Radical Surgery Best for Most Rectal Cancers

A new study recommends that local resection of rectal cancer should be reserved only for superficial tumor stage 1 (T1) disease in patients who will comply with aggressive postoperative surveillance.

Researchers at Massachusetts General Hospital (Boston, MA, USA) and the University of Amsterdam (the Netherlands) reviewed the records of 109 consecutive patients with preoperative imaging results suggestive of T1 or T2 disease who underwent total mesorectal excision. All patients underwent preoperative endorectal ultrasonography (US) or magnetic resonance imaging (MRI) and computed tomography (CT), with or without positron emission tomography. Final pathologic investigation identified T3 disease in 27 of the patients. History, physical examination results, and radiologic and pathologic data were evaluated for predictors of positive nodes in the remaining 82 patients.

The results showed that despite indications of negative nodes on radiographic examination, 4 of 35 patients with T1 disease (11%) and 13 of 47 with T2 disease (28%) had positive nodes. The only significant predictor was depth of invasion: 24 of 65 patients with negative nodes (37%) versus 13 of 17 patients with positive nodes (76%) had tumors invading the lower third of the submucosa and beyond. Endorectal US, MRI, and CT (with or without positron emission tomography) used for preoperative staging could not identify these patients reliably. In addition, histologic markers of aggressive disease were not helpful. The study was published in the May 2011 issue of Archives of Surgery.

"Negative results of imaging can be falsely reassuring; because patients with local recurrence have survival rates of 43% to 58% after salvage operations, we believe that local resection should be performed only for superficial T1 tumors, preferably using transanal endoscopic microsurgery, in patients who will adhere to aggressive postoperative surveillance," concluded lead author Harry Salinas, MD, and colleagues of the department of surgery.

Local resection of T1 and T2 rectal cancer results in lower morbidity compared with radical resection. However, recurrence rates after local resection are higher, likely owing to unresected nodal metastasis.

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Massachusetts General Hospital
University of Amsterdam