metricas
covid
Buscar en
Cirugía Española (English Edition)
Toda la web
Inicio Cirugía Española (English Edition) Time to Rethink Transanal Endoscopic Microsurgery for Rectal Cancer After Neoadj...
Información de la revista
Vol. 95. Núm. 4.
Páginas 179-180 (abril 2017)
Vol. 95. Núm. 4.
Páginas 179-180 (abril 2017)
Editorial
Acceso a texto completo
Time to Rethink Transanal Endoscopic Microsurgery for Rectal Cancer After Neoadjuvant Chemoradiation for Highly Selected Patients
Es tiempo de reconsiderar la microcirugía endoscópica transanal tras quimio-radioterapia neoadyuvante para el cáncer rectal en pacientes altamente seleccionados
Visitas
1982
Rodrigo Oliva Pereza,b,
Autor para correspondencia
rodrigo.operez@gmail.com

Corresponding author.
, Guilherme Pagin São Juliãoa, Bruna Borba Vailatia
a Angelita & Joaquim Gama Institute, São Paulo, Brazil
b Colorectal Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil
Este artículo ha recibido
Información del artículo
Texto completo
Bibliografía
Descargar PDF
Estadísticas
Texto completo

Transanal endoscopic microsurgery is an attractive alternative to radical surgery in patients with rectal cancer. The minimal associated postoperative morbidity, need for temporary or definitive stomas and excellent functional outcomes have been considered the main advantages for this approach.1 Unfortunately, oncological outcomes have been somewhat disappointing and paralleled the risk of lymph node metastases not being resected during local excision.2,3

Widespread implementation of multimodality treatment with neoadjuvant chemoradiation could set the ideal scenario for a local excision among select patients with rectal cancer. The development of significant tumor regression (in size and depth of invasion) and potential sterilization of perirectal (metastatic) lymph nodes would allow safe resection of the primary residual tumor obviating the need for total mesorectal excision and protectomy.4 In the present issue of the journal, an interesting study provides additional light into this controversial issue during management of these patients. Several reported findings are worth noticing including the excellent low local recurrence rates and the little or minimal postoperative associated morbidity.

However, caution should be considered before widespread implementation of this strategy into clinical practice. Besides the considerable limited sample size and inherent selection bias of the included patients, a few aspects should be considered.

First, a significant amount of these patients ultimately had complete pathological response. Despite the fact that clinical response did not precisely correlate to pCR in their study, there was still more than a third of patients that would eventually did not require any resection (not even local excision). In fact, non-operative management of patients with cCR have been shown to result in superior functional outcomes to local excision and similar oncological outcomes.5,6 As a matter of fact, none of the patients with pCR developed local recurrences as one would expect. One could argue that local excision was able to detect a few false cCRs. However, assessment of tumor response at 8 weeks may have been too early among these patients as there is data to suggest that longer intervals are associated with increased pCR rates.7,8

Second, the unique local recurrence was observed in a non-complete responder (ypT1). Perhaps the 4% reported local recurrence should have been considered exclusively among the non-responders (excluding pCR patients) and therefore, significantly higher than 4%. Local recurrence after local excision where no cancer has been resected will probably attest effectiveness of nCRT instead of the effectiveness of local excision. Local recurrence after local excision of residual cancers (exclusively non-responders) will definitely attest the effectiveness of local excision in this setting. With this in mind, we are ultimately attesting the effectiveness of highly selected 12 patients here (ypT1 or ypT2).

Third, local excision used to be an attractive alternative for most distal rectal cancers (<6–7cm from the anal verge). Distal rectal cancers usually require temporary if not definitive stomas, functional outcomes are significantly worse and postoperative morbidity is also higher. Instead, the present study reports on patients that refused radical surgery harboring tumors between 6 and 7cm.9 Considering the results of the MERCURY study where patients with T3a/b MR-staged and managed by TME had 1.7% local recurrence, one could argue that T3a/b (an definitely T2s) would not require any neoadjuvant CRT, particularly for tumors at the level of 6–7 from the anal verge.10 In fact, the considerably high location of these tumors may have contributed to the significantly low postoperative morbidity rate. Clearly, resection of lesions closer to the anal verge are more prone to postoperative pain and difficulties in healing with the limited elasticity (and consequently tension) of the anal canal previously irradiated.11 Still, caution should be taken as previous studies suggests that in the event of completion TME in patients with unfavorable pathological features, there is an increased poor quality of the specimen and the risk of abdominal perineal excision (clearly among patients primarily fit for a sphincter-saving procedure).12,13 In fact, several studies suggest that ypT2 cancers are probably best suited for completion TME than local excision alone after CRT due to the increased risk for local recurrences.14,15 Finally, in the event of a local recurrence, salvage TME appears to be associated with high rates of CRM+.16

The present study suggests that nCRT followed by local excision using endoscopic platforms may result in very good outcomes in highly selected patients. Selection here included a significant amount of patients that probably did not require any surgery (complete pathological responses) or did not require any CRT (T2/early T3 higher than 6–7cm).

References
[1]
S. Sengupta, J.J. Tjandra.
Local excision of rectal cancer: what is the evidence?.
Dis Colon Rectum, 44 (2001), pp. 1345-1361
[2]
B.M. Tsai, C.O. Finne, J.F. Nordenstam, D. Christoforidis, R.D. Madoff, A. Mellgren.
Transanal endoscopic microsurgery resection of rectal tumors: outcomes and recommendations.
Dis Colon Rectum, 53 (2010), pp. 16-23
[3]
P.G. Doornebosch, F.T. Ferenschild, J.H. de Wilt, I. Dawson, G.W. Tetteroo, E.J. de Graaf.
Treatment of recurrence after transanal endoscopic microsurgery (TEM) for T1 rectal cancer.
Dis Colon Rectum, 53 (2010), pp. 1234-1239
[4]
F.M. McLean Smith, A. Ahad, R. Oliva Perez, J. Marks, K. Bujko, R.J. Heald.
Local excision techniques for rectal cancer after neoadjuvant chemoradiotherapy: what are we doing?.
Dis Colon Rectum, 60 (2017), pp. 228-239
[5]
X. Serra-Aracil, C. Pericay, L. Mora-López, J.C. García Pacheco, J.I. Latorraca, J. Ocaña-Rojas, et al.
Neoadyuvancia y cirugía endoscópica transanal en neoplasias de recto T2-T3superficial, N0, M0. Recidiva local, respuesta clínica y patológica completa.
[6]
A. Habr-Gama, P.B. Lynn, J.M.N. Jorge, G.P. São Julião, I. Proscurshim, J. Gama-Rodrigues.
Impact of organ-preserving strategies on anorectal function in patients with distal rectal cancer following neoadjuvant chemoradiation.
Dis Colon Rectum, 59 (2016), pp. 264-269
[7]
A. Habr-Gama, J. Gama-Rodrigues, G.P. Sao Julião, I. Proscurshim, C. Sabbagh, P.B. Lynn, et al.
Local recurrence after complete clinical response and watch and wait in rectal cancer after neoadjuvant chemoradiation: Impact of salvage therapy on local disease control.
Int J Radiat Oncol Biol Phys, 88 (2014), pp. 822-828
[8]
M.F. Kalady, L.F. de Campos-Lobato, L. Stocchi, D.P. Geisler, D. Dietz, I.C. Lavery, et al.
Predictive factors of pathologic complete response after neoadjuvant chemoradiation for rectal cancer.
Ann Surg, 250 (2009), pp. 582-589
[9]
J. Garcia-Aguilar, L.A. Renfro, O.S. Chow, Q. Shi, X.W. Carrero, P.B. Lynn, et al.
Organ preservation for clinical T2N0 distal rectal cancer using neoadjuvant chemoradiotherapy and local excision (ACOSOG Z6041): results of an open-label, single-arm, multi-institutional, phase 2 trial.
Lancet Oncol, 16 (2015), pp. 1537-1546
[10]
F.G. Taylor, P. Quirke, R.J. Heald, B. Moran, L. Blomqvist, I. Swift, et al.
Preoperative high-resolution magnetic resonance imaging can identify good prognosis stage I, II, and III rectal cancer best managed by surgery alone: a prospective, multicenter, European study.
Ann Surg, 253 (2011), pp. 711-719
[11]
R.O. Perez, A. Habr-Gama, G.P. Sao Julião, I. Proscurshim, A. Scanavini Neto, J. Gama-Rodrigues.
Transanal endoscopic microsurgery for residual rectal cancer after neoadjuvant chemoradiation therapy is associated with significant immediate pain and hospital readmission rates.
Dis Colon Rectum, 54 (2011), pp. 545-551
[12]
R. Hompes, R. McDonald, C. Buskens, I. Lindsey, N. Armitage, J. Hill, et al.
Completion surgery following transanal endoscopic microsurgery: assessment of quality and short- and long-term outcome.
Colorectal Dis, 15 (2013), pp. e576-e581
[13]
M. Morino, M.E. Allaix, S. Arolfo, A. Arezzo.
Previous transanal endoscopic microsurgery for rectal cancer represents a risk factor for an increased abdominoperineal resection rate.
Surg Endosc, 27 (2013), pp. 3315-3321
[14]
M. Verseveld, E.J. de Graaf, C. Verhoef, E. van Meerten, C.J. Punt, I.H. de Hingh, et al.
Chemoradiation therapy for rectal cancer in the distal rectum followed by organ-sparing transanal endoscopic microsurgery (CARTS study).
Br J Surg, 102 (2015), pp. 853-860
[15]
S. Pucciarelli, A. de Paoli, M. Guerrieri, G. la Torre, I. Maretto, F. de Marchi, et al.
Local excision after preoperative chemoradiotherapy for rectal cancer: results of a multicenter phase II clinical trial.
Dis Colon Rectum, 56 (2013), pp. 1349-1356
[16]
R.O. Perez, A. Habr-Gama, G.P. Sao Julião, I. Proscurshim, L.M. Fernandez, R.U. de Azevedo, et al.
Transanal Endoscopic Microsurgery (TEM) following neoadjuvant chemoradiation for rectal cancer: Outcomes of salvage resection for local recurrence.
Ann Surg Oncol, 23 (2016), pp. 1143-1148

Please cite this article as: Oliva Perez R, Pagin São Julião G, Borba Vailati B. Es tiempo de reconsiderar la microcirugía endoscópica transanal tras quimio-radioterapia neoadyuvante para el cáncer rectal en pacientes altamente seleccionados. Cir Esp. 2017;95:179–180.

Descargar PDF
Opciones de artículo
es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos