Rectal Cancer: Management of T1 Rectal Cancer

P (patients)

I (intervention)

C (comparator)

O (outcomes)

Patients with T1 rectal cancer

Local excision

Radical resection

Oncologic outcomes, quality of life

A literature search in Pubmed, Embase, and Scopus databases was performed. The terms used for the search included: “T1 rectal cancer”; “early staged rectal cancer”; “local excision”; “radical resection”; “recurrence”; “sexual function”; “anorectal function” and “quality of life”. Only articles written in English and published between 2010 and 2015 and reporting original data or meta-analysis on T1 rectal cancer were selected. Important and evidence-based studies published before 2010 were also included.

Results

We found two meta-analyses which met our search criteria and included most of the significant data on the topic (Table 17.1) [1, 2]. Of these two studies, one was larger (2896 patients from 13 studies [1] versus 860 patients from seven studies [2]) and reported detailed preoperative diagnostic workup and oncologic data including lymphovascular invasion and surgical margin status as well as the use of neoadjuvant and/or adjuvant therapy [1]. However, these two meta-analyses included studies that were retrospective and non-randomized [3–15], and some of the retrospective studies included small numbers of patients. The one prospective randomized study on this topic which was included in both meta-analyses only enrolled 50 patients [16].

Table 17.1

Comparison of meta-analysis studies on T1 rectal cancer

Study	Year	Study design	Patients (LE/RR)	Local recurrence	Distant metastasis	DFS	OS	Morbidity	Mortality	Quality of evidence
Kidane et al. [1] (TAE, TEM, TAMIS vs. RR)	2015	Meta-analysis	2896 (1315/1581)	LE > RR (relative risk, 2.36; 95 % CI, 1.64–3.39)	n/a	5-years DFS, LE < RR (relative risk, 1.54; 95 % CI, 1.15–2.05)	5-years OS, LE < RR (relative risk, 1.46; 95 % CI, 1.19–1.77)	LE < RR (relative risk, 0.20; 95 % CI, 0.10–0.41)	LE < RR (relative risk, 0.31; 95 % CI, 0.14–0.71)	moderate
Lu et al. [2] (TEM vs. RR)	2015	Meta-analysis	860 (303/557)	LE > RR(OR, 4.62; 95 % CI, 2.03–10.53)	no difference(OR, 0.74; 95 % CI, 0.32–1.72)	no difference(OR, 1.12; 95 % CI, 0.31–4.12)	no difference(OR, 0.87; 95 % CI, 0.55–1.38)	n/a	n/a	moderate

LE local excision, RR radical resection, DFS disease-free survival, OS, overall survival, TAE, transanal excision, TEM, transanal endoscopic microsurgery, TAMIS, transanal minimally invasive surgery, CI, confidence interval, OR, overall risk, SEER, surveillance, epidemiology, and end results, HR hazard risk

Oncologic Outcomes

Local Recurrence

In our review of these two meta-analyses, rates of local recurrence were higher in patients undergoing a LE when compared to patients undergoing a RR (4–33 % versus 0–6 %, respectively) [1, 2].

Distant Metastasis

Of these two meta-analyses, only one compared distant metastasis rates between LE and RR and showed no significant differences (0–8 % versus 0–4 %, respectively) [2]. However, it is important to point out that this study included only patients undergoing TEM and did not include TAE or TAMIS.

Overall Outcome

In one meta-analysis, disease-free survival rate was higher in patients undergoing a RR [1]. However, in the other meta-analysis, no significant difference was noted in disease-free survival between the two surgical treatment options [2]. This may be due to the fact that in the latter met-analysis, only 2 studies reporting disease-free survival were included.

With regard to overall survival, one meta-analysis showed better results for RR over LE [1]. The other meta-analysis did not, even though it did demonstrate a significantly higher local recurrence rate in patients undergoing a LE (odds ratio, 4.62; 95 % confidence interval, 2.03–10.53) [2]. The authors do not provide an explanation for this. However, it is possible that salvage radical surgery and adjuvant chemotherapy and/or radiation therapy may have eradicated some of the locally recurrent rectal cancer and impacted survival in a positive manner. However, other studies suggest that failure following a local excision may not be salvageable in a significant number of cases [17].

Quality of Life

Of the two meta-analyses, only one reported on morbidity and noted a higher morbidity rate for RR over LE [1]. LE was associated with a much lower need for permanent stoma [1]. However, a number of the studies included were from over 20 years ago when sphincter sparing TME was not as established as it is today.

There is a paucity of literature comparing sexual or anorectal functions following RR and LE and none are prospective randomized studies. Therefore, the two meta-analyses [1, 2] did not discuss this topic. One study not included in the two meta-analysis, however, did compare the quality of life after TEM and TME in sex- and age-matched patients and reported no significant differences in quality of life between TEM and TME; but more frequent defecation disorders were observed after TME [18]. A trend toward better sexual function after TEM was also reported. However, a greater portion of patients in the TME group were T3 and received preoperative radiotherapy (18 % versus 0 %) which probably had a negative impact on sexual function.

Other Studies

There are several recently published papers comparing local excision to radical resection that were not included in our analyses for specific reasons. One study included T1 and T2 rectal cancers and did not provide a subset analysis on T1 cancers [19] and the other included endoscopic polypectomy in the LE group [20]. One single institution study comparing LE to RR was not included in either of the meta-analyses [21]. It was a small sample (n = 124), retrospective study which demonstrated a local recurrence rate of 11 % in the LE group versus 1.6 % in the RR group, but no difference in the disease-free and overall survival between the two groups. Our institutional experience at Memorial Sloan-Kettering Cancer Center (MSKCC) on a larger cohort (n = 282) with a similar length of follow-up demonstrated an inferior disease-specific survival for patients with a T1 rectal cancer undergoing a LE relative to those undergoing a RR (87 % versus 96 %) [12].

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