Management and outcome of local recurrence following transanal endoscopic microsurgery for rectal cancer.

BACKGROUND: Transanal endoscopic microsurgery is a faster and safer alternative to traditional surgical treatment of adenomas and low-risk (T1) rectal tumors. However, although overall survival appears similar, transanal endoscopic microsurgery has been shown to have higher recurrence rates.
OBJECTIVE: The aim of this study was to investigate the management of patients with local recurrence after transanal endoscopic microsurgery and to evaluate their long-term outcome.
DESIGN: This study was a retrospective review of medical records.
SETTING: Patients were treated at a large tertiary-care hospital in Rome, Italy, between 1990 and 2011. PATIENTS: Of 298 patients who underwent local excision with transanal endoscopic microsurgery, 144 patients with rectal adenocarcinoma were included in the study. INTERVENTION: Local excision was performed with transanal endoscopic microsurgery. In all cases complete full-thickness excision was attempted. MAIN OUTCOME MEASURES: Patient characteristics, operative record, pathology report, and tumor recurrence were analyzed. Survival was calculated using the Kaplan-Meyer method and groups were compared with the log-rank test.
RESULTS: Tumors were classified as pT1 in 86 patients (59.7%), pT2 in 38 (26.4%), and pT3 in 20 (13.9%). Median follow-up was 85 (range, 3-234) months. Median time to recurrence was 11.5 (range, 1-62) months; 44 patients had local or distal recurrence or both. The rate of local recurrence for patients with pT1 tumors was 11.6% (10/86). A total of 27 patients (18.8%) with local recurrence were eligible for salvage surgery: 17 had radical salvage resection, 9 had transanal re-excision, and 1 refused surgery. Overall 5-year survival was 83% in all 144 patients, and 92% in patients with pT1 tumors. The overall 5-year survival rate was higher in patients who had the radical salvage procedure than in those who had transanal re-excision (69% vs 43%; p = 0.05). LIMITATIONS: The study was limited by its retrospective nature, lack of technology at the beginning of the study, and the mixed nature of the study group.
CONCLUSIONS: The outcome after transanal excision for rectal cancer depends on close surveillance for early detection of recurrence. In patients able to undergo surgery, endoluminal or pelvic recurrence should be treated with an immediate radical salvage operation. Overall long-term survival after local excision with transanal endoscopic microsurgery followed by radical salvage surgery in cases of local recurrence is comparable to overall survival after initial radical surgery.