NEOADJUVANT THERAPY AND FULL THICKNESS LOCAL EXCISION FOR RECTAL CANCER

Aims:  To determine the safety and effectiveness to perform full thickness local excisions (FTLE) for select rectal cancers following high-dose irradiation or chemoradiation (HDR).

Methods:  All patients in whom FTLE was performed following HDR or chemoradiation for rectal cancer as part of a prospective program of rectal cancer management were reviewed. From Nov 84 to Jan 2001, 71 patients (57.8% men) in 2 defined categories, were treated by transanal (51.6%), transrectal (12.5%), transsphincteric (17.2%), or transanal endoscopic microsurgery (18.75%). The categories were:  (a) medically compromised (26.6%), and (b) staged-elected (73.4%). Full radiologic and clinical pre-treatment staging was performed. Preoperative irradiation 4000-55580 cGy in fractions of 180 cGy was administrated using a 4-field technique over 4.5-7 weeks. Surgery performed 4.5-8 weeks post irradiation. The median follow up is 50 months.

Results:  Tumors located at level £3 cm from the anorectal ring were 87.5%, £2 cm 67.2%, £0 18.75%. Pretreatment stages: T1 7(10.9%), T2 34(53.1%), T3 18(28.1%), unknown 5(7.8%). Pathologic stages: T0 19(29.7%), Tis 1(1.6%), T1 21(32.8%), T2 18(28.1%), T3 3(4.7%), T2N1 1(1.6%), T3N1 1(1.6%). There were no mortalities. Morbidity included 6 anastomotic disruptions, 2 required colostomy, 2 rectal prolapses, 1 rectovaginal fistula and 1 radiation enteritis that required discontinuation of treatment at 4320 cGy (17.2%). 12 patients experienced local recurrence (L/R) (18.7%), 7 of these associated with distant metastasis (58.3%). 2 patients had distant metastasis exclusively (3.1%). L/R according to pathologic stage was T0 4(21%), Tis 0, T1 2(9.5%), T2 18(16.7%), T3 2(66.6%), T3N1 1(100%), T2N1 0.

Conclusion: FTLE following HDR or chemoradiation for select patients can be a feasible option as an alternative to APR.

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