Local Excision vs Radical Resection of Colorectal Carcinoma
Objective: To compare cancer-specific results of local excision with major resection.
Background: Technological advances have enabled endoscopic and local excision techniques to be applied in the treatment of early colorectal cancer in preference to radical surgery.
Method: Patients with stage 0 (carcinoma in situ) or stage I (T1/2N0M0) adenocarcinoma of the colon or rectum undergoing surgery between 1998 and 2009 were included from the SEER (Surveillance, Epidemiology, and End Results) database. Local excision (endoscopic or surgical) was compared with major surgical resection using adjusted hazard ratios (HRs) for 5-year cancer-specific survival (CSS).
Results: This study included 7378 local excisions and 36,116 major resections. There were 3553 patients with carcinoma in situ and 39,941 with clinical stage I cancer. Local tumor excision for carcinoma in situ was associated with equivalent CSS compared to major resection (HRs = 1.06, P = 0.814, for colon and 0.78, P = 0.494, for rectum). Local excision of T1 and T2 colon cancer was associated with reduced CSS (HR = 1.31, P = 0.020, and 2.89, P < 0.001, respectively). Local excision of T1 rectal cancer did not affect CSS (HR = 1.16, P = 0.236), but it significantly reduced CSS for T2 cancer (HR = 1.71, P < 0.001). Subgroup analysis of T1 and T2 rectal cancer after neoadjuvant therapy and local excision showed oncological equivalence to major resection (HR = 1.12, P = 0.802, and 1.23, P = 0.802).
Conclusions: Local excision for early colorectal cancer was oncologically equivalent to major surgery for carcinoma in situ and T1 rectal cancer, but inferior for T1–2 colon and T2 rectal cancer. Exploratory data suggest local excision of T1–2 rectal cancer after neoadjuvant therapy may be safe.
The modern management of early colorectal cancer poses a dilemma for the colorectal surgeon and multidisciplinary team. With the advent of population-level colorectal cancer screening programs, the rate of these patients requiring curative treatment is expected to further increase. The high-quality oncological clearance obtained by major surgical resection must be balanced against the risk of postoperative morbidity and mortality. This surgery includes colectomy, anterior resection, and abdominoperineal resection of rectum, with the subsequent risk of anastomotic leak and/or poor functional outcome. Technological advances have enabled endoscopic and local excision techniques to be applied in the treatment of early colorectal cancer in preference to radical resectional surgery. Initially used as a means to treat frail patients, these have gained popularity and are now used as a first-line curative options.
Early failure after local excision (eg, for incomplete excision or adverse histopathology) may be effectively treated by salvage surgery, without apparent detriment to long-term oncologic survival. Late failure is also precipitated by poor histological features and high rates of positive resection margin, but incomplete and inaccurate lymph node assessment may also lead to oncological compromise. Up to 20% of patients with T0–2 colorectal cancer will harbor undetected lymph node metastases, increasing their stage and indicating the need for adjuvant chemotherapy. This rate can increase to 70% when poor tumor differentiation is present.
Concerns that these failures may cumulate in adverse survival outcome and a lack of high quality data from controlled trials indicate the need for further research. A previous analysis of local excision versus radical resection for T1/2 rectal cancer from the SEER (Surveillance, Epidemiology, and End Results) database found reduced cancer-specific survival (CSS) with local excision techniques. However, their histopathological inclusion criteria were wide, they included local destructive techniques as part of local excision, they did not assess colonic lesions or those with carcinoma in situ (T0), and their starting date (1988) lacks relevance to modern practice. Thus further research should be tailored toward refinement of definition for the precise patient group who are likely to benefit from endoscopic or endoluminal excision, without detriment to outcome. The aim of this study was to compare the survival outcome from local excision to major resection from stage 0 and stage I cancer of the colon and rectum.
Abstract and Introduction
Abstract
Objective: To compare cancer-specific results of local excision with major resection.
Background: Technological advances have enabled endoscopic and local excision techniques to be applied in the treatment of early colorectal cancer in preference to radical surgery.
Method: Patients with stage 0 (carcinoma in situ) or stage I (T1/2N0M0) adenocarcinoma of the colon or rectum undergoing surgery between 1998 and 2009 were included from the SEER (Surveillance, Epidemiology, and End Results) database. Local excision (endoscopic or surgical) was compared with major surgical resection using adjusted hazard ratios (HRs) for 5-year cancer-specific survival (CSS).
Results: This study included 7378 local excisions and 36,116 major resections. There were 3553 patients with carcinoma in situ and 39,941 with clinical stage I cancer. Local tumor excision for carcinoma in situ was associated with equivalent CSS compared to major resection (HRs = 1.06, P = 0.814, for colon and 0.78, P = 0.494, for rectum). Local excision of T1 and T2 colon cancer was associated with reduced CSS (HR = 1.31, P = 0.020, and 2.89, P < 0.001, respectively). Local excision of T1 rectal cancer did not affect CSS (HR = 1.16, P = 0.236), but it significantly reduced CSS for T2 cancer (HR = 1.71, P < 0.001). Subgroup analysis of T1 and T2 rectal cancer after neoadjuvant therapy and local excision showed oncological equivalence to major resection (HR = 1.12, P = 0.802, and 1.23, P = 0.802).
Conclusions: Local excision for early colorectal cancer was oncologically equivalent to major surgery for carcinoma in situ and T1 rectal cancer, but inferior for T1–2 colon and T2 rectal cancer. Exploratory data suggest local excision of T1–2 rectal cancer after neoadjuvant therapy may be safe.
Introduction
The modern management of early colorectal cancer poses a dilemma for the colorectal surgeon and multidisciplinary team. With the advent of population-level colorectal cancer screening programs, the rate of these patients requiring curative treatment is expected to further increase. The high-quality oncological clearance obtained by major surgical resection must be balanced against the risk of postoperative morbidity and mortality. This surgery includes colectomy, anterior resection, and abdominoperineal resection of rectum, with the subsequent risk of anastomotic leak and/or poor functional outcome. Technological advances have enabled endoscopic and local excision techniques to be applied in the treatment of early colorectal cancer in preference to radical resectional surgery. Initially used as a means to treat frail patients, these have gained popularity and are now used as a first-line curative options.
Early failure after local excision (eg, for incomplete excision or adverse histopathology) may be effectively treated by salvage surgery, without apparent detriment to long-term oncologic survival. Late failure is also precipitated by poor histological features and high rates of positive resection margin, but incomplete and inaccurate lymph node assessment may also lead to oncological compromise. Up to 20% of patients with T0–2 colorectal cancer will harbor undetected lymph node metastases, increasing their stage and indicating the need for adjuvant chemotherapy. This rate can increase to 70% when poor tumor differentiation is present.
Concerns that these failures may cumulate in adverse survival outcome and a lack of high quality data from controlled trials indicate the need for further research. A previous analysis of local excision versus radical resection for T1/2 rectal cancer from the SEER (Surveillance, Epidemiology, and End Results) database found reduced cancer-specific survival (CSS) with local excision techniques. However, their histopathological inclusion criteria were wide, they included local destructive techniques as part of local excision, they did not assess colonic lesions or those with carcinoma in situ (T0), and their starting date (1988) lacks relevance to modern practice. Thus further research should be tailored toward refinement of definition for the precise patient group who are likely to benefit from endoscopic or endoluminal excision, without detriment to outcome. The aim of this study was to compare the survival outcome from local excision to major resection from stage 0 and stage I cancer of the colon and rectum.
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