6. T1 Adenocarcinoma Of the Rectum: Transanal Excision Or Radical Surgery?
Philip B. Paty, MD*1, David J. Bentrem, MD*1, Satoshi Okabe, MD*1, Jose G. Guillem, MD1, Martin R. Weiser, MD*1, Larissa Temple, MD*1, Bruce D. Minsky, MD*1, Alfred M. Cohen, MD2, Douglas Wong, MD1
1Memorial Sloan-Kettering Cancer Center, New York, NY; 2Lucille Markey Cancer Center University of Kentucky, Lexington, KY
OBJECTIVE(S): Recent studies suggest local excision is adequate treatment for T1 adenocarcinoma of the rectum, but there is little comparative data with radical surgery to assess outcomes and quantify risk. We evaluated a consecutive series of patients with T1 rectal cancer treated surgically at our institution to assess patient selection, cancer recurrence, and survival.
METHODS: All patients treated by surgery for T1 adenocarcinomas of the rectum (0-15cm from anal verge) by either transanal excision (TAE) or radical resection (RAD) between 1987 and 2004 were identified from a prospective database. Data were analyzed using Fisher’s exact test, Kaplan-Meier method, and log-rank test.
RESULTS: Three hundred twenty six consecutive patients with T1 cancers were treated. RAD surgery was associated with higher tumor location, slightly larger tumor size, similar rate of adverse histology, and a LN metastasis rate of 19%. Despite these features, patients treated by RAD surgery had fewer local recurrences, fewer overall recurrences (RR=0.3), and significantly better recurrence free survival (p=.0003). Overall and disease specific survival were similar for RAD and TAE groups.
CONCLUSIONS: Patients with T1 rectal cancer treated by local excision have a three fold higher risk of tumor recurrence compared to patients treated by radical surgery. Local excision should be reserved for low risk cancers in patients who can accept prolonged surveillance, increased recurrence risk, and the important role of salvage surgery.
| TAE (n=154) | RAD (n=172) | P | ||
| Tumor | cm from AV, median | 5 | 8 | 0.0001 |
| size in mm, median | 23 | 28 | 0.04 | |
| Pathology | lymph node metastasis | unknown | 19% | |
| Adjuvant Tx | pelvic radiotherapy | 12% | 9% | NS |
| Outcome | median fup (months) | 46 | 58 | |
| overall recurrence | 17% | 6% | 0.001 | |
| local recurrence | 11% | 2% | 0.001 | |
| salvage surg for recurrence | 20 / 26 | 6 / 10 | 0.002 | |
| recurrence free suvival (at 7 yrs) | 83% | 94% | 0.003 |