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Is limited surgery justified in the treatment of T1 colorectal cancer?

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Abstract

Background

Surgical treatment of colorectal cancer (CRC) should be aimed primarily at achieving a combination of surgical-oncologic radicalness and the highest possible quality of life. In recent years, surgical therapy for T1 CRC has tended toward less radical interventions. The question regarding changes in survival and recurrence rates still is unanswered.

Methods

A retrospective medical chart review of patients surgically treated in our department for T1 CRC from January 1990 to December 2010 (n = 223) was performed. Charts were reviewed for tumor-specific parameters, local recurrence, distant metastasis, and patient survival. The different treatment options used were strictly separated for a more detailed workup.

Results

Radical resection (RR) was performed for 57.1 %, local resection (LR) for 14.8 %, and an endoscopic approach (EA) for 28.1 % of the study population. After receipt of the histology report, 35.7 % of the patients initially resected nonradically underwent reoperation, mostly using RR. Seven patients experienced a local recurrence over time (3.6 %): one after initial RR, three after LR, and three after EA. Systemic recurrence occurred for nine patients (4.6 %) over time, six of whom had undergone initial RR. High-risk criteria were shown for 20 T1 CRCs. For 60 % (12/20) of the patients, initial RR was performed. Radical reoperation was performed for 75 % of the nonradically treated high-risk tumors. One high-risk patient without reoperation experienced metastatic disease over time. The 5-year overall survival rate was 87.2 %, itemized for the defined subgroups as follows: 83.9 % for RR, 82.8 % for LR, and 58.2 % for EA.

Conclusion

Patients with T1 CRC had a distinctly higher incidence of local recurrence after EA or LR. Explicit workup in terms of risk classification is crucial to reducing the risk of local and systemic recurrence. A nonradical approach should be only a second option for patients with T1 CRC, namely, those solely in clearly low-risk situations or those with distinct comorbidities.

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References

  1. Boyle P, Levin B (2008) World cancer report 2008. WHO Press, Geneva

    Google Scholar 

  2. Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM (2010) Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer 127:2893–2917

    Article  PubMed  CAS  Google Scholar 

  3. Laubert T, Habermann JK, Bader FG, Jungbluth T, Esnaashari H, Bruch H-P, Roblick UJ, Auer G (2010) Epidemiology, molecular changes, histopathology, and diagnosis of colorectal cancer. Eur Surg 42:8

    Article  Google Scholar 

  4. Siegel RL, Jemal A, Ward EM (2009) Increase in incidence of colorectal cancer among young men and women in the United States. Cancer Epidemiol Biomarkers Prev 18:1695–1698

    Article  PubMed  Google Scholar 

  5. Nascimbeni R, Burgart LJ, Nivatvongs S, Larson DR (2002) Risk of lymph node metastasis in T1 carcinoma of the colon and rectum. Dis Colon Rectum 45:200–206

    Article  PubMed  Google Scholar 

  6. Tytherleigh MG, Warren BF, Mortensen NJ (2008) Management of early rectal cancer. Br J Surg 95:409–423

    Article  PubMed  CAS  Google Scholar 

  7. Haggitt RC, Glotzbach RE, Soffer EE, Wruble LD (1985) Prognostic factors in colorectal carcinomas arising in adenomas: implications for lesions removed by endoscopic polypectomy. Gastroenterology 89:328–336

    PubMed  CAS  Google Scholar 

  8. Kikuchi R, Takano M, Takagi K, Fujimoto N, Nozaki R, Fujiyoshi T, Uchida Y (1995) Management of early invasive colorectal cancer: risk of recurrence and clinical guidelines. Dis Colon Rectum 38:1286–1295

    Article  PubMed  CAS  Google Scholar 

  9. Schmiegel W, Pox C, Reinacher-Schick A, Adler G, Arnold D, Fleig W, Fölsch UR, Frühmorgen P, Graeven U, Heinemann V, Hohenberger W, Holstege A, Junginger T, Kopp I, Kühlbacher T, Porschen R, Propping P, Riemann JF, Rödel C, Sauer R, Sauerbruch T, Schmitt W, Schmoll HJ, Seufferlein T, Zeitz M, Selbmann HK (2010) S3 guidelines for colorectal carcinoma. results of an evidence-based consensus conference on February 6/7, 2004 and June 8/9, 2007 (for the Topic IV, VI, and VII). Z Gastroenterol 48:65–136

    Article  PubMed  CAS  Google Scholar 

  10. Yasuda K, Inomata M, Shiromizu A, Shiraishi N, Higashi H, Kitano S (2007) Risk factors for occult lymph node metastasis of colorectal cancer invading the submucosa and indications for endoscopic mucosal resection. Dis Colon Rectum 50:1370–1376

    Article  PubMed  Google Scholar 

  11. Stamos MJ, Murrell Z (2007) Management of early rectal T1 and T2 cancers. Clin Cancer Res 13:6885s–6889s

    Article  PubMed  CAS  Google Scholar 

  12. Kobayashi H, Mochizuki H, Kato T, Mori T, Kameoka S, Shirouzu K, Saito Y, Watanabe M, Morita T, Hida J, Ueno M, Ono M, Yasuno M, Sugihara K (2010) Is total mesorectal excision always necessary for T1–T2 lower rectal cancer? Ann Surg Oncol 17:973–980

    Article  PubMed  Google Scholar 

  13. Hazard LJ, Shrieve DC, Sklow B, Pappas L, Boucher KM (2009) Local excision vs. radical resection in T1–T2 rectal carcinoma: results of a study from the surveillance, epidemiology, and end results (SEER) registry data. Gastrointest Cancer Res 3:105–114

    PubMed  CAS  Google Scholar 

  14. Gao JD, Shao YF, Bi JJ, Shi SS, Liang J, Hu YH (2003) Local excision carcinoma in early stage. World J Gastroenterol 9:871–873

    PubMed  Google Scholar 

  15. Grumann MM, Noack EM, Hoffmann IA, Schlag PM (2001) Comparison of quality of life in patients undergoing abdominoperineal extirpation or anterior resection for rectal cancer. Ann Surg 233:149–156

    Article  PubMed  CAS  Google Scholar 

  16. Ganai S, Kanumuri P, Rao RS, Alexander AI (2006) Local recurrence after transanal endoscopic microsurgery for rectal polyps and early cancers. Ann Surg Oncol 13:547–556

    Article  PubMed  Google Scholar 

  17. Doornebosch PG, Tollenaar RA, De Graaf EJ (2009) Is the increasing role of transanal endoscopic microsurgery in curation for T1 rectal cancer justified? A systematic review. Acta Oncol 48:343–353

    Article  PubMed  Google Scholar 

  18. Zhao DB, Wu YK, Shao YF, Wang CF, Cai JQ (2009) Prognostic factors for 5-year survival after local excision of rectal cancer. World J Gastroenterol 15:1242–1245

    Article  PubMed  Google Scholar 

  19. Borschitz T, Gockel I, Kiesslich R, Junginger T (2008) Oncological outcome after local excision of rectal carcinomas. Ann Surg Oncol 15:3101–3108

    Article  PubMed  Google Scholar 

  20. Bretagnol F, Rullier E, George B, Warren BF, Mortensen NJ (2007) Local therapy for rectal cancer: still controversial? Dis Colon Rectum 50:523–533

    Article  PubMed  CAS  Google Scholar 

  21. You YN, Baxter NN, Stewart A, Nelson H (2007) Is the increasing rate of local excision for stage I rectal cancer in the United States justified? A nationwide cohort study from the National Cancer Database. Ann Surg 245:726–733

    Article  PubMed  Google Scholar 

  22. Steele GD, Herndon JE, Bleday R, Russell A, Benson A, Hussain M, Burgess A, Tepper JE, Mayer RJ (1999) Sphincter-sparing treatment for distal rectal adenocarcinoma. Ann Surg Oncol 6:433–441

    Article  PubMed  Google Scholar 

  23. Peng J, Chen W, Sheng W, Xu Y, Cai G, Huang D, Cai S (2011) Oncological outcome of T1 rectal cancer undergoing standard resection and local excision. Colorectal Dis 13:e14–e19

    Article  PubMed  CAS  Google Scholar 

  24. Huh JW, Park YA, Lee KY, Kim SA, Sohn SK (2009) Recurrences after local excision for early rectal adenocarcinoma. Yonsei Med J 50:704–708

    Article  PubMed  Google Scholar 

  25. Kantsevoy SV, Adler DG, Conway JD, Diehl DL, Farraye FA, Kwon R, Mamula P, Rodriguez S, Shah RJ, Song L, Tierney WM, ASGE Technology Committee (2008) Endoscopic mucosal resection and endoscopic submucosal dissection. Gastrointest Endosc 68:11–18

    Article  PubMed  Google Scholar 

  26. Zitt M, Mühlmann G, Weiss H, Kafka-Ritsch R, Oberwalder M, Kirchmayr W, Margreiter R, Ofner D, Klaus A (2006) Assessment of risk-independent follow-up to detect asymptomatic recurrence after curative resection of colorectal cancer. Langenbecks Arch Surg 391:369–375

    Article  PubMed  Google Scholar 

  27. Jass JR, Atkin WS, Cuzick J, Bussey HJR, Morson BC, Northover JMA, Todd IP (1986) The grading of rectal cancer: historical perspectives and a multivariate analysis of 447 cases. Histopathology 10:437–459

    Article  PubMed  CAS  Google Scholar 

  28. Costi R, Di Mauro D, Giordano P, Leonardi F, Veronesi L, Sarli L, Roncoroni L, Violi V (2010) Impact of palliative chemotherapy and surgery on management of stage IV incurable colorectal cancer. Ann Surg Oncol 17:432–440

    Article  PubMed  Google Scholar 

  29. Gallagher DJ, Kemeny N (2010) Metastatic colorectal cancer: from improved survival to potential cure. Oncology 78:237–248

    Article  PubMed  Google Scholar 

  30. Havenga K, Maas CP, DeRuiter MC, Welvaart K, Trimbos JB (2000) Avoiding long-term disturbance to bladder and sexual function in pelvic surgery, particularly with rectal cancer. Semin Surg Oncol 18:235–243

    Article  PubMed  CAS  Google Scholar 

  31. Kim NK, Aahn TW, Park JK, Lee KY, Lee WH, Sohn SK, Min JS (2002) Assessment of sexual and voiding function after total mesorectal excision with pelvic autonomic nerve preservation in males with rectal cancer. Dis Colon Rectum 45:1178–1185

    Article  PubMed  Google Scholar 

  32. Sacher-Huvelin S, Coron E, Gaudric M, Planche L, Benamouzig R, Maunoury V, Filoche B, Frédéric M, Saurin JC, Subtil C, Lecleire S, Cellier C, Coumaros D, Heresbach D, Galmiche JP (2010) Colon capsule endoscopy vs colonoscopy in patients at average or increased risk of colorectal cancer. Aliment Pharmacol Ther 32:1145–1153

    Article  PubMed  CAS  Google Scholar 

  33. Wijkerslooth TR, Bossuyt PM, Dekker E (2011) Strategies in screening for colon carcinoma. Neth J Med 69:112–119

    PubMed  Google Scholar 

  34. Winde G, Nottberg H, Keller R, Schmid KW, Bünte H (1996) Surgical cure for early rectal carcinomas (T1). Transanal endoscopic microsurgery vs anterior resection. Dis Colon Rectum 39:969–976

    Article  PubMed  CAS  Google Scholar 

  35. Garcia-Aguilar J, Mellgren A, Sirivongs P, Buie D, Madoff RD, Rothenberger DA (2000) Local excision of rectal cancer without adjuvant therapy: a word of caution. Ann Surg 231:345–351

    Article  PubMed  CAS  Google Scholar 

  36. Mellgren A, Sirivongs P, Rothenberger DA, Madoff RD, García-Aguilar J (2000) Is local excision adequate therapy for early rectal cancer? Dis Colon Rectum 43:1064–1071

    Article  PubMed  CAS  Google Scholar 

  37. Endreseth BH, Myrvold HE, Romundstad P, Hestvik UE, Bjerkeset T, Wibe A, Group NRC (2005) Transanal excision vs major surgery for T1 rectal cancer. Dis Colon Rectum 48:1380–1388

    Article  PubMed  Google Scholar 

  38. Kudo S (1993) Endoscopic mucosal resection of flat and depressed types of early colorectal cancer. Endoscopy 43:1064–1074

    Google Scholar 

  39. Tsikitis VL, Malireddy K, Green EA, Christensen B, Whelan R, Marcello P, Larach S, Lauter D, Sargent DJ, Nelson H (2009) Postoperative surveillance recommendations for early-stage colon cancer based on results from the clinical outcomes of surgical therapy trial. J Clin Oncol 27:3671–3676

    Article  PubMed  Google Scholar 

Download references

Disclosures

Pamela Kogler, Reinhold Kafka-Ritsch, Dietmar Öfner, Michael Sieb, Florian Augustin, Johann Pratschke and Matthias Zitt have no conflicts of interest or financial ties to disclose.

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Authors and Affiliations

  1. Department of Visceral, Transplant, and Thoracic Surgery, Center of Operative Medicine, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria

    Pamela Kogler, Reinhold Kafka-Ritsch, Michael Sieb, Florian Augustin, Johann Pratschke & Matthias Zitt

  2. Department of Surgery, Paracelsus Medical University, Salzburg, Austria

    Dietmar Öfner

Authors
  1. Pamela Kogler
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  2. Reinhold Kafka-Ritsch
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  3. Dietmar Öfner
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Correspondence to Matthias Zitt.

Additional information

Johann Pratschke and Matthias Zitt contributed equally to this work.

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Kogler, P., Kafka-Ritsch, R., Öfner, D. et al. Is limited surgery justified in the treatment of T1 colorectal cancer?. Surg Endosc 27, 817–825 (2013). https://doi.org/10.1007/s00464-012-2518-7

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  • DOI: https://doi.org/10.1007/s00464-012-2518-7

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