Introduction The role of local excision for early rectal cancer continues to be a topic of debate due to high local recurrence rates. The quality of local excision is an important factor determining risk of local recurrence. Small T1 (Sm1 and Sm2) tumours can be adequately treated with trans-anal excision using specialised techniques such as trans-anal endoscopic microsurgery (TEM) or trans-anal endoscopic operation (TEO). Current practice dictates radical surgery (RS) for all other rectal tumours to achieve acceptable oncological outcomes.
Method A retrospective analysis of prospectively kept data from a single centre case series of patients treated with TEM for early rectal cancer. We analysed data for patients who had rectal preservation without subsequent RS, and were followed up with regular clinical examination, blood tests, CT chest/abdomen/pelvis and MRI rectum. All local excisions were approved by the local MDT and performed by 2 trained consultant colorectal surgeons.
Results Sixty eight patients underwent TEM for early rectal cancer between June 2009 and August 2013, 25 patients went on to have RS and 1 TEM was converted intra-operatively to RS. Forty two patients (61.8%), 31 males (73.8%), were followed up with rectal preservation. The mean age was 74 years (S. D =/- 9.8) and ASA grades of patients: ASA I 2.4%; ASA II 35.7%; ASA III 54.8%; and ASA IV 7.1%. The median height of tumour was 7cm (range 1–15), operative time was 90 min (range 30 – 320), and in all cases blood loss was minimal. Median length of stay was 2 days (range 1–17).
Median tumour size was 20mm (range 2–50) and the pathological stage was T1 in 20/42 (45.2%) (Sm1 5/20[25%], Sm2 8/20[40%], Sm3 7/20[35%]), T2 in 17/42 (40.5%) and T3 in 3/42 (7.1%) patients. Two patients (4.8%) had no residual tumour following neo-adjuvant therapy/polypectomy. The TEM specimen contained lymph nodes in 6/42 cases (14.3%), positive in 2/42 (4.8%). The overall local recurrence rate was 9.5% (4/42 unfit or unwilling for RS, 2 with involved margins). The local recurrence rate with clear margins was 5.3%. Recurrence rate for T0, T1, T2 and T3 disease was 0% (0/2), 0% (0/19), 6.2% (1/16) and 33.3% (1/3) respectively when excluding recurrences with positive margins. The median length of follow up 17 months (range 3–60) and rectal cancer specific mortality was 2.4% (1 patient unfit for radical surgery with T3 disease).
Conclusion This case series demonstrates a very low recurrence rate in contrast to most of the published series. We believe the technique and quality of surgery is an important factor contributing to local recurrence following local resection. We propose that further studies should be considered for identifying additional patients in whom rectal preservation can be safely offered.
Disclosure of interest None Declared.
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