contributed to the high rate of local recurrence and poor survival rate compared with sphincter saving procedures for rectal cancer. Recently, there have been great efforts Debate and update issues for surgical treatment of mid and lower rectal cancer 21
for reducing theses problem and total levator excision or extended abdominoperineal resection concepts emerged. Surgeons who advocated this concept recommended perineal dissection under the Jack-knife position. Surgical management for low rectal cancer should be directed for radically and preserving function based on multimodality approach. We need more high level of evidence based on prospective clinical trials for tailored treatment of rectal cancer patients 22 Nam Kyu Kim