Perez Rodrigo Oliva, Habr-Gama Angelita, São Julião Guilherme Pagin, Proscurshim Igor, Fernandez Laura Melina, de Azevedo Rafael Ulysses, Vailati Bruna B, Fernandes Felipe Alexandre, Gama-Rodrigues Joaquim
Angelita and Joaquim Gama Institute, São Paulo, Brazil.
Colorectal Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil.
Ann Surg Oncol. 2016 Apr;23(4):1143-8. doi: 10.1245/s10434-015-4977-2. Epub 2015 Nov 17.
Transanal endoscopic microsurgery (TEM) has been considered an alternative for selected patients with rectal cancer following neoadjuvant chemoradiation (CRT). Immediate total mesorectal completion for all patients with unfavorable pathological features would result in unnecessary protectomies in a significant proportion of patients. Instead, salvage total mesorectal excision (TME) could be restricted for patients developing local recurrence. The aim of the present study is to determine oncological outcomes of salvage resection for local recurrences following CRT and TEM.
Consecutive patients undergoing TEM following neoadjuvant CRT for rectal cancer were reviewed. Patients with "near" complete response to CRT (≤3 cm; ycT1-2N0) were offered TEM. Salvage surgery was attempted in the event of a local recurrence.
A total of 53 patients were managed by CRT followed by TEM. Unfavorable pathological features were present in 36 patients (68 %). None of the patients underwent immediate completion TME. There were 12 patients who developed local recurrence resulting in a 2-year local recurrence-free survival of 77 % (95 % CI, 53-100 %). Of these patients, 9 developed exclusively local recurrences, and all had at least 1 unfavorable pathological feature in the specimen after TEM (100 %). Eight patients (8 of 9) underwent salvage resection (abdominoperineal resection [APR] in 87 %) with CRM+ in 7 of 8 patients (87 %). Four patients developed local re-recurrence after a median 36 months of follow-up. The 2-year local re-recurrence free survival was 60 %.
Salvage resection for local recurrence following CRT and TEM is associated with high rates of R1 resection (CRM+) and local re-recurrence. Immediate completion of TME should be considered for patients with unfavorable pathological features after TEM.
经肛门内镜显微手术（TEM）被认为是新辅助放化疗（CRT）后部分直肠癌患者的一种替代治疗方法。对所有具有不良病理特征的患者立即进行全直肠系膜完整切除术会导致相当一部分患者接受不必要的保肛手术。相反，挽救性全直肠系膜切除术（TME）可仅限于发生局部复发的患者。本研究的目的是确定CRT和TEM后局部复发的挽救性切除的肿瘤学结局。
回顾性分析新辅助CRT后接受TEM的连续性直肠癌患者。对CRT达到“接近”完全缓解（≤3 cm；ycT1-2N0）的患者进行TEM。如果发生局部复发，则尝试进行挽救性手术。
共有53例患者接受了CRT，随后进行了TEM。36例患者（68%）存在不良病理特征。没有患者接受即刻完整TME。12例患者发生局部复发，2年局部无复发生存率为77%（95%CI，53-100%）。在这些患者中，9例仅发生局部复发，且TEM术后标本中均至少有1个不良病理特征（100%）。8例患者（9例中的8例）接受了挽救性切除（87%为腹会阴联合切除术[APR]），8例患者中有7例（87%）切缘阳性（CRM+）。4例患者在中位随访36个月后发生局部再复发。2年局部无再复发生存率为60%。
CRT和TEM后局部复发的挽救性切除与高R1切除率（CRM+）和局部再复发相关。TEM后具有不良病理特征的患者应考虑立即完成TME。
