One patient (2.5%) with tumour stage T2 before RT developed distant metastasis. He underwent adjuvant chemotherapy and died at 2 years from the operation (Figure 3).
No-surgical operative techniques for early rectal cancer therapy have been introduced over the past few years. They include endoscopic mucosal resection (EMR), piecemeal EMR, and, more recently, endoscopic submucosal dissection (ESD)   . They are minimally invasive procedures that can be executed without general anaesthesia. However, they still entail considerable drawbacks and a higher risk of complications  , chiefly incomplete resection, which involves a high recurrence rate and may negatively affect pathological evaluation of invasion depth, state of resection margins, and vessel invasion; this is especially true of piecemeal EMR  .
Spreading non-granular tumours (LST-NG) ≥ 20 mm and laterally spreading granular lesions (LST-G) ≥ 20 mm are currently considered as indications for en bloc resection of early rectal cancer   . According to the literature, en bloc resection with EMR can be performed in 66.5% - 80% of tumours, but it is not recommended for lesions > 20 mm. En bloc resection with ESD can be performed in 80% - 94.5% of tumours, regardless of lesion size and site, but it is heavily operator-dependent and is greatly affected by patient condition and lesion status. Moreover, even with ESD incomplete vertical resection of a T1 rectal carcinoma makes it difficult for the pathologist to evaluate the tissue specimen  .
Recurrence rates for en bloc resection of malignant lesions vary greatly according to different reports (0% - 14%); however, such estimates do not include the recurrence of adenomatous lesions at the site of endoscopic resection. Incomplete resection with positive lateral or deep tumour margins involves even higher rates (18.4%, 23.1%, and 30.7% at 5, 12, and 24 months, respectively).
Analysis of the latest and largest studies of endoscopic resection discloses that EMR and ESD have in fact been applied to treat a fairly small proportion of rectal cancers  - . It is therefore difficult to assess their value in treating rectal malignancies. Moreover endoscopic resection, especially ESD, carries a high risk of perforation (1.4% - 10.4%), both immediate and up to 14 h after the procedure (delayed perforation) and bleeding (5%)     .
TEM is a safer technique that allows performing complete tumour resection in 98.9% of cases in this study.
TEM affords a magnified 3D binocular vision, which provides a clear view, maximizing the scope for obtaining free margins. Lately high-magnification chromoscopic colonoscopy has become available, but this technique provides 2D vision, and sometimes doesn’t allow a direct view of the lesion.
In early rectal cancer patients, TEM provides results that are comparable to open surgery  , as we stated in previous studies.
Our results show that TEM can reach tumours located in the upper rectum as far as 20 cm from the anal verge, and to excise lesions 2 - 3 cm from the anal ring, where complete endoscopic resection would be difficult to perform. In our series there were only two cases (1.06%) of positive resection margins on pathological examination.
Lesion diameter is not a limitation for TEM, as demonstrated by the successful excision of extensive circumferential lesions in some of our patients. TEM also allows full-thickness excision, i.e. removal not limited to mucosal and submucosal layers but extending into perirectal fat, even in cases of very low lesions  .
Another factor contributing to patient outcome is that surgical specimens removed by TEM afford optimum pathology material, thus providing reliable submucosal invasion information (Sm1, Sm2 and Sm3) to guide in decision-making for further surgical treatment.
No intraoperative complications arose in the present series of 187 patients. However, our experience indicates that even in case of rectal perforation TEM allows to suture the tear without need for emergency surgery.
TEM technique involves fewer postoperative complications, most of which can be managed conservatively (transfusion for bleeding and antibiotic therapy in case of suture dehiscence and fever).
The features discussed above allow achieving excellent oncological outcomes with very low recurrence rates and high disease free survival rates. There were only two local recurrences in our series and one cancer related death.
Several studies have documented a correlation between pathological T-stage and lymphnode involvment. It has been demonstrated that low-risk T1 rectal cancer have a very low rate of lymphnode metastasis which allow to consider TEM a safe procedure   - . The indications for TEM have considerably expanded since its introduction, in parallel with technical advances and surgeon experience, but patient accurate preoperative selection is the key element to the successful performance of TEM.
The limitations of TEM include a long surgeon learning curve (over than 50 operations) and the steep cost of the equipment.
Moreover one of the limits of our study is that we presented on a retrospective series and non randomized. Other studies will be necessary to confirm our observations.
TEM has been enabling surgeon to achieve all key treatment goals: complete tumour resection with negative margins, preservation of normal anatomy, minimization of morbidity and mortality, and preservation of sphincter function.
These considerations indicate that TEM could now be considered as the gold standard approach to early rectal cancer in selected patient.
Cite this paper
MarioGuerrieri,MonicaOrtenzi,Maria MichelaCappelletti Trombettoni,IndritKubolli,RobertoGhiselli, (2015) Local Excision of Early Rectal Cancer by Transanal Endoscopic Microsurgery (TEM): The 23-Year Experience of a Single Centre. Journal of Cancer Therapy,06,1000-1007. doi: 10.4236/jct.2015.611108
- 1. Buess, G., Hutterer, F., Theiss, J., Bobel, M., Isselhard, W. and Pichlmaier, H. (1984) A System for a Transanal Endoscopic Rectum Operation. Chirurg, 55, 677-680.
- 2. Marijnen, C.A. (2015) Organ Preservation in Rectal Cancer: Have All Questions Been Answered? The Lancet Oncology, 16, e13-e22.
- 3. Guerrieri, M., Baldarelli, M., Organetti, L., Grillo Ruggeri, F., Mantello, G., Bartolacci, S. and Lezoche, E. (2008) Transanal Endoscopic Microsurgery for the Treatment of Selected Patients with Distal Rectal Cancer: 15 Years Experience. Surgical Endoscopy, 22, 2030-2035.
- 4. Lezoche, G., Guerrieri, M., Baldarelli, M., Paganini, A.M., D’Ambrosio, G., Campagnacci, R., Bartolacci, S. and Lezoche, E. (2011) Transanal Endoscopic Microsurgery for 135 Patients with Small Nonadvanced Low Rectal Cancer (iT1-iT2, iN0): Short- and Long-Term Results. Surgical Endoscopy, 25, 1222-1229.
- 5. Guerrieri, M., Gesuita, R., Ghiselli, R., Lezoche, G., Budassi, A. and Baldarelli, M. (2014) Treatment of Rectal Cancer by Transanal Endoscopic Microsurgery: Experience with 425 Patients. World Journal of Gastroenterology, 20, 9556-9563.
- 6. Hermanek, P., Guggenmooss-Holzmann, I. and Gall, F.P. (1983) Prognostic Factors in Rectal Carcinoma A Contribution to the Further Development of Tumor Classification. Diseases of the Colon & Rectum, 32, 593-599.
- 7. Broders, A.C. (1925) The Grading of Carcinoma. Min Med, 8, 726-730.
- 8. Kikuchi, R., Takano, M., Takagi, K., Fujimoto, N., Nozaki, R., Fujiyoshi, T. and Uchida, Y. (1995) Management of Early Invasive Colorectalcancer. Risk of recurrence and clinical guidelines. Diseases of the Colon & Rectum, 38, 1286-1295.
- 9. Jense, M.P., Chen, C. and Brugger, A.M. (2005) Interpretation of Visual Analog Scale Ratings and Change Scores: A Reanalysis of Two Clinical Trials of Postoperative Pain. The Journal of Pain, 4, 407-414.
- 10. Fujishiro, M. (2009) Endoscopic Submucosal Dissection for Colorectal Neoplasms. World Journal of Gastrointestinal Endoscopy, 1, 32-38.
- 11. Tanaka, S., Kashida, H., Saito, Y., Yahagi, N., Yamamo, H., Saito, S., Hisabe, H., Yao, T., Watanabe, M., Yoshida, M., Kudo, S., Tsuruta, O., Sugihara, K., Watanabe, T., Saitoh, Y., Igarashi, M., Toyonag, T., Ajioka, Y., Ichinose, M., Matsui, T., Sugita, A., Sugano, K., Fujimoto, K. and Tajiri, H. (2015) JGES Guidelines for Colorectal Endoscopic Submucosal Dissection/Endoscopic Mucosal Resection. Digestive Endoscopy, 27, 417-434.
- 12. Arezzo, A., Matsuda, T., Rembacken, B., Miles, W.F.A., Coccia, G. and Saito, Y. (2015) Piecemeal Mucosectomy, Submucosal Dissection or Transanal Microsurgery for Large Colorectal Neoplasm. Colorectal Disease, 17, 44-51.
- 13. Onozato, Y., Kakizaki, S., Ishihara, H., Iizuka, H., Sohara, N., Okamura, S., Mori, M. and Itoh, H. (2007) Endoscopic Submucosal Dissection for Rectal Tumors. Endoscopy, 39, 423-427.
- 14. Fujishiro, M., Yahagi, N., Kakushima, N., Kodashima, S., Muraki, Y., Ono, S., Yamamichi, N., Tateishi, A., Oka, M., Ogura, K., Kawabe, T., Ichinose, M. and Omata, M. (2007) Outcomes of Endoscopic Submucosal Dissection for Colorectal Epithelial Neoplasms in 200 Consecutive Cases. Clinical Gastroenterology and Hepatology, 5, 678-683.
- 15. Saito, Y., Uraoka, T., Matsuda, T., Emura, F., Ikehara, H., Mashimo, Y., Kikuchi, T., Fu, K.I., Sano, Y. and Saito, D. (2007) Endoscopic Treatment of Large Superficial Colorectal Tumors: A Case Series of 200 Endoscopic Submucosal Dissections (with Video). Gastrointestinal Endoscopy, 66, 966-973.
- 16. Zhou, P.H., Yao, L.Q. and Qin, X.Y. (2009) Endoscopic Submucosal Dissection for Colorectal Epithelial Neoplasm. Surgical Endoscopy, 23, 1546-1551.
- 17. Saito, Y., Sakamoto, T., Fukunaga, S., Nakajima, T., Kiriyama, S. and Matsuda, T. (2009) Endoscopic Submucosal Dissection (ESD) for Colorectal Tumors. Digestive Endoscopy, 21, S7-S12.
- 18. Saito, Y., Matsuda, T. and Fujii, T. (2010) Endoscopic Submucosal Dissection of Non-Polypoid Colorectal Neoplasms. Gastrointestinal Endoscopy Clinics of North America, 20, 515-524.
- 19. Uraoka, T., Ishikawa, S., Kato, J., Higashi, R., Suzuki, H., Kaji, E., Kuriyama, M., Saito, S., Akita, M., Hori, K., Harada, K., Ishiyama, S., Shiode, J., Kawahara, Y. and Yamamoto, K. (2010) Advantages of Using Thin Endoscope-Assisted Endoscopic Submucosal Dissection Technique for Large Colorectal Tumors. Digestive Endoscopy, 22, 186-191.
- 20. Nakajima, T., Saito, Y., Tanaka, S., Iishi, H., Kudo, S.E., Ikematsu, H., Igarashi, M., Saitoh, Y., Inoue, Y., Kobayashi, K., Hisasbe, T., Matsuda, T., Ishikawa, H. and Sugihara, K. (2013) Current Status of Endoscopic Resection Strategy for Large, Early Colorectal Neoplasia in Japan. Surgical Endoscopy, 27, 3262-3270.
- 21. Fujishiro, M., Yahagi, N., Nakamura, M., Kakushima, N., Kodashima, S., Ono, S., Kobayashi, K., Hashimoto, T., Yamamichi, N., Tateishi, A., Shimizu, Y., Oka, M., Ogura, K., Kawabe, T., Ichinose, M. and Omata, M. (2006) Endoscopic Submucosal Dissection for Rectal Epithelial Neoplasia. Endoscopy, 38, 493-497.
- 22. Winde, G., Nottberg, H., Keller, R., Schmid, K.W. and Bünte, H. (1996) Surgical Cure for Early Rectal Carcinomas (T1). Transanal Endoscopic Microsurgery vs. Anterior Resection. Diseases of the Colon & Rectum, 39, 969-976.
- 23. Bosch, S.L., Teerenstra, S., deWilt, J.H., Cunningham, C. and Nagtegaal, I.D. (2013) Predicting Lymph Node Metastasis in pT1 Colorectal Cancer: A Systematic Review of Risk Factors Providing Rationale for Therapy Decisions. Endoscopy, 45, 827-834.
- 24. Ueno, H., Mochizuki, H., Hashiguchi, Y., Shimazaki, H., Aida, S., Hase, K., et al. (2004) Risk Factors for an Adverse Outcome in Early Invasive Colorectal Carcinoma. Gastroenterology, 127, 385-394.
- 25. Nascimbeni, R., Burgart, L.J., Nivatvongs, S. and Larson, D.R. (2002) Risk of Lymph Node Metastasis in T1 Carcinoma of the Colon and Rectum. Diseases of the Colon & Rectum, 45, 200-206.
- 26. Verseveld, M., de Graaf, E.J., Verhoef, C., van Meerten, E., Punt, C.J., de Hingh, I.H., Nagtegaal, I.D., Nuyttens, J.J., Marijnen, C.A. and de Wilt, J.H. (2015) Chemoradiation Therapy for Rectal Cancer in the Distal Rectum Followed by Organ-Sparing Transanal Endoscopic Microsurgery (CARTS Study). British Journal of Surgery, 102, 853-860.