Transanal Endoscopic Microsurgery of Locally Advanced High Rectal Cancers Downstaged Using Neoadjuvant Therapy
Abstracts
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Purpose: Our institution has previously demonstrated the efficacy of transanal local excision for locally advanced rectal cancers down-staged using neoadjuvant therapy. However, a subset of these patients had rectal cancers beyond the reach of standard open transanal excision. We hypothesized that transanal endoscopic microsurgery would provide access to these high tumors, allowing us to determine if our previous experience with local treatment for these rectal cancers could be extended to patients with tumors high in the rectum.Methods: Eighty-three patients with T3 rectal cancers staged using endorectal MRI or transanal ultrasonography (trUS), and digital rectal examination (DRE) revealing circumferential or bulky fixed lesions were treated with 4500Gy pre-operative neoadjuvant radiotherapy and 5FU/leucovorin chemotherapy. After neoadjuvant therapy, eight (9.6%) patients (Mean age 63.3?4.6 yr median:63.7 yr) with high rectal cancers (10.8?0.7cm from anal verge) down-staged their tumors to cT1 (50%) or cT0 (50%). One patient did not down-stage, and refused radical resection. These nine patients underwent transanal endoscopic microsurgery excision of their residual rectal tumors or post-treatment rectal scar. Intra-operative frozen section pathology confirmed negative margin status. All patients were followed with postoperative DRE, endoscopy, and trUS.Results: Mean follow-up was 22.2?3.4 (median: 18.9)mo. There was no operative morbidity or mortality. Final pathology and outcomes are summarized in Table I.Conclusions: Locally advanced high rectal cancers may be approached using transanal endoscopic microsurgery. Of those lesions that appeared to downstage to cT1 or cT0, all but one was at least pT2 on final pathologic examination. This finding is contrary to our previous experience with lower rectal cancers where clinical and pathologic stagewere directly correlated. Downstaging with neoadjuvant therapy followed by transanal endoscopic microsurgical resection of high rectal cancers was not shown advantageous with this pilot study. |
