Introduction
Rectal adenocarcinomas (ADC) are associated with a higher rate of recurrence but also with greater surgical morbidity when compared to those of the colon. Local excision (LE) of early colorectal ADC that meet curability criteria (CC) is associated with excellent outcomes, and only surveillance is recommended. However, in the presence of non-curative LE criteria, salvage treatment should be performed. Although in most cases this includes surgery with lymphadenectomy, another possible approach is radio +/- chemotherapy (RT/CRT) followed by surveillance, in a “watch and wait” (WW)-like strategy, with surgery only in case of persistence or recurrence of injury.
Aims & Methods
This work aims to evaluate oncological outcomes in a cohort of patients after LE of early rectal ADC without CC, submitted to different clinical options (surveillance, RT/CRT followed by WW and surgery).
It is a retrospective study including patients evaluated at two tertiary hospital centers for pT1/pT2 rectal ADC who underwent LE (endoscopic or transanal resection - TAR) between 12/2011-12/2022.
ADC pT1, low grade, sm1, without lymphovascular or perineural invasions, without high grade budding and with free margins were considered CC.
Clinical options in patients without CC, their complications and outcomes were analyzed.
Results
64 patients were included in which the CC for LE were not met (5 for pT2; 3 for high grade; 8 for lymphovascular invasion; 54 for positive resection margins; 36 for sm>1, 28 (44%) patients failed >1CC). Of these, 49 were male patients, mean age 65.4 years (44-88), 14 with a family history of colorectal cancer and 12 with current or past smoking habits. ADCs: 12 excised by polypectomy, 20 by mucosectomy, 26 by submucosal or intramuscular dissection, 1 endoscopic transmural resection; 2 TAR and 3 endoscopic+TAR resections; 47 lesions excised in a single fragment; 29 in flat lesions, 31 in sessile polyps, 4 in pedunculated polyps.
In 24 patients, surgery was performed with lymphadenectomy (4 with definitive colostomy); in 16 patients, only surveillance was performed (8 due to comorbidities; 2 due to risk of Abdominoperineal Resection; 4 due to LE > 12 weeks/unidentified site; 2 due to refusal of surgery); 19 patients received CRT and 5 only RT, followed by surveillance. There were CRT complications in 4 patients (grade 2/3) and surgery complications (grade II/III) in 6.
Average follow-up: 35 months; 3 relapses were identified in the surveillance only group (19%) – 2 local and 1 distant; 1 distant recurrence in the surgery group (4%); 1 local and 1 local+distant recurrence in the RT/CRT group (8%). All recurrences occurred in pT1. Two of the patients with recurrence died of the disease (1 of them had undergone surveillance, the other had surgery with lymphadenectomy).
Conclusion
Despite the short series, this work confirms the worse outcome of patients with malignant polyps and pT2 of the rectum excised without CC and only monitored, and supports promising results from RT/CRT; this may be an organ-preserving option with less morbidity than surgery in patients with malignant rectal polyps excised without CC.
References
. Saraiva S, Rosa I, Fonseca R, Pereira AD. Colorectal malignant polyps: a modern approach. Ann Gastroenterol. 2022 Jan-Feb;35(1):17-27. doi: 10.20524/aog.2021.0681.
. Glynne-Jones R, Wyrwicz L, Tiret E, Brown G, Rödel C, Cervantes A, Arnold D. ESMO Guidelines Committee. Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2017 Jul 1;28(suppl_4):iv22-iv40. doi: 10.1093/annonc/mdx224. Erratum in: Ann Oncol. 2018 Oct 1;29(Suppl 4):iv263.
. Al-Hawary M, Azad N, Chen Y, Ciombor K et al. Rectal Cancer, Version 2.2022, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2022 Oct;20(10):1139-1167. doi: 10.6004/jnccn.2022.0051.
. Bernier L, Balyasnikova S, Tait D, Brown G. Watch-and-Wait as a Therapeutic Strategy in Rectal Cancer. Curr Colorectal Cancer Rep. 2018;14(2):37-55. doi: 10.1007/s11888-018-0398-5.