NEW YORK (Reuters Health) May 24 - Local resection of rectal cancer should be reserved for superficial tumor stage (T) 1 disease in patients who will comply with "aggressive postoperative surveillance," the authors of a new study say.
To avoid the morbidity associated with radical resection, local surgery is increasingly being performed for patients with T1 and T2 disease, Dr. Harry M. Salinas of Massachusetts General Hospital and Harvard Medical School in Boston and colleagues write.
This is concerning, they add, because as many as 20% of patients with T1 rectal cancer have lymphatic involvement.
The researchers thought they might be able to use imaging results and tumor histology to identify T1 and T2 patients without lymph node metastases who could safely undergo local surgery. To investigate, they looked at records for 109 consecutive patients who had undergone total mesorectal excision. In all cases, preoperative imaging had suggested they had T1 or T2 disease with no lymph node involvement.
Twenty-seven of the patients actually had T3 disease and were removed from the analysis, leaving 82 patients. Four of the 35 patients with T1 tumors (11%) and 13 of 47 with T2 tumors (28%) had positive lymph nodes on final pathological examination.
The only factor independently associated with the likelihood of lymph node involvement was whether or not a tumor had invaded the lower third of the submucosa. Tumors reached this depth in 24% of patients without lymph node involvement and in 76% of patients with positive nodes.
On logistic regression analysis, patients with tumors invading the lower third of the submucosal were more than eight times as likely to have positive lymph nodes.
The findings, reported in the May Archives of Surgery, show that "negative results of imaging can be falsely reassuring," Dr. Salinas and his team say.
They conclude: "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."
In an editorial, Dr. Victor E. Pricolo of Rhode Island Hospital-Brown University in Providence states that for patients with T1 tumors and favorable histology, local excision to remove the entire tumor is a "reasonable alternative" to radical resection. "If the histologic findings are confirmed (low-risk T1), close observation by endoscopy and endorectal ultrasonography can be offered," Dr. Pricolo writes.
Larger cooperative studies are needed to determine whether it's possible to predict whether or not a patient with T1 rectal cancer can be treated by local excision alone, he concludes.
To avoid the morbidity associated with radical resection, local surgery is increasingly being performed for patients with T1 and T2 disease, Dr. Harry M. Salinas of Massachusetts General Hospital and Harvard Medical School in Boston and colleagues write.
This is concerning, they add, because as many as 20% of patients with T1 rectal cancer have lymphatic involvement.
The researchers thought they might be able to use imaging results and tumor histology to identify T1 and T2 patients without lymph node metastases who could safely undergo local surgery. To investigate, they looked at records for 109 consecutive patients who had undergone total mesorectal excision. In all cases, preoperative imaging had suggested they had T1 or T2 disease with no lymph node involvement.
Twenty-seven of the patients actually had T3 disease and were removed from the analysis, leaving 82 patients. Four of the 35 patients with T1 tumors (11%) and 13 of 47 with T2 tumors (28%) had positive lymph nodes on final pathological examination.
The only factor independently associated with the likelihood of lymph node involvement was whether or not a tumor had invaded the lower third of the submucosa. Tumors reached this depth in 24% of patients without lymph node involvement and in 76% of patients with positive nodes.
On logistic regression analysis, patients with tumors invading the lower third of the submucosal were more than eight times as likely to have positive lymph nodes.
The findings, reported in the May Archives of Surgery, show that "negative results of imaging can be falsely reassuring," Dr. Salinas and his team say.
They conclude: "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."
In an editorial, Dr. Victor E. Pricolo of Rhode Island Hospital-Brown University in Providence states that for patients with T1 tumors and favorable histology, local excision to remove the entire tumor is a "reasonable alternative" to radical resection. "If the histologic findings are confirmed (low-risk T1), close observation by endoscopy and endorectal ultrasonography can be offered," Dr. Pricolo writes.
Larger cooperative studies are needed to determine whether it's possible to predict whether or not a patient with T1 rectal cancer can be treated by local excision alone, he concludes.
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