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Local Excision Following Pelvic Imaging vs. Radical Resection for Stage I Rectal Cancer: Balancing Morbidity, Survival and Recurrence- A Matched Study
Leonardo C. Duraes*, Luca Stocchi, Emre Gorgun, Meagan Costedio, Matthew Kalady, David Dietz, James M. Church, Feza H. Remzi
Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH
Purpose
The use of local excision for stage I rectal cancer can reduce morbidity, but is associated with worse oncologic outcomes compared to radical resection. It is possible that technological advances in imaging could optimize patient selection and improve local excision outcomes. The aim of this study was to compare perioperative and oncologic outcomes of patients with stage I rectal cancers that had modern pelvic imaging followed by local excision vs. radical resection.
Methods
An institutional database was queried to identify patients with pT1-T2Nx/N0 rectal adenocarcinoma, electively operated with curative intent between 1980 and 2013. Exclusion criteria were neoadjuvant therapy, recurrent rectal cancer, inflammatory bowel disease, or hereditary colorectal cancer. Patients who underwent local excision (LE), and had preoperative pelvic imaging by Computed Tomography Scan (CT), Positron Emission Tomography Scan (PET), or Magnetic Resonance Imaging (MRI) were matched 1:1 to patients who underwent radical resection (RR) by age, gender, pathological T stage, ASA classification, tumor differentiation, and lymphovascular invasion. Perioperative and oncologic outcomes were compared between groups.
Results
Out of 254 patients that underwent LE, 57 patients with preoperative imaging by CT, PET or MRI (54 traditional trans-anal excision and 3 trans-anal endoscopic surgery) were well matched 1:1 to patients who underwent RR (49 low anterior resection and 8 abdomino-perineal resection). LE had lower post-operative morbidity and shorter hospital stay compared to RR. Adjuvant treatments were solely used among some patients following LE. There were no differences between groups in overall survival (p=0.930), disease-free survival (p=0.336), and cancer-specific survival (p=0.670). Although LE was associated with higher local recurrence rates for T2 tumors (p=0.035), there was no statistical difference between the groups for T1 tumors (p=0.147) (table, figure).
Conclusion
Improved patient selection due to advancements in pelvic imaging renders local excision a viable option in the surgical treatment of patients with T1 rectal cancers, with comparable oncologic results to radical resection.
Table - Patient characteristics and outcomes by surgery type. Patients matched by age, gender, pathological T stage, ASA classification, tumor differentiation, and lymphovascular invasion.
| | Local Excision
(n=57) | Radical Resection
(n=57) | p value | | Age (mean/SD) | 67.4 (11.7) | 67.7 (11.0) | 0.9 | | Female Gender | 19 (33.3%) | 19 (33.3%) | 1 | | BMI (mean/SD) | 29.6 (7.5) | 29.2 (11.1) | 0.32 | | ASA Classification | | | 1 | | ASA 1-2 | 17 (29.8%) | 17 (29.8%) | | | ASA 3-4 | 40 (70.2%) | 40 (70.2%) | | | Pathological T Stage | | | 1 | | pT1 | 32 (56.1%) | 32 (56.1%) | | | pT2 | 25 (43.9%) | 25 (43.9%) | | | Tumor Size (mean/SD) | 2.6 (1.5) | 3.2 (1.8) | 0.06 | | Distance from Anal Verge (mean/SD) | 5.1 (2.7) | 8.0 (4.1) | <0.001 | | Length of Hospital Stay - days (mean, median) | 2.7 / 1 | 10.9, 8 | <0.001 | | Postoperative Morbidity | 8 (14.0%) | 20 (35.1%) | 0.011 | | Reoperation | 1 (1.8%) | 5 (8.8%) | 0.21 | | Readmission | 3 (5.3%) | 2 (3.5%) | 1 | | Mortality | 1 (1.8%) | 1 (1.8%) | 1 | | Adjuvant Chemoradiotherapy | 10 (17.5%) | - | 0.001 | | Combined 5-yr overall survival %(CI) | 77.0% (62.8-86.3) | 74.1% (59.3-84.2) | 0.930 | | pT1 | 88.8% (69.1-96.3) | 83.3% (64.4-92.7) | 0.864 | | pT2 | 61.4% (38.6-77.9) | 58.9% (32.6-77.9) | 0.772 | | Combined 5-yr disease-free survival %(CI) | 65.2% (50.3-76.6) | 74.1% (59.3-84.2) | 0.336 | | pT1 | 77.4% (56.3-89.3) | 83.3% (64.4-92.7) | 0.417 | | pT2 | 49.5% (28.2-67.7) | 58.9% (32.6-77.9) | 0.515 | | Combined 5-yr cancer-specific survival %(CI) | 96.3% (85.9-99.1) | 93.3% (80.4-97.8) | 0.670 | | pT1 | 100% (100-100) | 96.3% (76.5-99.5) | 0.300 | | pT2 | 91.0% (68.6-97.7) | 87.5% (56.6-96.9) | 0.806 | | Combined 5-yr local recurrence %(CI) | 12.7% (5.8-26.5) | 0% (0-0) | 0.007 | | pT1 | 7.7% (1.9-28.3) | 0% (0-0) | 0.147 | | pT2 | 19.4% (7.6-44.5) | 0% (0-0) | 0.035 |
 Figure - Kaplan-Meier curves for overall survival (a), disease-free survival (b), cancer-specific survival (c) and local recurrence (d) for all patients (T1+T2 combined), and local recurrence subdivided by pathological T1 (e) and pathological T2 (f). Patients matched by age, gender, pathological T stage, ASA classification, tumor differentiation, and lymphovascular invasion.
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