Department of Surgery, Azienda Ospedaliera San Giovanni-Addolorata, Rome, Italy.
Dis Colon Rectum. 2014 Nov;57(11):1245-52. doi: 10.1097/DCR.0000000000000221.
Local excision, as an alternative to radical resection for patients with pathological complete response (ypT0) after preoperative chemoradiation, is under investigation.
The aim of the present study was to evaluate the long-term clinical outcome of a selected group of patients with ypT0 rectal cancer who underwent local excision with transanal endoscopic microsurgery as a definitive treatment.
Between 1993 and 2013, 43 patients with rectal adenocarcinoma underwent complete full-thickness local excision with a transanal endoscopic microsurgery procedure after a regimen of chemoradiation. In all patients, rectal wall penetration was preoperatively assessed by endorectal ultrasound and/or magnetic resonance. Chemoradiation and transanal endoscopic microsurgery were indicated in patients refusing radical procedures or patients unfit for major abdominal procedures.
Patient characteristics, operative record, pathology report, and tumor recurrence were analyzed at a median follow-up of 81 months. The potential prognostic factors for recurrence, screened in univariate analysis, were analyzed by multivariate analysis by using the Cox regression model.
Thirteen patients (30.2%), without residual tumor in the surgical specimen (ypT0), were treated with transanal endoscopic microsurgery only. In this ypT0 group, 2 patients (15.4%) had postoperative complications: 1 bleeding and 1 suture dehiscence. Postoperative mortality was nil. No local and distal recurrences were observed, and no tumor-related mortality occurred. In 30 patients (69.8%), partial tumor chemoradiation response or the absence of tumor chemoradiation response was observed. In this group, recurrence occurred in 17 patients (56.7%).
The study was limited by its retrospective nature, different protocols of chemoradiation and preoperative staging over time, and the small sample size.
Local excision with transanal endoscopic microsurgery can be considered a definitive therapeutic option in patients with rectal cancer treated with preoperative chemoradiation, when no residual tumor is found in the specimen. In this selected group, local excision offers excellent results in terms of survival and recurrence rates. In the presence of residual tumor, transanal endoscopic microsurgery should be considered as a large excisional biopsy (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A157).
对于术前放化疗后病理完全缓解（ypT0）的患者，局部切除术作为根治性切除术的替代方法正在研究中。
本研究旨在评估一组接受经肛门内镜微创手术（TEM）完全全层局部切除术作为确定性治疗的ypT0 直肠腺癌患者的长期临床结果。
1993 年至 2013 年，43 例直肠腺癌患者在接受放化疗后接受 TEM 全层局部切除术。在所有患者中，术前通过直肠腔内超声和/或磁共振评估直肠壁穿透情况。放化疗和 TEM 适用于拒绝根治性手术或不适合大型腹部手术的患者。
分析中位随访 81 个月的患者特征、手术记录、病理报告和肿瘤复发情况。在单变量分析中筛选出的潜在复发预后因素，通过 Cox 回归模型进行多变量分析。
13 例（30.2%）患者无肿瘤残留（ypT0），仅接受 TEM 治疗。在 ypT0 组中，2 例（15.4%）患者术后出现并发症：1 例出血，1 例缝线裂开。术后无死亡。未观察到局部和远端复发，也未发生肿瘤相关死亡。在 30 例（69.8%）患者中，观察到肿瘤部分对放化疗有反应或无肿瘤对放化疗的反应。在这组患者中，17 例（56.7%）复发。
本研究受到回顾性研究、不同时期的放化疗方案和术前分期以及样本量小的限制。
对于接受术前放化疗的直肠癌患者，如果标本中无肿瘤残留，TEM 全层局部切除术可作为一种确定性治疗选择。在这个选定的组中，局部切除术在生存率和复发率方面提供了优异的结果。如果存在残留肿瘤，TEM 应被视为大切除活检（参见视频，补充数字内容 1，http://links.lww.com/DCR/A157）。
